The History of Robotassisted Surgery in Urology

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From Leonardo to da Vinci: the history of robot-assisted surgery in urology BJUIBJU INTERNATIONAL David R. Yates , Christophe Vaessen and Morgan Roupret Academic Urology Department, la Pitié -Salp ê tri è re Hospital, Paris, France Accepted for publication 10 June 2011

The evolution of robots in general and as What ’ s known on the subject? and What does the study add? platforms to augment surgical practice is Numerous urological procedures can now be performed with robotic assistance. an intriguing story that spans cultures, Though not deﬁ nitely proven to be superior to conventional laparoscopy or traditional continents and centuries. A timeline from open surgery in the setting of a randomised trial, in experienced centres robot-assisted Yan Shi (1023 – 957 bc ), Archytas of surgery allows for excellent surgical outcomes and is a valuable tool to augment Tarentum (400 bc ), Aristotle (322 bc ), modern surgical practice. Heron of Alexandria (10 – 70 ad ), Leonardo da Vinci (1495), the Industrial Revolution Our review highlights the depth of history that underpins the robotic surgical platform (1790), ‘ telepresence ’ (1950) and to the da we utilise today, whilst also detailing the current place of robot-assisted surgery in Vinci® Surgical System (1999), shows the urology in 2011. incredible depth of history and development that underpins the modern surgical robot we use to treat our bladder. We perceive that robotic in radical prostatectomy, partial patients. Robot-assisted surgery is now evolution will continue inﬁ nitely, securing nephrectomy, pyeloplasty and radical well-established in Urology and although the place of robots in the history of cystectomy. not currently regarded as a ‘ gold standard ’ Urological surgery. Herein, we detail approach for any urological procedure, it the history of robots in general, in KEYWORDS is being increasingly used for index surgery and in Urology, highlighting operations of the prostate, kidney and the current place of robot-assisted surgery robotics , da Vinci , history , urology , review

HISTORY OF ROBOTS onetime Roman province of Ptolemaic humanoid robot made by the genius Italian Egypt. The ‘ clepsydra ’ , a water-clock with sculptor, painter, architect, engineer, Etymology of the word ‘ robot ’ is relevantly moveable fi gures on it, was made by anatomist and mathematician, Leonardo Da recent in the timeline of so-called ‘ robots ’ physicist and inventor Ctesibius of Vinci circa 1495. Da Vinci ’ s notebooks, ( Fig. 1 [ 18,30,38,45 ] ). ‘ Robota ’ is the Czech Alexandria (250 bc ) and Heron of Alexandria recovered in the 1950s, contained detailed word for compulsory work or forced labour (10 – 70 ad ) made numerous innovations in sketches of a mechanical knight, and almost and it was a term used to describe artifi cial the fi eld of automata, including one that certainly represent an extension of the people (roboti) in a 1920s Czech play allegedly could speak. The famous Greek landmark anatomical research described in entitled ‘ R.U.R: Rossum ’ s Universal Robots ’ philosopher Aristotle, referencing Homers Vitruvian Man. However, the Industrial written by Karel Capek. ‘ Robotics ’ describes Iliad, profoundly speculated in his ‘ Politics ’ Revolution of the late 18th century was the the fi eld of study of robots and is a phrase book (Part 4, 322 bc ) that ‘ if every tool, instrumental phase in robotic advancement that was fi rst coined in 1942 by science when ordered, or even of its own accord, as it led to the development of key factors, fi ction writer, Isaac Asimov. However, the could do the work that befi ts it then there namely complex mechanics and electricity, story of robots begins many hundreds of would be no need either of apprentices for and the future application of robotics to the years previous to this and it is an intriguing the master workers or of slaves for the fi eld of surgery. story that spans cultures, continents and lords ’. Al-Jazari (1136 – 1206), an Arab Muslim centuries. In ancient China (1023 – 957 bc ), inventor, designed and constructed several An important early concept in robotic an ‘ artifi cer ’ (mechanical engineer) called automatic machines and the fi rst surgery was ‘ telepresence ’ , a term describing Yan Shi, presented King Mu of Zhou with a programmable humanoid robot, a robotic the sensation that you are in one location life-size, human-shaped mechanical fi gure. boat with automated musicians used to while being in another. Telepresence In the 4th century bc (428 – 347 bc ), the entertain guests at royal drinking parties. robotic arms, a direct descendant of what Greek mathematician Archytas of Tarentum Interest in automata was largely non- we recognise as a surgical robot today, designed a mechanical bird ( ‘ the pigeon ’ ), existent in medieval Europe but the reason were developed in the 1950s. These early which was propelled by steam. Further why today we refer to the ‘ da Vinci ® robot ’ master/slave manipulators where initially automatons were described in Alexandria, a are the seminal recorded designs of a used in hazardous environments, e.g. the

FIG. 1. The timeline of the history of robots. of robots suitable for modern surgical practice. 1023−957BC - Yan Shi human shaped mechanical figure HISTORY OF ROBOTS IN SURGERY Archytas of Tarentum mechanical bird - 428−347BC

322BC - Aristotle postulating future role of robots Robotic devices have taken various forms with specifi c aims in mind and have been Ctesibius of Alexandria 'Clepsydra' (waterclock) - 250BC used in several surgical specialities, including orthopaedics, neurosurgery, urology, 10−70AD - Heron of Alexandria cardiothoracics, general surgery and gynaecology. The world ’ s fi rst surgical robot Al-Jazari programmable humanoid robot - 1136−1206 was the ‘ Arthrobot ’ , designed to assist in orthopaedic procedures, and used for the 1495 - Leonardo Da Vinci designed mechanical knight fi rst time in Vancouver, Canada in 1983. In 1985, PUMA 560 (Unimate), the fi rst true Industrial Revolution - 1790 non-laparoscopic robotic device, was used 1920 - Karel Capek origin of word ‘robot’ to guide precise percutaneous needle placement during brain biopsy. This was Isaac Asimov laws of 'robotics' - 1942 followed in 1988 by ROBODOC (Integrated Surgical Systems), a system used in total hip 1950 - Telepresence concept developed by NASA arthroplasty to allow precise pre-operative First industrial robot (Unimate, General Motors) - 1961 planning [ 1 ] . The fi rst application in Urology 1969 - Stanford Arm First computer controlled robotic arm occurred in 1988 at Imperial College (London, UK) with the use of the PROBOT in clinical trials to perform transurethral 1983 - Arthrobot Worlds first surgical robot (Orthopaedics) surgery [ 2 ] . In 1993, Computer Motion, Inc. PUMA 560 robot for needle brain biopsy - 1985 (Santa Barbara, California, USA), founded in 1988 - ROBODOC robot for total hip arthroplasty1 1989 and the original leading supplier of medical robots, released AESOP ® (Automated Endocope System for Optimal Positioning), a PROBOT robot device for transurethral surgery2 - 1988 robotic arm to assist in laparoscopic camera ®3 1993 - Unger et al, AESOP holding and positioning. The initial model (1000) was foot pedal controlled but further Adler et al, CyberKnife®4 - 1994 models were released with voice control 1999 - Intuitive Surgical, Inc, founded (AESOP ® 2000; 1996) and greater degrees of freedom (AESOP ® 3000; 1998) [ 3 ] . The Autschbach et al, Robotic heart bypass6 - 1998 CyberKnife ® (Accuray), introduced in 1994 1998 - Falcone et al, First robotic operation5 for neurosurgical applications, was used to perform stereotactic radiosurgery [ 4 ] . In First (standard) da Vinci® robot launched - 1999 1998, the ZEUS ® Robotic Surgical System 2000 - Abbou et al, First RARP (Paris, France)7 (Computer Motion, Inc.) was used for the Marescaux et al, Transatlantic remote surgery8 - 2001 fi rst full endoscopic robotic procedure (fallopian tube re-anastomosis, Cleveland, 38 2001 - Guillonneau et al, RAR described USA) and consists of a surgical control Computer Motion, bought by Intuitive Surgical - 2003 centre and three table-mounted robotic 2003 - Menon et al, RARC described45 arms [ 5 ] . In the same year, the fi rst da da Vinci® upgrade - 4th arm - 2003 Vinci ® robotic surgery (Intuitive Surgical, 2004 - Gettman et al, RAPN described30 Inc., Sunnyvale, CA, USA) was performed, a da Vinci® S launched - 2006 robot-assisted heart bypass, in Leipzig, 2009 - da Vinci® Si launched Germany [ 6 ] . In 2000, the da Vinci ® robot was awarded Food Drug and Administration approval in the USA for use in laparoscopic procedures, the same year the fi rst reported bottom of the ocean, in space or moving electronics and display technology. The robot-assisted radical prostatectomy (RARP) hazardous material. Further key advances in vision of a remote surgery program took place in Paris, France [ 7 ] . Remote robotics occurred in the 1980s with the targeted towards battle fi eld triage, funded surgery, with the patient and surgeon in development of microelectronics, computing by the USA agency DARPA (Defense different locations, was fi rst achieved in and the invention of a charge-coupled Advanced Research Projects Agency), 2001 using the ZEUS ® system. A female in device needed for digital imaging, video was the stepping stone to the development patient in Strasbourg, France, had a robotic

cholecystectomy performed by a surgeon in well-established advantages of Naturally, as there are proponents of RARP, New York, USA [ 8 ] . Intuitive Surgical, Inc. minimallyinvasive surgery namely, less there exists a body of opinion that is bought Computer Motion, Inc. in 2003 for bleeding, decreased transfusion rates, unconvinced and this scepticism is based $150 million after a fi erce legal battle and is reduced hospital stay, earlier return to upon several factors: lack of evidence of now the sole company marketing robotic activities of daily living, decreased analgesic superiority, issues of exorbitant cost, the surgical devices in Urology. Currently, requirements, and better cosmesis [ 9,10 ] . infl uence of aggressive marketing and robot-assisted surgery is da Vinci surgery, Below we detail the progress that has been provocative studies in high-profi le journals as all contemporary robotic procedures made in the surgical approaches relative to highlighting potential issues with RARP, and publications relate solely to the da RP, partial nephrectomy (PN), pyeloplasty namely increased ‘ regret ’ after RARP [ 21 ] Vinci robot manufactured by Intuitive and radical cystectomy (RC). and an increased complication rate [ 22 ] . Surgical, Inc. PROSTATE Despite all this, the facts speak for THE DA VINCIROBOT themselves. In the USA in 2007, 79 875 From the fi rst descriptions of open perineal RARPs were performed, accounting for Intuitive Surgical, Inc.was founded in 1995 prostatectomy in 1905 by Hugh Hampton 60 – 70% of all RPs [ 23 ] . Medicare and the fi rst (standard) da VinciRobotic Young [ 11 ] and retropubic RP in 1945 by benefi ciaries (aged > 65 years) who received Surgical System was introduced to the Terence Millin [ 12 ] , there have been surgical a diagnosis of prostate cancer in 2005 were market in 1999. The da Vinci robot refi nements, advances, improved anatomical 14% more likely to have undergone surgery technology including three-dimensional knowledge and new techniques in the by 2007 than their counterparts whose vision, EndoWrist ® instrumentation, surgical treatment of prostate cancer. Not prostate cancer was diagnosed 3 years Intuitive ® motion, ergonomic superiority and ignoring the controversy of whether we earlier [ 24 ] and if all radical extirpative surgical precision, and has surmounted the need to surgically treat prostate cancer, if surgery for prostate cancer was undertaken diffi culties preventing the widespread surgery is deemed necessary, there is no robotically it would incur $1.1 – 2.5 billion adoption of laparoscopic RP (LRP). The fi rst consensus opinion as to which surgical additional healthcare costs per year [ 25 ] . The upgrade occurred in 2003, with the addition approach is best but it can be said that time proven benefi ts of minimally invasive of a fourth robotic arm, allowing the leads to expertise irrespective of approach. surgery coupled with the diffi culties in console surgeon greater control of In the same way retropubic RP has establishing LRP as the ‘ gold standard ’ retraction. In 2006, the da Vinci ® S system developed from Millin (1945) [ 12 ] to Walsh surgical treatment for localised prostate was released, offering high defi nition vision (1983) [ 13 ] , LRP has developed from cancer is the background upon which this and TilePro ® , a multi-image display feature. Schuessler (1992) [ 14 ] to Guillonneau (2000) extraordinary expansion in RARP has The latest model, da Vinci ® Si (2009), has [ 15 ] and RARP from Abbou (2000) [ 7 ] to occurred. Skilful yet aggressive marketing by dual console capability, allowing for Vattikuti Institute (2007) [ 16 ] . Several recent Intuitive Surgical, Inc. has a large role in this collaborative surgical opportunities. Intuitive editorials have soundly concluded that it is scenario but the high costs associated with Surgical, Inc. are one of most successful the expertise of the surgeon that dictates RARP need to be considered. With costs companies of recent times, with an the outcome and not the surgical approach of $1.4 –2.2 million per robot, a yearly approximate revenue of $1 billion in 2009, chosen [ 17 ] . The published literature maintenance fee of $100 000 – 200 000 and up 20% from 2008. Worldwide to-date, abounds with reports of the virtues of RARP $1000 – 2000 per patient in disposable 1661 da Vinci systems have been installed over LRP and retropubic RP but the quality robotic instruments, it is not unsurprising a (1228 USA; 292 Europe; 141 rest of world, of evidence is best described as ‘ low ’ [ 18 ] . lot of publicly funded institutions have e.g. Australasia) and the total number of It is safe to assume both RARP and LRP reservations. It is reported you need to robot-assisted procedures performed decrease the estimated blood loss and perform something in the order of > 10 worldwide between 2007 and 2009 tripled transfusion rates but arguably this is procedures a week or 250 cases a year to from 80 000 to 205 000 [ 9 ] . Over this period more a benefi cial consequence of the achieve cost equivalence with open RP [ 26 ] . the number of da Vinci systems installed in pneumoperitoneum rather than an improved the USA grew by ≈ 75% and with an surgical ability to achieve haemostasis It is worth remembering that the da estimated 35% growth in the number of afforded by minimallyinvasive surgery. When VinciSurgical System was not designed procedures in 2010 compared with 2009, concerning the ‘ trifecta ’ of outcome after RP solely with RP in mind but once the the company are targeting a potential (cure, continence and potency), there is no technology became available and a niche in 1.8 million procedures annually across all evidence that RARP is better than retropubic the market identifi ed, RP was targeted as surgical specialities (Intuitive Surgical, Inc. RP but there is a suggestion that RARP may the index case suited to robotic surgery. For data, Sunnyvale, CA, USA). be superior to LRP [ 17,19 ] . A systematic a disease that we often may not have to review by Kang et al . [ 20 ] of 75 original treat (but do), for an operation that does HISTORY OF ROBOTS IN UROLOGY RARP publications concluded that the not necessarily improve outcomes and for published literature was limited to the signifi cantly increased healthcare Minimallyinvasive surgery, laparoscopic or observational studies of low methodological expenditure that using a robot induces, one robotic, is relevant to a signifi cant number quality, which led them to draw into might muse that the da Vinci robot would of urological procedures but it is best versed question to what extent valid conclusions not have been as well embraced if stricter in surgery of the prostate, kidney and about the relative superiority of RARP to technology regulatory bodies existed (akin to bladder. Both approaches possess the other surgical approaches can be drawn. the pharmaceutical industry).

KIDNEY short learning curve, warm-ischaemia time cancer, it was rationale that laparoscopic RC of < 20 min and console time of < 100 min (LRC) would be used to treat invasive PN [ 33 ] . bladder cancer. The initial report of LRC by Sanchez de Badajoz et al . [ 41 ] in 1995 has Open PN (OPN) dates back to 1950 and Pyeloplasty been followed with numerous accounts Vincent Vermooten eloquently surmised reporting the ability to laparoscopically ‘ there are certain circumstances when, for a The classic open dismembered pyeloplasty perform RC, extended pelvic lymph node patient ’ s well-being, it is unwise to do a technique was described in 1949 by dissection and various forms of urinary nephrectomy, even in the presence of a Anderson and Hynes [ 34 ] and remains the diversion, either intra- or extracorporeally malignant growth involving the kidney. It benchmark method of treating PUJ [ 42,43 ] . However, ORC remains the standard may also occur when the total renal obstruction, with a success rate > 95%. of care for invasive bladder cancer. LRC is a function is such that nephrectomy for It is this technique that all other time-consuming, challenging procedure carcinoma would result in fatal uraemia. minimallyinvasive surgical approaches to even in experienced hands and critics If there is no evidence of metastasis and pyeloplasty must emulate. In 1993, question the standard of lymphadenectomy, the neoplasm involves only the cortex of Schuessler et al . [ 35 ] reported the fi rst the incision for specimen extraction and/or the kidney, excision of the tumour is laparoscopic pyeloplasty and in experienced urinary diversion needed and the duration unquestionably advisable. The question hands the results of laparoscopic pyeloplasty of pneumoperitoneum in an often aged, is, whether such a procedure (partial are equivalent to open dismembered co-morbid population [ 44 ] .The technique of nephrectomy) is ever justifi able when the pyeloplasty [ 36 ] . However, the diffi culties of robot-assisted RC (RARC) was published in opposite kidney is normal. I am inclined to dissection and suturing are issues 2003 by Menon et al . [ 45 ] , and it is safe and think that in certain circumstances it may encountered by non-expert laparoscopic feasible to perform any manner of urinary be ’ [ 27 ] . Open PN is the current standard surgeons and may ultimately affect the diversion robotically [ 46 ] . When considering nephron-sparing surgery (NSS) technique for long-term outcome. As a reconstructive both the many variables concerned with small renal masses but this is now open procedure, the success of pyeloplasty is performing a high standard RC and the for debate with the gain of expertise in dependent upon accurate suture placement, existing potential to improve morbidity and minimallyinvasive NSS. Laparoscopic PN a criteria well suited to the suturing cancer outcomes after RC, it is not was described in 1993 [ 28 ] , but again its dexterity offered by robotic surgery. The unsurprising that there are numerous recent widespread adoption has been limited by all feasibility of robot-assisted pyeloplasty publications exploring the roll of RARC. the confounding factors of laparoscopy. In (RAP) was fi rst described in a porcine model There is growing evidence detailing the particular, the diffi culty of laparoscopic in 1999 [ 37 ] and subsequently in humans positive infl uence of RARC on many of these suturing to achieve haemostasis, collecting [ 38 ] , and can be effectively performed both variables including perioperative morbidity system closure and re-approximation of trans- and retroperitoneally. In a systematic (decreased blood loss, transfusion rate, parenchyma leads to longer warm-ischaemia review and meta-analysis comparing length of stay), lymph node yield, positive times and increased bleeding rates [ 29 ] . laparoscopic pyeloplasty with RAP, Braga margin status, complication rate, local et al . [ 39 ] have shown that RAP shortens the recurrence rate, operative time and cost RAPN was reported in 2004 [ 30 ] and there is operative time and hospital stay whilst [ 47 ] . The International Robotic Cystectomy comparative evidence that RAPN, whilst maintaining a low rate of complications and Consortium has published recent reports for maintaining the oncological outcomes of equivalent outcome. However, the data the learning curve of RARC. They state an open NSS, is superior to laparoscopic PN in quality is poor and there is no randomized acceptable level of profi ciency is possible by terms of length of stay, bleeding and controlled trial evidence on which to base a the 30th case when trying to achieve proxy ischaemia times [ 29 ] . The improvements in defi nitive recommendation or conclusion for measures of RARC quality [ 48 ] . They have ischaemia and bleeding are a combination operative approach to pyeloplasty at this also shown previous RARP case volume is of robotic capabilities, sliding clip time. However, it is foreseeable that with related to decreased operative time, blood renorrhaphy and selective clamping greater adoption of RAP and longer loss and lymph node yield at RARC [ 49 ] . techniques, including early clamp removal or follow-up, the improved anastomotic ability Therefore, while ORC remains the accepted a no-clamp ‘ zero-ischaemia ’ approach [ 31 ] . afforded by RAP will translate into excellent standard of care currently, the continued Naturally, the realisation of the benefi ts of a long-term outcomes, shorter hospital stay expansion of the evidence base and robotic approach to PN has led to an and potentially reduced duration of internal experience with pelvic robotic surgery will increase in the threshold of surgical cases stenting. potentially lead to a new ‘ gold standard ’ appropriate for NSS. RAPN allows you to surgical treatment for invasive bladder safely and effectively remove larger BLADDER cancer. tumours, hilar tumours and more complex masses. It is has even been suggested by The earliest records of open RC to treat some that RAPN is now the new ‘ gold bladder cancer date from the late 1800s but EXPANDING THE ROLE OF ROBOTS standard ’ NSS technique, replacing open PN the key principles of open RC (ORC) we still IN UROLOGY [ 32 ] . It is has been proven that the skills adopt today were published by Marshall and developed during a RARP training Whitmore in 1949 [ 40 ] . After authors had Although robotic surgery in Urology has programme are eminently transferable to demonstrated and established LRP as a been founded upon RARP, the versatility RAPN and surgeons can achieve, with a treatment strategy for localised prostate shown by procedures such as RAPN and

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Retrocaval are not (yet) equivalent to open cystectomy ; NSS , nephron-sparing surgery ; ureter; a case diagnosed pre-operatively cystectomy . Curr Opin Urol 2009 ; 19 : RAP , robot-assisted pyeloplasty ; LESS , and treated successfully by a plastic 522 – 6 laparoendoscopic single-site surgery ; operation . Br J Urol 1949 ; 21 : 209 – 45 Menon M , Hemal AK , Tewari A et al . NOTES , natural orifi ce transluminal 14 Nerve-sparing robot-assisted radical endoscopic surgery.