reproduction in nonobstructive azoospermia men, who

were previously thought to be reproductive cripples.

TECHNOLOGICAL AND SYSTEMATIC

ADVANCES IN UROLOGIC

MICROSURGERY

The history of microsurgery in urology is not con

ned to

the development of surgical techniques. Indeed, many of

the advances that drove acceptance of operative micro-

scopy were unrelated to urologic practice. Robert Acland,

an orthopedic and hand surgeon at the University of

Louisville, was essential in convincing Swiss instrument

developers Wener Spingler and Eugen Tritt, owners of

S&T Microsurgical Instruments Co.,

to develop

ner

suture and needles that facilitated accurate suture place-

ment. Furthermore, Acland was instrumental in deter-

mining optimal microsurgical ergonomics.

Technical

improvement of the microscope, including integration of

ned

ber optics and controls usable by the surgeon

while operating, are attributed to Peter Horenz.

Other

advancements, including bipolar electrocautery, xenon

lamps,

ner instruments, and variable magni

cation mi-

croscopes have all led to further technological advance-

ments, facilitating ease of use and contributing to better

outcomes.

Indeed, instruments like the Lipshultz

Pattern Scissors have been developed by urologists

recognizing

needs

optimize

surgical

tools

and

approaches.

The work of relatively few pioneers in microsurgery

greatly advanced the

eld, but formal training opportu-

nities have also proved crucial. The work of the Vaso-

vasostomy Study Group, headed by Arnold Belker, in the

1980s is believed to have piqued interest in urologic

microsurgery through reporting of the outcomes of

1400

microsurgical vasectomy reversals.

Formal fellowship

training in urologic microsurgery was

rst introduced by

Larry I. Lipshultz in 1981,

furthering the rapid growth of

the

eld and cementing urologic microsurgery as an

advanced and academic discipline while simultaneously

improving patient outcomes.

THE FUTURE OF MICROSURGERY IN

UROLOGY

Microsurgical practice in urology is likely to expand,

particularly with the growing use of the da Vinci surgical

robot, which has been applied to vasectomy reversal and

management of orchalgia.

45-47

Ureteral and urethral

anastomoses, pediatric hypospadias repairs, and testicular

denervation to treat chronic pain have also been sug-

gested as possible microsurgical procedures given the

manual dexterity and steady hands needed to complete

these.

With respect to robotic-assisted microsurgery,

better instrumentation and magni

cation are needed

before its more widespread application. However, possible

applications include vas deferens repair in the deep pelvis,

ureteral repairs,

and as a general remedy for

tremors.

Looking further, technologic advancements

may lead to wholly new procedures. For example, the use

of high magni

cation intraoperatively may identify and

facilitate harvest of germ line stem cells from the

sub-basement membrane of azoospermic men, with sub-

sequent in vitro culture and injection into the vasa

efferentia or rete testes to repopulate the germ cell

line.

9,10

The use of microsurgery in humans is less than a cen-

tury old, with the technology progressing from its

nascence to a highly developed state during that time

together with a growing list of clinical applications. In

urology, microsurgical techniques are essential in the

treatment of male infertility and have been applied to a

broad range of surgical problems. With the continued

iterative improvement by the growing cohort of urologic

microsurgeons,

well

persistent

technologic

improvement, the future of urologic microsurgery will

only broaden.

Acknowledgment.

The authors thank Drs. Arnold Belker,

Marc Goldstein, and Sherman J. Silber for their candid and

comprehensive perspectives on the history of microsurgery in

urology, without which this work would not possess the depth

that it does.

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