Fig. 30.1
Two-hit theory on cause of chronic orchialgia
Fig. 30.2
Nerve fiber with and without Wallerian degeneration on H&E staining
Prevalence can range up to 33 % of men after vasectomy [11] and 63 % after inguinal hernia repair [12–14]. After hernia repair the pain can be neuropathic or non-neuropathic secondary to mesh. Even with such a high prevalence after hernia repair, only 1 % of patients who suffer from CO may be referred for further evaluation [15]. Parekattil et al. in 2008 reported on the advantages of robotic-assisted targeted microsurgical denervation of the spermatic cord (RMDSC) for chronic groin and testicular pain [7, 8]. The technique targets denervation at specific nerves found to have abnormal fibers (Wallerian degeneration) within the spermatic cord [16]. The three primary locations for abnormal nerves (highest to lowest) are cremasteric nerve fibers, perivasal tissue and vasal sheath, and posterior lipomatous/posterior-arterial tissue.
In this chapter we will highlight specific procedures for the management of male infertility and chronic orchialgia: robotic-assisted microsurgical vasovasostomy, vasoepididymostomy, subinguinal varicocelectomy, and targeted denervation of the spermatic cord.
Preoperative Preparation
Anticoagulant medications or supplements are generally held 5–7 days prior to the procedure. A broad-spectrum antibiotic is administered at least 30 min prior to skin incision. Mechanical lower extremity compression stockings are used for deep venous thrombosis prophylaxis.
Operative Setup and Patient Positioning
The patient is placed in a supine position and prepped and draped in a standard surgical fashion. Skin incisions are made and appropriate operative tissues are exposed. The robot is brought in from the right side of the patient for the microsurgical portion of the case (Fig. 30.3). Figure 30.4 illustrates the trocar robotic arm placement. Trocars are loaded to allow the instruments to function and to stabilize their movements outside the patient’s body. Instruments are advanced 4–5 cm beyond the tip of the trocar to optimize range of motion. A 0° camera lens is used to optimize the visual field during procedures.
Fig. 30.3
General robotic position and setup for microsurgery cases
Fig. 30.4
Robotic arm and trocar placement for microsurgery cases
Figure 30.5 illustrates our utilization of the VITOM (Karl Storz Inc., Tuttlingen, Germany) camera system for enhanced 16–18× magnification with a nitrogen powered fifth arm (Point setter arm, Karl Storz Inc., Tuttlingen, Germany). The real-time video images from VITOM are transported to the surgeon console utilizing the TilePro (Intuitive Surgical, Sunnyvale, CA) robotic surgical console software system to provide simultaneous real-time images to the microsurgeon. Figure 30.6 illustrates the cockpit view of the surgeon console (1) the da Vinci Si 3D HD camera view, (2) the VITOM optical 16–18× camera lens system view, and (3) a 40–100× optical microscopic view from the intra-op andrology laboratory microscope (Nikon Inc., Tokyo, Japan).
Fig. 30.5
Positioning of VITOM on nitrogen powered fifth robotic arm
Fig. 30.6
Cockpit view of surgeon console with TilePro software
Robotic-Assisted Microsurgical Vasovasostomy
Technique
The proximal and distal vas deferens (beyond the previous vasectomy site) is palpated through the scrotal skin. Through the skin the distal vas is fixed into place with a towel clip (Fig. 30.7). Local anesthetic is infiltrated into this area. A 1–2 cm vertical incision is made over the vas starting inferiorly from the previously placed towel clip (Fig. 30.8). Using fine electrocautery and sharp dissection, the distal and proximal ends of the vas are dissected free. The distal vas is dissected to allow a tension-free anastomosis to the proximal vas. The proximal vas is carefully transected with a #11 blade. Microscopic examination of the proximal vas fluid is performed. If no sperm is present in this proximal fluid, robotic-assisted microsurgical vasoepididymostomy (RAVE) is performed. If sperm is found, then RAVV is performed. The adventitia from either end of the vasa is now secured together with a 3-0 prolene suture to allow a tension-free anastomosis.
Fig. 30.7
Skin and vas under towel clip for robotic vasectomy reversal
Fig. 30.8
Midline skin incision for robotic vasectomy reversal
The robot is now positioned from the right of the patient to perform the microsurgical vasovasostomy. Black diamond micro-forceps are inserted on the right and left robotic arms. The micro Potts scissors are inserted onto the fourth robot arm. The 0° camera lens is inserted onto the robot camera arm. The two ends of the vas are placed over a 1/4 in. Penrose drain. The assistant passes the 9-0 nylon suture that is kept in its inner packaging to the surgical field. The suture is grasped using the black diamond right-hand grasper and cut to about 2 in. length using the micro Potts scissors. The 9-0 nylon suture is held and manipulated using the black diamond forceps in both left and right arms as needle drivers. The posterior muscularis layer of the two ends of the vas is now approximated (Fig. 30.9). Two or three double-armed 10-0 nylon sutures are now placed inside out to reanastomose the posterior mucosal lumen of the vas (Fig. 30.10). Three double-armed 10-0 nylon sutures are used to close the anterior mucosal lumen of the vas (Fig. 30.11). Five to six 9-0 nylon sutures are used to approximate the anterior muscularis layer of the vas (Fig. 30.12). The same procedure is now performed on the contralateral side by repositioning the robotic arms. The Penrose drain is gently removed from under the repair. The vas is placed back into the scrotal cavity and the tissue and skin are closed with absorbable suture.
Fig. 30.9
RAVV posterior muscular anastomosis
Fig. 30.10
RAVV posterior luminal anastomosis
Fig. 30.11
RAVV anterior luminal anastomosis
Fig. 30.12
RAVV anterior muscular anastomosis
Robotic-Assisted Microsurgical Vasoepididymostomy
Technique
The RAVE procedure starts from above when there is no sperm in the fluid from the proximal vas. The scrotal incision is enlarged by 1–2 cm inferiorly. The testicle is delivered and the tunica is incised to expose the epididymis. The adventitial layer of the epididymis is incised above the level of epididymal obstruction (blue/gray zone with dilated epididymal tubules above this area). A 3-0 prolene suture is used to attach the testicle to the adventitia of the vas to prevent tension between the anastomosis. The vas is stripped off the adventitia and flipped towards the epididymal tubules. The robot is now positioned similar to above. Two 10-0 nylon double-armed suture needles are placed longitudinally through a single epididymal tubule to expose the tubule (Fig. 30.13). This tubule is then incised longitudinally using the micro Potts scissors between the two suture needles to create a lumen in the tubule (Fig. 30.14). The fluid is then aspirated and examined under a separate phase contrast microscope for the presence of sperm.
