University of Florida urologists have used robot-assisted surgery to cut about 20 minutes off the average surgery time for a conventional vasectomy reversal, and it appears to also provide a quicker return of the sperm count after surgery. “For a couple that's trying to get pregnant, this is a big deal,” said Sijo Parekattil, M.D., director of male infertility and microsurgery at UF, who led the study.
The findings, which will appear in an upcoming print edition of the Journal of Endourology, represent the first head-to-head comparison of robot-assisted vasectomy reversal and the microscope procedure that is widely used. But robotic vasectomy reversal is not without controversy among specialists who say that using an expensive robot to do something that is already done well simply with a microscope is a waste of resources.
Most patients pay out of pocket for vasectomy reversal. The robot-assisted procedure can cost up to $3,000 more than the microscope method. “Did it improve outcomes — either pregnancy rates or the time spent in surgery?” asked professor Jay Sandlow, M.D., vice chair of the department of urology at Medical College of Wisconsin in Milwaukee. Sandlow initially had reservations about the robotic procedure, but after seeing the preliminary results now says he sees value in the method.
Since many hospital fees are based on time, cutting operating time might offset some of the extra charges associated with the use of the robot. Parekattil, who has the rare combination of being fellowship trained in both infertility microsurgery and robotics, suspects that the time reduction happens because the robot allows for more efficient use of instruments with multiple arms and tools functioning simultaneously.
It is too soon to tell whether pregnancy rates have improved since the mid-2009 conclusion of the one-year study in which 20 men had the robotic procedure and seven had the microscopic one. But two months after surgery, average sperm count in the robotic surgery group was 54 million, compared with 11 million in the microscopic surgery group. Early results show that the difference in sperm count between the two procedures decreases over time, however.
Another potential advantage of the robotic procedure is less discomfort for some surgeons who would otherwise stand or sit with their backs bent for extended periods over a microscope.
The robotic procedure also has its limitations, as it might not be as useful for a more complicated reversal that involves clearing a secondary blockage close to the testicles. That's because in that case the surgeon has to hold the sperm tube during surgery, which is difficult to do robotically because a keen sense of pressure is needed in order to avoid crushing the microscopic tubes involved. Parekattil, however, says he has developed techniques to stabilize such small tubules while using the robot.
Despite the study's small sample size, physicians say it is promising, and requires more evaluation and longer follow-up of patients to yield more widely applicable results. “I don't think there's going to be a huge change in practice,” Sandlow said. “But in academia part of what we do is try to push the envelope and try to see what works and what doesn't — and it's through studies like this that we answer those questions.”