Nahas WC, Rodrigues GJ, Rodrigues Gonçalves FA, et al. Perioperative, oncological, and functional outcomes between robot-assisted laparoscopic prostatectomy and open radical retropubic prostatectomy: a randomized clinical trial. J Urol. 2024; 212(1):32-40. doi:10.1097/JU.0000000000003967

Special thanks to Drs Luca Lambertini and Simone Crivellaro at the University of Illinois at Chicago.

What does minimally invasive really mean from the perspective of the patient undergoing surgery? How do we measure the impact of surgery on a patient’s everyday life? These questions haunt surgeons with answers based mainly on individual surgeon experience. The benefits of robot-assisted radical prostatectomy compared with an open approach seem self-evident, but does the story change when the patient experience after surgery is truly taken into account? These authors performed a randomized clinical trial assessing as the primary end point the difference in postoperative complications, and as secondary, the difference in functional outcomes between the 2 approaches. The robot-assisted approach demonstrated statistically significant improvements with about 20% of the benefit in both urinary continence and erectile function. The authors ascribed these results to a more precise dissection of the neurovascular bundle as well as an improved watertight vesicourethral anastomosis due to the inherent features of the robot, such as magnified vision and better instrument control. In this particular study, there was a lack of reimbursement for postoperative sexual and urinary rehabilitation, and they were not performed, isolating the operative outcomes from other possible confounders. So minimally invasive surgery mainly means leaving things as best as you found them, and the robotic approach represents the most straightforward way to do that.

Punjani N, Marinaro JA, Kang C, et al. Gabapentin for postoperative pain control and opioid reduction in scrotal surgery: a randomized controlled clinical trial. J Urol. 2024;211(5):658-666. doi:10.1097/JU.0000000000003884

Special thanks to Drs Halsie Donaldson and Mahmoud Mima at the University of Illinois at Chicago.

Patients facing surgery to improve their fertility, a hopeful step towards growing a family, also confront a common fear: postsurgical pain. These investigators asked, would the use of gabapentin effectively reduce pain scores? Additionally, could it also lead to less reliance on opioid painkillers and, ultimately, happier patients? They divided 74 patients into 2 groups randomly assigned to receive multimodal pain control with either gabapentin 600 mg 2 hours before surgery and 300 mg 3 times a day for 3 days or placebo. While gabapentin resulted in a statistically significant reduction in the initial pain score and a reduction in pain during the first 3 days after surgery, it did not significantly impact opioid usage, overall patient satisfaction, or adverse effects. The significant pain reduction with gabapentin is a promising first step. We can imagine that eventually we will find the secret sauce that will reduce both pain and opioid use, a win for everyone.

Hayon S, Kumar SKS, Greenberg D, et al. Distribution and positive predictive value of follicle stimulating hormone among nonazoospermic men. J Urol. 2024;212(1):145-152. doi:10.1097/JU.0000000000003957

Special thanks to Drs Gabe van de Walle and Samuel Ohlander at the University of Illinois at Chicago.

The semen analysis is a great prognostic test when it reveals azoospermia, but since its inception, it has been beset by difficulty in correlating it to fertility outcomes. Assessing follicle-stimulating hormone (FSH) levels in azoospermia helps determine whether it is due to obstruction or spermatogenic dysfunction and also in guiding endocrine therapy prior to microdissection testicular sperm extraction, but the utility of FSH assessment in men with sperm in the ejaculate has been less clear.

These researchers analyzed FSH levels by differing thresholds in a large cohort of both fertile and subfertile men presenting for infertility evaluation, noting a broad range of values among subfertile individuals. But although FSH levels were significantly higher in subfertile patients overall, most FSH thresholds did not reliably distinguish fertile from subfertile men. Only the highest thresholds at the 95th and 99th percentiles were observed to be clearly predictive of subfertility.

While FSH testing remains a valuable tool in the overall fertility evaluation, especially in the case of azoospermia, we clearly need others. We can expect investigations into nonhormonal domains such as the epigenome to help refine our ability to discern male infertility from just a bad semen analysis day.