Robotic Microsurgery in Male Infertility and Urology
Robotic Microsurgery in Male Infertility and Urology
The diagnosis of testicular spermatogenesis failure or NOA is considered in the presence of azoospermia with no discrete blockage in the male reproductive tract. Failure of spermatogenesis can be due directly from intrinsic testicular deficiency (primary) or secondary to endocrine disorders. Although NOA can be differentiated from OA with clinical findings such as a hormone profile and physical exam, the definitive diagnosis can only be establish on histologic examination of testicular tissue. The current standard is that testicular biopsy not be used only to establish the diagnosis, but it should also be performed to retrieve sperm for use in ART.
There are various sperm retrieval techniques including needle aspiration from the epididymis or testis, percutaneous or open testicular biopsy and microsurgical testicular sperm extraction (micro-TESE). Micro-TESE provides the highest success in sperm retrieval.
The safety and effectiveness of robotic assisted micro-TESE (ROTESE) is being assessed and preliminary outcomes seem comparable to the pure microsurgical approach. The use of adjunctive simultaneous imaging technology in the future to better detect sperm during micro-TESE may create a role for the robotic micro-TESE platform.
The surgical technique for ROTESE is similar to the standard microsurgical approach except the robot is utilized for the evaluation of the seminiferous tubules. Once the tunica is incised, the robotic platform is docked from the patient's right side (patient in supine position). The Black Diamond micro forceps are used in the right arm, the micro-bipolar forceps in the left arm and the Potts scissors in the fourth arm (Figure 3). Figure 3 illustrates the surgeon view in the surgeon console during the ROTESE procedure. The primary 3D view (middle top) provides digital magnification at 10–15×, the left lower view provides simultaneous real-time imaging from the andrologist/embryologist's phase contrast microscope as they are assessing the testicular tissue and the right lower image provides a 15–20× optical magnification view of the tubules.
(Enlarge Image)
Figure 3.
A surgeon view in surgeon console during robotic TESE: main image from 3D high-definition robot camera, image on the left hand side from optical microscope and image on the right hand side from video telescope operating monitor (VITOM) camera. The surgeon can simultaneously asses the extracted tissue at the same time with the embryologist. TESE, testicular sperm extraction.
Recently, utilization of a probe-based confocal laser endomicroscope for in situ localization of viable spermatozoa has been shown. Confocal laser endomicroscopy was able to identify fluorescent-labeled spermatozoa, spermatocytes and spermatogonia in the seminiferous tubules. Another group has also shown the utility of multi-photon microscopy in detecting spermatozoa in testicular tissue. Once these adjunctive imaging tools are more readily available for clinical use, they would be a natural fit for the robotic platform and could be incorporated rather easily and manipulated using the additional fourth arm.
Robotics in the Management of Non-obstructive Azoospermia (NOA)
The diagnosis of testicular spermatogenesis failure or NOA is considered in the presence of azoospermia with no discrete blockage in the male reproductive tract. Failure of spermatogenesis can be due directly from intrinsic testicular deficiency (primary) or secondary to endocrine disorders. Although NOA can be differentiated from OA with clinical findings such as a hormone profile and physical exam, the definitive diagnosis can only be establish on histologic examination of testicular tissue. The current standard is that testicular biopsy not be used only to establish the diagnosis, but it should also be performed to retrieve sperm for use in ART.
There are various sperm retrieval techniques including needle aspiration from the epididymis or testis, percutaneous or open testicular biopsy and microsurgical testicular sperm extraction (micro-TESE). Micro-TESE provides the highest success in sperm retrieval.
The safety and effectiveness of robotic assisted micro-TESE (ROTESE) is being assessed and preliminary outcomes seem comparable to the pure microsurgical approach. The use of adjunctive simultaneous imaging technology in the future to better detect sperm during micro-TESE may create a role for the robotic micro-TESE platform.
Technique
The surgical technique for ROTESE is similar to the standard microsurgical approach except the robot is utilized for the evaluation of the seminiferous tubules. Once the tunica is incised, the robotic platform is docked from the patient's right side (patient in supine position). The Black Diamond micro forceps are used in the right arm, the micro-bipolar forceps in the left arm and the Potts scissors in the fourth arm (Figure 3). Figure 3 illustrates the surgeon view in the surgeon console during the ROTESE procedure. The primary 3D view (middle top) provides digital magnification at 10–15×, the left lower view provides simultaneous real-time imaging from the andrologist/embryologist's phase contrast microscope as they are assessing the testicular tissue and the right lower image provides a 15–20× optical magnification view of the tubules.
(Enlarge Image)
Figure 3.
A surgeon view in surgeon console during robotic TESE: main image from 3D high-definition robot camera, image on the left hand side from optical microscope and image on the right hand side from video telescope operating monitor (VITOM) camera. The surgeon can simultaneously asses the extracted tissue at the same time with the embryologist. TESE, testicular sperm extraction.
Recently, utilization of a probe-based confocal laser endomicroscope for in situ localization of viable spermatozoa has been shown. Confocal laser endomicroscopy was able to identify fluorescent-labeled spermatozoa, spermatocytes and spermatogonia in the seminiferous tubules. Another group has also shown the utility of multi-photon microscopy in detecting spermatozoa in testicular tissue. Once these adjunctive imaging tools are more readily available for clinical use, they would be a natural fit for the robotic platform and could be incorporated rather easily and manipulated using the additional fourth arm.