New vistas in robotic surgery in urology

Introduction

The idea of having a mechanical apparatus to aid or augment what is possible with the human hands is not new, and has been explored in diverse fields ranging from industry to military to medicine. Nevertheless, perhaps the most significant utilization of this demand is reflected in the fields of surgery, including urology.¹   Yu HY, Friedlander DF, Patel S, et al. CA Cancer J Clin. 2013;63(1):45-56.  ^,2   Hans S, Delas B, Gorphe P, et al. Eur Ann Otorhinolaryngol Head Neck Dis. 2012;129(1):32-7. This is because despite making achievable a variety of complex operations, traditional laparoscopy has certain major limitations, such as the 2-dimensional vision, instrumentation with restricted degrees of freedom, and reduced tactile feedback (haptics); all of which make delicate dissections and anastomoses difficult if not impossible. Like this, as minimally invasive procedures increasingly found way into surgical domain, the advent of Robots (derived from the Czech word “robota”, meaning “work” or “forced labor”) has possibly allowed to further refine these procedures by overcoming the limitations of minimally invasive surgery − thereby allowing for excellent surgical outcomes.^3-73) Mcaninch JW, Lue TF. Smith & Tanagho’s General Urology, 18e. 2012. McGraw-Hill Lange publications. Meng MV. Chapter 10. Robotic Surgery in Urology.
4) Acar O, Esen T. Prostate Cancer. 2014;2014:367675.
5) Yates DR, Vaessen C, Roupret M. BJU Int. 2011 Dec;108(11):1708-13; discussion 1714.
6) Parekattil SJ, Gudeloglu A. Asian J Androl. 2013;15(1):67-74.
7) Ahmed K, Khan MS, Vats A, et al. Int J Surg. 2009;7(5):431-40.    Some of the consistently reproducible advantages that robotic surgery offers over open approaches include enhanced precision, smaller incisions, reduced intraoperative blood loss, decreased postoperative pain, and shorter hospital lengths of stay and convalescence.¹   Yu HY, Friedlander DF, Patel S, et al. CA Cancer J Clin. 2013;63(1):45-56.^,8-10   8) Richards KA, Kader K, Hemal AK. ScientificWorldJournal. 2010;10:2215-27.
9) Raynor MC, Pruthi RS. Open Access J Urol. 2010 May 19;2:85-9.
10) Babbar P, Hemal AK. Urol Ann. 2011;3(1):1-7.

Consequently, this introduction of robotic assistance has significantly altered the landscape of laparoscopic surgery in urology; being eagerly adopted by patients and surgeons alike, and making robot-assisted urologic surgery an emerging and safe technology for most urologic operations.¹¹   Merseburger AS, Herrmann TR, Shariat SF, et al. Eur Urol. 2013;64(2):277-91.   It seems that this trend will continue to have important role in the future as robotic systems allow reducing the difficulty involved in performing complex laparoscopic procedures and the related steep learning curve (Table 1).¹²   Cozzi G, Lorenzis ED, Palumbo C, et al. Ecancermedicalscience. 2013;7:355.   Even so, the trend also reflects the necessity for surgeons to

acquire crucial skills (either in simulated or clinical environment) to maintain competence and patient safety. Herein, while novice surgeons would need to acquire both domain as well as technical knowledge; the need for technical skills remains equally relevant for the experienced open surgeons, so that they become competent in robotic surgery.¹³   Sood A, Jeong W, Ahlawat R, et al. J Minim Access Surg. 2015;11(1):10-5.   Fortunately, a variety of training programs and skill courses are available to adequately cater these needs and expectations of urology surgeons, while robots per se help to shorten the learning curve for both laparoscopically skilled and naïve surgeons.¹⁴   Matsunaga GS, Ahlering TE, Skarecky DW. cientificWorldJournal. 2006;6:2542-52.^,15   Binder J, Brautigam R, Dieter J, et al. BJU Int. 2004;94(8):1183-7.

Evolution of robots in urology

Historically, the first robot utilized in urology was the “PROBOT”, an example of the last type where the robot performed transurethral resection of prostate (TURP) based on directions programmed into the controlling computer.³   Mcaninch JW, Lue TF. Smith & Tanagho’s General Urology, 18e. 2012. McGraw-Hill Lange publications. Meng MV. Chapter 10. Robotic Surgery in Urology. The technique has however seen significant evolution overtime, and the currently used robots are telesurgical or master-slave systems, wherein the surgeon controls the robotic arms during the procedure from a remote console and the robot acts merely as an instrument. As such, given the lack of automation, procedures performed with these newer machines may be better categorized as “roboticassisted surgery” rather than robotic surgery.¹⁶   Wedmid A, Llukani E, Lee DI. et al. BJU International 2011;108(6b):1028-1036.  ^,17   Murphy D, Challacombe B, Khan MS, et al. Postgrad Med J. 2006;82(973):743-7.

Around 12 years back, in 2003, Computer Motion Inc., the company which developed both AESOP (designed to control the endoscope using either voice or hand/foot control) and the ZEUS surgical system (consisting of 3 robotic arms attached to operating table and controlled remotely by the operating surgeon) was acquired by the Intuitive Surgical Inc., which had developed and introduced the da Vinci surgical system in 1999.³   Mcaninch JW, Lue TF. Smith & Tanagho’s General Urology, 18e. 2012. McGraw-Hill Lange publications. Meng MV. Chapter 10. Robotic Surgery in Urology.   This merger thus rendered a monopolistic position to Intuitive Surgical as the sole producer of robotic surgical devices.¹⁸   Jacobs EF, Boris R, Masterson TA. Prostate Cancer 2013;2013:902686.

The da Vinci system

Launched in 1999, da Vinci system is the sole commercially available robotic surgical unit, making it the most widely utilized surgical robot with nearly 1500 units in operation worldwide. The system received US Food and Drug Administration (US FDA) approval in 2000 for adult and pediatric surgeries, and since then has had several upgrades and revisions overtime to extend its use for a wider range of medical applications.¹   Yu HY, Friedlander DF, Patel S, et al. CA Cancer J Clin. 2013;63(1):45-56. Basically, the da Vinci robotic system is composed of three main elements: a surgeon console (Figure 1a) with an integrated 3-D stereoscopic viewer; a patient-side cart comprising 3 or 4 robotic arms (Figure 1b); and a vision system (Figure 1c).¹⁹   Image source. Available at: http://gyneco-obstetrique.hug-ge.ch/images/robotdavinci.jpg [Accessed on 5/2/15]   The surgeon sits at the console where an immersive, 3-D view of the surgical field is provided, and operates instruments by means of two master controls. In order to ensure natural and predictable movements of the instruments, extremities of the instruments are aligned on the display screen by the master controls; and instruments control is achieved via free-moving finger controls using a kinematic system (based on the principles of articulated movements) at the console, which translates physical motion of the fingers and wrists into electrical and computerized signals such that the robotic arms emulate these movements for minimally invasive surgery at the surgical field.²Hans S, Delas B, Gorphe P, et al. Eur Ann Otorhinolaryngol Head Neck Dis. 2012;129(1):32-7.  ^,3Mcaninch JW, Lue TF. Smith & Tanagho’s General Urology, 18e. 2012. McGraw-Hill Lange publications. Meng MV. Chapter 10. Robotic Surgery in Urology.   For precision, the electronic components of the robot allow scaled reduction of surgeon’s hand movements, to proportionally smaller movements of the extremity of the instrument in the surgical field. Overall, the 3-D vision (augmented with high-definition video) and 7^o of freedom of movement combine intricate and dexterous movement with gentle tissue handling, which together with tremor filtering and motion scale allow for minimally invasive surgery in areas previously considered too difficult or even impossible, and to dissect, suture and tie knots endoscopically much as would be possible in open surgery.1¹²   Cozzi G, Lorenzis ED, Palumbo C, et al. Ecancermedicalscience. 2013;7:355.&nbsp  ^,20Kearns JT, Gundeti MS. J Indian Assoc Pediatr Surg. 2014;19(3):123-8.

Broadening of the robotassisted surgery

Robotics has become increasingly more common in the armamentarium of urologic surgeons since the first descriptions of robotassisted radical prostatectomy (RALP) in Frankfurt in May 2000.²¹Sharma NL, Shah NC, Neal DE. Br J Cancer. 2009;101(9):1491-6.   The procedure has since achieved widespread clinical use,²²Murphy DG, Challacombe BJ, Zaheer LU, et al. ScientificWorldJournal. 2006;6:2573-80.   with unverified estimates suggesting it to account for roughly more than 80% of radical prostatectomies in the United States;²⁰Kearns JT, Gundeti MS. J Indian Assoc Pediatr Surg. 2014;19(3):123-8.  ^,23Lowrance WT, Tarin TV, Shariat SF. ScientificWorldJournal. 2010;10:2228-37.  ^,24Abbou CC, Hoznek A, Salomon L, et al. J Urol. 2001 Jun;165(6 Pt 1):1964-6.   making it the second most performed robotic-assisted surgical procedure worldwide.²⁵Gainsburg DM. Minerva Anestesiol. 2012;78(5):596-604.   RALP was also found to yield better 12-month potency rates than open and laparoscopic radical prostatectomy.¹²Cozzi G, Lorenzis ED, Palumbo C, et al. Ecancermedicalscience. 2013;7:355.  ^,26Ficarra V, Novara G, Ahlering TE, et al. Eur Urol. 2012;62(3):418-30.  

Nonetheless, even if robotics in its current form has established itself as a viable treatment option for several indications, surgeons have been constantly trying to refine and improve upon current technical aspects of operation, with intent to broaden the robotic utilization both adult and pediatric urology.¹⁶Wedmid A, Llukani E, Lee DI. et al. BJU International 2011;108(6b):1028-1036.   Herein, recent areas of published modifications include procedures like bladder neck anastomosis and reconstruction, bladder drainage, nerve sparing approaches and techniques, and perioperative and postoperative management.¹⁸Jacobs EF, Boris R, Masterson TA. Prostate Cancer 2013;2013:902686.  

Applying robotics for better visualization

Besides development of approaches for improved dissection; concurrently, efforts have also been made to apply robotic systems to laparoscopic technology for better visualization of tissues like prostate. While improved visualization and localization is imperative for all such approaches at all stages, this need is significant during the initial experience of surgeons with procedures like RALP.²⁷Kaye DR, Stoianovici D, Han M. Curr Opin Urol. 2014;24(1):75-80.   Herein, peroperative transrectal ultrasonography (TRUS) has been introduced as a tool to ease the learning curve of RALP. It has been shown that peroperative TRUS during RALP decreases the positive surgical margin rate at the base of the prostate during the initial experience of RALP.²⁸van der Poel HG, de Blok W, Bex A, et al. BJU Int. 2008;102(7):849-52.   In addition, intra-operative TRUS with doppler ultrasound can also improve the localization of neurovascular bundles, preservation of what is important for post-operative recovery of continence and potency. Following this need, TRUS robots have been developed to hold and manipulate the TRUS probe in combination with 3-D reconstruction software and the da Vinci surgical robot to provide intraoperative guidance to identify and preserve the neurovascular bundles (Figure 2).²⁰Kearns JT, Gundeti MS. J Indian Assoc Pediatr Surg. 2014;19(3):123-8.  ^,29-3129) URobotics. Available at: http://urobotics.urology.jhu.edu/ [Accessed on 5/2/15].
30) Han M, Kim C, Mozer P, et al. Urology. 2011;77(2):502-6.
31) Hung AJ, Abreu AL, Shoji S, et al. Eur Urol. 2012;62(2):341-8.   TRUS robot is comprised of a robotic orientation remote center of motion module that is attached to an ultrasound probe and an arm attaching to the operating table. It is controlled remotely by the surgeon via a joystick located next to the da Vinci console, and allows four degrees of freedom.

Modifications in robots for microsurgical procedures

It seems intuitive to imagine that the benefits offered by robotic platforms would be significantly enhanced

when applying them for delicate microsurgical procedures. As follows, robotic assisted microsurgery is being utilized to a greater degree in andrology and a number of other microsurgical fields in some centers.⁶Parekattil SJ, Gudeloglu A. Asian J Androl. 2013;15(1):67-74.   Furthermore, modifications have also been made in the original system to make the device better suited for such microsurgical applications.³²Passerotti C, Peters CA. ScientificWorldJournal. 2006 20;6:2581-8.   The left and right arms of the four-arm da Vinci type Si robotic system are loaded with Black Diamond Micro Needle Drivers, and an additional 4^th arm provides the microsurgeon with one additional tool, which is best suited to dynamic retraction. Parekattil and colleagues further modified this application and developed a unique fivearm approach for robotic microsurgical procedures.⁶Parekattil SJ, Gudeloglu A. Asian J Androl. 2013;15(1):67-74.   For this modified system, a 16-18 times optical high magnification lens camera system is attached to the patient table. The VITOM camera system of Karl Storz Inc. is held by nitrogen powered 5^th arm (Point setter arm).⁶Parekattil SJ, Gudeloglu A. Asian J Androl. 2013;15(1):67-74.   Real-time video images from this camera are incorporated into the surgeon console view, using the TilePro (Intuitive Surgical) software system, which allows for displaying up to 3 simultaneous real-time images to the microsurgeon. The typical cockpit view of the microsurgeon in the surgeon console has following images: (a) the da Vinci Si 3D HD camera view in the middle (the main image), (b) the 16-18 times optical magnification camera view from the VITOM, and (c) a 40-100 times optical magnified microscopic view from the intra-operative andrology laboratory microscope (Nikon Inc). This tri-view realtime imaging allows the surgeon to use the da Vinci camera for the overall tissue and suture handling at a medium zoom, while simultaneously using the VITOM 16-18 times magnification view to look for fine ultrastructural details at high zoom. This enhanced real-time view thus provides considerable advantage in comparison to standard microscopic microsurgery, wherein due to limited depth of focus the microscope has to be zoomed in or out for different components of the procedure; use of the tri-view system improves operative efficiency by obviating this need to zoom in and out during microsurgical procedures as the surgeon is able to see the field simultaneously at two different focal lengths. As such, this new platform seems to provide the surgeon with an excess of options in urological microsurgery.

Advances in robotic surgery in pediatric urology

Robotic surgery in pediatric urology has undergone tremendous growth since its first application in 2002 and is evolving (Figure 3).²⁰Kearns JT, Gundeti MS. J Indian Assoc Pediatr Surg. 2014;19(3):123-8.  ^,33Ganpule AP, Sripathi V. J Minim Access Surg. 2015;11(1):45-9.   The first pediatric robotic procedure performed at majority of institutions was the robotic assisted laparoscopic pyeloplasty; and it has since become increasingly and commonly performed. Perhaps the relatively high-incidence of ureteropelvic junction obstruction alongside surgeons familiarity with laparoscopic pyeloplasty was responsible for making it a natural first robotic procedure in children;

though this was soon followed by dissemination of robotic-assisted laparoscopic ureteral reimplantation and uretero-ureterostomy into widespread clinical practice. The refinements in technology and increased ease of surgeons with robotics, attributable to increased exposure and experience, is possibly accounting for this trend being now inclined towards describing more complex reconstructive procedures, such as robot-assisted laparoscopic Mitrofanoff appendicovesicostomy (RALMA),³⁴Famakinwa OJ, Rosen AM, Gundeti MS. Eur Urol. 2013;64(5):831-6.   robot-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy (RALIMA),³⁵Gundeti MS, Acharya SS, Zagaja GP, BJU Int. 2011;107(6):962-9.   robotassisted bladder neck reconstruction,³⁶Bagrodia A, Gargollo P. J Endourol. 2011;25(8):1299-305.   and robotassisted laparoscopic retroperitoneal lymph node dissection (R-RPLND).²⁰Kearns JT, Gundeti MS. J Indian Assoc Pediatr Surg. 2014;19(3):123-8.  ^,37Cost NG, DaJusta DG, Granberg CF, et al. J Endourol. 2012;26(6):635-40.   These procedures seem to expand the scope of complex robotic reconstruction in children, rather than just focusing on the relatively straightforward pyeloplasties and ureteral reimplantations. Early data on these applications of pediatric robotic urological surgery seems promising, though large-scale series and long-term outcomes on them have not yet been published. Even so, they do provide proof of principle that complex reconstructive surgeries can be performed robotically in children. However, there are still specific areas with scope of further refinement when viewing pediatric urologic applications of robotic surgery; for instance, miniaturization of instruments, especially that of robotic arms in the form of table-mounted systems, without compromising the level of control; forcefeedback mechanisms for haptics, or augmented reality for compensating haptics. This is because a lack of specialized instruments for pediatric cases may affect the ability of pediatric surgeons to maximize efficiency of an operative procedure.¹⁵Binder J, Brautigam R, Dieter J, et al. BJU Int. 2004;94(8):1183-7.   However, as more companies bring additional instruments and robots onto the market in coming years, it is hoped that both hardware and software improvements in robotic instruments will allow enhanced working conditions in the limited operating space that children provide; besides improving precision, this will help to minimize future complications as well.

Conclusion

With continually advancing technology, robotic surgery has gained increasing application in different fields of surgery in favor of the precision and ease it offers to the operating surgeons, while being equally accepted by patients for its overall benefits. The approach is now well-established in urology, being increasingly used for index operations of different urological pathologies of prostate, kidney and bladder. Yet, the high price of the sole commercial da Vinci platform with its associated costs might be a limitation in developing countries like India, possibly preventing greater uptake of the robotic surgery. It is however hoped that subsidizing the system together with measures to lower the consumption of disposables will help to make it more affordable and accessible in future. Concurrently, the trend underscores the need for surgeons to acquire necessary skills in robotic applications in order to maintain competence and patient safety. Overall, with further experience and realization of longer-term outcomes, robotic surgery will likely play an increasing role in surgical management of several urological conditions.

References

1. Yu HY, Friedlander DF, Patel S, et al. CA Cancer J Clin. 2013;63(1):45-56.
2. Hans S, Delas B, Gorphe P, et al. Eur Ann Otorhinolaryngol Head Neck Dis. 2012;129(1):32-7.
3. Mcaninch JW, Lue TF. Smith & Tanagho’s General Urology, 18e. 2012. McGraw-Hill Lange publications. Meng MV. Chapter 10. Robotic Surgery in Urology.
4. Acar O, Esen T. Prostate Cancer. 2014;2014:367675.
5. Yates DR, Vaessen C, Roupret M. BJU Int. 2011 Dec;108(11):1708-13; discussion 1714.
6. Parekattil SJ, Gudeloglu A. Asian J Androl. 2013;15(1):67-74.
7. Ahmed K, Khan MS, Vats A, et al. Int J Surg. 2009;7(5):431-40.
8. Richards KA, Kader K, Hemal AK. ScientificWorldJournal. 2010;10:2215-27.
9. Raynor MC, Pruthi RS. Open Access J Urol. 2010 May 19;2:85-9.
10. Babbar P, Hemal AK. Urol Ann. 2011;3(1):1-7.
11. Merseburger AS, Herrmann TR, Shariat SF, et al. Eur Urol. 2013;64(2):277-91.
12. Cozzi G, Lorenzis ED, Palumbo C, et al. Ecancermedicalscience. 2013;7:355.
13. Sood A, Jeong W, Ahlawat R, et al. J Minim Access Surg. 2015;11(1):10-5.
14. Matsunaga GS, Ahlering TE, Skarecky DW. cientificWorldJournal. 2006;6:2542-52.
15. Binder J, Brautigam R, Dieter J, et al. BJU Int. 2004;94(8):1183-7.
16. Wedmid A, Llukani E, Lee DI. et al. BJU International 2011;108(6b):1028-1036.
17. Murphy D, Challacombe B, Khan MS, et al. Postgrad Med J. 2006;82(973):743-7.
18. Jacobs EF, Boris R, Masterson TA. Prostate Cancer 2013;2013:902686.
19. Image source. Available at: http://gyneco-obstetrique.hug-ge.ch/images/robotdavinci.jpg [Accessed on 5/2/15]
20. Kearns JT, Gundeti MS. J Indian Assoc Pediatr Surg. 2014;19(3):123-8.
21. Sharma NL, Shah NC, Neal DE. Br J Cancer. 2009;101(9):1491-6.
22. Murphy DG, Challacombe BJ, Zaheer LU, et al. ScientificWorldJournal. 2006;6:2573-80.
23. Lowrance WT, Tarin TV, Shariat SF. ScientificWorldJournal. 2010;10:2228-37.
24. Abbou CC, Hoznek A, Salomon L, et al. J Urol. 2001 Jun;165(6 Pt 1):1964-6.
25. Gainsburg DM. Minerva Anestesiol. 2012;78(5):596-604.
26. Ficarra V, Novara G, Ahlering TE, et al. Eur Urol. 2012;62(3):418-30.
27. Kaye DR, Stoianovici D, Han M. Curr Opin Urol. 2014;24(1):75-80.
28. van der Poel HG, de Blok W, Bex A, et al. BJU Int. 2008;102(7):849-52.
29. URobotics. Available at: http://urobotics.urology.jhu.edu/ [Accessed on 5/2/15].
30. Han M, Kim C, Mozer P, et al. Urology. 2011;77(2):502-6.
31. Hung AJ, Abreu AL, Shoji S, et al. Eur Urol. 2012;62(2):341-8.
32. Passerotti C, Peters CA. ScientificWorldJournal. 2006 20;6:2581-8.
33. Ganpule AP, Sripathi V. J Minim Access Surg. 2015;11(1):45-9.
34. Famakinwa OJ, Rosen AM, Gundeti MS. Eur Urol. 2013;64(5):831-6.
35. Gundeti MS, Acharya SS, Zagaja GP, BJU Int. 2011;107(6):962-9.
36. Bagrodia A, Gargollo P. J Endourol. 2011;25(8):1299-305.
37. Cost NG, DaJusta DG, Granberg CF, et al. J Endourol. 2012;26(6):635-40.