Review Article

Emerging role of robotics in urology

Rajeev Kumar, Ashok K. Hemal Department of Urology, All India Institute of Medical Sciences, New Delhi, India

Address for correspondence: R Kumar, Assistant Professor of Urology, All India Institute of Medical Sciences, New Delhi, India, E-mail: [email protected]

Abstract This is amply highlighted by the developments in the field of laparoscopy and the rapid improvements Robotic assistance is one of the latest additions to in the instrumentation for these surgeries. the field of laparoscopic surgery. The most commonly used robotic device in Urology is the da Limitations of traditional laparoscopy such as two- Vinci® system of which over 200 devices are dimensional vision, limited movement of installed worldwide including 3 in India. This robot instruments, complex reconstruction and difficult consists of three or four arms, one of which is used suturing and also surgeon fatigue have prompted the to hold and manipulate the laparoscopic camera introduction and rapid assimilation of robotic systems while the others are used to manipulate specialized laparoscopic instruments with endowrist® in laparoscopic urology. technology that allows 7 degrees of freedom. The robot is currently used primarily for radical A robot is defined as a computerized system with a where complex dissection and motorized part, usually an arm that is capable of reconstruction can be performed in less than 2 hours interacting with the environment. Depending on the with excellent outcomes. There is a progressive increase in the number of surgeries being performed amount of surgeon-machine interaction, robotic by this device which allows laparoscopy naïve surgery can be further divided into shared-control, surgeons to offer the benefits of minimally invasive telesurgical and supervisory-controlled. In the surgery to their patients.The other surgeries where shared-control system, the robot simply offers this device has been used to benefit are pyeloplasty, steady-hand manipulations of an instrument placed cystectomy with urinary diversion, nephrectomy and ureteric re-implant. in its arms. The surgeon directly carries out the The principal drawbacks of the device are the steep procedure and the robot, more or less, replaces an cost of machine and disposables. However, the assistant. In a telesurgical system, the surgeon does benefits achieved in terms of improved surgical not directly operate but manipulates the robotic precision, magnified 3 dimensional vision, scaling arms during the procedure and the robot is like an of movements, remote surgery and as a teaching instrument in his hands. Using real-time image tools will help the robot establish a definitive place in the urologic armamentarium. feedback, the surgeon may operate from a remote location using sensor data from the robot. Because Key words: Robotic surgery, robot, da Vinci®, radical technically the robot is performing the procedure, , laparoscopy it is considered robotic surgery. In a supervisory- controlled system, the surgeon feeds directions into the computer before the procedure and the robot then carries out the instructions without any INTRODUCTION surgeon interference during the actual procedure. Since the robot performs the entire procedure based Necessity has always been the mother of invention. on a predetermined set of commands, the

Journal of Minimal Access Surgery | October 2005 | Volume 1 | Issue 4 202

202 CMYK Kumar and Hemal: Emerging role of robotics in Urology programming has to be carefully done individually da Vinci. In 2003 Intuitive Surgical Inc. acquired before each surgery. Computer Motion Inc. to become the leader in operative surgical robotics. History of robotics[1] Computer Motion Inc., a high-tech medical devices The da Vinci® device[2] company was founded in 1989 in order to develop The da Vinci® system is currently the most widely newer surgical systems and devices that could used robotic device in surgery. There are over 220 improve surgical practices. The first robot-assisted systems installed worldwide including 12 in Asia and human hip replacements were performed in 3 in India. From about 1500 robotic procedures in California using Robodoc- a device manufactured by 2000, over 20,000 robotic surgeries were performed Integrated Surgical Systems in 1992. The first in 2004. One of the largest growths has been in commercially used robotic assistant, the AesopTM Urology where from 36 radical prostatectomies in 1000, was developed in 1993 by Computer Motion. 2000, the number has increased to 8000 in 2004. This device worked on the shared-control principle This constitutes over 10% of all radical and was used for holding an endoscopic camera in prostatectomies performed in the USA. The device minimal invasive laparoscopic surgery. The device consists of a surgeon console, patient-side cart, was controlled by foot pedals that were often a EndoWrist® Instruments, and high resolution 3D problem for new users as they had to look down on Endoscope. the pedals before they could adjust them. The device was modified in 1996 and the Aesop 2000 used voice Surgeon Console: The surgeon operates the robot from control while the Aesop 3000 added another degree a console that is placed away from the patient of freedom in the arm. The Aesop HR version was operating table and is connected to the robot with networked with other smart devices. These devices cables. A magnified 3 dimensional image is are still in use at some centers transmitted to this console from the endoscope similar to the traditional laparoscope placed inside The ZeusTM Robotic Surgical System from Computer the patient through a port and held by one of the Motion consisted of three robotic arms attached to arms of the robot. The console also contains the the side of the operation table. In this device, the “masters” and pedals which are moved by the surgeon surgeon used small hand held joysticks to control and which in turn move the instruments in the robot’s the movements of the arms. It was used in 1998 for arms. The console also has the facility to “scale” the the first robot-assisted surgery in the USA and in movements that help eliminate tremors. 1999, the first robotically-assisted, closed-chest, beating heart cardiac bypass was performed in Patient-side Cart: This is the main “robot” with its three London using this device. This device was used for or four arms. One of the arms holds the laparoscope tele-surgery in 2001 when a surgeon in New York providing 3-D images while in the other two or three performed cholecystectomy at a center in France. arms, specialized instruments are placed that enter the body through ports similar to laparoscopy ports. In 1995, a group of physicians and engineers founded The surgeon at the console controls these instruments Intuitive Surgicals Inc. based on their research and and the laparoscope. training done at the Stanford Research Institute, USA. In 1997, their device, the da Vinci Surgical System, Detachable Instruments: The Endowrists® exist at the became the first assisting surgical robot based on tips of the detachable laparoscopy instruments in the the telesurgical principle to receive FDA approval for robotic arms. Unlike traditional laparoscopy laparoscopic surgery and the first telesurgical instruments where the tip allows very limited cholecystectomy using this device was performed in movement, these instruments have 7 degrees of Brussels. A prototype endowrist device was used in freedom, mimicking the human hand. There are 1998 to perform the first mitral valve repair with the various types of instruments for grasping, dissection,

203 Journal of Minimal Access Surgery | October 2005 | Volume 1 | Issue 4

CMYK203 Kumar and Hemal: Emerging role of robotics in Urology cautery, suturing etc. The instruments can be made Ability to perform complex procedures: A natural to rotate in full circles. The surgeon is also able to consequence of the above two attributes is the ability control the amount of force applied and filter out to perform complex procedures that may be difficult hand tremors and scale movements. As a result, the to achieve with pure laparoscopy. This includes surgeon’s large hand movements can be translated reconstructive surgeries such as radical into smaller ones by the robotic device. prostatectomy, cystectomy and pyeloplasty where difficult suturing can be made simple by this device. 3-D Vision System: The camera and laparoscope unit of this system uses two independent image sensors Decreased learning curve: The ability of the device to that are blended to provided a 3 dimensional vision. mimic human movements minimizes the learning This magnified high-resolution real-time image curve. 3 dimensional magnified image adds to this provides over a thousand frames of the instrument by making the entire procedure similar to open position per second and filters each image through a surgery. video processor that eliminates background noise. Laparoscopy naïve surgeons: The robotic device has Advantages of the da Vinci device allowed laparoscopy naïve individuals to perform Robotic assistance has certain well-recognized complex minimal invasive procedures. Menon et al[3] advantages over traditional laparoscopy. report that robotic assistance permitted them to graduate from open surgery to laparoscopy without 3 Dimensional vision: The integrated 3 dimensional mastering the traditional laparoscopy technique. vision provided by the robotic system allows depth Their results are as good if not better than traditional perception that standard 2 dimensional vision of laparoscopy.[4] Ahlering and colleagues[5] reported that traditional laparoscopy does not. This greatly a surgeon with experience in open prostatectomy but enhances surgeon dexterity and precision and no experience in laparoscopy could perform robotic decreases the number of false movements. The radical prostatectomy at a skill level equivalent to magnified view adds to the confidence and dexterity. that of skilled laparoscopic surgeons after more than 100 traditional laparoscopy procedures. This Endowrist® : One of the biggest problems of traditional advantage of robotic assistance would be particularly laparoscopy is the limited movements available at useful in regions such as India where experience of the tip of the instruments. Most instruments allow laparoscopic radical prostatectomies is limited. only two or three degrees of freedom. The endowrist, however, allows seven degrees of freedom similar to Ergonomics: One of the least considered issues in the human hand. The end result is something akin laparoscopy is that of surgeon fatigue. Laparoscopy to inserting the surgeon’s hand directly inside the is a difficult surgery often requiring hours of awkward port. The instruments allow circular rotation, surgeon positioning resulting in significant surgeon something even the human wrist does not allow and fatigue. The robotic device allows the surgeon to sit makes manipulation extremely simple. comfortably at the console and operate. This may not only help increase surgeon output but may also Stability: The da Vinci device allows “scaling” of the help decrease complications that may occur due to surgeon’s movements from the master console. This surgeon fatigue. means that the machine is able to convert large movements of the hand into smaller movements of Telementoring and telesurgery: Telesurgery devices have the instruments, thus eliminating tremor and been used to perform remote telesurgery. This allows providing stability to the instruments. This allows surgeons situated miles away from the patient to minute and complex procedures to be performed with perform surgery without actual contact. This can greater precision. potentially have a major role in large countries such

Journal of Minimal Access Surgery | October 2005 | Volume 1 | Issue 4 204

204 CMYK Kumar and Hemal: Emerging role of robotics in Urology as India where expert help is not universally available. multiple C-arm X-rays. Later, in vitro experiments that However, at least for the time-being, the costs of the evaluated the system performance showed a targeting device preclude this from being a major reason for accuracy of less than 1.5 mm. The first robot to receive its use. FDA approval was AESOP (Automated Endoscopic System for Optimal Positioning) from Compute Disadvantages Motion Inc. and this device offered 6 degrees of The main drawback to this technology is the cost. freedom. The Aesop and its variants were used in The device itself costs upwards of INR 5,00,00,000 laparoscopic urology for holding the camera in a and then requires annual maintenance and disposable steadier and more effective manner than human instruments. This has probably been the biggest assitance.[10] AESOP was one of the first to control hindrance to its widespread use but, as with other laparoscopic tools in urologic surgery with its new technologies, this is likely to come down with manipulator arms. time and greater availability. The possibility of stereotactic-robotic assistance using Another major challenge facing surgeons who train an interface was first reported in 1997.[11] The authors on this device was that they felt hindered by the loss successfully punctured the desired calyx in 10 out of of tactile or haptic sensation. Newer technologies are 12 procedures using a robotic system. The following being developed to overcome this problem and may year, the same authors described their robotic system be resolved within some time. “PAKY” which permitted the insertion of a needle in both in-vitro porcine model and actual patients using fluoroscopic guidance.[12] The device was successful Urological applications in each of its attempts within a mean access time of While it was initially described for and used in cardiac 8.2 min. surgery, the majority or robotic applications today are in the field of Urology. Laparoscopy provides an Radical prostatectomy ideal modality for the management of a number of Greater awareness and wider availability of screening urologic organs such as the , adrenal and tests such as PSA have made carcinoma prostate a kidney which are deep seated with the body and more common clinical diagnosis. Progressively larger require incisions much larger than the pathology they number of patients is being diagnosed in the early are used to treat. A number of these procedures organ confined stages of the disease where radical involve extensive reconstruction, a technique difficult prostatectomy offers a possible cure. This has led to to master laparoscopically with a steep learning curve. a massive increase in the number of these surgeries The robot provides an exquisite solution to these being performed every year and in the USA, where issues allowing relatively less experienced screening is widely prevalent, over 75,000 radical laparoscopists the ability to offer minimally invasive prostatectomies are performed every year. surgery to their patients with a shorter learning curve than with pure laparoscopy with improvement in Radical prostatectomy is a difficult procedure and is technical performance.[6,7,8] associated with significant morbidity such as urinary incontinence and erectile dysfunction. There is a natural attempt to minimize this morbidity and also The first urological robot, also known as URobot was that of the large incision of open surgery and minimal the PROBOT in 1989 which was used in clinical trials invasive techniques are being developed to achieve for transurethral resection of the prostate.[9] In 1994, these ends.[13] Laparoscopic radical prostatectomy is Potamianos looked into a robotic system to assist in one of the most difficult laparoscopic surgeries. It intraoperative percutaneous renal access.[10] The has been categorized variously as being difficult to access needle was positioned by hand as prescribed very difficult.[14] Despite there being a large number by a computer, which formed the calyx location from of centers performing laparoscopic urology, few offer

205 Journal of Minimal Access Surgery | October 2005 | Volume 1 | Issue 4

CMYK205 Kumar and Hemal: Emerging role of robotics in Urology laparoscopic radical prostatectomy as a routine and puboprostatic ligaments are generally left intact and there are few reports on this procedure.[13,15,16] the urethra is dissected to place the dorsal vein stitch. The bladder neck is identified and divided anteriorly In the few years since the initial robotic radical to expose the urethral catheter that is then used to prostatectomies were reported, this procedure has retract the prostate caudally. The posterior bladder emerged as the single largest indication for the use neck is divided to expose the which of the robot.[4,5,17,18] The robot is particularly suited are then dissected off the posterior surface of the for this surgery because of the small and deep bladder. An articulated robotic scissors is used to incise working space, need for precise dissection of apex of the prostatic fascia anterior and parallel to the the urethra, preservation of the neuro-vascular neurovascular bundles. The posterior dissection plane bundle and reconstruction of the urethra-vesical is within layers of Denonvillier fascia. Unlike open junction. prostatectomy that shows a single layer, the magnified robotic vision shows multiple layers of this fascia. Majority of current literature on robotic prostatectomy Dissection is continued in this plane, leaving an added has come from the Vattikuti Urology Institute at the protective fascial layer over the rectum. Precise Henry Ford Hospital, Detroit.[3,4,18-22] Investigators at periurethral biopsies are sent for frozen section before this institute transitioned to robotic prostatectomy division of the urethra. Urethrovesical anastomosis after a period of mentoring in laparoscopic radical is performed using two 3-0 braided Monocryl® prostatectomy. They have prospectively gathered data sutures, one dyed and one undyed. Using the dyed on their cases since the inception of their robotic end, the anastomosis is started by passing the needle prostatectomy program in October 2000. This outside in at the 4-o’clock position on the bladder program is unique in having a dedicated teaching and inside out on the urethra. Suturing is continued program and began with extensive laparoscopic clockwise up to the 10-o’clock position. Suturing is mentoring during its first year. then begun with the undyed end of the suture from outside in on the urethra and then inside out on the Robotic radical prostatectomy is performed most bladder. This suture is run counterclockwise up to often using the Vattikuti Institute Prostatectomy (VIP) the 11-o’clock position. The needles are cut off and technique that they have described.[4,20,21] The the free dyed and undyed ends are tied together. procedure involves 6 ports, three used by the robot and three by two patient-side surgeons. A 12-mm While presenting the results of their large series of port is placed at the umbilicus for the binocular scope over 1100 cases, Menon et al4 reported an operating of the robot. Two 8-mm ports are used for the robotic time of 70–160 min including 20-40 minutes spent instrument arms and are placed approximately 10 in placing the ports, lysing any adhesions, retrieving cm from the midline on a line joining the the specimen and closing the port sites. The blood anterosuperior iliac spine to the umbilicus. Two loss ranged from 50-150 ml with no blood additional ports are placed in the right side for transfusions. They also discharged over 95% of their retraction and suction by the first assistant and for patients within 24 hours. Total continence was the insertion of sutures. The lateral one is a 10-mm achieved in 96% patients by 6 months and return of and the medial one is a 5-mm port. A 5 mm port is sexual function in 82% of previously potent patients placed in the left flank, slightly inferior to the left below 60 years of age. There was no mortality and robotic port. The robot is then docked to the various acceptable morbidity. They also found their results ports in terms of continence and erection to be better than An initial incision is made just above the pubic those for open or laparoscopic prostatectomy. symphysis starting on either side of the medial umblical ligaments and ending with urachal The University of California at Irvine compared the transection. The extraperitoneal space is developed results of 60 open prostatectomy patients with 60 of and the bladder is dropped posteriorly. The their most recent robotic cases after excluding the

Journal of Minimal Access Surgery | October 2005 | Volume 1 | Issue 4 206

206 CMYK Kumar and Hemal: Emerging role of robotics in Urology learning curve of the intial 45 robotic procedures.[23] The first telerobotic nephrectomy in a human was The operating time for robotic surgery was 231 min performed using a Zeus robotic surgical system with compared to 214 min for open surgery. The positive two arms for surgical manipulation and an AESOP surgical margin rate was 16.7% and 20% for the robotic robotic arm to control the camera.[27] Subsequently, and open surgery respectively. Robotic prostatectomy a series of 18 robot assisted laparoscopic compared favorably with open surgery in terms of nephrectomies was reported where the operative blood loss (103 vs 418 cc), transfusion rate (0% vs time with the robot was longer.[28] The telementoring 2%), complication rate (6.7% vs 10%) and length of capability of the robot was demonstrated in 2000 hospital stay (25.9 vs 52.8 hours). Urinary continence when a radical nephrectomy was performed in was 75% in both groups at 3 months. Singapore by a surgeon in USA.[29]

Cathelineau et al[17] reported the Montsouris However, there have been no consistent series of cases experience with robotic prostatectomy in 105 reported in the literature on the use of the robot for patients. The initial 70 cases were performed through nephrectomies. One of the principal reasons for this a transperitoneal approach while the more recent 35 is probably the absence of benefit perceived with using an extraperitoneal approach. Median operating purely ablative procedures which have become time was 180 minutes and the median blood loss standardized in pure laparoscopy. was 500 ml with a transfusion rate of 6%. The overall positive surgical margin rate was 22%. A more likely application for the reconstructive skills of the robot-assisted technique is Robotic radical prostatectomy is clearly emerging as nephroureterectomy with removal of bladder cuff and the frontrunner in new technologies in urology and partial nephrectomy. Endoscopic resection, pluck these early results suggests that it may obtain a removal, stapling and free hand suturing are all used preeminent place in the management of prostate to manage the bladder cuff in a radical cancer. nephroureterectomy.[30] Free hand suturing in the depth of the pelvis could be aided through robotic Renal surgery assistance. Similarly, management of the open The use of the robot for renal surgery is less well pelvicalyceal system and bleeding parenchyma defined. Most renal procedures such as a nephrectomy following a partial nephrectomy may be simplified are standardized laparoscopic procedures requiring using the robot. Pedraza et al[31] reported the use of no reconstruction. However, radical nephrectomy, robotic assistance in a bilateral hemi­ radical nephroureterectomy and reconstructive renal nephroureterectomy for duplicated ureters and non­ and ureteral surgery are difficult for naïve functional upper poles. The robot was used for hilar laparoscopic surgeons. dissection and isolation of the renal pole while the remaining procedure was completed through pure In the first description of a robot assisted laparoscopy. nephrectomy, Kavoussi et al[24] controlled the camera through a robot, while the surgery was performed Laparoscopic donor nephrectomy for live-related renal laparoscopically by another surgeon. Gill and transplantation has become established in over a 100 colleagues[25] described the first completely robotic, centers worldwide.[32,33] This technique with its lower telepresent nephrectomy in a porcine model. They morbidity may have contributed to an increase in the were technically successful in all their patients with number of donor nephrectomies performed, thus longer operative times than conventional helping minimize the gap between donors and laparoscopy and they also showed that the da Vinci recipients.[32] The robot has also found a use in this system was more intuitive and allowed shorter surgery, considering the immense meticulousness operating times than the Zeus system.[26] required in its performance. Horgan et al34 used the

207 Journal of Minimal Access Surgery | October 2005 | Volume 1 | Issue 4

CMYK207 Kumar and Hemal: Emerging role of robotics in Urology da Vinci robot for 12 donor nephrectomies and all of an alternative urinary drainage system. Advances kidneys functioned immediately. In comparison with in the use of bowel segments in Urology has lead to laparoscopic donor nephrectomy, they noted shorter the creation of continent urinary diversions and hospital stay and lower blood loss in the robotic orthotopic neobladders in order to provide the best group. They also reported a relatively longer length functional outcome to the patient. Construction of of vessels retrieved in the robot-assisted group when the neobladder requires significant surgical skills. compared with the pure laparoscopy group. Robot There have been extremely few reports of this being assisted surgery could be especially useful in the done through pure laparoscopy, primarily because harvest of right-sided kidneys where due to a shorter of the extremely long operative times and complexity length of renal vein, it sometimes needs to be divided of the procedure.[44,45,46] The availability of the robot as it enters the vena cava. and its dexterity have opened the possibility of an entirely laparoscopic approach to this procedure. Laparoscopic pyeloplasty for uretero-pelvic junction obstruction (UPJO) has become a standardized The initial report by Menon et al[47] described the procedure with success rates equivalent to open technique of robotic cystectomy. In these patients, pyeloplasty and minimal morbidity due to its less the diversion was constructed extra corporeally but invasive nature.[35] Robotic technology is ideally suited the Vesico-enteric anastomosis was performed to decrease the technical difficulty in this robotically after re-creation of the reconstructive procedure. Sung et al[36], in a porcine pneumoperitoneum. Subsequently, complete study, demonstrated the technical feasibility of robot laparoscopic procedures using the robot have been assisted pyeloplasty. Gettman and colleagues reported described.[48-50] With the possibility of fertility- their experience of robotic assisted dismembered preserving cystectomy with orthotopic neobladder pyeloplasty in 9 patients with a mean operative time in females, robotic radical cystectomy may well of 138 minutes and no intra-operative complications become the standard of care for this debilitating or conversion.[37] They also reported shorter operative condition. and anastomotic times with the robot when compared with pure laparoscopy.[38] This surgery has highlighted Others one of the basic advantages of robotic assistance in Robots are also being used to help enhance surgical that even laparoscopy naïve surgeons have directly skills and training. Hoznek et al[51] describe the proceeded to robot assisted laparoscopy.[39,40] development of a surgical model that can assist the surgeon in choosing the best possible port position Adrenalectomy for the robot in order to reach the target organ. It The deeply situated adrenal gland is ideally suited for also considers data such as optimal tissue handling, a laparoscopic approach. Most tumors are small and ergonomy, visibility and instrument require a large incision for open surgical access. After maneuverability. Such models are also being used the initial porcine studies at Cleveland Clinic,[21] Horgan for surgeon training. They also described a cadaveric et al[41] reported the first human adrenalectomy using renal transplantation with the entire vascular and the robot in 2001. There have been a number of uretero-vesical anastomosis being performed by a subsequent reports on the use of robot assistance for remote surgeon using a robot.[52] The robot has also adrenalectomy and while there was a higher operative been used in the performance of a vaso-vasotomy time for robotic surgery, it progressively decreased for recanalization of the vas-deferens. The small with increasing experience.[42,43] lumen and precise anastomosis is simpler to perform with the robot and may become feasible for Cystectomy and urinary diversion microscopy-naïve surgeons.[53] Radical cystectomy is the treatment of choice for patients with muscle invasive, carcinoma urinary Management of vesicoureteric reflux using ureteric bladder. Removal of the bladder requires construction reimplantation may also be feasible using robotic

Journal of Minimal Access Surgery | October 2005 | Volume 1 | Issue 4 208

208 CMYK Kumar and Hemal: Emerging role of robotics in Urology assistance. For the extravesical Lich Gregior interface: Initial experience with laparoscopic radical prostatectomy. J Urol 2003;170:1738-41. technique, a three-port approach with incision on the 6. Bentas W, Wolfram M, Brautigam R, Probst M, Beecken WD, Jonas detrusor followed by reapproximation over the in­ D, et al. Vinci robot assisted Anderson-Hynes dismembered laid ureter is performed.[54] In an experimental model, pyeloplasty: technique and 1 year follow-up. World J Urol 2003;21:133-8. [55] Olsen et al described an intravesical repair of 7. Gettman MT, Peschel R, Neururer R, Bartsch G. A comparison of bilateral reflux using the Cohen technique of laparoscopic pyeloplasty performed with the daVinci robotic reimplant. The robotic ports are placed into the system versus standard laparoscopic techniques: initial clinical results. Eur Urol 2002;42:453-7. bladder through the abdomen after saline distension. 8. Hubert J, Feuillu B, Mangin P, Lobontiu A, Artis M, Villemot JP. The bladder is kept distended with gas insufflation Laparoscopic computer-assisted pyeloplasty: the results of while the surgery is completed. experimental surgery in pigs. BJU Int 2003;92:437-40. 9. http://pegasus.me.jhu.edu/~rwebster/index_files/pub_files/ chapter.pdf CONCLUSIONS 10. Hemal AK, Menon M. Laparoscopy, robot, telesurgery and urology: future perspective. J Postgrad Med 2002;48:39-41. 11. Cadeddu JA, Bzostek A, Schreiner S, Barnes AC, Roberts WW, Robot assistance is emerging as a significant adjunct Anderson JH, et al. A robotic system for percutaneous renal access. to pure laparoscopy. It has to be viewed as a tool for J Urol 1997;158:1589-93. laparoscopy rather than as independent surgical 12. Cadeddu JA, Stoianovici D, Chen RN, Moore RG, Kavoussi LR. Stereotactic mechanical percutaneous renal access. J Endourol modality. The initial reports cited above attest to its 1998;12:121-5. safe applicability in surgeries that are otherwise 13. Gill IS, Zippe CD. Laparoscopic radical prostatectomy: Technique. Urol Clin North Am 2001;28:423-36. feasible through pure laparoscopy. The main 14. Guillonneau B, Abbou CC, Doublet JD, Gaston R, Janetschek G, advantages for this technology are its enhanced Mandressi A, et al. Proposal for a European scoring system for dexterity, precision and ergonomics. It has also laparoscopic operations in urology. Eur Urol 2001;40:2-6. 15. Guillonneau B, el-Fettouh H, Baumert H, Cathelineau X, Doublet enabled availability of laparoscopy to patients who JD, Fromont G, et al. Laparoscopic radical prostatectomy: would otherwise be candidates for open surgery. The oncological evaluation after 1,000 cases at Montsouris Institute. lack of significant experience and training J Urol 2003;169:1261-6. 16. Rassweiler J, Seemann O, Schulze M, Teber D, Hatzinger M, Frede opportunities for pure laparoscopy makes it T. Laparoscopic versus open radical prostatectomy: a comparative imperative that easier learning tools such as robotic study at a single institution. J Urol 2003;169:1689-93. assistance are available to surgeons. 17. Cathelineau X, Rozet F, Vallancien G. Robotic radical prostatectomy: the European experience. Urol Clin North Am 2004;31:693-9. The issues of cost of equipment and surgery are major 18. Menon M, Hemal AK, Tewari A, Shrivastava A, Bhandari A. The technique of apical dissection of the prostate and urethrovesical hindrances to the widespread use of this technology. anastomosis in robotic radical prostatectomy. BJU Int It is difficult to expect a robotic revolution if the costs 2004;93:715-9. remain what they are today. However, expansion of 19. Hemal AK, Bhandari A, Tewari A, Menon M. The window sign: an aid in laparoscopic and robotic radical prostatectomy. Int Urol indications and increasing use will help lowering of Nephrol 2005;37:73-7. equipment costs as more machines are sold. 20. Menon M, Tewari A. Vattikuti Institute Prostatectomy Team. Robotic radical prostatectomy and the Vattikuti Urology Institute technique: an interim analysis of results and technical points. REFERENCES Urology 2003;61:15-20. 21. Menon M, Tewari A, Peabody J. The VIP Team. Vattikuti Institute 1. http://biomed.brown.edu/Courses/BI108/BI108 2005 Groups/04/ prostatectomy: technique. J Urol 2003;169:2289-92. index.html; accessed Aug 18:2005 22. Menon M, Shrivastava A, Sarle R, Hemal A, Tewari A. Vattikuti 2. http://www.intuitivesurgical.com/products/da_vinci.html; Institute Prostatectomy: a single-team experience of 100 cases. J accessed August 18:2005 Endourol 2003;17:785-90. 3. Menon M, Hemal AK. Vattikuti Institute Prostatectomy: A 23. Ahlering TE, Woo D, Eichel L, Lee DI, Edwards R, Skarecky DW. Technique of Robotic Radical Prostatectomy: Experience in More Robot-assisted versus open radical prostatectomy A comparison than 1000 Cases. J Endourol 2004;18:611-8. of one surgeon’s outcomes, Urology 2004;63:819-22. 4. Menon M, Tewari A, Peabody JO, Shrivastava A, Kaul S, Bhandari 24. Kavoussi LR, Moore RG, Partin AW, Bender JS, Zenilman ME, Satava A, et al. Vattikuti Institute prostatectomy, a technique of robotic RM. Telerobotic assisted laparoscopic surgery: initial laboratory radical prostatectomy for management of localized carcinoma and clinical experience. Urology 1994;44:15-9. of the prostate: experience of over 1100 cases. Urol Clin North 25. Gill IS, Sung GT, Hsu TH, Meraney AM. Robotic remote laparoscopic Am 2004;31:701-17. nephrectomy and adrenalectomy: the initial experience. J Urol 5. Ahlering TE, Skarecky D, Lee D, Clayman RV. Successful transfer of 2000;164:2082-5. open surgical skills to a laparoscopic environment using a robotic 26 Sung GT, Gill IS. Robotic laparoscopic surgery: a comparison of

209 Journal of Minimal Access Surgery | October 2005 | Volume 1 | Issue 4

CMYK209 Kumar and Hemal: Emerging role of robotics in Urology

the da Vinci and Zeus systems. Urology 2001;58:893-8. 43. Brunaud L, Bresler L, Ayav A, Tretou S, Cormier L, Klein M, et al. 27. Guillonneau B, Jayet C, Tewari A, Vallancien G. Robot assisted Advantages of using robotic Da Vinci system for unilateral laparoscopic nephrectomy. J Urol 2001;166:200-1. adrenalectomy: early Results. Ann Chir 2003;128:530-5. 28. Marella VK, Wise GJ, Silver DA. Adjunctive technologies in 44. Gill IS, Kaouk JH, Meraney AM, Desai MM, Ulchaker JC, Klein EA, laparoscopic nephrectomy-comparison of hand-assisted and et al. Laparoscopic radical cystectomy and continent orthotopic robotic techniques. J Urol 2004;171:339. ileal neobladder performed completely intracorporeally: the initial 29. Lee BR, Png DJ, Liew L, Fabrizio M, Li MK, Jarrett JW, et al. experience. J Urol 2002;168:13-8. Laparoscopic telesurgery between the United States and 45. Kaouk JH, Gill IS, Desai MM, Meraney AM, Fergany AF, Abdelsamea Singapore. Ann Acad Med Singapore 2000;29:665-8. A, et al. Laparoscopic orthotopic ileal neobladder. J Endourol 30. Steinberg JR, Matin SF. Laparoscopic radical nephroureterectomy: 2001;15:131-42. dilemma of the distal ureter. Curr Opin Urol 2004;14:61-5. 46. Turk I, Deger S, Winkelmann B, Baumgart E, Loening SA. Complete 31. Pedraza R, Palmer L, Moss V, Franco I. Bilateral robotic assisted laparoscopic approach for radical cystectomy and continent laparoscopic heminephoureterectomy. J Urol 2004;171:2394-5. urinary diversion (sigma rectum pouch). Tech Urol 2001;7:2-6. 32. Ratner LE, Buell JF, Kuo PC. Laparoscopic donor nephrectomy: 47. Menon M, Hemal AK, Tewari A, Shrivastava A, Shoma AM, El- pro. Transplantation 2000;70:1544. Tabey NA, et al. Nerve-sparing robot-assisted radical 33. Merlin TL, Scott DF, Rao MM, Wall DR, Francis DM, Bridgewater and urinary diversion. BJU Int 2003;92:232­ FH, et al. The safety and efficacy of laparoscopic live donor 6. nephrectomy: a systematic review. Transplantation 48. Balaji KC, Yohannes P, McBride CL, Oleynikov D, Hemstreet GP 2000;70:1659-66. 3rd. Feasibility of robot-assisted totally intracorporeal 34. Horgan S, Vanuno D, Sileri P, Cicalese L, Benedetti E. Robotic- laparoscopic ileal conduiturinary diversion: initial results of a assisted laparoscopic donor nephrectomy for kidney single institutional pilot study. Urology 2004;63:51-5. transplantation. Transplantation 2002;73:1474-9. 49. Menon M, Hemal AK, Tewari A, Shrivastava A, Shoma AM, Abol- 35. Klingler HC, Remzi M, Janetschek G, Kratzik C, Marberger MJ. Ein H, et al. Robot-assisted radical cystectomy and urinary Comparison of open versus laparoscopic pyeloplasty techniques diversion in female patients: technique with preservation of the in treatment of uretero-pelvic junction obstruction. Eur Urol uterus and vagina. J Am Coll Surg 2004;198:386-93. 2003;44:340-5. 50. Hemal AK, Abol-Enein H, Tewari A, Shrivastava A, Shoma AM, 36. Sung GT, Gill IS, Hsu TH. Robotic-assisted laparoscopic pyeloplasty: Ghoneim MA, et al. Robotic radical cystectomy and urinary a pilot study. Urology 1999;53:1099-103. diversion in the management of bladder cancer. Urol Clin North 37. Gettman MT, Neururer R, Bartsch G, Peschel R. Anderson-Hynes Am 2004;31:719-29. dismembered pyeloplasty performed using the da Vinci robotic 51. Hoznek A, Hubert J, Antiphon P, Gettman MT, Hemal AK, Abbou system. Urology 2002;60:509-13. CC. Robotic renal surgery. Urol Clin North Am 2004;31:731-6. 38. Gettman MT, Peschel R, Neururer R, Bartsch G. A comparison of 52. Hoznek A, Zaki SK, Samadi DB, Salomon L, Lobontiu A, Lang P, et laparoscopic pyeloplasty performed with the daVinci robotic al. Robotic assisted kidney transplantation: an initial experience. system versus standard laparoscopic techniques: initial clinical J Urol 2002;167:1604-6. results. Eur Urol 2002;42:453-7. 53. Schiff J, Li PS, Goldstein M. Robotic microsurgical 39. Bentas W, Wolfram M, Brautigam R, Probst M, Beecken WD, Jonas and vasoepididymostomy: a prospective randomized study in a D, et al. Vinci robot assisted Anderson-Hynes dismembered rat model. J Urol 2004;171:1720-5. pyeloplasty: technique and 1 year follow-up. World J Urol 54. Peters CA. Robotically assisted surgery in pediatric urology. Urol 2003;21:133-8. Clin North Am 2004;31:743-52. 40. Hubert J, Feuillu B, Mangin P, Lobontiu A, Artis M, Villemot JP. 55. Olsen LH, Deding D, Yeung CK, Jorgensen TM. Computer assisted Laparoscopic computer-assisted pyeloplasty: the results of laparoscopic pneumovesical ureter reimplantation a.m. Cohen: experimental surgery in pigs BJU Int. 2003;92:437-40. initial experience in a pig model. APMIS Suppl. 2003:23-5. 41. Horgan S, Vanuno D. Robots in laparoscopic surgery. J Laparoendosc Adv Surg Tech 2001;11:415-9. Cite this article as: Kumar R, Hemal AK. Emerging role of robotics in 42. Beninca G, Garrone C, Rebecchi F, Giaccone C, Morino M. Robot- Urology. J Min Access Surg 2005;202-11. assisted laparoscopic surgery. Preliminary results at our Center. Date of submission: 05/12/05, Date of acceptance: 12/12/05 Chir Ital 2003;55:321-31.

Journal of Minimal Access Surgery | October 2005 | Volume 1 | Issue 4 210

210 CMYK