Ahmet Gudeloglu

Robotic assisted versus pure microsurgical vasectomy reversal: technique and prospective database control trial.

Microsurgical vasectomy reversal is a technically demanding procedure. Previous studies have shown the possible benefit of robotic assistance during such procedures. Our goal was to compare robotic assisted vasovasostomy and vasoepididymostomy to standard microsurgical vasovasostomy (MVV) and vasoepididymostomy (MVE). The use of robotic assistance for vasectomy reversal may provide the microsurgeon with improved visualization, elimination of tremor, and decreased fatigue and obviate the need for a skilled microsurgical assistant. This study provides the first clinical prospective control trial of robotic assisted versus pure microsurgical vasectomy reversal. The use of robotic assistance in microsurgical vasovasostomy and vasoepididymostomy may have benefit over MVV and MVE with regards to decreasing operative duration and improving the rate of recovery of postoperative total motile sperm counts based on our study.

Robotic assisted andrological surgery

The introduction of the operative microscope for andrological surgery in the 1970s provided enhanced magnification and accuracy, unparalleled to any previous visual loop or magnification techniques. This technology revolutionized techniques for microsurgery in andrology. Today, we may be on the verge of a second such revolution by the incorporation of robotic assisted platforms for microsurgery in andrology. Robotic assisted microsurgery is being utilized to a greater degree in andrology and a number of other microsurgical fields, such as ophthalmology, hand surgery, plastics and reconstructive surgery. The potential advantages of robotic assisted platforms include elimination of tremor, improved stability, surgeon ergonomics, scalability of motion, multi-input visual interphases with up to three simultaneous visual views, enhanced magnification, and the ability to manipulate three surgical instruments and cameras simultaneously. This review paper begins with the historical development of robotic microsurgery. It then provides an in-depth presentation of the technique and outcomes of common robotic microsurgical andrological procedures, such as vasectomy reversal, subinguinal varicocelectomy, targeted spermatic cord denervation (for chronic orchialgia) and robotic assisted microsurgical testicular sperm extraction (microTESE).

Clinical Practice Guidelines on Prostate Cancer: A Critical Appraisal

PURPOSE Clinical practice guidelines are increasingly being used by leading organizations to promote high quality evidence-based patient care. However, the methodological quality of clinical practice guidelines developed by different organizations varies considerably. We assessed published clinical practice guidelines on the treatment of localized prostate cancer to evaluate the rigor, applicability and transparency of their recommendations. MATERIALS AND METHODS We searched for English based clinical practice guidelines on treatment of localized prostate cancer from leading organizations in the 15-year period from 1999 to 2014. Clinical practice guidelines limited to early detection, screening, staging and/or diagnosis of prostate cancer were excluded from analysis. Four independent reviewers used the validated AGREE II instrument to assess the quality of clinical practice guidelines in 6 domains, including 1) scope and purpose, 2) stakeholder involvement, 3) rigor of development, 4) clarity of presentation, 5) applicability and 6) editorial independence. RESULTS A total of 13 clinical practice guidelines met inclusion criteria. Overall the highest median scores were in the AGREE II domains of clarity of presentation, editorial independence, and scope and purpose. The lowest median score was for applicability (28.1%). Although the median score of editorial independence was high (85.4%), variability was also substantial (IQR 12.5-100). NICE and AUA clinical practice guidelines consistently scored well in most domains. CONCLUSIONS Clinical practice guidelines from different organizations on treatment of localized prostate cancer are of variable quality and fall short of current standards in certain areas, especially in applicability and stakeholder involvement. Improvements in these key domains can enhance the impact and implementation of clinical practice guidelines.

Trifecta Nerve Complex: Potential Anatomical Basis for Microsurgical Denervation of the Spermatic Cord for Chronic Orchialgia

PURPOSE We identified structural abnormalities in the spermatic cord nerves that may explain how microsurgical denervation of the spermatic cord provides pain relief in patients with chronic orchialgia. MATERIALS AND METHODS We retrospectively reviewed a prospective database to compare spermatic cord biopsy specimens from 56 men treated with a total of 57 procedures for microsurgical denervation of the spermatic cord for chronic orchialgia vs a control group of men without pain treated with cord surgery, including varicocelectomy in 4 and radical orchiectomy in 6. Tissue biopsies were obtained from mapped regions of the spermatic cord in all cases. Biopsies stained with hematoxylin and eosin were examined by an independent pathologist. Three human cadaveric spermatic cords were dissected to confirm localization of the nerve distribution identified on pathological mapping. RESULTS We identified a median of 25 small diameter (less than 1 mm) nerve fibers in the spermatic cord. Of the 57 procedures for orchialgia 48 (84%) showed wallerian degeneration in 1 or more of these nerves but only 2 of 10 controls (20%) had such degeneration (p = 0.0008). In decreasing order of nerve density the 3 primary sites (trifecta nerve complex) of these changes were the cremasteric muscle fibers (19 nerves per patient), perivasal tissues and vasal sheath (9 nerves per patient), and posterior cord lipomatous/perivessel tissues (3 nerves per patient). Cord nerve distribution mapped by the biopsies was confirmed by cadaveric dissection. CONCLUSIONS In men with chronic orchialgia there appears to be wallerian degeneration in reproducible patterns in the spermatic cord nerve fibers. Transection of these nerves may explain the effect of the denervation procedure.

Update in the evaluation of the azoospermic male

Approximately 1% of all men in the general population suffer from azoospermia, and azoospermic men constitute approximately 10 to 15% of all infertile men. Thus, this group of patients represents a significant population in the field of male infertility. A thorough medical history, physical examination and hormonal profile are essential in the evaluation of azoospermic males. Imaging studies, a genetic workup and a testicular biopsy (with cryopreservation) may augment the workup and evaluation. Men with nonobstructive azoospermia should be offered genetic counseling before their spermatozoa are used for assisted reproductive techniques. This article provides a contemporary review of the evaluation of the azoospermic male.

Prevalence and predictors of benign lesions in renal masses smaller than 7 cm presumed to be renal cell carcinoma.

UNLABELLED The present study was designed to determine the incidence and predictive factors of benign renal lesions in 450 patients who underwent surgical removal of solitary renal masses <7 cm in diameter. Of the 450 renal masses, 88 (19.9%) were benign lesions. Female sex, nephron-sparing surgery, surgery between 1990 and 1996, cystic components on imaging, and small tumors (<4 cm) were independently associated with benign pathology. PURPOSE To determine the association between preoperative parameters with final benign pathology in patients who underwent surgical removal of solitary renal masses <7 cm in diameter. MATERIALS AND METHODS A database of 450 patients without metastatic disease who underwent radical nephrectomy or nephron-sparing surgery (NSS) for removal of renal masses <7 cm between January 1990 and December 2009 was reviewed. Age, sex, symptoms, year and type of surgery, solid or cystic appearance, and tumor size were analyzed as presumed predictors of benign pathology. Multivariate analysis was performed to identify parameters associated with benign pathology. RESULTS In all, 88 (19.9%) of the tumors were benign, including 39 (8.7%) oncocytomas and 22 (4.9%) angiomyolipomas. The benign lesion rate for tumors ≤2, 2.1-4, and 4.1-7 cm was 30.3%, 27.1%, and 12.5%, respectively (2P < .001). For the periods of 1990-1996, 1997-2003, and 2004-2009, the frequency of benign tumors was 25%, 17.3%, and 18.4% (2P = .271), the incidental tumor rate was 48.1%, 60.4%, and 63.8% (2P = .027), mean tumor size was 5, 4.6, and 4.1 cm (2P < .001), and the NSS rate was 28.8%, 43.2%, and 52.7% (2P < .001), respectively. Logistic regression analysis revealed that female sex, NSS, surgery between 1990 and 1996, cystic components on imaging, and small tumors (<4 cm) based on radiologic examination were independently associated with benign pathology (odds ratio [OR] = 3.26, 2.56, 2.43, 2.41, and 1.96, respectively). CONCLUSIONS The incidence of incidental and small tumors amenable to NSS increased over time. Female sex was the strongest predictor of benign pathology.

Renal cell carcinoma with inferior vena cava thrombus: The Hacettepe experience

OBJECTIVES We evaluated the clinical outcome and factors affecting survival in patients with renal cell carcinoma (RCC) and tumor thrombus involving inferior vena cava (IVC). METHODS Between 1990 and 2007, 28 patients with RCC and tumor thrombus extending into IVC underwent radical nephrectomy and thrombectomy. Patient data were reviewed retrospectively to evaluate the demographics, clinical presentation, surgical approach, pathological features, clinical outcomes, and survival. RESULTS Twenty-eight patients with a mean age of 52.7 years were operated. Thrombus level was infrahepatic in 15 patients (54%), intrahepatic in 3 patients (10%), suprahepatic in 3 patients (10%), supradiaphragmatic in 2 patients (8%), and intracardiac in 5 patients (18%). All patients with intracardiac thrombi underwent cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA). The mean tumor size was 98.21 mm. Four patients had distant metastases and 3 patients had lymph node involvement. Pathological examination revealed RCC of clear cell type in 26 patients, papillary in 1 and chromophobe in 1 patient. At a mean follow-up of 36.4 months, 16 patients were still alive while 8 patients died due to disease progression and 2 patients died of other causes. Two patients died of pulmonary emboli in the early postoperative period. Lymph node involvement, distant metastases, hypercalcemia, and sarcomatoid component were found to be factors affecting overall survival significantly. Level of tumor thrombus and Fuhrman grade did not affect survival. CONCLUSIONS Radical nephrectomy and tumor thrombectomy is currently known to be the most effective method in patients with RCC and tumor thrombus extending into IVC. Factors affecting survival are the ones related to tumor biology. Tumor thrombus level does not affect the prognosis.

Robotic-assisted microsurgery for an elective microsurgical practice.

Robotic-assisted microsurgery can be utilized for either intracorporal or extracorporeal surgical procedures. Three-dimensional high-definition magnification, a stable ergonomic platform, elimination of physiologic tremor, and motion scaling make the robotic platform attractive for microsurgeons for complex procedures. Additionally, robotic assistance enables the microsurgeon to take microsurgery to challenging intracorporeal locations in a minimally invasive manner. Recent adjunctive technological developments offer the robotic platform enhanced optical magnification, improved intraoperative imaging, and more precise ablation techniques for microsurgical procedures. The authors present the current state-of-the art tools available in the robotic-assisted microsurgical platform.

Medical Management of Male Infertility in the Absence of a Specific Etiology

Idiopathic male infertility can be diagnosis in approximately one-third of infertile males. The empirical medical treatment with or without assisted reproductive techniques appears common in male infertility practice. This type of management can be classified as hormonal treatment including gonadotropins, antiestrogens, and aromatase inhibitors and support with antioxidant supplements such as carnitine, lycopene, glutathione, and vitamin E. This review investigates the evidence of commonly used empirical medical management of male infertility when there is no demonstrable diagnosis.

Robotic microsurgery in male infertility and urology—taking robotics to the next level

The initial reports of robotic assisted microsurgery began to appear in the early 1990s. Animal and early human studies were the initial publications. Larger series papers have recently been published from a few institutions. The field of robotic assisted microsurgery is still in evolution and so are adjunctive tools and instruments. It is clearly a different and unique skill set—is it microsurgery or is it robotic surgery, or both. It is clear from history that the art of surgery evolves over time to encompass new technology as long as the outcomes are better for the patient. Our current robotic platforms may not be ideal for microsurgery, however, the use of adjunctive tools and instrument refinement will further its future potential. This review article presents the current state of the art in various robotic assisted microsurgical procedures in male infertility and urology. Some novel applications of taking microsurgery to areas not classically accessible (intra-abdominal vasovasostomy) and adjunctive tools will also be presented.