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- Original Article -
Initial experience with robot-assisted varicocelectomy
Tung Shu1, Shaya Taghechian2, Run Wang2,3
1Vanguard Urologic Institute Houston, Houston, TX 77030, USA
2Division of Urology, University of Texas Medical School at Houston, TX 77030, USA
3Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
Abstract
Aim: To determine if robot-assisted varicocelectomy can be safely and effectively performed when compared to
microscopic inguinal varicocelectomy.
Methods: Eight patients aged 29.1 ± 12.5 years underwent microscopic
subinguinal varicocelectomies: seven patients with left-sided repair, and one patient with bilateral repair. Eight patients
aged 22.0 ± 8.0 years underwent robot-assisted varicocelectomies: seven patients with left-sided repair and one
patient with bilateral repair.
Results: The average operative time for microscopic inguinal varicocelectomy was
73.9 ± 12.2 min, whereas the robot-assisted technique took 71.1 ± 21.1 min. There were no difficulties in
identifying and isolating vessels and the vas deferens with robot-assisted subinguinal varicocelectomy. Hand tremor was
eliminated using the robotic procedure. Patients who underwent either microscopic or robot-assisted
varicocelectomies were able to resume daily activities on the day of surgery and full activities within 2 weeks. There were no
complications or recurrences of
varicocele. Conclusion: From our experience, compared to microscopic surgery,
robot-assisted varicocelectomy can be safely and effectively performed, with the added benefit of eliminating hand
tremor. (Asian J Androl 2008 Jan; 10: 146_148)
Keywords: varicocele; microscopic varicocelectomy; robot-assisted varicocelectomy
Correspondence to: Run Wang, MD, FACS, Departments of Urology, University of Texas Medical School at Houston and University of
Texas MD Anderson Cancer Center, 6431 Fannin Street, MSB 6.018, Houston, TX 77030, USA.
Tel: +1-713-500-7337 Fax: +1-713-500-0546
E-mail: run.wang@uth.tmc.edu
DOI: 10.1111/j.1745-7262.2008.00354.x
1 Introduction
A varicocele is defined as a meshwork of distended blood vessels in the scrotum, usually left-sided, resulting from
the dilatation of the spermatic veins. It is currently the most common surgically correctable finding identified in men
being evaluated for infertility, and is observed in 8.0%_16.2% of the normal male population and in 21%_39% of
infertile men [1, 2].
Several theories have been proposed to explain the
observed pathophysiology of varicoceles. Semen quality
uniformly declines in animals with induced varicoceles, even when only a left varicocele is produced. The reduction in
scrotal temperature after varicocele ligation supports a causative role of increased temperature on the infertility
produced by the varicocele. It has been hypothesized that varicoceles cause hypoxia, which might play a role in altering
spermatogenesis in the varicocele patient [3]. Recently, a higher frequency of sperm cells with fragmented DNA has
been reported in the ejaculate of subjects with varicocele, in comparison with fertile donors, a phenomenon that might
be correlated with an increase in reactive oxygen species [4].
Numerous studies have reported the significant benefits on semen parameters with surgical treatment of
varicocele [4_7, 8]. Currently there are several surgical approaches available for the treatment of varicocele,
including the retroperitoneal high ligation technique, laparoscopic ligation of spermatic veins, the open inguinal approach, and the
subinguinal microscopic procedure. Of these approaches, several studies have come to the
conclusion that subinguinal microscopic varicocelectomy, a minimally invasive procedure, offers the best outcomes, including shorter
hospitalization stays, preservation of the testicular arteries and lymphatics, least number of postoperative
complications and recurrences, and a higher number of pregnancies [2, 9].
The microscopic approach also takes the longest amount of time to perform. Surgeons need time to become accustomed to dealing with micro-instruments and operating
without being able to see their hands.
Today, robot-assisted operations are gaining
popularity in urological procedures. A benefit of robotic surgical
systems is the increased dexterity that the operator has with
use of the instruments, which allows the use of traditional
surgical techniques and movements in a minimally
invasive environment. The motion-scaling and
tremor-filtering also permit more measured, precise movements for
complex tasks. They also provide advanced viewing
capabilities that provide a large, stable, immersive 3-D image.
With more experience using these robotic systems,
dramatic improvements in speed and skill can occur [10, 11].
The present study reports our preliminary experience
using robot-assisted varicocelectomy in comparison with
the standard microscopic varicocelectomy for the
treatment of varicocele.
2 Materials and methods
Eight patients aged 29.1 ± 12.5 years underwent
microscopic subinguinal varicocelectomies: seven patients
with left-sided repair, and one patient with bilateral repair.
Eight patients aged 22.0 ± 8.0 years underwent
robot-assisted varicocelectomies: seven patients with left-sided
repair and one patient with bilateral repair.
All varicocelectomies were performed through
subinguinal incisions (Figure 1A). The spermatic cord was
exposed and delivered out of the wound, and a Penrose
drain placed underneath the cord structures (Figure 1B).
At this time the Da Vinci robot or operating microscope
was then brought in and placed above the surgical field
(Figure 1C). The testicular artery and vas deferens with
vasal artery and small vasal veins were identified and
isolated (Figure 1D). All other veins within the cord were
isolated (Figure 1E) and ligated with 5-0 Vicryl sutures
and divided (Figure 1F). At the completion of the
varicocelectomy, only the testicular artery, lymphatics
and vas deferens with its vessels remained.
3 Results
The average operative time for microscopic inguinal
varicocelectomy was 73.9 ± 12.2 min, whereas the
robot-assisted technique took 71.1 ± 21.1 min. Average
follow-up time for the patients in the microscopic
inguinal varicocelectomy group was 34.3 ± 6.4 months,
whereas for the robot-assisted technique, the average
follow-up time was 10.9 ± 7.1 months (Table 1).
In our experience, with the robot-assisted subinguinal
varicocelectomy, there were no difficulties in identifying
and isolating vessels and the vas deferens. A short
learning curve for tying 5-0 sutures was required because of
the lack of tactile sensation when using the robot. In
comparison to the microscopic technique, there was no
hand tremor noticed with the robotic technique. Patients
in both groups were able to resume daily activities on the
day of surgery and full activities within 2 weeks.
Neither intraoperative or postoperative complications nor
recurrences of varicocele were observed in either group
undergoing varicocelectomy.
4 Discussion
To our knowledge this is the first report regarding
the use of robot-assisted varicocelectomy. From our
experience, we believe that robot-assisted
varicocelectomy can be safely and effectively performed when
compared to microscopic surgery. In terms of operating
time, there does not seem to be a significant difference
even with our initial experience with robotic
varicocelectomy. It is a common understanding that with
increasing experience and interaction with the Da Vinci robot,
surgeons are able to perform any given task more quickly
over time. In addition, there is an added benefit of
eliminating tremor with the robot in comparison to the
microsurgical technique. Also, the advantage of decreased
intraoperative and postoperative complications experienced
with the microsurgical technique is maintained with the
robot technique.
The cost-effectiveness and efficacy regarding the
improvement of semen quality and pregnancy for patients with infertility treated with robot-assisted
subinguinal varicocelectomy needs to be studied in a larger
population.
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