Infertility| Volume 172, P115-120, February 2023

A Comparative Analysis of Ergonomic Risk Utilizing the 4K-3D Exoscope Versus Standard Operating Microscope for Male Fertility Microsurgery

Published:November 30, 2022DOI:



      To stratify ergonomic risk in a urologic microsurgeon using the 4K-3D exoscope versus the operating microscope (OM) with wearable technology.


      The surgeon was calibrated with wearable sensor inertial measurement units (IMUs) on the head and upper arms. Each inertial measurement units contained an accelerometer, magnetometer, and gyroscope to measure surgeon joint angle change during microscopic procedures for male fertility. The validated modified rapid upper limb assessment was used to determine the proportion of time spent in ranges of risk. Categories 1-4 were assigned for the head and upper extremities (4= highest ergonomic risk). Chi-squared analysis was used to analyze differences in proportions.


      A total of 500 and 479 minutes from 4K-3D exoscope and OM guided surgeries were analyzed. The 4K-3D exoscope significantly favored upper arm category 1 positioning compared to the OM (56.2% vs 37.7%; P < .0001). The OM exposed the surgeon to higher category 3 positioning (14.6% vs 1.6%; P <.0001). More time was spent with the neck “extended” using the 4K-3D exoscope (51.8% vs 19.5%; P < .0001) with 67% of neck extension between 0-10° (category 1). Overall, more time was spent with the neck in risk group 1-2 with the OM (P < .0001).


      The 4K-3D exoscope offers favorable ergonomic positioning for the upper extremities which may reduce work stress-related injury. More operative time was spent with the neck in mild extension with 4K-3D exoscope utilization. However, the OM favored longer operative times in low-risk neck ergonomic positions.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Urology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Cohen-Rosenblum AR
        • Varady NH
        • Leonovicz O
        • Chen AF.
        Repetitive musculoskeletal injuries: a survey of female adult reconstruction surgeons.
        J Arthroplasty. 2022; 37 (1474-1477.e6)
        • Kelly N
        • Mousset M
        • Althubaiti A
        • Agarwal R
        • Onwuka A
        • Chiang T.
        Using the craniovertebral angle to quantify intraoperative ergonomic risk.
        Otolaryngol Head Neck Surg. 2022; (1945998211068726)
        • Tjiam IM
        • Goossens RH
        • Schout BM
        • et al.
        Ergonomics in endourology and laparoscopy: an overview of musculoskeletal problems in urology.
        J Endourol. 2014; 28: 605-611
        • Gabrielson AT
        • Clifton MM
        • Pavlovich CP
        • et al.
        Surgical ergonomics for urologists: a practical guide.
        Nat Rev Urol. 2021; 18: 160-169
        • Nam CS
        • Daignault-Newton S
        • Kraft KH
        • Herrel LA.
        Projected US urology workforce per capita, 2020-2060.
        JAMA Netw Open. 2021; 4e2133864
        • Catanzarite T
        • Tan-Kim J
        • Whitcomb EL
        • Menefee S.
        Ergonomics in surgery: a review.
        Female Pelvic Med Reconstr Surg. 2018; 24: 1-12
        • Lakhiani C
        • Fisher SM
        • Janhofer DE
        • Song DH.
        Ergonomics in microsurgery.
        J Surg Oncol. 2018; 118: 840-844
        • Meltzer AJ
        • Hallbeck MS
        • Morrow MM
        • et al.
        Measuring ergonomic risk in operating surgeons by using wearable technology.
        JAMA Surg. 2020; 155: 444-446
        • Davila VJ
        • Meltzer AJ
        • Fortune E
        • et al.
        Intraprocedural ergonomics of vascular surgeons.
        J Vasc Surg. 2021; 73: 301-308
        • McAtamney L
        • Nigel Corlett E
        RULA: a survey method for the investigation of work-related upper limb disorders.
        Appl Ergon. 1993; 24: 91-99
        • Bigham JJ
        • Chang EK
        • Sorensen M
        • Chansky HA
        • Telfer S.
        Using wearable technology to measure the association between neck posture and pain during urologic open and robotic surgery.
        J Endourol. 2021; 35: 1710-1715
        • Best JC
        • Gonzalez D
        • Alawamlh OAH
        • Li PS
        • Ramasamy R.
        Use of 4K3D video microscope in male infertility microsurgery.
        Urol Video J. 2020; 7
        • Kresch E
        • Efimenko I
        • Gonzalez D
        • Rizk PJ
        • Ramasamy R.
        Novel methods to enhance surgical sperm retrieval: a systematic review.
        Arab J Urol. 2021; 19: 227-237
        • Chu KY
        • Diaz P
        • Dullea A
        • et al.
        Future of male infertility evaluation and treatment: brief review of emerging technology.
        Urology. 2022;
      1. Olympus. ORBEYE. Vol 20222022. Date acessed: 08/01/2022

        • Yu D
        • Green C
        • Kasten SJ
        • Sackllah ME
        • Armstrong TJ.
        Effect of alternative video displays on postures, perceived effort, and performance during microsurgery skill tasks.
        Appl Ergon. 2016; 53 Pt A: 281-289
        • Sivak-Callcott JA
        • Diaz SR
        • Ducatman AM
        • Rosen CL
        • Nimbarte AD
        • Sedgeman JA.
        A survey study of occupational pain and injury in ophthalmic plastic surgeons.
        Ophthalmic Plast Reconstr Surg. 2011; 27: 28-32
        • Babar-Craig H
        • Banfield G
        • Knight J.
        Prevalence of back and neck pain amongst ENT consultants: national survey.
        J Laryngol Otol. 2003; 117: 979-982
        • Liounakos JI
        • Urakov T
        • Wang MY.
        Head-up display assisted endoscopic lumbar discectomy-A technical note.
        Int J Med Robot. 2020; 16: e2089
        • Shugaba A
        • Lambert JE
        • Bampouras TM
        • Nuttall HE
        • Gaffney CJ
        • Subar DA.
        Should all minimal access surgery be robot-assisted? a systematic review into the musculoskeletal and cognitive demands of laparoscopic and robot-assisted laparoscopic surgery.
        J Gastrointest Surg. 2022; 26: 1520-1530
        • Diaz-Piedra C
        • Sanchez-Carrion JM
        • Rieiro H
        • Di Stasi LL
        Gaze-based technology as a tool for surgical skills assessment and training in urology.
        Urology. 2017; 107: 26-30
        • Monfared S
        • Athanasiadis DI
        • Umana L
        • et al.
        A comparison of laparoscopic and robotic ergonomic risk.
        Surg Endosc. 2022; 36: 8397-8402
        • Yang K
        • Perez M
        • Hossu G
        • Hubert N
        • Perrenot C
        • Hubert J.
        Alarm-corrected" ergonomic armrest use could improve learning curves of novices on robotic simulator.
        Surg Endosc. 2017; 31: 100-106