Live Donation of Corneal Tissue in the Setting of Orbital Exenteration for Malignancy.

Background. The availability of corneal tissue is a major limiting factor in utilizing keratoplasty for correction of corneal blindness. Viable corneal tissue is typically difficult to obtain as posthumous donation is required to avoid significant morbidity and loss of vision in live patients. As a result, the possibility of obtaining viable corneal tissue from a living donor is rarely discussed. This report describes a case in which corneal donation was completed in a living patient undergoing exenteration for invasive squamous cell carcinoma of the maxillary sinus. Performing corneal donation in similar patients in the future should be considered by head and neck surgeons as an opportunity to increase the availability of corneal tissue.

Medical and surgical management male infertility.

Male infertility is the result of a variety of highly treatable conditions. The critical step in treating male infertility is to evaluate properly every male partner of an infertile couple and to generate the proper treatment strategy. There are many medical and surgical options that can help most couples overcome male factor infertility. Male infertility can most easily be broken down into problems of sperm production (testicular dysfunction) and problems of sperm transport (obstruction). When applicable, medical therapies are used as an initial strategy to improve sperm production or as a preliminary therapy to boost production transiently in anticipation of a surgical sperm retrieval attempt. A range of surgical options is available to correct varicoceles, reconstruct the obstructed system, or retrieve sperm for assisted reproduction.

The morphology of extracted testicular sperm correlates with fertilization but not pregnancy rates.

OBJECTIVE: To investigate sperm morphology on the day of fresh testicular sperm extraction (TESE) with intracytoplasmic sperm injection (ICSI), and its effect on fertilization and pregnancy rates, as TESE in conjunction with ICSI results in high fertilization and pregnancy rates in most patients, but to our knowledge only one small study has assessed the morphology of retrieved sperm and found no correlation with the success of fertilization. PATIENTS AND METHODS: In a retrospective database analysis in a large academic centre, 68 men had 75 cycles of TESE combined with ICSI from January 2004 until April 2006. Sperm obtained by TESE was morphologically analysed at high (x 400-600) magnification and used for ICSI on the day of tissue retrieval. Sperm were classified as being either normal, having an amorphous head, having a mid-piece defect or having multiple defects. The calculated percentage of abnormal sperm injected was compared with the normal fertilization rate using Pearson's correlation coefficient, and pregnancy rates between groups were compared using chi-square analysis. RESULTS: Fifteen cycles had all morphologically normal sperm; 21 cycles had 50-99% normal forms and 39 cycles had <50% normal sperm. There was a highly significant correlation between the percentage of normal sperm used for ICSI and fertilization rates (P = 0.007). Overall, 43 clinical pregnancies resulted in this series, i.e. three among the group with all normal sperm injected, 12 in the group with 50-99% normal sperm and 28 in the group with <50% normal forms. There were also 11 pregnancies in cycles that used no normal forms. Pregnancy rates did not differ significantly among the groups (P = 0.08). CONCLUSIONS: TESE with ICSI frequently results in successful pregnancy; normal morphology was highly and significantly associated with successful fertilization, but importantly there were still 10 clinical pregnancies in cycles where only abnormal sperm were used. Sperm morphology after TESE should be assessed at the time of the procedure, and whenever possible, morphologically normal sperm chosen for injection. However, it is reassuring that acceptable fertilization and pregnancy rates are still achievable in cases with no morphologically normal sperm available.

Ion channel gene therapy for smooth muscle disorders: relaxing smooth muscles to treat erectile dysfunction.

The promise of gene therapy to treat diseases remains largely unfulfilled. Past setbacks and the complexity of the delivery systems used, in terms of both targeting the appropriate cells and inducing expression of products at therapeutic levels, thus far have prevented significant success for gene therapy. Smooth muscle disorders represent a unique target for gene therapy. In many cases, smooth muscle is readily accessible and, to induce a therapeutic effect, will not require very high levels of gene product expression. This allows a lower efficiency of gene transfer to be successful. With these important features in mind, we believe that naked DNA transfer of potassium ion channels represents a novel and successful way to treat smooth muscle disorders. Herein, we present a rationale for treating erectile dysfunction, a smooth muscle disorder of the cavernosal bodies of the penis, with naked DNA gene transfer therapy. By inserting the hSlo gene, which codes for Maxipotassium channels, into smooth muscle cells, we can improve smooth muscle relaxation in the corporal bodies and thus improve erectile function. This method of gene transfer has proven to be safe and effective for erectile dysfunction, and human trials are ongoing.

Success of testicular sperm extraction [corrected] and intracytoplasmic sperm injection in men with Klinefelter syndrome.

PURPOSE: The aim of this study was to report the successful fertility treatment of men with Klinefelter syndrome using testicular sperm extraction (TESE) and intracytoplasmic sperm injection (ICSI). METHODS: A total of 42 men with Klinefelter syndrome who underwent 54 TESE procedures were identified. Before TESE, patients with serum testosterone levels less than 15.6 nmol/liter were treated with an aromatase inhibitor. Sperm retrieval rates and results of ICSI, including fertilization and clinical pregnancy, were collected. RESULTS: Mean pretreatment FSH and testosterone levels were 33.2 IU/liter and 9.8 nmol/liter. During medical therapy, the mean testosterone level rose to 17.0 nmol/liter (P < 0.01). Spermatozoa were found during 39 microdissection TESE procedures, on the day before, or day of oocyte retrieval during a programmed in vitro fertilization cycle. The sperm retrieval rate was 72% (39 of 54) per TESE attempt, and 29 of the 42 different men (69%) had adequate sperm found for ICSI. Thirty-three in vitro fertilization cycles yielded embryos for transfer in the 39 (85%) cycles with sperm retrieved. Eighteen clinical pregnancies have resulted in 21 live births [18 of 39 (46%)]. All children had a normal karyotype. CONCLUSION: TESE/ICSI is a successful intervention for the majority of patients with azoospermia and Klinefelter syndrome. Sperm retrieval and ICSI success in men with Klinefelter syndrome are comparable with other men with nonobstructive azoospermia treated at our center.

Rapid disappearance of spermatozoa after vasal occlusion in the dog.

The reproductive system of the male dog is unusual in that the seminal vesicles and bulbourethral glands are absent. Therefore, we chose the dog as a model to evaluate the effect of seminal vesicles on clearance of spermatozoa from the male reproductive tract after vasal occlusion. Thirty adult male beagle dogs with ejaculates containing at least 500 x 10(6) sperm with greater than 90% motility were used for this study. The dogs' vasa were occluded percutaneously using a Vasocclude clip-applying device through a small scrotal puncture site. Dogs were ejaculated and semen analysis was performed before and after vas occlusion. The first 24 dogs were completely azoospermic 1 week following vas occlusion. In order to explain these unanticipated results, an additional 6 dogs were evaluated to determine the specific time course of sperm disappearance from the ejaculate at 1, 3, 5, and 7 days after vas occlusion. The results revealed that spermatozoa were almost completely absent within 1 day after vas occlusion (99.9% reduction, X = 1.0 + 1.1 x 10(6) sperm per milliliter at 1 day, P <.0005 vs prevas occlusion). The rapid elimination of spermatozoa after vas occlusion indicates that sperm transit rapidly through the vas deferens in dogs. Therefore, the delayed clearance of spermatozoa from the ejaculate in humans may be due to sperm storage in the seminal vesicles.

Sex chromosome micromosaicism in infertile men with normal karyotypes.

OBJECTIVE: To define the prevalence of low-level sex chromosome mosaicism in a cohort of infertile men. DESIGN: Prospective cohort study of infertile men. SETTING: Tertiary university infertility center. PATIENT(S): One hundred one consecutive men who presented with primary infertility for evaluation. INTERVENTION(S): Fluorescent in situ hybridization for X and Y was performed on 200 cells, and if an aberrant sex chromosome complement was noted, 400 cells were counted. For this study, any abnormality in sex chromosome complement was defined as micromosaicism. MAIN OUTCOME MEASURE(S): Low-level sex chromosome mosaicism. RESULT(S): Sixty-seven of these men (67%) had no mosaicism, and 34 men (34%) had micromosaicism. The median percentage of abnormal chromosomes in these men was 2%. The mean age of the men without micromosaicism was lower than for men with micromosaicism (31.1 years vs. 35.2 years). A trend toward higher FSH levels in men with low-level mosaicism was seen. Median sperm density and percent motility were higher in normal men. Percent normal morphology was identical between groups. CONCLUSION(S): We found low-level sex chromosome mosaicism in 34% of infertile men who presented for evaluation. Men with low-level mosaicism were significantly older. Low-level mosaicism may emerge with advancing age and may therefore help to explain the decline in fertility potential seen in older men.

Renal artery thrombosis following secondary cytoreduction in a patient with ovarian cancer.

BACKGROUND: In order to successfully perform aggressive cytoreductive surgery for patients with recurrent epithelial ovarian cancer, resection of retroperitoneal disease in close proximity to major vessels is often required. CASE: We describe a case of a 44-year-old female patient with a history of Stage IV carcinoma of the ovary, who underwent a successful secondary debulking procedure. To remove the left para-aortic tumor implant she required complete mobilization of the left kidney, with skeletonization of the left renal artery and vein. Postoperatively, the patient developed left renal artery thrombosis necessitating a unilateral nephrectomy. CONCLUSION: This is, to our knowledge, the first reported case of renal artery thrombosis following a debulking procedure. Gynecologic oncologists should be aware of this possibility and be familiar with the diagnosis and management of this condition.

Innovative single-armed suture technique for microsurgical vasoepididymostomy.

OBJECTIVES: Vasoepididymostomy outcomes are heavily dependent on the surgeon's microsurgical experience and skill. To avoid back-walling the tubular lumen, the needles are generally placed inside-out through the vasal lumen using double-armed microsutures. These double-armed sutures for infertility microsurgery are very expensive and may be difficult to obtain. We describe a randomized trial that used a novel single-armed suture placement pattern for vasoepididymostomy. METHODS: Male adult Wistar rats underwent vasectomy. Two weeks later, vasoepididymostomies were performed using either a single-armed longitudinal intussusception vasoepididymostomy (n = 6) or a standard double-armed longitudinal intussusception vasoepididymostomy (n = 6) technique. After 9 weeks, patency was assessed functionally by evaluating for motile sperm distal to the anastomosis. If no motile sperm were visible, the mechanical patency of the anastomoses was tested by the ability of methylene blue to pass through the surgical anastomosis. RESULTS: The patency rate for the double-armed vasoepididymostomy group was 100% (6 of 6) compared with 83.3% (5 of 6) for the single-armed vasoepididymostomy group. This difference was not significant (P = 0.50). Sperm granulomas were found in three (50%) of six anastomoses in the double-armed group and five (83%) of six anastomoses in the single-armed vasoepididymostomy group (P = 0.27). The mean operative times for the double and single-armed longitudinal intussusception vasoepididymostomy techniques were similar (35 minutes versus 43 minutes; P = 0.39). CONCLUSIONS: The results of our study have shown that the single-armed suture technique to perform vasoepididymostomy is almost as effective as the double-armed technique. Although we still prefer to use double-armed sutures, we believe that this is a practical and effective alternative when specialized double-armed microsurgical sutures are not available.

An analysis of the natural history of Peyronie's disease.

PURPOSE: Little information exists on the natural history of PD. We defined the course of PD in a group of men with this condition who received no treatment. MATERIALS AND METHODS: The study population comprised patients with PD who presented within 6 months of disease onset, had no medical treatment and were followed until at least 12 months after disease onset. At baseline and followup penile abnormality was determined following intracavernous injection and by measurement at maximum penile rigidity. RESULTS: A total of 246 patients met inclusion criteria. At presentation mean age +/- SD was 52 +/- 22 years and the duration of PD was 3.5 +/- 1.5 months. At baseline in men with documented curvature 72% had dorsal, 17% had ventral and 11% had lateral curvature. Mean curvature at baseline was 42 +/- 22 degrees. Mean stretched flaccid penile length was 12.2 cm. The mean duration of PD at the followup assessment was 18 +/- 7 months. At followup stretched flaccid length had decreased to 11.4 cm (p = 0.035). Of the patients 32% complained of some degree of erectile dysfunction at baseline. All patients who reported penile pain had improvement and 89% reported complete resolution at followup. Of men with curvature 12% had improved, 40% remained stable and 48% had worsened at followup. In those in whom curvature improved the mean change was 15 degrees, while in those in whom curvature worsened the mean change was 22 degrees. CONCLUSIONS: To our knowledge this is the largest study to explore the natural history of PD. A minority of men experienced improvement in penile abnormality, while penile length decreased during the 1-year followup. This information will permit clinicians to provide patients with realistic expectations at presentation for the evaluation of PD.

Early use of a phosphodiesterase inhibitor after brachytherapy restores and preserves erectile function.

OBJECTIVE: To investigate whether the early use of phosphodiesterase inhibitors (PDEIs) after brachytherapy (BT) is associated with better erectile function, as of men potent before BT 38-70% have erectile dysfunction afterward. PATIENTS AND METHODS: We evaluated a prospectively created database of 2500 patients who had had BT at our institution since 1992. We measured baseline age, cancer stage, Gleason grade, prostate specific antigen (PSA) level at diagnosis, implant type, use of neoadjuvant and adjuvant hormonal suppression therapy, use of external beam radiotherapy in conjunction with interstitial therapy, and follow-up PSA levels. Men were stratified by their use of PDEIs at <1 year (early group) or >1 year after implantation (late group). We excluded all men who did not have baseline Sexual Health Inventory for Men (SHIM) scores and at least one follow-up SHIM score; the latter were obtained at 6-month intervals after BT. Data were analysed using the Mann-Whitney U-test. RESULTS: In all, 210 men met the inclusion criteria; 85 began using PDEIs within a year of BT, and 125 started after a year. The mean time to PDEI use was 191 days in the early and 595 days in the late group. The median age was 62 years in the early and 63 years in the late group (P = 0.02). Baseline Gleason scores did not differ, nor did PSA levels between the groups. Of men in the early group, 48% received neoadjuvant and/or adjuvant hormonal suppression therapy, vs half of men in the late group. Baseline SHIM scores were not significantly different, nor were scores at the first two follow-up assessments, but the scores at 18-36 months after BT were significantly different. CONCLUSION: The early use of PDEIs after BT is associated with a significant improvement in and maintenance of erectile function compared with late use. Men undergoing BT should be encouraged to use PDEIs early after implantation, to preserve erectile function.

Correlation of ultrasound-measured venous size and reversal of flow with Valsalva with improvement in semen-analysis parameters after varicocelectomy.

We studied 68 men with varicoceles to determine preoperative parameters that are associated with improvements in semen analysis after varicocelectomy. Ultrasound-measured venous diameter and reversal of flow were found to correlate with successful outcome.

Neuroprotective strategies in radical prostatectomy.

In this section, authors from New York give their views on the various neuroprotective strategies for patients having a radical prostatectomy, such as the use of nerve grafts and other approaches. A joint study from Korea, the USA, Canada and the UK is presented in a paper on the importance of patient perception in the clinical assessment and management of BPH. There is also a review of robotic urological surgery. Finally, authors from New York give a review on the life of Isaac Newton. This is a new historical review in the journal, but one that will be of general interest.

Managing varicoceles in children: results with microsurgical varicocelectomy.

UNLABELLED: Authors from New York present their experience of elective varicocelectomy, using microsurgical techniques, in a large series of children. They found the procedure to be safe and effective, and gave a much lower complication rate than the published rate in open varicocelectomy. The results of urethroplasty in post-traumatic paediatric urethral strictures are presented by authors from Mansoura. They found the overall success of one-stage perineal anastomotic repair of such strictures to be excellent, with very little morbidity. OBJECTIVE: To report our experience of microsurgical subinguinal varicocelectomy in boys aged < or = 18 years. PATIENTS AND METHODS: Boys aged < or = 18 years treated with microsurgical varicocelectomy between 1996 and 2000 at one institution were retrospectively reviewed. Indications for surgery included ipsilateral testicular atrophy, large varicocele or pain. Microsurgery was assisted by an operating microscope (x10-25) allowing preservation of the lymphatics, and the testicular and cremasteric arteries. Patient age, varicocele grade, complications and follow-up interval were recorded. RESULTS: In all there were 97 microsurgical subinguinal varicocelectomies (23 bilateral) in 74 boys (mean age 14.7 years). Left-sided varicoceles were significantly larger (mean grade 2.9) than right-sided (mean grade 1.4) varicoceles. The mean follow-up was 9.6 months. There were four complications: two hydroceles, of which one resolved spontaneously after 4 months; one patient had persistent orchialgia that resolved after 8 months; and one developed hypertrophic scarring at the inguinal incision site. There were no infections, haematomas or intraoperative injuries to the vas deferens or testicular arteries. All boys were discharged home on the day of surgery. CONCLUSIONS: Microsurgical subinguinal varicocelectomy in boys is a safe, minimally invasive and effective means of treating varicoceles. Compared with published results of the retroperitoneal mass ligation technique, which has a 15% overall complication rate and a 7-9% hydrocele occurrence rate, the microsurgical subinguinal approach appears to offer less morbidity, with a 1% hydrocele rate. We consider that microsurgical subinguinal varicocelectomy offers the best results with lower morbidity than other techniques.

Outcome and late failures compared in 4 techniques of microsurgical vasoepididymostomy in 153 consecutive men.

PURPOSE: Vasoepididymostomy remains one of the most technically challenging procedures in all of microsurgery. The technique has evolved from an end-to-end, to an end-to-side technique, then to intussusception end-to-side methods. We recently reported the superiority of 2-suture longitudinal and 3-suture triangulation intussusception techniques in rats. In the present study we report our results in humans. We evaluated all vasoepididymostomies performed by 1 surgeon from January 1992 until the present for patency, pregnancy and for disappearance of sperm after initial return of sperm to the ejaculate. MATERIALS AND METHODS: We recorded the results of 153 consecutive vasoepdidymostomies done by 1 surgeon (MG) from January 1992 until February 2004. Four techniques were used, namely end-to-end (EE), end-to-side (ES), 3-suture triangulation intussusception (TIVE) and 2-suture longitudinal intussusception (LIVE). Data collected included technique, months of followup, sperm density, motility and morphology (WHO 1992 criteria), pregnancy outcome and late failures. Late failures were defined as having return of sperm to the ejaculate after vasoepididymostomy and then becoming azoospermic on at least 2 subsequent semen analyses. RESULTS: A total of 153 men underwent bilateral vasoepididymostomies. The most recent 17 were LIVE, preceeded by 38 TIVE, 32 ES and 66 EE. Mean followup for the groups were 17.2 (LIVE), 70.8 (TIVE), 116.7 (ES) and 140.2 (EE) months, respectively. Intact sperm were seen in the ejaculates of 12 men (80%) in the LIVE group, 16 in the TIVE group (84%), 20 in the ES group (74%) and 30 men in the EE group (73%). Motile sperm were found in the ejaculates of 10 of 15 (67%) in the LIVE group, 13 of 19 (68%) in the TIVE group, 10 of 27 (37%) in the ES group and 20 of 41 (49%) in the EE group (p =0.2). Mean times for return of sperm to the ejaculate were 2.9, 2.8, 2.8 and 3.5 months, respectively. Pregnancies were reported by 4 men in the LIVE group all before 12 months, 6 in the TIVE group and 3 were by 12 months, and 4 each by the ES and EE groups with 3 and 2 by 12 months (p =0.07). Thus far, there have been no late failures in the LIVE group, only 1 in the TIVE group (8%), 5 in the ES group (50%) and 6 in the EE group (30%) (p =0.04). CONCLUSIONS: Although vasoepididymostomy remains a technically demanding microsurgical procedure, recent technical innovations of TIVE and LIVE offer better or comparable outcomes compared with EE and ES procedures with the use of fewer sutures, which simplifies the performance of the anastomosis. In addition, the late failure rate is lower with the use of the intussusception techniques (LIVE and TIVE) with only 1 late failure in 22 men with return of sperm to the ejaculate procedures (4%) compared with 11 of 30 (37%) in the nonintussusception groups (p =0.006).

Laparoscopic adrenalectomy for pheochromocytoma.

Laparoscopic adrenalectomy has become the standard technique for the surgical removal of the adrenal gland for functional adrenal tumors including aldosteronoma, glucocorticoid, and androgen/estrogen-producing adenomas. Many laparoscopic surgeons also think that for small to moderately sized pheochromocytomas, the laparoscopic approach is as safe and effective as the open technique. Several physiologic considerations specific to pheochromocytoma must be addressed before and during surgery regardless of the operative approach. The advantages of laparoscopic adrenalectomy over open adrenalectomy remain the same for pheochromocytomas as for other pathologic conditions of the adrenal gland. These include a shorter length of stay, a decrease in postoperative pain, a shorter time to return to preoperative activity level, and improved cosmesis.

Laparoscopic vs open partial nephrectomy in consecutive patients: the Cornell experience.

OBJECTIVE: To compare a contemporary series of laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN) at one institution, to evaluate the size and types of tumour in each group and the early outcome after each procedure, as LPN is replacing open radical nephrectomy as the standard of care for uncomplicated renal tumours but partial nephrectomy remains significantly more difficult laparoscopically, especially if the goal is to duplicate the open surgical technique. PATIENTS AND METHODS: We retrospectively analysed the records of all patients who underwent partial nephrectomy at our institution from January 2000 to April 2004, identifying 66 who had LPN and compared them with 59 who had OPN (mean age at LPN and OPN, 62.1 and 64.2 years, respectively; 70% men in each group). Variables analysed included operative time, blood loss, creatinine levels before and after partial nephrectomy, time to resuming clear liquids and regular diet, length of stay, tumour size, tumour pathological type and complications. Groups were compared using Student's t-test, with P < 0.05 taken to indicate significance. RESULTS: Of those having LPN, 59% had right-sided tumours, vs 53% in the OPN group; the respective mean tumour size was 2.2 and 3.4 cm, the mean operative duration 144 and 239 min (both P < 0.001), and the mean estimated blood loss 236 and 363 mL (P = 0.09). Seven patients in the OPN group had obligatory partial nephrectomy for either a solitary kidney (two) or azotaemia (five). No patient in the LPN group required an obligatory partial nephrectomy. Serum creatinine levels were measured before and 1 and 2 days after surgery, and were 88, 88 and 97 micromol/L for the LPN group, and 97, 106 and 106 micromol/L for the OPN group. Clear fluids were started a mean of 41 h after surgery, a regular diet resumed 76 h after and discharge was 129 h after surgery in the OPN group; the respective values for the LPN group were 24 h (P = 0.01), 49 h (P = 0.2) and 82 h (P < 0.001). Complications were similar in both groups but the pathological subtypes differed. CONCLUSIONS: LPN offers early functional advantages over OPN in terms of earlier resumption of diet and slightly earlier discharge. However, the two groups of patients were clearly not evenly matched for size nor pathological subtypes, with larger, malignant subtypes more predominant in the OPN group. These results suggest that while LPN is a safe, effective treatment for small renal tumours, obligatory partial nephrectomy or large tumours continue to be performed using open techniques with good results.

Pulmonary embolus related to PC-SPES use in a patient with PSA recurrence after radical prostatectomy.

Patients diagnosed with a rising prostate-specific antigen level after radical prostatectomy represent a therapeutic dilemma. Herbal therapies including PC-SPES have gained popularity as alternatives to conventional hormonal ablation in such patients as a result of the perceived benefits of using natural products and proven clinical response in decreasing prostate-specific antigen levels. PC-SPES is one of the most popular herbs with known estrogenic activity in vitro and in vivo. Estrogenic compounds increase the risk of thromboembolic events. However, no specific guidelines are available with regard to the risk of thromboembolic events for patients using PC-SPES. We report a case of a patient treated with PC-SPES for prostate-specific antigen recurrence after radical prostatectomy who presented with pulmonary embolus and a right common femoral deep venous thrombus.

Robotic microsurgical vasovasostomy and vasoepididymostomy: a prospective randomized study in a rat model.

PURPOSE: Microsurgical vasovasostomy and vasoepididymostomy remain technically challenging procedures. Refinements in technique have continually improved patency and pregnancy rates for the 2 procedures in experienced hands. Advances in surgical robotics produced the Da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, California) with motion reduction and no tremor, features that may improve outcomes in microsurgery. We report a randomized prospective study of vasoepididymostomy and vasovasostomy using the Da Vinci robot in rats. MATERIALS AND METHODS: A total of 24 adult male Wistar rats underwent vasectomy through a midline abdominal incision. Two weeks later the animals were randomized to microsurgical multilayer vasovasostomy, longitudinal vasoepididymostomy or robotic vasovasostomy and vasoepididymostomy groups. Outcomes measured included surgical time, complications, patency and sperm granuloma formation at 9 weeks. RESULTS: Animals were sacrificed 9 weeks after microsurgery. There were no significant differences in complications among the groups. Robotic vasovasostomy was significantly faster than the conventional microsurgical technique (68.5 vs 102.5 minutes, p = 0.002). The robotic and microsurgical vasoepididymostomy groups did not differ significantly in time. Patency rates were 100% for the robotic vasovasostomy and vasoepididymostomy groups, and 90% in the microsurgical vasovasostomy and vasoepididymostomy groups. These differences were not significant. Sperm granulomas were found in 70% of microsurgical vasovasostomy anastomoses and 27% of robotic vasovasostomy anastomoses (p = 0.001). No significant difference in the sperm granuloma rate was found between the robotic or microsurgical vasoepididymostomy groups (42% and 50%, respectively, p = 0.37). CONCLUSIONS: To our knowledge we report the first randomized prospective study using the Da Vinci robot for microsurgery. We believe that the improved stability and motion reduction during microsurgical suturing with the robot helped achieve excellent patency rates for vasovasostomy and vasoepididymostomy. The robot may also allow experienced microsurgeons to perform microsurgical procedures in patients at remote locations where no experienced microsurgeons are available.