reproduction in nonobstructive azoospermia men, who
were previously thought to be reproductive cripples.
TECHNOLOGICAL AND SYSTEMATIC
ADVANCES IN UROLOGIC
The history of microsurgery in urology is not con
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.,
suture and needles that facilitated accurate suture place-
ment. Furthermore, Acland was instrumental in deter-
mining optimal microsurgical ergonomics.
improvement of the microscope, including integration of
ber optics and controls usable by the surgeon
while operating, are attributed to Peter Horenz.
advancements, including bipolar electrocautery, xenon
ner instruments, and variable magni
croscopes have all led to further technological advance-
ments, facilitating ease of use and contributing to better
Indeed, instruments like the Lipshultz
Pattern Scissors have been developed by urologists
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
microsurgical vasectomy reversals.
training in urologic microsurgery was
rst introduced by
Larry I. Lipshultz in 1981,
furthering the rapid growth of
eld and cementing urologic microsurgery as an
advanced and academic discipline while simultaneously
improving patient outcomes.
THE FUTURE OF MICROSURGERY IN
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.
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
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,
and as a general remedy for
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
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
improvement, the future of urologic microsurgery will
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.
Applied Photographic Optics: Lenses and Optical Systems for
Photography, Film, Video, Electronic and Digital Imaging
MA: Focal Press; 2002
Schultheiss D, Denil J. History of the microscope and development
of microsurgery: a revolution for reproductive tract surgery.
The Evolution of the Microscope
. Oxford: Pergamon Press;
s Vascular Surgery
. Hoboken, NJ: Wiley; 2012
Tamai S. History of microsurgery
from the beginning until the end
of the 1970s.
. Munchen, Germany: Callwey; 1981
Studien Am Menschlichen Sperma
. Basel: B. Scwabe; 1942
Geschichte der Mikrochirurgie
Die Historische Entwick-
lung in den Verschiedenen Operative Disziplinen
. Munchen: Urban &
9. Telephone Interview with Sherman Silber, 2011, November 16.
10. Telephone Interview with Marc Goldstein, 2011, June 28.
Silber SJ, Crudop J. Kidney transplantation in inbred rats.
Silber SJ. Microsurgery in clinical urology.
Owen ER. Microsurgical vasovasostomy: a reliable vasectomy
Silber SJ. Microscopic vasectomy reversal.
Silber SJ. Perfect anatomical reconstruction of vas deferens with a
new microscopic surgical technique.
anastomosis to the epididymal tubule.
Klosterhalfen H, Wagenknecht LV, Becker H, et al. Surgical results
of epididymovasostomy and vaso-vasostomy.
Fogdestam I, Fall M, Nilsson S. Microsurgical epididymovasostomy
in the treatment of occlusive azoospermia.
Fenster H, McLoughlin MG. Epididymovasostomy for epididymal
obstruction. In: Lipshultz LI, Corriere Jr JN, Hafez ESE, eds.
UROLOGY 85 (5), 2015