Garg H, Psutka SP, Hakimi AA, et al. A decade of robotic-assisted radical nephrectomy with inferior vena cava thrombectomy: a systematic review and meta-analysis of perioperative outcomes. J Urol. 2022;208(3):542-560.

Special thanks to Drs Grace Chen and Simone Crivellaro at the University of Illinois at Chicago.

Before any surgical approach can be accepted into common practice, feasibility and safety must first be demonstrated. This is especially important for a case as technically complex as the radical nephrectomy with inferior vena cava thrombectomy, which is traditionally performed through an open approach mostly due to alleged superior vascular control. These authors sought to demonstrate the safety of the robotic approach to this procedure by reviewing literature published in the past decade.

They included 28 studies on the robotic radical nephrectomy and inferior vena cava thrombectomy and stratified them into single-arm case series or comparative studies between the open and robotic approaches. Only 1 study reported on predictors of perioperative outcomes, identifying a higher level of thrombus (III-IV), greater length of thrombus, and being early in the surgical learning curve as independent predictors of intraoperative and early postoperative complications. Compared to open, the robotic approach was associated with lower blood loss, shorter length of stay, and lower complication rates while having similar outcomes with regards to postoperative mortality and progression-free survival. Patients who underwent the robotic approach were noted to have higher rates of preoperative angioembolization, which enhanced robotic efficiency. These results are very encouraging and beg for a well-designed prospective trial.

Harper JD, Lingeman JE, Sweet RM, et al. Fragmentation of stones by burst wave lithotripsy in the first 19 humans. J Urol. 2022;207(5):1067-1076.

Special thanks to Drs Graham Hale and Omer Acar at the University of Illinois at Chicago.

A technology originally developed to address kidney stones in NASA astronauts is making big waves closer to home. Physicians and researchers from the University of Washington partnered with Indiana University to bring us results from the first human feasibility case series using burst wave lithotripsy to fragment kidney and ureteral stones. Using an extracorporeal handheld transducer, this ultrasound system can visualize stones and then deliver short, focused ultrasound bursts to either fragment or reposition stones to encourage spontaneous passage.

This study reported the efficacy and safety of a 10-minute burst wave lithotripsy treatment cycle in 19 patients and 23 stones under direct ureteroscopic vision. Ninety-one percent of the stones were fragmented, and 39% of the stones were completely treated with all fragments less than 2 mm. Impressively, a median of 90% of stone volume ended in fragments less than 2 mm. The ureteroscopic videos were reviewed by a blinded expert to assess safety, reporting no intraoperative injuries beyond mild petechial hemorrhage or erythema. During follow-up, there were no reported adverse events. To sum up, burst wave lithotripsy demonstrated its ability to fragment stones of a variety of sizes, locations, and densities with no significant tissue injury including 10 patients with calcium oxalate monohydrate stones.

Urologists are familiar with the increasing prevalence and large associated costs of treating kidney stones. The prospect of treating stones safely with a noninvasive, office-based platform without general anesthesia or ionizing radiation is extremely compelling.

Leathersich S, Hart RJ. Immune infertility in men. Fertil Steril. 2022;117(6):1121-1131.

Special thanks to Dr Ashraf Selim at the University of Illinois at Chicago.

The first report of sperm-agglutinating antibodies, also known as anti-sperm antibodies, was in 1954. These antibodies were correlated with infertility in the 1970s. Despite extensive research in the ensuing decades, their clinical utility, indications, methods of testing, and the management of immune infertility remain controversial. As an example of this controversy, in its latest laboratory manual for the examination and processing of human semen, the World Health Organization states that “the mere presence of sperm antibodies is insufficient for the diagnosis of sperm autoimmunity.”

Anti-sperm antibodies are found in serum, semen, and secretions of the female genital tract. Their presence in the male is expected to be a result of a breach of the testis-blood barrier. Based on this idea, conditions such as testicular surgery, trauma, infection, varicoceles, inguinal hernia repairs, and cryptorchidism were thought to contribute to the pathogenesis of immune infertility. None of these factors was proven to cause anti-sperm antibodies with a substantial degree of confidence.

Because sperm with anti-sperm antibodies were observed to have poor cervical mucous penetration and migration, intrauterine insemination yielded higher birth rates, as were in vitro fertilization with intracytoplasmic sperm injection. This was the main outcome from the wide literature search performed by these authors, that assisted reproductive technology and medically assisted reproduction are currently the primary treatment for immune infertility associated with clinically significant anti-sperm antibodies.