Abstract Objectives: To present the current state of the art  in  various  robot- assisted microsurgical procedures in male infertility and review the latest literature, as  the  technology  in  infertility  procedures  has  substantially  developed  since the incorporation  of the  Vinci® robotic platform  (Intuitive  Surgical,  Inc.,  Sunnyvale,CA, USA).

Materials and methods: The search strategy in this review was conducted in accor- dance with Cochrane guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A search strategy was conducted in MED- LINE, PubMed and the Cochrane electronic databases (from 2000 to present) to identify studies that included both robotic and male    infertility.

Results: In all, 23 studies were found, 12 of which met our inclusion criteria. Arti- cles were excluded if the study did not include both male infertility and robotics.

Conclusions: Robotic assistance for microsurgical procedures in male infertility appears to be safe and feasible. It has several advantages including elimination of tremor, multi-view magnification, additional instrument arms, and enhanced dexter- ity with articulating instrument arms. It also has a short learning curve with a small

Introduction

In 1970s, the operative  microscope  was  introduced into male infertility procedures. Since then, several developments have occurred in assisted reproductive technology (ART) [1,2]. The technology in infertility procedures has evolved substantially since the   incorpo-ration  of  the  da  Vinci®  robotic  platform     (IntuitiveSurgical, Inc., Sunnyvale, CA, USA)  into microsurgi- cal procedures [3].The da Vinci surgical system is currently the only commercially available USA Food and Drug Adminis- tration (FDA) approved robotic platform. Today all types of microsurgical procedures for male  infertility can  be  performed  using  this  robotic  platform [3]. The latest version of the da Vinci robot features a high-resolution  three-dimensional  (3D)  view  (with   up-to × 10–15 magnification) and three robotic instru- ment   arms.   These   instruments   are   capable   of  sixdegrees-of-freedom, thus mimicking  the  surgeon’s hand, wrist and finger movements with 180° articula- tion  and  540°  rotation.  It  enhances  the  ability  of the surgeon to rotate instruments to a wider range  than the human hand and provides a new capability in microsurgery. The robotic instrument arms also elimi- nate physiological tremors and provide motion scal- ing. The surgeon console provides a comfortable, ergonomic interphase to minimise surgeon fatigue. Having an extra third robotic instrument arm also allows the surgeon to control one additional instru- ment and be less reliant on the surgical bedside assis- tant. This extra arm can also hold adjunctive imaging or sensing tools, e.g. a Doppler ultrasonography  (US) probe and provide additional real-time inputs to aid the surgeon [4].Abbou et al. [5] first reported the use of robot- assisted laparoscopic radical prostatectomy in 2000 to help alleviate some of the surgeon fatigue and technical limitation issues of  laparoscopy.

As robot-assisted laparoscopic procedures became more widespread, the potential for using this platform for robot-assisted microsurgery was also explored in animal studies [6–8]. These studies were then followed by early human trials  [9–11].  Further  exploration  of the use of this platform in larger studies is ongoing [12]. The present article reviews the latest literature in robot-assisted microsurgical procedures in male infertil- ity: microsurgical vasectomy reversal, microsurgical sub- inguinal  varicocelectomy,  and  microsurgical testicular sperm extraction (micro-TESE).