Infertility story offers a lesson for all urologists

October 1, 2006

This story about the operating microscope and the vas has two morals.

The operating microscope certainly played a fundamental role in the genesis of male reproductive surgery as a specialty within urology. Beginning with scrotal ductal reconstruction and evolving into Schlegel's elegant means of scouring testes for sperm in men with nonobstructive azoospermia, microsurgery became a central tool in treating the infertile man.

Why did urologists apply the microscope to scrotal ductal reconstruction? Because we could see the microscopic anatomy of the vasal lumen and epididymis better. Were the outcomes using the operating microscope better than reconstruction performed with the naked eye or with loupes? It surely seemed so.

Does this story sound familiar? A new technological apparatus provides better visualization and finer technique and increases the time it takes to perform an operation, while hard data comparing the traditional technique and the newer one are lacking. If you're a cancer surgeon, chances are you may be thinking about the daVinci robot (Intuitive Surgical, Sunnyvale, CA) right now. While well-controlled clinical trials comparing outcomes of open radical prostatectomy to those of the robotic laparoscopic approach are lacking, robots are proliferating rapidly, and the surgeons who use them are often overheard intimating that they feel they can perform a superior anastomosis under optical magnification and with fine instrument control or that the periprostatic nerves are more easily spared.

So this story about the operating microscope and the vas has two morals. The obvious one is that if you're a urologist reconstructing a vas and using an operating microscope, good data exist to support your choice of tools. But if you're a cancer surgeon using the robot, there's another story here, a deeper one about over 3 decades of time between adoption of a surgical technology and the hard data to support its use. I'm not sure if it's good or bad, but it is interesting.

Dr. Niederberger, a member of the Urology Times Editorial Council, is chief of the division of andrology, University of Illinois, Chicago.