Material and methods

The search strategy was conducted in accordance with Cochrane guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [13]. A search strategy was conducted in MEDLINE, PubMed and the Cochrane electronic data- bases (from 2000 to present) to identify studies that included both robotic and male infertility.  The search was conducted using the following keywords; ‘robotic’, ‘robot-assisted’ and ‘male infertility’. Medical Subject Heading (MeSH) phrases included: (‘Robotic’ [MeSH]) AND (‘male infertility’ [MeSH]), (‘Robotics’ [Mesh]) AND (‘Andrology’ [MeSH]), (‘Varicocelectomy’ [MeSH]) AND (‘Robotics’ [MeSH]). Both retrospective and comparative studies were included (Fig. 1). The lan- guage of the articles was restricted to English and arti- cles were excluded if the study did not  include both male infertility and  robotics.

Results

After excluding duplicate articles, eligible articles were assessed by their full text and 23 articles were eventually included in the systematic review. In all, 12 articles met our inclusion criteria and nine were excluded as they did not meet our inclusion criteria. After full text screening two more articles were excluded as they did not contain complete male infertility data in the manuscript. These 12 studies discussed the role of the robotic in male infer- tility as regards vasectomy reversal, varicocelectomy, and TESE.

Robot-assisted  microsurgical  vasectomy reversal

Vasectomy  is  the  method  of  contraception  chosen by

>500,000 American men annually, and by upwards of 8% of married couples worldwide. About 2–6% of American men will ultimately undergo vasectomy rever- sal [14].

Vasectomy reversal was one of the most uniquely dif- ficult challenging procedures in urology until the   intro-duction of the operating microscope, which improved outcomes and performance of these procedures [15]. However, these techniques require dedicated training, experience, and a skilled microsurgical assistant. Robot-assisted microsurgical approaches with the da Vinci robotic platform  can  provide  some  advantages to overcome some of these challenges. Parekattil and Gudeloglu [12] reported comparable outcomes for robot-assisted microsurgical vasectomy reversal (110 patients) compared with the pure microsurgical tech- nique (45 patients). The median clinical follow-up was 17 months. The median (range) duration from vasec- tomy in the robot-assisted vasovasostomy (RAVV) group was 7 (1–21) years and 6.5 (1–19) years in the microscopic group. The median age of  the  patients in the RAVV group was 41 years and 39 years in the microscopic group. A significantly  better  patency rate of 96% was achieved in the RAVV cases vs 80% in microscopic group. Pregnancy rates (within 1 year post- operatively) did not differ significantly between the two groups: 65% for the RAVV group and 55% for the microscopic group. Operative duration (skin to skin) started at 150–180 min initially for the first 10 cases of RAVV. However, the median (range) operative duration for RAVV overall was significantly decreased at 97 (40–180) min compared  with  microscopic  group  at 120 min.  The  median  (range)  operation  duration    for robot-assisted microsurgical vasoepididymostomy (RAVE), at 120 (60–180) min, was also significantly fas- ter than the microscopic group at 150 min. Kavoussi [16] also reported similar outcomes when he compared both groups.

Santomauro et al. [17] reported a 93% patency rate in 20 patients who underwent RAVV. In this study, surgi- cal residents (novice surgeons) were allowed to perform RAVV on one side, and the staff surgeon (experienced surgeon) performed the anastomosis on the contralat- eral side. The operative time between the experienced and novice surgeons was not statistically significantly different. This study illustrated that the robotic platform could potentially be used to decrease the learning curve for microsurgery.