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The robotic platform offers theoretical and practical advantages to microsurgical male infertility surgery. These include reduction or elimination of tremor, 3-dimensional visualization, and decreased need for skilled surgical assistance. This article reviews the application of robotic surgery to each of the 4 primary male infertility procedures: vasectomy reversal, varicocelectomy, testicular sperm extraction, and spermatic cord denervation. Historical perspective is presented alongside the available outcomes data, which are limited in most cases. Before the robotic approach can be widely adopted, further clinical trials are needed to compare outcomes and costs with those of other validated surgical techniques., Competing Interests: Disclosure The authors have nothing to disclose., (Published by Elsevier Inc.)

Objective: To assess the timing of patency and late failure (secondary azoospermia) after vasovasostomy (VV) using standardized kinetics definitions., Design: Retrospective cohort study., Setting: University-affiliated hospital., Patient(s): Patients with obstructive azoospermia., Intervention(s): Vasovasostomy., Main Outcome Measure(s): Univariate and multivariate logistic regression assessed predictors of patency and late failure. Patency was defined as any sperm return to the ejaculate; and >2 million total motile sperm (TMS) in ejaculate. Late failure after VV was defined as azoospermia; or <2 million TMS in ejaculate., Result(s): 429 men underwent VV, with median follow up of 242 days. Mean time to patency was 3.25 months versus 5.29 months in the "any sperm" versus ">2 million TMS" groups. Finding sperm intraoperatively during VV significantly improved patency rates in multivariable analysis (odds ratio [OR] 4.22). This association was further boosted when sperm was found bilaterally (OR 6.70). Late failure rate (azoospermia) was 10.6% at mean time of 14.1 months and 23% for <2 million, at mean time of 15.7 months. When assessing predictors of late failure, intraoperative motile sperm bilaterally was a statistically significant protective factor on multivariate analysis (hazard ratio 0.22)., Conclusion(s): Vasovasostomy remains highly efficacious in treating obstructive azoospermia. Young patients, shorter obstructive intervals, and sperm identified intraoperatively predict improved outcomes. Clinicians can expect VV patency in 3 months and late failure within the first 2 years after surgery. However, patency rates, late failure rates, and kinetics vary by definition., (Copyright © 2019 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Over the past few decades, there have been numerous paradigm shifts in male reproductive surgery, resulting from a combination of technologic advancements in both the operating room and the laboratory. The operating microscope transformed the field of male reproductive surgery, enabling novel techniques and higher precision for the treatment of male-factor subfertility. The subsequent widespread adoption of microsurgical approaches was largely responsible for the emergence of a cadre of highly specialized male infertility microsurgeons. The advent and evolution of in vitro fertilization/intracytoplasmic sperm injection was a concurrent story that further revolutionized the field. The ability to achieve fertilization and pregnancy with just a single sperm changed the ways in which male reproductive surgeons could approach a wide range of pathologies from obstructive to nonobstructive causes, culminating in the microdissection testicular sperm extraction procedure for the treatment of nonobstructive azoospermia. Here we review the recent advancements in fertility-enhancing male reproductive surgery for the treatment of four disease processes: varicocele, obstruction of the excurrent ductal system, ejaculatory duct obstruction, and nonobstructive azoospermia. While examining the great strides of the past, we look forward to exciting developments on the horizon., (Copyright © 2019 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Vasectomy reversal is the most common microsurgical intervention for the treatment of male infertility. Originally introduced in 1977, microsurgical vasectomy reversal has become highly sophisticated and is a minimally invasive, highly efficient and cost-effective treatment option for men with a desire to have children after vasectomy. It can be an effective physiological method of restoring fertility in more than 90% of vasectomized men. Although assisted reproductive technology (ART) is an alternative to vasectomy reversal, it is normally associated with higher costs without offering higher cumulative chances of a pregnancy. Recovery of physiological male fertility can take up to 2 years after vasectomy reversal, especially if reversal is performed >10 years after vasectomy, owing to impaired epididymal function. Under these circumstances, ART can be used to bridge the time until recovery of natural fertility. Although the basic principles of microsurgical vasovasostomy have been established since the late 1970s, there have since been numerous technical innovations to improve the delicate operation and promising new technical modifications, particularly for vasoepididymostomy, have been described. Robotic vasectomy reversal is an emerging field in specialized urologic centers, but whether the high quality of conventional microsurgical vasectomy reversal can be matched by robotic platforms is yet to be seen.

Background: On surgical simulators, measures of economy of hand motion have been shown to be reliable, valid, and objective measures of technical competence. Our goal was to validate hand-motion analysis (HMA) as an objective measure of surgical skill on real patients., Methods: HMA (hand movement frequency, hand travel distance) was evaluated serially on 2 standardized, live patient surgeries (vasectomy, vasectomy reversal) for both a novice and experienced surgeon. HMA parameters were correlated with blinded, case-matched assessments of technical skill using previously validated global rating scales and surgical checklist scores applied to unedited surgical videos. Serial hand-motion data from the novice and experienced surgeon were plotted to establish competency-based learning curves over time., Results: Intraoperative HMA correlated significantly with case-matched global rating and checklist scores. Meaningful improvements in the number of hand movements and hand travel distance were shown over time for the novice surgeon, but remained stable for the experienced surgeon., Conclusions: Intraoperative assessment of economy of hand motion represents a feasible, objective, and valid measure of technical skill and can be used to establish competency-based surgical learning curves.

We retrospectively reviewed our experiences with repeat vasectomy reversal and report the patency and natural pregnancy rates. Our data demonstrate that repeat vasectomy reversal is a valid option in patients with a failed initial reversal, although the suitability of repeat reversal should be based on the obstructive interval, the original reversal, the experience of the reversal surgeon, and any female factors, as well as the couple's wishes.

Objective: To determine whether sperm harvesting and cryopreservation at the time of vasectomy reversal is cost-effective., Design: Model of actual costs and results at five institutions., Setting: Multicenter study comprising five centers, including university hospitals and private practices., Patient(s): Men undergoing vasectomy reversal., Intervention(s): We established two models for vasectomy reversal. The first model was sperm harvesting and cryopreservation at the time of vasectomy reversal. The second model was sperm harvesting at the time of IVF only if the patient remained azoospermic after vasectomy reversal. Vasectomy reversal procedures modeled included bilateral vasovasostomy and bilateral epididymovasostomy. The costs for each procedure at the five institutions were collated and median costs determined., Main Outcome Measure(s): Median cost of procedure and calculated financial comparisons., Result(s): The median cost of testicular sperm extraction/cryopreservation performed at the time of bilateral vasovasostomy was $1,765 (range, $1,025-$2,800). The median cost of microsurgical epididymal sperm aspiration or testicular sperm extraction with cryopreservation performed at the time of epididymovasostomy was $1,209 (range, $905-$2,488). The average of the median costs for percutaneous sperm aspiration or testicular sperm aspiration for those patients with a failed vasectomy reversal was $725 (range, $400-$1,455)., Conclusion(s): Sperm retrieval with cryopreservation at the time of vasectomy reversal is not a cost-effective management strategy.

Results of 273 consecutive macroscopic vasovasostomy procedures performed at a single institution over a nine-year period between 1978 and 1987 were reviewed. When patients operated on less than five years after vasectomy were compared with those in whom more than five years had elapsed since vasectomy, significant declines in technical success rates as measured by return of sperm to the ejaculate (93% vs. 74%, p less than 0.004), biologic recovery as measured by mean sperm counts (55 million vs. 35 million) and mean progressive sperm motility (30% vs. 13%), and clinical success as measured by pregnancy rates (52% vs. 30%, p less than 0.02), were observed. Examination of complications of vasovasostomy showed a 7.7 percent overall complication rate and a 1.5 percent incidence of major complications.