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    Is It Possible to Draw a Risk Map for Obturator Nerve Injury During Pelvic Lymph Node Dissection? The Heilbronn Experience and a Review of the Literature
    (Mary Ann Liebert, Inc, 2015) Goezen, Ali Serdar; Aktoz, Tevfik; Akin, Yigit; Klein, Jan; Rieker, Philip; Rassweiler, Jens
    Objective: Obturator nerve injury (ONI) is a rare complication during pelvic lymph node dissection (PLND), in extraperitoneal laparoscopic radical prostatectomy (e-LRP), and/or extraperitoneal robotic-assisted laparoscopic radical prostatectomy (e-RALP). It is important to recognize ONI during the initial operation, maximizing the feasibility of simultaneous repair. Here we report our experience with ONI during e-LRP/e-RALP procedures and draw an injury risk map. Materials and Methods: Between December 1999 and November 2014, 2531 e-LRPs and 1027 e-RALPs were performed. Five patients (3 during e-LRP, 2 during e-RALP) experienced ONI in the proximal part of the nerve. Obturator nerves were clipped during the 3 e-LRP cases. Clips were immediately removed, and patients received physiotherapy with medical treatments in the postoperative period. During e-RALP, two obturator nerves were transected and subsequently repaired using the robotic Da Vinci((R)) Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA). ONI types were investigated in detail in these patients, and current published studies were analyzed in order to draw a risk map. Results: Mean follow-up was 18.82.7 months. In total, 3558 cases (2531 e-LRPs, 1027 e-RALPs) were performed. ONI occurred in 3 e-LRP (0.1%) and 2 e-RALP (0.1%) patients. Simultaneous repair was performed successfully in all cases, as clips were removed in e-LRP cases and obturator nerves were repaired using 6/0 polypropylene (Prolene((R)); Ethicon, Somerville, NJ) suture in e-RALP cases. There was no complication associated with obturator nerve functions such as adductor function and/or neurologic deficiency during long-term follow-up. In view of published studies in the literature, the proximal part of the obturator nerve is at highest risk for injury during PLND, representing 77.8% of reported cases of ONI. Conclusions: According to our ONI risk map, the proximal part of the obturator nerve is at higher risk for injury during PLND. Careful dissection and a good knowledge of pelvic anatomy are essential for preventing ONI. Successful ONI management can be performed simultaneously in experienced hands.
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    Robot-assisted vasovasostomy and vasoepididymostomy: Current status and review of the literature
    (Aves, 2020) Gozen, Ali Serdar; Tokas, Theodoros; Tawfick, Ahmed; Mousa, Waleed; Kotb, Mohamed; Tzanaki, Eirini; Rassweiler, Jens
    Objective: Microscope-assisted vasovasostomy (MAVV) is a standard procedure used to reverse vasectomies. Robotic surgery has been established primarily for technically demanding urological procedures and has also been recently implemented in male reproductive surgery. We aimed to review the current evidence of robot-assisted vasovasostomy (RAVV) and robot-assisted vasoepididymostomy (RAVE). Material and methods: We performed a systematic literature review using PubMed to identify relevant original articles. We identified 2017 records through database search, and after removing duplicates, 782 records remained for further analysis. Results: In total, 12 human and three animal studies were selected. Reported vasal patency rate ranges were 88%-100% for RAVVs and 55%-61% for RAVEs. The sperm count and postoperative pregnancy rates of RAVV ranged between 8.4 x 10(6)-120 x 10(6) sperm/mL and 65%, respectively. Finally, procedure times in the human studies, recorded for extracorporeal RAVVs and RAVEs ranged from 97 to 238 minutes. Conclusion: Robot-assisted vasal reversal is feasible with similar patency rates as for the microsurgical approach and showing comparable outcomes. Additional benefits of this technique include improved vision and movement precision.