Abstrakt Urologie Říjen 2009

“Robotic radical cystectomy for bladder cancer.”

Ismail, A. F., P. Dasgupta, et al. (2009).

Minerva Urol Nefrol 61(4): 341-350.


This article will focus on the evolution of robotic-assisted radical cystectomy (RARC) as the treatment for muscle invasive or uncontrolled superficial bladder cancer. Authors describe the current implementation of technology in their patients. The results of published case series and comparative studies on RARC available to date are also reviewed, to identify the surgical, pathological, oncological and quality of life outcomes of RARC.




“Prospective Randomized Controlled Trial of Robotic versus Open Radical Cystectomy for Bladder Cancer: Perioperative and Pathologic Results.”

Nix, J., A. Smith, et al. (2009).

Eur Urol.


BACKGROUND: In recent years, surgeons have begun to report case series of minimally invasive approaches to radical cystectomy, including robotic-assisted techniques demonstrating the surgical feasibility of this procedure with the potential of lower blood loss and more rapid return of bowel function and hospital discharge. Despite these experiences and observations, at this point high levels of clinical evidence with regard to the benefits of robotic cystectomy are absent, and the current experiences represent case series with limited comparisons to historical controls at best. OBJECTIVE: We report our results on a prospective randomized trial of open versus robotic-assisted laparoscopic radical cystectomy with regard to perioperative outcomes, complications, and short-term narcotic usage. DESIGN, SETTING, AND PARTICIPANTS: A prospective randomized single-center noninferiority study comparing open versus robotic approaches to cystectomy in patients who are candidates for radical cystectomy for urothelial carcinoma of the bladder. Of the 41 patients who underwent surgery, 21 were randomized to the robotic approach and 20 to the open technique. INTERVENTION: Radical cystectomy, bilateral pelvic lymphadenectomy, and urinary diversion by either an open approach or by a robotic-assisted laparoscopic technique. MEASUREMENTS: The primary end point was lymph node (LN) yield with a noninferiority margin of four LNs. Secondary end points included demographic characteristics, perioperative outcomes, pathologic results, and short-term narcotic use. RESULTS AND LIMITATIONS: On univariate analysis, no significant differences were found between the two groups with regard to age, sex, body mass index, American Society of Anesthesiologists classification, anticoagulation regimen of aspirin, clinical stage, or diversion type. Significant differences were noted in operating room time, estimated blood loss, time to flatus, time to bowel movement, and use of inpatient morphine sulfate equivalents. There was no significant difference in regard to overall complication rate or hospital stay. On surgical pathology, in the robotic group 14 patients had pT2 disease or higher; 3 patients had pT3/T4 disease; and 4 patients had node-positive disease. In the open group, eight patients had pT2 disease or higher; five patients had pT3/T4 disease; and seven patients had node-positive disease. The mean number of LNs removed was 19 in the robotic group versus18 in the open group. Potential study limitations include the limited clinical and oncologic follow-up and the relatively small and single-institution nature of the study. CONCLUSIONS: We present the results of a prospective randomized controlled noninferiority study with a primary end point of LN yield, demonstrating the robotic approach to be noninferior to the open approach. The robotic approach also compares favorably with the open approach in several perioperative parameters.




“The feasibility of robot-assisted laparoscopic radical cystectomy with pelvic lymphadenectomy: From the viewpoint of extended pelvic lymphadenectomy.”

Seung, C. K., G. K. Sung, et al. (2009).

Korean Journal of Urology 50(9): 870-878.


Purpose: We evaluated the feasibility of robot-assisted laparoscopic radical cystectomy (RARC) with pelvic lymph node dissection (PLND), especially extended PLND (ePLND), during our initial experience with this technique. Materials and Methods: From August 2007 to March 2009, prospective data were obtained from the 21 consecutive patients who underwent RARC with PLND at Korea University Hospital. Data included baseline characteristics, perioperative variables, pathological outcomes, and complications. Evidence of the lymph node yield curve was examined by using linear regression to compare the number of lymph nodes obtained. Results: Among 21 patients who underwent RARC, 13 had ileal conduit urinary diversion and 8 had orthotopic neobladder. Standard PLND (sPLND) was performed in the first 15 patients, and ePLND was performed in the more recent 6 patients. The mean total operative time was 515.5±145.1 minutes, and the mean estimated blood loss was 346.8±205.9 ml. The mean time for PLND was 106.7±25.2 minutes in patients with ePLND and 72.1±14.1 minutes in patients with sPLND (p=0.001). All patients had negative surgical margins. The mean number of retrieved nodes was 23.5±12.8 (range, 8-50) in all patients: 38.6±10.8 (range, 29-50) in ePLND and 15.7±12.2 (range, 8-21) in sPLND. Conclusions: Perioperative data and oncologic features showed that RARC with PLND is feasible. Robot-assisted laparoscopic surgery is a safe and effective procedure with acceptable morbidity and good oncologic results from the viewpoint of PLND, especially ePLND. © The Korean Urological Association, 2009.




“Current status of ureteroscopic treatment for urolithiasis.”

Skolarikos, A. A., A. G. Papatsoris, et al. (2009).

International Journal of Urology 16(9): 713-717.


Intracorporeal treatment of urolithiasis is characterized by continuous technological evolution. In this review we present updated data upon the use of ureteroscopy for the management of urolithiasis. Novel digital flexible ureteroscopes are used in clinical practice. Ureteroscopic working tools are revolutionized resulting in safer and more efficient procedures. Special categories of stone patients such as pregnant women, children and patients on anticoagulation medication can now undergo uneventful ureteroscopy. Routine insertion of stents and access sheaths as well as bilateral ureteroscopy is still a controversial issue. Future perspectives include smaller and better instruments to visualize and treat a stone, while robotic ureteroscopy is becoming a fascinating reality. © 2009 The Japanese Urological Association.




“Current status of robot-assisted radical cystectomy.”

Smith, A. B., M. E. Nielsen, et al. (2009).

Curr Opin Urol.


PURPOSE OF REVIEW: To assess the current status of robot-assisted radical cystectomy with pelvic lymphadenectomy and urinary diversion for the treatment of bladder cancer. RECENT FINDINGS: Robot-assisted radical cystectomy is steadily growing with a feasible learning curve in those experienced in robotic prostatectomy. Pelvic lymphadenectomy appears to provide adequate nodal yield in several studies. Urinary diversions are most commonly performed extracorporeally, but several centers are attempting intracorporeal techniques. Short-term perioperative outcomes appear acceptable, but oncologic efficacy remains unknown. SUMMARY: Robot-assisted radical cystectomy with urinary diversion appears to be growing steadily in academic institutions. Long-term data regarding oncologic efficacy remain lacking but perioperative outcomes appear favorable.




“Robot-assisted laparoscopic distal ureterectomy and ureteral reimplantation.”

Sung, G. K., H. Choi, et al. (2009).

Korean Journal of Urology 50(9): 921-924.


We report here on our technique and outcomes of the first case of robot-assisted laparoscopic distal ureterectomy with a bladder cuff excision and ureteroneocystostomy. A 74-year-old male patient who had a distal ureter tumor underwent robot-assisted transperitoneal distal ureterectomy. After distal ureterectomy with bladder cuff excision was performed, direct ureteroneocystostomy was performed. The whole procedure was successfully performed by using the robot without conversion to open surgery. The total operative time was 207 minutes, and the estimated blood loss was 30 ml. The final pathological examination showed stage T2 invasive transitional cell carcinoma of the distal ureter. The patient’s postoperative recovery was uneventful and the bladder cuff was free of tumor. Robot-assisted laparoscopic distal ureterectomy with ureteroneocystostomy is safe and feasible and offers patients the advantages of minimally invasive surgery. © The Korean Urological Association, 2009.




“Robotic-assisted ileovesicostomy: initial results.”

Vanni, A. J., M. S. Cohen, et al. (2009).

Urology 74(4): 814-818.


OBJECTIVES: To assess the safety and efficacy of robotic-assisted ileovesicostomy in treating patients with a neurogenic bladder that is unsuitable for clean intermittent self-catheterization. METHODS: Robotic-assisted ileovesicostomy was performed using a 5-port approach for patients with a neurogenic bladder unable to tolerate clean intermittent or chronic bladder catheterization. Intraperitoneal operative steps included the creation of a full thickness U-shaped posterior bladder wall flap, intracorporeal harvesting of 15 cm of terminal ileum for use as a urinary conduit, and intracorporeal enterovesical anastomosis. Then, a counter incision was made over the marked stoma site on the abdominal wall, and bowel continuity was restored through an extracorporeal side-side anastomosis by the stomal incision. Ileovesicostomy stoma maturation was then completed. RESULTS: Eight robotic ileovesicostomies were performed. The median patient age was 53 years, body mass index was 29.0 kg/m(2), and preoperative bladder compliance was 5.7 mL/cm/H(2)O. The median blood loss was 100 mL. The median operative time was 330 minutes (range 240-420). No intraoperative complications occurred. Four patients had postoperative complications, including urethral incontinence (2) and ileus (2). No wound complications occurred. Bowel function returned after a median of 4.8 days after surgery, and median hospital stay was 7.7 days. Over a median 14-month follow-up, all patients had a functioning ileovesicostomy, and median postoperative residual bladder volume was 10 mL. CONCLUSIONS: This study is the first to describe the robotic ileovesicostomy procedure. Robotic ileovesicostomy appears to be safe and effective, with low morbidity.




“Reply to Ben Challacombe, Anthony Costello and Dinesh Agarwal’s Letter to the Editor re: Brian M. Benway, Agnes J. Wang, Jose M. Cabello and Sam B. Bhayani. Robotic Partial Nephrectomy with Sliding-Clip Renorrhaphy: Technique and Outcomes.

Benway, B. M., A. J. Wang, et al. (2009). Eur Urol 2009;55:592-9.”

European Urology 56(5).




“Robotic-assisted laparoscopic pyeloplasty and nephropexy for ureteropelvic junction obstruction and nephroptosis.”

Boylu, U., B. R. Lee, et al. (2009).

Journal of Laparoendoscopic and Advanced Surgical Techniques 19(3): 379-382.


A 22-year-old female was referred with right flank pain and recurrent urinary infections. Flank pain was persistent while standing and relieved upon supine position. Intravenous urography demonstrated change of position with descent approximately 6-7 cm as the patient moved from the supine to the erect position. Diuretic renography corroborated the finding of right ureteropelvic junction obstruction (UPJO). A robotic-assisted laparoscopic dismembered pyeloplasty with simultaneous nephropexy was performed. The proximal ureter appeared to course posterior to the renal vein and then anterior to the lower pole renal artery. There was a significant “nutcracker effect” to the proximal ureter, which was causing the patient’s UPJO, and the concomitant nephroptosis contributed to increase the degree of obstruction. The robotic-assisted laparoscopic pyeloplasty and nephropexy offer advantages for patients and surgeons and can be used in challenging cases with an efficacy similar to that of open repair. The robotic-assisted laparoscopic pyeloplasty is the evolving standard for UPJO, especially in the presence of crossing vessels. © Mary Ann Liebert, Inc.




“Systematic Review and Meta-Analysis of Robotic-Assisted versus Conventional Laparoscopic Pyeloplasty for Patients with Ureteropelvic Junction Obstruction: Effect on Operative Time, Length of Hospital Stay, Postoperative Complications, and Success Rate.”

Braga, L. H. P., K. Pace, et al. (2009).

European Urology 56(5): 848-858.


Background: Although robotic-assisted procedures may theoretically be more advantageous than conventional laparoscopic ones, few studies have shown clear superiority of robotic-assisted laparoscopic pyeloplasty (RAP) over conventional laparoscopic pyeloplasty (CLP) for ureteropelvic junction obstruction (UPJO). Objective: To undertake a systematic review and meta-analysis to evaluate the effect of RAP versus CLP for patients with UPJO, focusing on operative time, length of hospital stay, postoperative complications, and success rate. Design, setting, and participants: We searched four electronic bibliographic databases, including the related articles PubMed feature, reference lists from articles, and program abstracts from scientific meetings. Consequently, 58 citations were identified. Two individuals independently screened the titles and abstracts of each citation to select the articles (90% agreement). Intervention: Studies that compared RAP with CLP for treatment of UPJO were included. Case series on RAP or CLP were excluded because of large heterogeneity. Measurements: We utilized weighted mean difference (WMD) to measure operative time and length of hospital stay and odds ratio (OR) and risk difference (RD) to measure complication and success rates. These ORs were pooled using a random effects model and were tested for heterogeneity. Results: We identified eight publications that strictly met our eligibility criteria. Meta-analysis of extractable data showed that RAP was associated with a 10-min operative time reduction (WMD: -10.4 min; 95% CI: -24.6-3; p = 0.15) and significantly shorter hospital stay compared with CLP (WMD: -0.5 d; 95% CI: -0.6–0.4; p < 0.01). There were no differences between the approaches with regard to rates of complication (OR: 0.7; 95% CI: 0.3-1.6; p = 0.40) and success (OR: 1.3; 95% CI: 0.5-3.5; p = 0.62). Conclusions: RAP and CLP appear to be equivalent with regard to postoperative urinary leaks, hospital readmissions, success rates, and operative time. © 2009 European Association of Urology.




“[Technical aspects of laparoscopic robot-assisted pyeloplasty.].”

Ferhi, K., M. Roupret, et al. (2009).

Prog Urol 19(9): 606-610.


From 2000, the robot-assisted laparoscopic approach has been developed for the management of ureteropelvic junction obstruction (UJO) with equivalent outcomes to conventional laparoscopic access regarding functional results. This system has simplified the suturing and has improved the precision of operative technique. The main surgical steps of the transperitoneal laparoscopic robot-assisted pyeloplasty are as follows: four or five port arrangement; initial dissection and early identification of the ureteropelvic junction; renal pelvis section; transection of the ureter and preparation of a spatula; continuous posterior suture; confection of a handle racket suture; placement of a double J stent; ending of the anastomosis. Outcomes after robotic and pure laparoscopic pyeloplasties are equivalent nowadays. Despite the financial cost, it seems easier and technically feasible and accessible for surgeons accustomed to the laparoscopic techniques and even beginners to learn the robotic technique if the system is available in their institution with success rate (radiologic and clinical) almost similar with those obtain with open techniques.




“Editorial Comment on: Systematic Review and Meta-Analysis of Robotic-Assisted versus Conventional Laparoscopic Pyeloplasty for Patients with Ureteropelvic Junction Obstruction: Effect on Operative Time, Length of Hospital Stay, Postoperative Complications, and Success Rate.” Fornara, P. and F. Greco (2009).

European Urology 56(5): 858.




“Robot-assisted partial nephrectomy: current perspectives and future prospects.”

Gautam, G., B. M. Benway, et al. (2009).

Urology 74(4): 735-740.


The widespread adoption of laparoscopic partial nephrectomy (LPN) has been curtailed by its technical complexity. With the introduction of robotic technology, there is a potential for a shorter learning curve for minimally invasive nephron-sparing surgery (NSS). Initial published data on robot-assisted partial nephrectomy show promising perioperative outcomes comparable to large LPN series performed by highly experienced laparoscopic surgeons. Intraoperative parameters (operating room time, warm ischemia time, and blood loss) and short-term oncologic results demonstrate that this technique, unlike LPN, has a relatively short learning curve. Economic factors, as well as the necessity of an experienced bedside assistant, present the potential shortcomings of the procedure.




“Outcome analysis of robotic pyeloplasty: a large single-centre experience.”

Gupta, N. P., R. Nayyar, et al. (2009).

BJU Int.


OBJECTIVE To present our experience and outcomes of robot-assisted laparoscopic pyeloplasty (RALP) for pelvi-ureteric junction obstruction (PUJO). PATIENTS AND METHODS This was a prospective study of 85 consecutive patients who had RALP for PUJO at our institute from July 2006 to December 2008. The preoperative evaluation included intravenous urography (IVU) and diuretic renography. The type of pyeloplasty was decided based on the size of the pelves, presence of crossing vessel, level of ureteric insertion and the length of obstruction. All surgery was done through a transperitoneal approach using four or five ports. The follow-up comprised IVU and renal dynamic scintigraphy. Relevant data were collected and analysed for perioperative morbidity, complications and long-term functional outcomes. RESULTS In all, 86 RALPs were performed, including one bilateral, 41 right-sided and 43 left-sided cases. The mean operative time was 121 min, including an anastomosis time of 47 min. The mean estimated blood loss was 45 mL. The drain was removed within 48 h. The mean hospital stay was 2.5 days. Three patients had stents that migrated upwards, and prolonged drainage. The success rate was 97% (82/85) with a mean follow-up of 13.6 months. CONCLUSIONS RALP is highly effective for managing PUJO, with low morbidity, quick recovery and a durable success rate.




“A Critical Analysis of the Actual Role of Minimally Invasive Surgery and Active Surveillance for Kidney Cancer.”

Heuer, R., I. S. Gill, et al. (2009).

Eur Urol.


CONTEXT: The incidence of renal cell carcinomas (RCCs) has increased steadily-most rapidly for small renal masses (SRMs). Paralleling the changing face of RCC in the past 2 decades, new, less invasive surgical options have been developed. Laparoscopic radical nephrectomy (LRN) is an established procedure for the treatment of RCC. Treatment of SRMs includes open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), thermal ablation, and active surveillance. OBJECTIVE: To present an overview of minimally invasive treatment options and data on surveillance for kidney cancer. EVIDENCE ACQUISITION: Literature and meeting abstracts were searched using the terms renal cell carcinoma, minimally invasive surgery, laparoscopic surgery, thermal ablation, surveillance, and robotic surgery. The articles with the highest level of evidence were identified with the consensus of all the collaborative authors and reviewed. EVIDENCE SYNTHESIS: Renal insufficiency, as measured by the glomerular filtration rate, occurs more often after radical nephrectomy than partial nephrectomy (PN). OPN and LPN show comparable results in long-term oncologic outcomes. The treatment modality for SRMs should therefore be nephron-sparing surgery (NSS). In select patients, thermal ablation or active surveillance of SRMs is an alternative. CONCLUSIONS: LRN has become the standard of care for most organ-confined tumours not amenable to NSS. Amongst NSS options, PN is the treatment of choice, yet remains underutilised in the community. Initial data during its learning curve revealed that LPN had higher urologic morbidity. However, current emerging data indicate that in experienced hands, LPN has shorter ischaemia times, a lower complication rate, and equivalent long-term oncologic and renal functional outcomes, yet with decreased patient morbidity compared to OPN. Robotic partial nephrectomy is being explored at select centres, and cryotherapy and radiofrequency ablation are options for carefully selected tumours. Active surveillance is an option for selected high-risk patients. Percutaneous needle biopsy is likely to gain increasing relevance in the management of small renal tumours.




“Laparoscopic partial nephrectomy versus robot-assisted laparoscopic partial nephrectomy.”

Jeong, W., S. Y. Park, et al. (2009).

Journal of Endourology 23(9): 1457-1460.


Purpose: Laparoscopic partial nephrectomy (LPN) is an alternative treatment modality for small-sized renal tumors. Robot-assisted LPN (RLPN) has also been performed with an advantage in repairing the defect after a resection of the tumor. We compared the perioperative data of patients treated with LPN with patients who underwent RLPN. Materials and Methods: From September 2006 to April 2008, 26 patients were treated with LPN and 31 with RLPN. Three arms were used for RLPN; camera was inserted through the 12mm umbilical trocar port. Laparoscopic Bulldog clamps were used for clamping the renal hilum. We retrospectively compared each group on tumor size, operative time, estimated blood loss, warm ischemic time, and hospital stay. Result: Operative time of LPN was shorter than that of RLPN (p=0.034). Tumor size, estimated blood loss, and hospital stay were not significantly different in each group. No case was converted to open surgery. One patient in the RLPN group, however, was converted to robot-assisted radical nephrectomy because of severe bleeding. Conclusion: RLPN is safe and feasible for small-sized renal tumors. Warm ischemic time is within reasonable limits. Associated morbidity is also low. © Copyright 2009, Mary Ann Liebert, Inc.




“Initial clinical experience with robot-assisted laparoscopic partial nephrectomy for complex renal tumors.”

Kyung, H. C., K. O. Cheol, et al. (2009).

Korean Journal of Urology 50(9): 865-869.


Purpose: Robot-assisted laparoscopic partial nephrectomy (RLPN) is gaining acceptance as an alternative to open partial nephrectomy and laparoscopic partial nephrectomy for small renal masses. However, it still remains a technically challenging procedure even for experienced laparoscopists. Endophytic tumors or renal hilar tumors pose an additional challenge. Materials and Methods: We reviewed the medical records of 11 patients (mean age: 49.3 years; range: 31-67 years) who underwent RLPN for small, complex renal masses including hilar tumors and endophytic tumors. RLPN was performed with the Da Vinci® surgical system (Intuitive Surgical, Sunnyvale, USA) with three robot arms and intraoperative ultrasonography (Tile-pro® System). Results: RLPN was performed successfully without complications in all cases. The mean tumor size was 3.2 cm (range, 1.1-8.0 cm). The mean operative time was 177 minutes (range, 150-260 minutes), and the mean warm ischemia time was 32 minutes (range, 25-41 minutes). The mean estimated blood loss was 177 ml (range, 50-350 ml), and the mean hospital stay was 4 days (range, 3-7 days). Pathology found four patients with clear cell type renal cell carcinoma, one with multilocular multicystic renal cell carcinoma, two with papillary type, one with chromophobe type, and three with angiomyolipoma. Conclusions: RLPN is a feasible and safe surgery for complex renal tumors. In our experiences, RLPN could be a nephron-sparing surgical option for patients with compromised renal function and it could be an alternative to open partial nephrectomy and laparoscopic partial nephrectomy for a select group of patients. © The Korean Urological Association, 2009.




“Editorial Comment on: Systematic Review and Meta-Analysis of Robotic-Assisted versus Conventional Laparoscopic Pyeloplasty for Patients with Ureteropelvic Junction Obstruction: Effect on Operative Time, Length of Hospital Stay, Postoperative Complications, and Success Rate.” Novara, G. (2009).

European Urology 56(5): 857-858.




“Economics of robotics in urology.”

Lotan, Y. (2009).

Curr Opin Urol.


PURPOSE OF REVIEW: New technologies such as robotics are constantly introduced clinically without a complete understanding of benefits and costs. In order for urologists to optimize their care of patients, there is a need to understand the economic factors that impact on their ability to practice medicine. This review will discuss general concepts of health economics and apply them to the application of robotics to urologic procedures. RECENT FINDINGS: Utilization of robotic surgery, especially for robotic-assisted laparoscopic prostatectomy, has increased dramatically in recent years. The robot adds significant costs in terms of acquisition, maintenance, and daily instrument costs. These added costs, thus far, have not been associated with significant improvement in outcomes over ‘pure’ laparoscopy or open procedures. In order for the robot to be cost-effective, efficacy needs to be improved over alternative approaches and costs of the robot or instrumentation needs to be decreased. SUMMARY: Robotic application is not cost-effective compared with open or laparoscopic approaches and future studies will need to determine whether there are indirect benefits that will justify its use.




“Critical appraisal of technical problems with robotic urological surgery.”

Nayyar, R. and N. P. Gupta (2009).

BJU Int.


OBJECTIVE To record the technical problems and complications associated with the use of da Vinci S robotic system (Intuitive Surgical, Sunnyvale, CA, USA) and to review previous reports. METHODS We analysed our records for all machine- or instrument-related errors during the course of 340 consecutive robot-assisted urological operations at our centre from July 2006 to March 2009, using one robotic machine. The cause of the error (machine or human), troubleshooting methods and consequences of the errors were evaluated. RESULTS The overall device failure rate was 10.9% (37/340). The most frequent technical problems were related to robotic instruments (23/37). Other failures included colour/hue changes in the console image, intermittent double vision, fused illuminator bulb and problems with the master tool-manipulator device (hand-piece unit), patient cart circuitry, patient-side manipulator arm, closed-circuit camera unit or camera cable. Of 37 problems, 28 (76%) were surmountable during the course of surgery. The overall conversions to standard open/laparoscopic procedure attributable to mechanical failures of the robot were 0.6% (2/340). There were no complications or direct harm to the patient in any case. Most faults could be corrected or bypassed with some addition to operating room time. CONCLUSIONS Despite an association of various types of new technical problems with robotic surgery, it provides a safe mode of minimally invasive surgery with very low conversion rates attributable to it, and no direct patient injury.




“Expansion of robotics in urology: the pioneer and the ostrich.”

Su, L. M. (2009).

Curr Opin Urol.




“Robotics in urologic surgery.”

Zhao, L. C., J. J. Meeks, et al. (2009).

Minerva Urol Nefrol 61(4): 331-339.


Robotic surgery is becoming rapidly integrated in urology. Nearly every open or laparoscopic procedure has been described with robotic assistance. While the da Vinci robot is recently applied to the upper urinary tract, it has become widely adopted for performing radical prostatectomy. Benefits of robotics include 3-D vision, blood-less field from pneumoperitoneum, and ease of intracorporeal suturing. Disadvantages include cost, lack of haptic feedback, surgical learning curve and longer operative times. Here, the authors describe the state of the art applications and outcomes of robotics in urologic surgery.




“The impact of robotic surgery on pelvic lymph node dissection during radical prostatectomy for localized prostate cancer: the Brown University early robotic experience.”

Autorino, R. and R. J. Stein (2009).

Can J Urol 16(5): 4846.




“Erectile dysfunction after radical prostatectomy.”

Becker, A. J., C. G. Stief, et al. (2009).

Erektile dysfunktion nach radikaler prostatektomie 40(5): 289-293.


In the age of nerve-sparing radical prostatectomy, rates of postoperative erectile dysfunction (ED) have significantly decreased. However, on comparing open retropubic, laparoscopic and robot-assisted procedures, none of these techniques seem to show specific advantages in this respect. PDE5 inhibitors are considered to be the gold standard in the first-line therapy of postoperative ED, as far as relevant contraindications can be excluded. Intraurethral and intracavernosal injections with prostaglandin E1 represent the second-line treatment. Implantation of penile prostheses still remains as the third-line and ultima ratio. Meanwhile, the administration of PDE5 inhibitors has been proven to be most effective. When applying this therapy regimen, these substances are highly useful when they are administered early after the intervention. After curative treatment of prostate cancer, testosterone substitution can be an efficient way to reduce hypogonadal symptoms in patients with manifest testosterone deficiency. It may even contribute to the improvement of post- interventional erectile disorders. According to the recent literature, testosterone substitution therapy is safe and does not show any additional risk of recurrence when there is a well considered indication and when patients are carefully selected. © Georg Thieme Verlag KG.




“Outcomes of locally advanced (T3 or greater) prostate cancer in men undergoing robot-assisted laparoscopic prostatectomy.”

Casey, J. T., J. J. Meeks, et al. (2009).

Journal of Endourology 23(9): 1519-1522.


Objectives: Despite nearly equivalent outcomes between open and robot-assisted laparoscopic prostatectomy (RALP) for organ-confined prostate cancer (PCa), the role of primary treatment with RALP in men with locally advanced (T3 or greater) PCa has not been described in detail. We report our experience with RALP for pathologically advanced disease. Patients and Methods: From October 2005 to November 2008, 220 RALPs were performed by a single surgeon (R.B.N.). Outcomes were assessed prospectively in an institutional review board-approved database. Results: Of 220 RALPs, 35 (15.9%) were performed for pT3 PCa; none of them were identified preoperatively. There was no difference in operative time compared with patients with pT2 disease (271 vs. 295 minutes, p=0.09). The positive surgical margin (PSM) rate was 20% compared with 4.9% for pT2 (p=0.004). Sural nerve grafts were performed in 20%, and 57% had bilateral nerve sparing. The use of bilateral or unilateral nerve sparing was not associated with increased PSM (p=0.85). Biochemical recurrence occurred in 28.6% of men with pT3 disease over an average of 13 months of follow-up time, 30% of which occurred in men with a PSM. At 6 months, an 85% continence rate was achieved, and at 1 year continence was 100% for pT3. Compared with pT2, men with advanced disease had similar recovery after RALP based on postsurgery questionnaires. Conclusions: RALP is a feasible approach to patients with pathologically advanced PCa as 71% were without evidence of disease at 13 months postoperatively. PSM rate (20%) is comparable to previously reported open PSM rates (24-66%). © Copyright 2009, Mary Ann Liebert, Inc.




“Robotic-assisted radical prostatectomy: a review of current outcomes.”

Coelho, R. F., S. Chauhan, et al. (2009).

BJU Int 104(10): 1428-1435.


With the widespread diffusion of the screening for prostate cancer, the disease has been diagnosed more commonly in the organ-confined stage, and in younger and healthier men. For these patients, radical prostatectomy (RP) is still the standard treatment. In an effort to decrease the morbidity associated with open RP, minimally invasive approaches have been described, including robotic-assisted RP (RALP). Almost one decade after the introduction of RALP, large and mature series have now been reported. We reviewed the outcomes of the largest series of RALP published recently. We searched Medline for reports published between 2006 and 2009, to identify articles describing intraoperative data, surgical complications, oncological outcomes, continence and potency rates after RALP. Relevant articles were selected and the outcomes evaluated.




“A multi-institutional comparison of radical retropubic prostatectomy, radical perineal prostatectomy, and robot-assisted laparoscopic prostatectomy for treatment of localized prostate cancer.” Coronato, E. E., J. D. Harmon, et al. (2009).

Journal of Robotic Surgery: 1-4.


To evaluate the pathological stage and margin status of patients undergoing radical retropubic prostatectomy (RRP), radical perineal prostatectomy (RPP) and robot-assisted laparoscopic prostatectomy (RALP). We performed a retrospective analysis of 196 patients who underwent RRP, RPP, and RALP as part of our multi-institution program. Fifty-seven patients underwent RRP, 41 RPP, and 98 RALP. Patient age, preoperative prostate specific antigen (PSA), preoperative Gleason score, preoperative clinical stage, pathological stage, postoperative Gleason score, and margin status were reviewed. The three groups had similar preoperative characteristics, except for PSA (8.4, 6.5, and 6.2 ng/ml) for the retropubic, robotic, and perineal approaches. Margins were positive in 12, 24, and 36% of the specimens from RALP, RRP, and RPP, respectively (P = 0.004). The positive margin rates in patients with pT2 tumors were 4, 14, and 19% in the RALP, RRP, and the RPP groups, respectively (P = 0.03). Controlling for age and pre-operative PSA and Gleason score, the rate of positive margins was statistically lower in the RALP versus both the RRP (P = 0.046) and the RPP groups (P = 0.02). In the patients with pT3 tumors, positive margins were observed in 36% of patients undergoing the RALP and 53 and 90% of those patients undergoing the RRP and RPP, respectively (P = 0.015). Controlling for the same factors, the rate of positive margins was statistically lower in the RALP versus the RPP (P = 0.01) but not compared with the RRP patients (P = 0.32). The percentage of positive margins was lower in RALP than in RPP for both pT2 and pT3 tumors. RRP had a higher percentage of positive margins than RALP in the pT2 tumors but not in the pT3 tumors. © 2009 Springer-Verlag London Ltd.




“Predictors of Positive Surgical Margins After Laparoscopic Robot Assisted Radical Prostatectomy.” Ficarra, V., G. Novara, et al. (2009).

Journal of Urology.


Purpose: We identified the predictors of positive surgical margins in a series of patients undergoing robot assisted laparoscopic radical prostatectomy. Materials and Methods: We prospectively collected data from 322 patients who underwent robot assisted laparoscopic radical prostatectomy for clinically localized prostate cancer between April 2005 and October 2008, and who had not received any prior hormonal therapy. Results: Positive surgical margins were observed in 95 cases (29.5%). Specifically positive surgical margins were at the apex in 22 cases (6.8%), anterior in 5 (1.6%) and posterolateral in 68 (21%). Among the preoperative variables prostate volume on transrectal ultrasound (HR 0.420, p = 0.002) and cT stage (HR 2.217, p = 0.008) were independent predictors of the presence of any positive surgical margin in the cohort while cT stage (HR 2.070, p = 0.025) and biopsy Gleason score (p = 0.019) were predictors of posterolateral positive surgical margins. Considering pathological variables only extraprostatic extension of the primary tumor was an independent predictor of any positive surgical margin (HR 11.852, p <0.001) and posterolateral positive surgical margins (HR 7.484, p <0.001) in the series. Of those patients with organ confined disease positive surgical margins were present in 21 (10.6%). Only perineural invasion was an independent predictor of any positive surgical margin (HR 4.096, p = 0.028) while a not statistically significant trend was identified with regard to posterolateral positive surgical margins (HR 6.938, p = 0.067). Conclusions: Pathological extension of the primary tumor was the most relevant predictor of positive surgical margins. In patients with organ confined disease the presence of perineural invasion was significantly associated with positive surgical margins. © 2009 American Urological Association.




“Quantitative and qualitative analysis of the recovery of potency after radical prostatectomy: effect of unilateral vs bilateral nerve sparing.”

Finley, D. S., E. Rodriguez, Jr., et al. (2009).

BJU Int 104(10): 1484-1489.


OBJECTIVES: To analyse the impact of a approximately 50% reduction of cavernous nervous tissue on the qualitative and quantitative recovery of sexual function after unilateral (UNS) and bilateral (BNS) nerve-sparing robotic radical prostatectomy (RALP), by evaluating these differences in two groups treated with cautery and a cautery-free technique (CFT). PATIENTS AND METHODS: UNS was defined as wide-excision of one neurovascular bundle (NVB). Only men aged < or =65 years with preoperative International Index of Erectile Function (IIEF-5) scores of > or =22 were included. The cautery group comprised 42 men (of case numbers 1-125) undergoing RALP with cautery, and the CFT group (62 men of cases 151-350) had a cautery-free technique along the NVB. Data were collected prospectively using validated self-administered questionnaires. Potency was defined as two affirmative answers to: do you have erections ‘adequate for vaginal penetration?’ and ‘Are they satisfactory?’. Patient-reported IIEF-5 scores and quality of erections (i.e. an estimate of erection as 0%, 25%, 50%, 75% or 100% of preoperative fullness) were obtained after surgery. RESULTS: In the cautery group, doubling the nerve volume increased potency by 1.36 times (UNS 50% vs BNS 68%). The results were similar in the CFT group as doubling nerve tissue increased potency by 1.15 times (UNS 80% and BNS 93%). At 24 months, comparing IIEF-5 scores, there was no difference between UNS and BNS for the cautery group, at 19.6 (95% confidence interval 15.7-23.5) vs 18.9 (16.6-21.0), or the CFT group, at 22.0 (20.2-23.8) vs 21.0 (19.8-22.1). CONCLUSIONS: Doubling the nerve volume only increased potency by 1.15-1.36 times for both the CFT and cautery groups. Furthermore, the quality of erections and IIEF-5 scores did not vary appreciably with doubling of nerve tissue.




“Pure laparoscopic versus robotic-assisted laparoscopic radical prostatectomy: Comparative study to assess functional urinary outcomes.”

Gosseine, P. N., P. Mangin, et al. (2009).

Prostatectomie totale laparoscopique standard versus laparoscopique robot-assistée : étude comparative sur les résultats fonctionnels urinaires 19(9): 611-617.


Purpose: To compare urinary functional outcomes after LP prostatectomy or robotic assisted laparoscopic prostatectomy performed by a single surgeon regarding to his initial experience. Material: Between March 2005 and April 2007, 247 consecutive patients underwent radical prostatectomy, either by LP approach (125) or by robotic-assisted laparoscopic (RALP) approach (122). The only criteria to chose robot or not, was the Robot Da Vinci®’s availability. Results: There was no statistical difference between the two groups in terms of preoperative characteristics. The continence rate was 83% in PL group versus 81% in RALP group. More precisely, among men wearing at least one pad, 71% of patients in PL groups wear one pad/day versus 87% of patients in RALP group. Multivariate analysis on continence appears to be in favors of RALP group (Odd Ratio 2.1 [CI: 0,86-5,48]). Conclusion: Incontinence appears to be less severe and frequent in the RALP group. In practice, surgeon’s impression of the robot’s interest is evident, but more important number of patients and longer follow-up is necessary. © 2009 Elsevier Masson SAS. All rights reserved.




“Robotic prostatectomy in patient with an abdominoperineal resection.”

Ham, W. S., S. W. Kim, et al. (2009).

Journal of Laparoendoscopic and Advanced Surgical Techniques 19(3): 383-387.


Robotic prostatectomy (RP) has been reported to be technically challenging in patients with a history of prior complex lower abdominal or pelvic surgery, morbid obesity, large prostate, prior pelvic irradiation, neoadjuvant hormonal therapy, or prior prostate surgery. In this paper, we report an experience of RP in a prostate cancer patient with abdominoperineal resection, adjuvant chemotherapy, and pelvic irradiation for rectal cancer. © Mary Ann Liebert, Inc.




“Robotic radical prostatectomy for patients with locally advanced prostate cancer is feasible: Results of a single-institution study.”

Ham, W. S., S. Y. Park, et al. (2009).

Journal of Laparoendoscopic and Advanced Surgical Techniques 19(3): 329-332.


Objectives: The aim of this study was to compare the outcomes of robotic prostatectomy (RP) in patients with clinically localized or locally advanced prostate cancer (PC). Patients and Methods: Between July 2005 and February 2008, we performed RP in 357 patients by using the da Vinci® robot system and a transperitoneal approach. We defined locally advanced PC as cases with a clinical T-stage ≥T3a with any serum prostate-specific antigen (PSA) or Gleason score. Among the 321 men not treated with neoadjuvant hormonal therapy, 200 patients had clinically localized PC and 121 patients had locally advanced PC. We compared perioperative variables and early surgical outcomes between the two groups. Results: Although advanced PC patients had significantly higher mean preoperative PSA levels, prostatectomy Gleason scores, and extracapsular extension rates, there were no significant differences in mean operation time, estimated blood loss, duration of bladder catheterization, hospital stay, or initiation of a regular postoperative diet between the two groups. Except for some early cases, a bilateral extended lymphadenectomy was performed without difficulty in both groups. Although both the frequency of lymph node invasion and the positive surgical margin rates were higher in the advanced PC patients, the positive surgical margin rate (48.8) in the present study was similar to those of open radical retropubic prostatectomy in other studies. The overall complication rate did not differ between the two groups. Two intraoperative rectal injuries occurred in patients with locally advanced PC and were closed primarily without specific problems, except for 1 case. Conclusions: Our results suggest that RP may be performed safely on patients with locally advanced PC. © Mary Ann Liebert, Inc.




“Prostate cancer in the age of the da vinci robotic radical prostatectomy.”

Kolombo, L., M. Toběrný, et al. (2009).

Praktický lékař 2009 89(8): 420-428.


Robotic surgery with the davinci system (Intuitive Surgical®, USA) is the most sophisticated medical technology in urology, integration or modern computer technologies, digital imaging and robotic technologies are now bringing opportunities to improve results of surgical procedures. One of the greatest advantages (in comparison to standard laparoscopy) is that the image of the operation field is three-dimensional and magnified. Further major advantages are the instruments themselves. Laparoscopic instruments only allow for rotation and have only one joint. Robotic instruments with technology of Endowrist®not only mimic but even surpass the movements of a human hand, because all the joints are near the very tip of the instruments, allowing manoeuvres in previously inaccessible spaces. This greatly enhances surgeon dexterity and precision and decreases the number of false movements. Robotic technology is ideally suited to decrease the technical difficulty in the most demanding urooncological and reconstructive procedures. Robotic da Vinci radical prostatectomy is the new gold standard for minimally invasive surgical treatment of clinically localized prostate cancer. Our results from the Centre of Robotic Surgery and Urology in Hospital Na Homolce, Prague also confirm the benefits for patients after da Vinci prostatectomy (shorter hospital stay, quicker convalescence, better early continence and potency rate) similarly for patients after another urologie robotic surgery procedures. The learning curve for robotic surgery is much shorter than it’s laparoscopic counterpart and skills are acquired faster avoiding the need for lengthy training in minimally invasive surgery. Robotic surgery with the da Vinci system has gradually switched many complex surgical procedures, such as radical prostatectomy, from open and laparoscopic to the robotic approach.




“Posterior support for urethrovesical anastomosis in robotic radical prostatectomy: single surgeon analysis.”

Krane, L. S., C. Wambi, et al. (2009).

Can J Urol 16(5): 4836-4840.


INTRODUCTION: Posterior urethrovesical anastomotic support has been reported to improve early return of urinary continence following radical prostatectomy. We adapted this technique to evaluate enhancement of early urinary control in patients undergoing robotic radical prostatectomy. MATERIALS AND METHODS: Forty-two consecutive men undergoing radical prostatectomy by a single surgeon between September and December 2007 received a posterior urethrovesical supporting stitch prior to the standard urethrovesical anastomosis (group 1). Operative data, postoperative complications, and follow up data were compared with those of the 42 consecutive men who underwent robotic radical prostatectomy by the same surgeon between March and August 2007 with a standard urethrovesical anastomosis (group 2). Continence was assessed at routine follow up visit 6 to 8 weeks following catheter removal. Continence was defined as zero pads or small security liner for infrequent urinary leakage in 24 hours. RESULTS: Thirty-four (81%) and 37 (88%) men in groups 1 and 2 respectively had follow up available between 45 and 75 days following prostatectomy. Preoperative demographics were similar between the two groups. At a mean follow up of 60 and 53 days following surgery, 29/34 (85%) of men in group 1 and 32/37 (86%) of men in group 2 were continent. On multivariate logistic regression analysis, no factors were associated with improved continence between the two groups. CONCLUSIONS: Posterior urethrovesical anastomotic support did not result in improved early urinary control following radical prostatectomy. Excellent urinary control can be achieved in the patients undergoing robotic radical prostatectomy without posterior urethrovesical anastomotic support.




“Posterior support for urethrovesical anastomosis in robotic radical prostatectomy: single surgeon analysis.”

Moinzadeh, A. (2009).

Can J Urol 16(5): 4841.




“Are functional outcomes after robot-assisted laparoscopic radical prostatectomy better than those obtained with other surgical approaches?”

Rouprêt, M. (2009).

Les résultats fonctionnels obtenus après prostatectomie totale laparoscopique robot-assistée sont-ils meilleurs que ceux obtenus avec les autres voies d’abord chirurgicales ? 19(9): 617-618.




“Robotic-assisted laparoscopic prostatectomy.”

Sharma, N. L., N. C. Shah, et al. (2009).

Br J Cancer 101(9): 1491-1496.


Prostate cancer remains a significant health problem worldwide and is the second highest cause of cancer-related death in men. While there is uncertainty over which men will benefit from radical treatment, considerable efforts are being made to reduce treatment related side-effects and in optimising outcomes. This article reviews the development and introduction of robotic-assisted laparoscopic radical prostatectomy (RALP), the results to date, and the possible future directions of RALP.




“Endoscopic extraperitoneal radical prostatectomy: Evolution of the technique and experience with 2400 cases.”

Stolzenburg, J. U., P. Kallidonis, et al. (2009).

Journal of Endourology 23(9): 1467-1472.


Objectives: We report the outcome of 2400 endoscopic extraperitoneal radical prostatectomy (EERPE) cases performed in three institutions, with emphasis on the evolution of the EERPE technique. Methods: In total, 2400 EERPE procedures were performed in three institutions. Several surgeons performed the operations. The presented cases also include the learning curve of the surgeons. EERPE was performed in all cases of localized prostate cancer with the same indications to open and transperitoneal laparoscopic radical prostatectomy. Results: Average patient age was 63.3 years (range 41-81 years), and mean preoperative prostate specific antigen (PSA) level was 9.8ng/mL (range 0.08-93ng/mL); 857 (38%) patients had previously undergone abdominal or pelvic surgery, while 143 (5.8%) patients had prior prostatic treatment. Pelvic lymph node dissection took place in 1219 (50.8%) patients. Bilateral nerve sparing was performed in 672 patients and unilateral in 284 patients; 100 patients underwent intraoperative hernia repair with mesh placement (82 unilateral and 18 bilateral). Mean operative time was 150.7 minutes (range 50-340 minutes). Conversion to open surgery was never deemed necessary. Fifteen patients received transfusion (0.7%). The mean catheterization time was 6.19 days (range 3-40 days). Overall, 71.7% and 94.7% of the patients were continent at 3 and 12 months,respectively. Totally, 956 patients were treated with nerve-sparing procedure either interfascial or intrafascial; 672 patients underwent bilateral neurovascular bundle preservation, and 284, unilateral. Younger patients tend to have better postoperative potency. Bilateral nerve-sparing EERPE in patients younger than 55 years results in potency rate of 32.4%, 75.3%, and 84.9% at 3, 6, and 12 months postoperatively. Conclusions: The functional and oncological outcome of EERPE is comparable to other approaches for radical prostatectomy. Continuous refinements contribute to the improving outcome of the procedure. Long-term results especially in terms of oncological efficacy are expected. © Copyright 2009, Mary Ann Liebert, Inc.




“Port-site complications after pediatric urologic robotic surgery.”

Tapscott, A., S. S. Kim, et al. (2009).

Journal of Robotic Surgery: 1-4.


The incidence of port-site hernia development after adult laparoscopic surgery is reported to be between 0.1% and 3.0%. There are no published reports concerning hernia incidence or related factors after pediatric urologic laparoscopic interventions. We present our experience with port-site complications following pediatric urologic robotic surgery (PURS). From July 2005 to June 2009 we prospectively followed the first 200 PURS cases performed at Children’s Hospital of Philadelphia. All cases had follow-up available for at least 2 months postoperatively. The data collected allowed for evaluation of the outcomes for each port site separately and compared its size, location, and fascial closure status. Median age was 3.2 years (0.4-18.8 years). All 200 patients had follow-up with median of 11 months (0.2-83.4 months). There were 600 port sites analyzed in the 200 cases. Of the 600 port sites, 200 were umbilical. The other 400 port sites were lateral to the rectus muscle, either subcostal or at the level of the anterior superior iliac spine. There was no wound irrigation prior to closure on any sites. All the patients received perioperative antibiotics. One umbilical port had a hernia diagnosed 2 weeks postoperatively. Four of the 600 ports (0.6%) developed skin dehiscence secondary to superficial wound infection within 1 week postoperatively. At our institution, the overall incidence of port-site complications after PURS was 0.83%. This is slightly lower than the published incidence in adults undergoing conventional laparoscopy. Due to the low incidence of complications it is difficult to draw conclusions on contributing factors. © 2009 Springer-Verlag London Ltd.




“Robot assisted laparoscopic prostatectomy: initial tips and tricks.”

Van Der Poel, H. G., E. Van Muilekom, et al. (2009).

Minerva Urol Nefrol 61(4): 351-362.


Robot assisted laparoscopic prostatectomy (RALP) has become a widely accepted and applied surgical method of localized prostate cancer treatment. Initial studies suggest a shorter learning curve for RALP when compared to conventional laparoscopic prostatectomy. Although dexterity for the RALP procedure is increased by the da Vinci surgical robotic system compared to laparoscopic approaches, the anatomical and technical approaches to prostatectomy still require considerable experience in anatomical variations to become proficient and improve oncological and surgical approaches. Several aspects with respect to that can be recognized in the early phases of training. The following aspects helped the author in his initial 150 cases to improve surgical skills: use intraoperative transrectal ultrasound for bladder neck recognition, record and review surgical procedures, experiment with port positioning, training of table assistance. The more recent da Vinci surgical robot systems allow for new dimensions in surgical approaches with particular intraoperative imaging modalities not earlier so easy accessible during surgery. These properties render robot procedures appealing for the now-a-days more and more image-guided approach to surgery.




“The impact of robotic surgery on pelvic lymph node dissection during radical prostatectomy for localized prostate cancer: the Brown University early robotic experience.”

Yates, J., G. Haleblian, et al. (2009).

Can J Urol 16(5): 4842-4846.


INTRODUCTION: Open pelvic lymph node dissection (PLND) remains the gold standard in patients with intermediate and high-risk prostate cancer undergoing radical retropubic prostatectomy (RRP). Recently, our institution has adopted robotic assistance for performing radical prostatectomy. We sought to determine whether robot-assisted laparoscopic PLND yields comparable numbers of lymph nodes compared to open PLND. METHODS: The medical records of patients undergoing open or robot-assisted laparoscopic radical prostatectomy (RALRP) with concurrent pelvic lymph node dissection (PLND) between 2003 and 2008 were reviewed. Demographic factors including age, PSA, and Gleason score were recorded. Pathology reports were reviewed to determine the number of pelvic lymph nodes obtained during PLND. Lymph node yield was further evaluated based on surgeon. Student’s t-test was used to compare the number of lymph nodes obtained with each method. RESULTS: A total of 61 patients undergoing open RRP with PLND and 62 patients undergoing RALRP with PLND were included. The mean number of lymph nodes obtained via open PLND was 7.3 while the mean number obtained via robotic PLND was 3.3. These means were significantly different with a p value < 0.001. One patient in the open cohort (1.6%) and two patients in the robotic cohort (3.2%) had micrometastatic disease on PLND. CONCLUSION: Robot-assisted laparoscopic PLND yielded fewer lymph nodes compared to open PLND at the time of radical prostatectomy for organ confined disease. Patients with higher risk disease may benefit from open prostatectomy with PLND early in a program’s robotics experience. These findings may be related to the relative youth of our robotics program and further comparisons as our data mature will be revealing.




“Robot-assisted radical prostatectomy: Current evaluation of surgical margins in clinically low-, intermediate-, and high-risk prostate cancer.”

Yee, D. S., N. Narula, et al. (2009).

Journal of Endourology 23(9): 1461-1465.


Purpose: Concern exists over a lack of tactile sensation and positive surgical margins (PSMs) in patients undergoing robot-assisted radical prostatectomy. We report our PSM rates in our most current 500 cases and particularly in clinically high-risk disease. Materials and Methods: After implementation of our present technique at case #251, we report PSM rates according to pathologic stage and D’Amico’s risk stratification: low risk (prostate-specific antigen [PSA] <10, Gleason score [GS] 5-6, cT1-T2A), intermediate risk (PSA 10-20, GS 7, cT2B), and high risk (PSA >20, GS 8-10, cT3). Patients with cT2b/T3 disease or GS 8 to 10 and multiple cores with >30% involvement underwent wide excision of the neurovascular bundle. PSM was defined as ink on tumor. Results: The overall PSM rate was 7.4%: pT2=3.1%, pT3=15.9%, and pT4=55.6%. PSMs occurred in 13 (4.9%) low, 10 (5.8%) intermediate, and 14 (22.6%) high D’Amico risk patients. Of the 62 high-risk patients, the median PSA was 6.9 (range 2.2-97.9); biopsy GS was 6 to 7 (26%) and 8 to 10 (74%). For preoperatively palpable disease, the PSM rate was 9.9%: cT1=6.0%, cT2=7.7%, and cT3=26.3%. No PSMs occurred along the neurovascular bundle. Conclusion: Since 2005, 500 men with clinically low-, intermediate-, and high-risk prostate cancer have undergone robot-assisted radical prostatectomy with acceptable surgical margin rates. In patients with high-risk and usually palpable disease, PSM rates were also acceptable despite the lack of tactile sensation with the robot. © Copyright 2009, Mary Ann Liebert, Inc.




“Continued improvement of perioperative, pathological and continence outcomes during 700 robot-assisted radical prostatectomies.”

Zorn, K. C., M. A. Wille, et al. (2009).

The Canadian journal of urology 16(4).


BACKGROUND: Several robot-assisted radical prostatectomy (RARP) series have reviewed the impact of the initial learning curve on perioperative outcomes. However, little is known about the impact of experience on urinary and sexual outcomes. Herein, we review the perioperative, pathological and functional outcomes of our initial 700 consecutive procedures with at least 1 year follow up. METHODS: From 2003-2006, 700 consecutive men underwent RARP at a single, academic institution. Perioperative data and pathologic outcomes were prospectively collected. Validated, UCLA-PCI-SF36v2 quality-of-life questionnaires were also obtained at 1, 3, 6 and 12 months following surgery. Outcomes between groups (cases 1-300, 301-500, and 501-700) were compared. RESULTS: Mean operative time (OT) and blood loss significantly decreased during the experience (286, 198, 190 min; p <or= 0.001; 266, 190, 169 ml; p <or=0.001). Positive surgical margin (PSM) rate decreased in pT2 patients (15% versus 10% versus 7%; p = 0.03) despite operating on men with higher grade disease (biopsy GS>or=7 in 24%, 40%, 44%; p <or= 0.001). At 12 months postRARP, pad free continence rate was 81% when self reported and 62% when assessed by the UCLA-PCI-SF36v2 questionnaire in the initial group. Continence rates improved to 93% and 75%, respectively, for cases 501-700 (p <or= 0.05). Furthermore, significant improvement in continence rates between consecutive case groups was observed at all postoperative time points. Potency rate was 83% (bilateral nerve preservation) and 56% (unilateral nerve preservation) at 12 months when self reported and 63% and 37% respectively by the UCLA-PCI-SF36v2. No significant differences in sexual function were noted with increased experience. CONCLUSIONS: A prolonged learning curve is observed for EBL, OT and pT2-PSM. In addition, to the best of our knowledge, this is first series demonstrating a continued improvement in urinary continence with increased RARP experience.




“Transumbilical laparoscopic urological surgery: Are special devices strictly necessary?”

Branco, A. W., W. Kondo, et al. (2009).

BJU International 104(8): 1136-1142.


Objective To evaluate the safety and feasibility of transumbilical laparoscopic surgery using conventional laparoscopic instruments and ports. Patients and methods Since January 2008 we have been using laparoscopic transumbilical procedures. Patient selection was determined by any situation, pathological or not, for which laparoscopy was deemed appropriate as the standard of care in our practice. Exclusion criteria included patients who had undergone multiple abdominal procedures. The Veress needle was placed through the umbilicus, to allow insufflation with carbon dioxide. A 10-mm trocar was placed in the peri-umbilical site for the laparoscope, followed by placing two additional 5-mm peri-umbilical trocars. The entire procedure was done using conventional laparoscopic instruments. At the end of surgery the trocars were removed and all three peri-umbilical skin incisions were united for specimen retrieval. Patients undergoing surgery using this approach were evaluated prospectively and data were collected during and after surgery for analysis. Results Six procedures were performed using this technique (three nephrectomies, one adrenalectomy, one ureterolithotomy and one retroperitoneal mass resection). The mean operative duration and blood loss were 70.5 min and 108.3 mL, respectively. There were no complications during surgery and no patients needed a blood transfusion. Analgesia comprised metamizole (1 g intravenous every 6 h) and ketoprofen (100 mg intravenous every 12 h). The time to first oral intake was 8 h and the mean hospital stay was 28 h. Conclusion Laparoscopic transumbilical surgery seems to be feasible and safe even using conventional laparoscopic instruments, and can be considered a potential alternative for traditional laparoscopic urological procedures. © 2009 BJU International.




“Novel magnetically guided intra-abdominal camera to facilitate laparoendoscopic single-site surgery: initial human experience.”

Cadeddu, J., R. Fernandez, et al. (2009).

Surgical Endoscopy 23(8): 1894-1899.


BACKGROUND: Magnetic anchoring guidance systems (MAGS) are composed of an internal surgical instrument controlled by an external handheld magnet and do not require a dedicated surgical port. Therefore, this system may help to reduce internal and external collision of instruments associated with laparoendoscopic single-site (LESS) surgery. Herein, we describe the initial clinical experience with a magnetically anchored camera system used during laparoscopic nephrectomy and appendectomy in two human patients. METHODS: Two separate cases were performed using a single-incision working port with the addition of a magnetically anchored camera that was controlled externally with a magnet. RESULTS: Surgery was successful in both cases. Nephrectomy was completed in 120 min with 150 ml estimated blood loss (EBL) and the patient was discharged home on postoperative day 2. Appendectomy was successfully completed in 55 min with EBL of 10 ml and the patient was discharged home the following morning. CONCLUSIONS: Use of a MAGS camera results in fewer instrument collisions, improves surgical working space, and provides an image comparable to that in standard laparoscopy.




“Single-port, single-operator-light endoscopic robot-assisted laparoscopic urology: pilot study in a pig model.”

Crouzet, S., G. P. Haber, et al. (2009).

BJU Int.


OBJECTIVES To present our initial operative experience in which single-port-light endoscopic robot-assisted reconstructive and extirpative urological surgery was performed by one surgeon, using a pig model. MATERIALS AND METHODS This pilot study was conducted in male farm pigs to determine the feasibility and safety of single-port, single-surgeon urological surgery. All pigs had a general anaesthetic and were placed in the flank position. A 2-cm umbilical incision was made, through which a single port was placed and pneumoperitoneum obtained. An operative laparoscope was introduced and securely held using a novel low-profile robot under foot and/or voice control. Using articulating instruments, each pig had bilateral reconstructive and extirpative renal surgery. Salient intraoperative and postmortem data were recorded. Results were analysed statistically to determine if outcomes improved with surgeon experience. RESULTS Five male farm pigs underwent bilateral partial nephrectomy and bilateral pyeloplasty before a completion bilateral radical nephrectomy. There were no intraoperative complications and there was no need for additional ports to be placed. The mean (range) operative duration for partial nephrectomy, pyeloplasty, and nephrectomy were 120 (100-150), 110 (95-130) and 20 (15-30) min, respectively. The mean (range) estimated blood loss for all procedures was 240 (200-280) mL. The preparation time decreased with increasing number of cases (P = 0.002). CONCLUSIONS The combination of a single-port, a robotic endoscope holder and articulated instruments operated by one surgeon is feasible. With a single-port access, the robot allows more room to the surgeon than an assistant.




“Natural orifice transluminal endoscopic surgery (NOTES).”

Dallemagne, B. and S. Perretta (2009).

Endoscopy 41(10): 895-897.




“Pure ‘natural orifice transluminal endoscopic surgery’ for transvaginal nephrectomy in the porcine model.”

Haber, G. P., S. Brethauer, et al. (2009).

BJU Int 104(9): 1260-1264.


OBJECTIVES: To determine the technical feasibility and reproducibility of pure natural orifice transluminal endoscopic surgery (NOTES) transvaginal nephrectomy using NOTES-specific instrumentation, with no transabdominal assistance. MATERIALS AND METHODS: Five female farm pigs (mean weight 45 kg) had a right NOTES nephrectomy, using a single-channel gastroscope in the first three pigs and a dual-channel gastroscope in the remaining two. The peritoneal cavity was accessed through the posterior fornix of the vagina. Dissection was started at the lower pole of the kidney, and the ureter was retracted laterally and followed towards the hilum. An XL articulated 60 cm endo-GIA stapler (US Surgical, Norwalk, CO, USA), inserted transvaginally via a separate vaginal incision, was used for tissue retraction and renal hilar transection. The kidney was freed, entrapped in an impermeable sac, and extracted intact transvaginally. RESULTS: All five procedures were successful with no addition of a transabdominal laparoscopic port or open conversion. The total operative duration decreased from 200 min in the first pig to 60 min in the last (mean 113 min); the mean blood loss was <50 mL, the mean kidney length was 13.9 cm and the weight was 142 g. There were no intraoperative complications; at autopsy, there was no pelvic or bowel injury. CONCLUSIONS: Pure NOTES transvaginal nephrectomy is feasible in the porcine model. It has the potential of a less morbid approach, providing truly scar-less surgery. Further development of instrumentation is necessary.




“Transgastric and transperineal natural orifice translumenal endoscopic surgery (NOTES) in an appendectomy test bed.”

Jayaraman, S. and C. M. Schlachta (2009).

Surgical Innovation 16(3): 223-227.


Introduction. Our purpose was to establish a NOTES appendectomy test bed to evaluate whether the transgastric or transperineal (transvaginal) approach is most efficient. Methods. Using the uterine horns of female pigs as a model for appendectomy, 18 NOTES appendectomies were performed in 2 arms: 9 transgastric and 9 transvaginal. The primary outcome was mean total operative time for each technique excluding access closure. Secondary outcomes were peritoneal access and resection times. Means were compared using Student’s t-test. Results. Transgastric cases were faster than transperineal (46.5 ± 14.5 vs 60.0 ± 20.2 minutes, P = .02). Most of the improvement in transgastric times was due to faster resection (37.9 ± 17.4 vs 51.3 ± 16.5 minutes, P = .03). Neither approach was faster for peritoneal access (8.2 ± 3.4 vs 8.3 ± 4.5 minutes, nonsignificant). A significant learning curve was not demonstrated for the transgastric approach (53.0 vs 40.3 minutes, nonsignificant). A significant learning curve was demonstrated for the transperineal approach (76.0 vs 46.7 minutes, P = .02). Transperineal times improved over the study and approached transgastric; however, the last three transgastric cases were still significantly faster than the last three transperineal (40.3 vs 46.7 minutes, P = .02). No complications occurred in either group. Conclusions. The transgastric as compared with transperineal approach to NOTES appendectomy resulted in improved operative time in this model. The transperineal approach demonstrated a significant learning curve with operative times between techniques converging over time. This NOTES appendectomy test bed is suitable for evaluating NOTES innovations.




“Gasless single-port access endoscopic surgery in urology: Minimum incision endoscopic surgery, MIES: Review Article.”

Kihara, K., S. Kawakami, et al. (2009).

International Journal of Urology 16(10): 791-800.


Minimum incision endoscopic surgery (MIES) is a gasless, single-port access, cost-effective, and minimally invasive surgery that has been in development since the late 1990s. Use of MIES has steadily increased in Japan and Asia and has been introduced into Europe and the USA. In 2006, MIES was certified by the Japanese government as an advanced surgery and since 2008 it has been covered by the Japanese universal health insurance system as a new surgical technique. Briefly, MIES involves an initial minimum incision (a single port) that permits extraction of the target specimen. A wide working space through the port is then made by separating the anatomical plane extraperitoneally. This is maintained with special retractors instead of gas insufflation. All instruments including an endoscope are inserted through the port and the operation is completed. The size of the port can be tailored to the situation if necessary, which contributes to preclusion of patient selection. The procedure uses only two disposable devices that are inexpensive, resulting in low equipment costs. Surgeons have the benefits of magnified vision through endoscopy as well as stereovision and panoramic vision of naked eyes through the port, which reduces the technical demands of the procedure. Techniques for two basic MIES procedures allow MIES to be performed for most urological organs and in extraordinary cases by their modifications. Thus, the MIES system permits minimally invasive surgery without use of CO2 gas, which is ideal from medical, environmental and economic perspectives, is cost-effective and minimizes patient selection. © 2009 The Japanese Urological Association.




“Video. Natural Orifice Translumenal Endoscopic Surgery with a miniature in vivo surgical robot.” Lehman, A. C., J. Dumpert, et al. (2009).

Surgical Endoscopy 23(7): 1649.


BACKGROUND: The application of flexible endoscopy tools for Natural Orifice Translumenal Endoscopic Surgery (NOTES) is constrained due to limitations in dexterity, instrument insertion, navigation, visualization, and retraction. Miniature endolumenal robots can mitigate these constraints by providing a stable platform for visualization and dexterous manipulation. This video demonstrates the feasibility of using an endolumenal miniature robot to improve vision and to apply off-axis forces for task assistance in NOTES procedures. METHODS: A two-armed miniature in vivo robot has been developed for NOTES. The robot is remotely controlled, has on-board cameras for guidance, and grasper and cautery end effectors for manipulation. Two basic configurations of the robot allow for flexibility during insertion and rigidity for visualization and tissue manipulation. Embedded magnets in the body of the robot and in an exterior surgical console are used for attaching the robot to the interior abdominal wall. This enables the surgeon to arbitrarily position the robot throughout a procedure. RESULTS: The visualization and task assistance capabilities of the miniature robot were demonstrated in a nonsurvivable NOTES procedure in a porcine model. An endoscope was used to create a transgastric incision and advance an overtube into the peritoneal cavity. The robot was then inserted through the overtube and into the peritoneal cavity using an endoscope. The surgeon successfully used the robot to explore the peritoneum and perform small-bowel dissection. CONCLUSION: This study has demonstrated the feasibility of inserting an endolumenal robot per os. Once deployed, the robot provided visualization and dexterous capabilities from multiple orientations. Further miniaturization and increased dexterity will enhance future capabilities.




“Robotic-assisted single-incision right colectomy: early experience.”

Ostrowitz, M. B., D. Eschete, et al. (2009).

Int J Med Robot.


BACKGROUND: Application of laparoendoscopic single-site surgery (LESS) is increasing across surgical disciplines. In addition to the possibility of decreased postoperative pain, LESS offers better cosmesis with virtually ‘scarless’ surgeries, while avoiding the increased costs and complexity of natural orifice surgery. Instrument conflict minimization often requires the crossing of articulating instruments, which we believe can be more intuitively facilitated using the daVinci-S((R)) robotic system. We describe our early experience with three robotic single-incision right hemicolectomies. METHODS: Three robotic single-incision right hemicolectomies were performed using the daVinci-S robotic system, utilizing a single 4 cm incision through or around the umbilicus. The procedure was performed using three robotic arms, a 12 mm camera and two 8 mm robotic ports. A medial to lateral approach was used and an extracorporeal resection and anastomosis was performed after undocking the robot. RESULTS: There were no intraoperative or postoperative complications. Average operative time was 152 min. The first case was converted to non-robotic single-incision right hemicolectomy during mobilization of the ascending colon, due to uncontrollable air leakage around the ports. The second and third cases were successfully completed without air loss by purse-stringing sutures around each individual port and the use of the SILS() port, respectively. CONCLUSIONS: Robotic-assisted single-incision right hemicolectomy can be successfully and safely performed using the daVinci-S robotic system. Several techniques may be employed to prevent the loss of pneumoperitoneum. We believe right hemicolectomy lends itself to single-site surgery because specimen extraction requires a 4 cm incision and may confer patient benefit, with decreased postoperative pain and improved cosmesis. By crossing the robotic instruments and reassigning control of the arms, the robot represents a means to help perform these procedures safely by allowing them to be performed in a more intuitive fashion. Copyright (c) 2009 John Wiley & Sons, Ltd.




“Women’s positive perception of transvaginal NOTES surgery.”

Peterson, C. Y., S. Ramamoorthy, et al. (2009).

Surgical Endoscopy 23(8): 1770-1774.


BACKGROUND: Two decades ago, minimally invasive surgery (MIS) was introduced and led to a revolution in modern surgery. Currently MIS procedures are the standard of care for many surgical interventions and patients often seek out surgeons with special training in MIS. Today, natural orifice transluminal endoscopic surgery (NOTES) appears to be on the threshold of another such revolution. We surmise that its advantages are similar to those of other MIS procedures, but there are no associated abdominal wall complications as there are no abdominal incisions. To date, there is no data evaluating women’s perceptions of such a procedure and their willingness to consent to this type of surgical approach. METHODS: We surveyed 100 women who were given a written description of MIS and NOTES surgery along with a 10-question survey exploring their concerns and opinions regarding transvaginal surgery. RESULTS: The majority of women (68%) indicated that they would want a transvaginal procedure in the future because of decreased risk of hernia and decreased operative pain (90 and 93%, respectively), while only 39% were concerned with the improved cosmesis of NOTES surgery. Of the women polled, nulliparous women and those under age 45 years were significantly more often concerned with how transvaginal surgery may affect healthy sexual life and fertility issues (p < 0.05). Of the women who would not prefer transvaginal surgery, a significant number indicated concerns over infectious issues (p < 0.05). CONCLUSIONS: Our study shows that there is considerable public interest in NOTES surgery and women would be receptive to this new surgical technique. Our study highlights a strong need for early reporting of outcomes data to enlighten ourselves, and our patients, about this exciting new technology.




“Laparo-endoscopic single-site surgery in urology: Is robotics the missing link?”

Rané, A., G. Y. Tan, et al. (2009).

BJU International 104(8): 1041-1043.




“Single-port urological surgery: single-center experience with the first 100 cases.”

White, W. M., G. P. Haber, et al. (2009).

Urology 74(4): 801-804.


OBJECTIVES: To present perioperative outcomes in an observational cohort of patients who underwent LaparoEndoscopic Single Site (LESS) surgery at a single academic center. METHODS: A prospective study was performed to evaluate patient outcomes after LESS urologic surgery. Demographic data including age, body mass index, operative time, estimated blood loss, operative indications, complications, and postoperative Visual Analog Pain Scale scores were accrued. Patients were followed postoperatively for evidence of adverse events. RESULTS: Between September 2007 and February 2009, 100 patients underwent LESS urologic surgery. Specifically, 74 patients underwent LESS renal surgery (cryoablation, 8; partial nephrectomy, 15; metastectomy, 1; renal biopsy, 1; simple nephrectomy, 7; radical nephrectomy, 6; cyst decortication, 2; nephroureterectomy, 7; donor nephrectomy, 19; and dismembered pyeloplasty, 8) and 26 patients underwent LESS pelvic surgery (varicocelectomy, 3; radical prostatectomy, 6; radical cystectomy, 3; sacral colpopexy, 13; and ureteral reimplant, 1). Mean patient age was 54 years. Mean body mass index was 26.2 kg/m(2). Mean operative time was 199 minutes. Mean estimated blood loss was 136 mL. No intraoperative complications occurred. Six patients required conversion to standard laparoscopy. Mean length of hospitalization was 3 days. Mean Visual Analog Pain Scale score at discharge was 1.5/10. At a mean follow-up of 11 months, 9 Clavien Grade II (transfusion, 7; urinary tract infection, 1; deep vein thrombosis, 1) and 2 Clavien Grade IIIb (recto-urethral fistula, 1; angioembolization, 1) surgical complications occurred. CONCLUSIONS: In our experience, LESS urologic surgery is feasible, offers improved cosmesis, and may offer decreased pain. Complications are consistent with the published data. Whether LESS urologic surgery is superior in comparison with standard laparoscopy is currently speculative.




“Influence of 2D and 3D view on performance and time estimation in minimal invasive surgery.” Blavier, A. and A. S. Nyssen (2009).

Ergonomics 52(11): 1342-1349.


This study aimed to evaluate the impact of two-dimensional (2D) and three-dimensional (3D) images on time performance and time estimation during a surgical motor task. A total of 60 subjects without any surgical experience (nurses) and 20 expert surgeons performed a fine surgical task with a new laparoscopic technology (da Vinci robotic system). The 80 subjects were divided into two groups, one using 3D view option and the other using 2D view option. We measured time performance and asked subjects to verbally estimate their time performance. Our results showed faster performance in 3D than in 2D view for novice subjects while the performance in 2D and 3D was similar in the expert group. We obtained a significant interaction between time performance and time evaluation: in 2D condition, all subjects accurately estimated their time performance while they overestimated it in the 3D condition. Our results emphasise the role of 3D in improving performance and the contradictory feeling about time evaluation in 2D and 3D. This finding is discussed in regard with the retrospective paradigm and suggests that 2D and 3D images are differently processed and memorised.




“A novel tactile force probe for tissue stiffness classification.”

Darvish, B., S. Najarian, et al. (2009).

American Journal of Applied Sciences 6(3): 512-517.


In this study, we have proposed a new type of tactile sensor that is capable of detecting the stiffness of soft objects. The sensor consists of a brass cylinder with an axial bore. An iron core can easily move inside the bore. Three peripheral bobbins were machined in the cylinder around which three coils have been wound. One of the coils was excited with an alternating current which caused a voltage to be induced in two other coils. A return spring was used to return the core to its initial position after it has been moved. The sensor was pressed against the surface of the object whose stiffness was going to be measured. The position of the core in this state was depended on the stiffness of the given object and the spring constant and was measured by measuring the change in the induced voltage in secondary coils. The proposed sensor was capable of measuring two contact parameters namely the applied force and the stiffness of the object. Using the data of this sensor, three different objects, made of polyurethane, silicon rubber and paraffin gel were discriminated. Thus, this sensor could be used in robot hands and minimally invasive surgery tools to improve their operation. © 2009 Science Publications.




“Robotically Assisted Ablation Produces More Rapid and Greater Signal Attenuation Than Manual Ablation.”

Koa-Wing, M., P. Kojodjojo, et al. (2009).

J Cardiovasc Electrophysiol.


Robotically Assisted Ablation. Introduction: Robotic remote catheter ablation potentially provides improved catheter-tip stability, which should improve the efficiency of radiofrequency energy delivery. Percentage reduction in electrogram peak-to-peak voltage has been used as a measure of effectiveness of ablation. We tested the hypothesis that improved catheter-tip stability of robotic ablation can diminish signals to a greater degree than manual ablation. Methods:In vivo NavX maps of 7 pig atria were constructed. Separate lines of ablation were performed robotically and manually, recording pre- and postablation peak-to-peak voltages at 10, 20, 30, and 60 seconds and calculating signal amplitude reduction. Catheter ablation settings were constant (25W, 50 degrees , 17 mL/min, 20-30 g catheter tip pressure). The pigs were sacrificed and ablation lesions correlated with NavX maps. Results: Robotic ablation reduced signal amplitude to a greater degree than manual ablation (49 +/- 2.6% vs 29 +/- 4.5% signal reduction after 1 minute [P = 0.0002]). The mean energy delivered (223 +/- 184 J vs 231 +/- 190 J, P = 0.42), power (19 +/- 3.5 W vs 19 +/- 4 W, P = 0.84), and duration of ablation (15 +/- 9 seconds vs 15 +/- 9 seconds, P = 0.89) was the same for manual and robotic. The mean peak catheter-tip temperature was higher for robotic (45 +/- 5 degrees C vs 42 +/- 3 degrees C [P < 0.0001]). The incidence of >50% signal reduction was greater for robotic (37%) than manual (21%) ablation (P = 0.0001). Conclusion: Robotically assisted ablation appears to be more effective than manual ablation at signal amplitude reduction, therefore may be expected to produce improved clinical outcomes. (J Cardiovasc Electrophysiol, Vol. pp. 1-7).




“Towards image guided robotic surgery: Multi-arm tracking through hybrid localization.”

Kwartowitz, D. M., M. I. Miga, et al. (2009).

International Journal of Computer Assisted Radiology and Surgery 4(3): 281-286.


Objective: Use of the robotic assisted surgery has been increasing in recent years, due both the continuous increase in the number of applications and the clinical benefits that surgical robots can provide. Currently robotic assisted surgery relies on endoscopic video for navigation, providing only surface visualization, thus limiting subsurface vision. To be able to visualize and identify subsurface information, techniques in image-guidance can be used. As part of designing an image guidance system, all arms of the robot need to be co-localized in a common coordinate system. Methods: In order to track multiple arms in a common coordinate space, intrinsic and extrinsic tracking methods can be used. First, the intrinsic tracking of the daVinci, specifically of the setup joints is analyzed. Because of the inadequacy of the setup joints for co-localization a hybrid tracking method is designed and implemented to mitigate the inaccuracy of the setup joints. Different both optical and magnetic tracking methods are examined for setup joint localization. Results: The hybrid localization method improved the localization accuracy of the setup joints. The inter-arm accuracy in hybrid localization was improved to 3.02 mm. This inter-arm error value was shown to be further reduced when the arms are co-registered, thus reducing common error. © CARS 2009.




“Tool guidance using a compact robotic assistant.”

Nelson, C. A., X. Zhang, et al. (2009).

Journal of Robotic Surgery: 1-3.


Surgical robots in popular clinical use are generally large machines, which limits their practical use to some extent. This study aims to investigate the potential of a small, table-mounted robot for tool guidance in minimally invasive surgery (MIS). In particular, its multipurpose use for guidance of various tools was investigated. A compact robot capable of manipulating MIS tools was designed and built. The robot can move in four degrees of freedom (DOF): three rotational and one translational. These DOF correspond to motion constrained by a trocar. The robot kinematics are based on a bevel-geared “spherical mechanism,” which allows trocar-constrained motion using a small mechanical device. The robot was tested in a porcine model by manipulating scopes and robotic grasping tools using a joystick as directed by a surgeon. Holding a laparoscope, the robot provided superior stability as a camera assistant. It manipulated the scope for visualization of the liver, spleen, bowel, etc. during manual tissue manipulation. Its compactness allowed increased space around the operating table, and the robot was in fact manipulated by joystick from across the room. Maneuvering grasping tools, the robot similarly provided a stable and dexterous platform for tissue manipulation. The test results suggest that the use of robotics for surgery may be enhanced via compact devices to include more hybrid robotic-manual procedures. The robot motion is smoother and more repeatable than that of a human operator. Use of a foot joystick could also place camera control directly with the surgeon. Flexible endoscopes can also be used with the robot for highly dexterous visualization. Notably, changing tools with this system is a very straightforward process and can be achieved without re-registration of the robot’s position/orientation. Therefore, combined with other simple robotic tools for grasping, cautery, etc., compact robotic systems based on this technology could replace the large systems in current use, potentially increasing the impact of robots on medical care. This represents an important step towards multifunctional compact surgical robots. © 2009 Springer-Verlag London Ltd.




“Video Technique for Human Robot-Assisted Microsurgical Vasovasostomy.”

Parekattil, S. J., H. N. Atalah, et al. (2009).

J Endourol.


Abstract Previous studies have shown that robot-assisted microsurgical vasovasostomy (RAVV) has technical advantages over pure microscopic vasovasostomy (MVV) in animal and human models. This study presents a video technique and initial results for RAVV in 20 human cases compared with 7 MVV cases by a single fellowship-trained microsurgeon from July 2007 to June 2009. A three-layer 10-0 and 9-0 suture anastomosis was performed with up to 22 months follow-up (mean 3 months). Mean operative duration for the RAVV cases was 109 and 128 minutes for MVV (p = 0.09). At 2 months postoperatively, all patients were patent. Mean sperm count was 54 million in RAVV and 11 million in MVV (p = 0.04). The use of robotic assistance in microsurgical vasovasostomy may have potential benefit over MVV in decreasing operative duration and significantly improving early semen analysis measures. Further evaluation and longer follow-up is needed to assess its clinical potential.




“Air-cushion force-sensitive probe for soft tissue investigation during minimally invasive surgery.”Zbyszewski, D., B. Challacombe, et al. (2009).

Journal of Endourology 23(9): 1421-1424.


Purpose: We propose a novel air-cushion force-sensitive indentation probe for rapidly locating abnormalities within soft tissues during minimally invasive surgery (MIS). Method: This system comprises a spherical-tipped optical-based force-sensing device that employs an air-cushion technique to conduct continuous rolling indentation over the surface of soft tissues. The device combines rapid acquisition of tissue resistance forces with high manoeuvrability. To determine the stiffness variation, the interaction forces acquired during rolling indentation can be integrated to generate spatio-mechanical stiffness images that can be used for tissue diagnosis. Results: Rolling indentation tests on the probe were carried out on excised porcine liver. The results demonstrate that the probe can be used to acquire force signals for constructing mechanical images, reliably indicating areas of variable stiffness. Conclusions: This probe could be used to characterize the force tissue deflection profile of soft tissues during minimally invasive surgery providing surgeons with enhanced haptic feedback. © Copyright 2009, Mary Ann Liebert, Inc.