Office-Based Andrology and Male Infertility Procedures

A Cost-Effective Alternative

Manaf Alom; Matthew Ziegelmann; Josh Savage; Tanner Miest; Tobias S. Köhler; Landon Trost

Disclosures

Transl Androl Urol. 2017;6(4):761-772. 

In This Article

Abstract and Introduction

Abstract

Background: From 2014–2016, our clinical practice progressively incorporated several male infertility and andrology procedures performed under local anesthesia, including circumcision, hydrocelectomy, malleable penile prostheses, orchiectomy, penile plication, spermatocelectomy, testicular prostheses, varicocelectomy, vasectomy reversal (VR), and testicular and microepididymal sperm aspiration (TESE/MESA). Given the observed outcomes and potential financial and logistical benefits of this approach for surgeons and patients, we sought to describe our initial experience.

Methods: A retrospective analysis was performed of all andrologic office-based (local anesthesia only) and select OR (general or monitored anesthesia care) procedures performed from 2014–2016. Financial and outcomes analyses were performed for infertility cases due to the homogeneity of payment modalities and number of cases available. Demographic, clinicopathologic, and procedural costs (direct and indirect) were reviewed and compared.

Results: A total of 32 VRs, 24 hydrocelectomies, 24 TESEs, 10 circumcisions, 9 MESA/TESEs, 4 spermatocelectomies, 3 orchiectomies (1 inguinal), 2 microTESEs, 2 testicular prostheses, 1 malleable penile prosthesis, 1 penile plication, and 1 varicocelectomy. Compared to the OR, male infertility procedures performed in the clinic with local anesthesia were performed for a fraction of the cost: MESA/TESE (78% reduction), TESE (89% reduction), and VR (62% reduction). All office-based procedures were completed successfully without significant modifications to technique. Outcomes were similar between the office and OR including operative time (VR: 181 vs. 190 min, P=0.34), rate of vasoepididymostomy (VE) (23% vs. 32%, P=0.56), total sperm counts (72.2 vs. 50.9 million, P=0.56), and successful sperm retrieval (MESA/TESE 100% vs. 100%, P=1.00; TESE 80% vs. 100%, P=0.36). To our knowledge, the current study also represents the first report of office-based VE under local anesthesia alone. For hydrocelectomy procedures, recurrence (4%) and hematoma (4%) rates were low (mean 4.2 months follow-up), although this likely relates to modifications with technique and not the anesthesia or operative setting. Overall, when given the choice, 86% of patients chose an office-based approach over the OR.

Conclusions: Office-based andrology procedures using local anesthesia may be successfully performed without compromising surgical technique or outcomes. This approach significantly reduces costs for patients and the overall healthcare system and has become our treatment modality of choice.

Introduction

Andrologic and male infertility procedures represent a distinct class of urologic surgeries. In contrast to other urologic procedures, which may involve intra-abdominal organs and thus require general anesthesia, andrologic and male infertility procedures are performed in the penis and scrotum, where pain can be fully controlled with local anesthesia. Office-based surgical procedures under local anesthesia offer several potential advantages over those performed with general or monitored anesthesia, including absence of post-op extended recovery, elimination of risk of pulmonary or cardiac complications, ability to communicate with the patient, avoidance of side effects from general anesthetic medications, and improved convenience for patients and surgeons.

Despite these known benefits, relatively little has been published on the topic of office-based andrologic and male infertility procedures.[1] Authors have previously described performing several andrologic and male infertility procedures under local anesthesia including hydrocelectomy, malleable penile prosthesis, microepididymal and testicular sperm aspiration (MESA)/TESE, orchiectomy, spermatocelectomy, and varicocelectomy.[1–15] However, many of these reports include the use of IV sedation, monitored anesthesia care, or are limited to 3rd world countries, with relatively few described in contemporary practices. Additionally, to our knowledge, no studies have reported on the complex procedure of vasoepididymostomy (VE) under local anesthesia alone.

Similarly, very limited data exist on the comparative cost-effectiveness of andrologic and male infertility office-based procedures over those performed under general anesthesia in the OR. Cost efficiency has become an important consideration in clinical practice, as insurance reimbursements continue to decline and value-based care is increasingly utilized as a metric of overall quality. This is particularly the case with andrologic and male infertility surgery, where the decision to proceed is often based on deductibles, copayments, and insurance coverage, rather than medical necessity alone. As many male infertility procedures are cash pay, some couples may even elect to pursue less effective options or to avoid treatment altogether to limit costs.

As just one example, cost considerations have led many to recommend PESA/TESA over the arguably superior MESA/TESE procedures due to lower costs, easier technique, ready availability, and minimally-invasive nature.[16,17] Similarly, numerous publications and debates have argued the role for VR versus in-vitro fertilization (IVF), with cost-effectiveness often used as a key differentiator.[18–22] Men seeking VR may also face a dilemma of choosing a less expensive office-based procedure (where a VE is not available) or paying significantly more for the ability to perform the more complex surgery in the OR.[13] Investigators have even attempted to mitigate this limitation by defining pre-operative predictors for VE in an attempt to identify patients who would be appropriate candidates for office-based procedures.[23]

Given the limited published data, we sought to report our experience in performing office-based andrology and male-infertility procedures. The objective of the current manuscript is therefore to assist providers who wish to introduce office-based procedures by providing practical tips and tricks as well as what to avoid in the hopes of reducing the overall learning curve. Additionally, clinical and financial-analysis comparisons are presented for male infertility procedures to highlight potential cost savings without compromising outcomes.

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