This article compared robot-assisted vasovasostomy (RAVV) and robot-assisted vasoepididymostomy (RAVE) to traditional microsurgical vasovasostomy (MVV) and microsurgical vasoepididymostomy (MVE) using data from 123 cases. RAVV achieved a higher patency rate of 96% compared to 80% for MVV. RAVV also had a shorter median operative duration of 90 minutes versus 120 minutes for MVV. Additionally, the sperm count recovery was significantly higher for RAVV than RAVE. The authors concluded that robotic techniques may offer advantages over traditional microsurgery for vasectomy reversal based on improved outcomes. However, further

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Maurizio Seratia,*, Elena Cattonia, Andrea Bragaa,
[3] Laurikainen E, Kiilholma P. The tension-free vaginal tape procedure
Giacomo Novarab
for female urinary incontinence without preoperative urodynamic
a
evaluation. J Am Coll Surg 2003;196:579–83.
[4] Patel AK, Chapple CR. Urodynamics in the management of female
stress incontinence—which test and when? Curr Opin Urol 2008;
18:359–64.
Department of Obstetrics and Gynecology, University of Insubria,
Del Ponte Hospital, Varese, Italy
b
Department of Surgical, Oncological, and Gastroenterological Sciences,
Urology Clinic, University of Padua, Padua, Italy
[5] Novara G, Artibani W, Barber MD, et al. Updated systematic review
and meta-analysis of the comparative data on colposuspensions,
*Corresponding author. Department of Obstetrics and
pubovaginal slings, and midurethral tapes in the surgical treatment
Gynecology, University of Insubria, Del Ponte Hospital,
of female stress urinary incontinence. Eur Urol 2010;58:218–38.
[6] Abdel-Fattah M, Ford JA, Lim CP, Madhuvrata P. Single-incision
Piazza Biroldi 1, Varese 21100, Italy.
E-mail address: mauserati@hotmail.com (M. Serati).
mini-slings versus standard midurethral slings in surgical management of female stress urinary incontinence: a meta-analysis of
effectiveness and complications. Eur Urol 2011;60:468–80.
Re: Prospective Assessment of Prostate Cancer Aggressiveness Using 3-T Diffusion-weighted Magnetic Resonance Imaging–guided Biopsies Versus a Systematic
10-core Transrectal Ultrasound Prostate Biopsy Cohort
Hambrock T, Hoeks C, Hulsbergen-van de Kaa C, et al
Eur Urol 2012;61:177–84
Experts’ summary:
In this article, the diagnostic accuracy of prostate cancer (PCa)
using magnetic resonance imaging (MRI)–guided biopsy was
investigated in patients with elevated serum prostate-specific
antigen (PSA) level and a negative transrectal ultrasound
biopsy (TRUSB) compared with patients who completed a
10-core TRUSB. Using T2-weighted, diffusion-weighted
(DW), and dynamic contrast-enhanced (DCE) MRI, the apparent diffusion coefficient (ADC) value was calculated and suspicious lesions were identified. Biopsies performed in
the suspicious areas were guided by multiparametric MRI
(MP-MRI) to obtain the tissue, and the pathology diagnosis
and Gleason score were determined. The results showed that
specimens from the MRI-guided biopsies were superior to
those collected by TRUSB for pretreatment risk stratification
with Gleason score and more accurately reflected the Gleason
score of the radical prostatectomy specimen (88% vs 55%). The
authors concluded that MRI could be a valuable diagnostic
tool for PCa.
Experts’ comments:
This article elucidated the value of MRI-guided biopsy as a
diagnostic tool for PCa. MRI-guided prostate biopsy is performed in two sessions: diagnostic MRI examination and
MRI-guided biopsy. In this study, the results of DW-MRI
and T2-MRI of the prostate showed promising value in PCa
localization because of its high-contrast resolution between
tumors and normal tissue. For example, ADC produced by
DW-MRI is significantly lower in malignant tissue compared
to nonmalignant prostate tissue, and this aids in locating
cancer tissue. Moreover, ADC is a significant predictor of
Gleason score [1]. MRI-guided biopsy based on the results
of MP-MRI (T2-weighted combined with DW imaging) is
more accurate than digital rectal examination and systematic
random biopsy results and is able to target previously determined regions suspicious for cancer. DW-MRI combined with
T2-weighted MRI can detect PCa with 89% sensitivity and 91%
http://dx.doi.org/10.1016/j.eururo.2012.07.018
specificity; using TRUSB, cancer was missed in 10–38% of PCa
patients [2]. Furthermore, for the patients with elevated
serum PSA and a negative TRUSB, Engelhard et al recently
reported a 38% detection rate for MRI-guided rebiopsies,
compared with a 20–30% detection rate for TRUS saturation
rebiopies[3].
There are still some limitations with MRI-guided biopsy.
Many factors, such as temperature, blood perfusion,
different MP-MRI sequence, and magnetic susceptibility
in the tissue, could vary the MP-MRI results, affecting values
such as ADC. There is also a lack of standardization
regarding the MRI technique and imaging protocols
(eg, surface or endorectal coil, field strengths, and sequence)
across multiple centers, which makes defining the guidelines problematic. Also, the presence of benign prostatic
hyperplasia, prostatitis, hemorrhage, and fibrosis, make
cancer in central and transition zones more difficult to
discern using both the T2-MRI and DW-MRI.
There is limited availability of MRI-guided biopsy due to
long examination times, space restriction, material restriction, organ motion, and need to adjust the needle’s
direction. Prostate motion during the procedure could also
affect the accuracy of the biopsy. To compensate for
technical limitations, technological advancements have
been developed, such as real-time fusion of ultrasound
and magnetic resonance (MR) images of the prostate and
MR-compatible robots for transrectal prostate biopsy
systems [4,5]. Further research is still needed to determine
their diagnostic effectiveness.
In future MP-MRI studies, the focus should be to obtain
evidence to improve the performance of MRI. Random
clinical trials are needed to evaluate the feasibility of
replacing the TRUSB with the MRI-guided biopsy. The
clinical implications and optimal technique for PCa
diagnosis using MRI needs to be evaluated to establish a
standardized protocol. The development of new instrumentation for use in the MRI environment is necessary to
enhance the suitability for clinical application as well as to
overcome any pitfalls. Moreover, the next generation of
iconography should be molecular imaging, which could
provide unprecedented opportunities for accurate cancer
localization, staging, and prognosis evaluation. These, in
turn, could lead to the prevention of overtreatment and
better cancer control. For example, hypoxia-inducible

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factors or iron oxide nanoparticles should be the future of
prostate cancer imaging.
[4] Singh AK, Kruecker J, Xu S, et al. Initial clinical experience with real-
Conflicts of interest: The authors have nothing to disclose.
[5] Xu H, Lasso A, Vikal S, et al. MRI-guided robotic prostate biopsy: a
time transrectal ultrasonography-magnetic resonance imaging
fusion-guided prostate biopsy. BJU Int 2008;101:841–5.
clinical accuracy validation. Med Image Comput Comput Assist
Interv 2010;13:383–91.
References
[1] Morgan VA, Riches SF, Thomas K, et al. Diffusion-weighted mag-
Jinyi Li*, Siobhan Gruschow, Ashutosh Tewari
Institute of Prostate Cancer and LeFrak Center for Robotic Surgery,
netic resonance imaging for monitoring prostate cancer progres-
James Buchanan Brady Foundation Department of Urology,
sion in patients managed by active surveillance. Br J Radiol
Weill Cornell Medical College–New York Presbyterian Hospital,
New York, NY, USA
2011;84:31–7.
[2] Giannarini G, Petralia G, Thoeny HC. Potential and limitations of
diffusion-weighted magnetic resonance imaging in kidney, pros-
*Corresponding author. Institute of Prostate Cancer and LeFrak Center
tate, and bladder cancer including pelvic lymph node staging: a
for Robotic Surgery, James Buchanan Brady Foundation
Department of Urology, Weill Cornell Medical College,
critical analysis of the literature. Eur Urol 2012;61:326–40.
[3] Engelhard K, Hollenbach HP, Kiefer B, et al. Prostate biopsy in
525 East 68th St., New York, NY 10065, USA.
the supine position in a standard 1.5-T scanner under real time
E-mail address: jil2024@med.cornell.edu (J. Li).
MR-imaging control using a MR-compatible endorectal biopsy
device. Eur Radiol 2006;16:1237–43.
Re: Video Technique for Human Robot-assisted
Microsurgical Vasovasostomy
Parekattil SJ, Atalah HN, Cohen MS
J Endourol 2010;24:511–4
Experts’ summary:
The reviewed article is the first prospective control trial of
significant size to compare robot-assisted vasovasostomy
(RAVV) and robot-assisted vasoepididymostomy (RAVE) with
traditional microsurgical vasovasostomy (MVV) and microsurgical vasoepididymostomy (MVE). Below, we will discuss
this manuscript and also refer to a follow-up publication
published shortly thereafter by Parekattil and Brahmbhatt
on this topic [1]. RAVV achieved a 96% patency rate versus
80% for MVV for 123 total cases. Median operative duration
(which did not include robot or operating microscope setup)
was 90 min for RAVV versus 120 min for MVV. The rate of
postoperative sperm count recovery was significantly greater
in RAVV versus RAVE (13 million/mo vs 3 million/mo), although mean total motile sperm counts were not significantly
increased. The authors, in their practice, also reported a reduced cost for RAVV and RAVE that has recently made it less
expensive at their institution than MVV or MVE.
Experts’ comments:
Previous studies in animals have suggested potential advantages of RAVV over MVV, including increased patency rates
and ease of performing the procedure afforded by more ergonomic instrument manipulation [2]. The authors are to
be commended for pursuing a relatively large cohort in a
prospective trial to further elucidate an increasingly important and timely question: Are robot-assisted techniques
superior to traditional microsurgical approaches in vasectomy reversal?
The authors note 96% patency in the robotic group, which
was superior to the MVV group (80%) and approaches the
maximum published patency rate for MVV of 97% [3].
Significantly, data available for the first 90 study subjects
http://dx.doi.org/10.1016/j.eururo.2012.07.019
reveal a RAVV population with median duration from
vasectomy at 8 yr (range: 1–19) compared with 6.5 yr
(range: 1–19) for MVV. Thus RAVV seems to have outperformed MVV even in a group possessing a stronger
independent risk factor (longer obstructive interval) for
reversal failure, as described in a recently published
nomogram [4]. It is noteworthy that both surgeons
and support staff require an initial training investment and
experience a learning curve regarding equipment setup and
technique (eg, bent needles, suture breakage). While
Parekattil et al noted a shorter operative duration for RAVV
and RAVE, the robot and operating microscope setup times
were not included in the measure of operative duration.
These specific time measurements are important data points
to consider when comparing the two operative techniques.
Surgical robotics is a quickly advancing urologic
platform. In their study, Parekattil et al provide early
insight into the application of robotic technology in the
field of vasectomy reversal. Enhancements in operating
technique and rate of sperm return to the ejaculate have
been nicely highlighted by the authors. Limitations of this
study include a lack of randomization, a relatively short
follow-up time, and lack of incorporation of robotic and
operating microscope setup in the reported operative
times. Long-term follow-up derived from multicenter,
randomized trials is needed to further clarify the role of
robot-assisted vasectomy reversal procedures. At this time,
it is unclear whether the potential incremental technical
enhancements outweigh the probable increase in cost and
operative time that most surgeons would incur with this
approach.
Conflicts of interest: The authors have nothing to disclose.
References
[1] Parekattil SJ, Brahmbhatt JV. Robotic approaches for male infertility
and chronic orchialgia microsurgery. Curr Opin Urol 2011;21:
493–9.