Applications of Robotics in Urology- A Review

 

Arunima Chandran, Ammu, Merlin. N. J*, Shaiju S Dharan

Department of Pharmacology, Ezhuthachan College of Pharmaceutical Sciences Trivandrum

 

ABSTRACT:

A robot is defined as a computerized system that can even perform surgeries called robotic surgery. Initially robotics was used in cardiac surgery. But nowadays mainly it is used in urological procedures. Robotics are used in radical cystectomy, partial cystectomy, partial nephrectomy, pyeloplasty, nephroureterectomy, management of urolithiasis and uretal surgery. Robot assistance is emerging as a significant adjunct to pure laparoscopy.

 

 

 

INTRODUCTION:

Urology is a dynamic surgical discipline, which has undergone many developments and refinements over the past few decades. The advent of laparoscopic surgery was a major breakthrough in the urologic landscape and provided a minimally invasive alternative to conventional open procedures. The decreased intra operative estimated blood loss (EBL), shorter hospital stay and quicker return to function makes laparoscopic urologic surgery extremely appealing to physicians and patients alike. The bottleneck with respect to laparoscopic urologic surgery seems to be relatively long learning curve that is required for a surgeon to achieve proficiency.¹

 

 

 

 

 

 

A robot is defined as a computerized system with a motorized part, usually an arm that is capable of interacting with the environment. Depending on the amount of surgeon-machine interaction, robotic surgery can be further divided into shared-control, telesurgical and supervisory-controlled. In the shared-control system, the robot simply offers steady-hand manipulations of an instrument placed in its arms. The surgeon directly carries out the procedure and the robot, replaces an assistant. In a telesurgical system, the surgeon does not directly operate but manipulates the robotic arms during the procedure and the robot is like an instrument in his hands. Using real-time image feedback, the surgeon may operate from a remote location using sensor data from the robot. Because technically the robot is performing the procedure, it is considered robotic surgery.

 

Applications of Robotics:

During the course of the past century, man has developed numerous automated tools to increase productivity, quality, and product performance. As the need for production versatility emerged, man created programmable tools which could easily adapt to new operations. These systems, usually termed as robots, are mechanical systems controlled by microprocessors and equipped with sensors and motors.²

 

Robot-assisted radical cystectomy:

The probability of developing carcinoma of the bladder increases as an individual gets older; moreover, in patients over the age of 80, bladder cancer becomes the fourth highest killer. Therefore, in older patients who are acceptable surgical candidates, it is imperative that we utilise surgical techniques that will minimise stress inflicted to the body and allow for a smoother return to function. Robot-assisted radical cystectomy (RARC) offers an attractive minimally invasive alternative to the current gold standard of open radical cystectomy (ORC) for muscle-invasive bladder cancer and high-risk non-muscle–invasive disease. While there is still much work that needs to be done to assess longterm oncological outcomes, RARC is an evolving technique that affords patients and physicians alike an efficacious minimally invasive treatment option in the treatment of bladder cancer.³

 

Robot-assisted partial cystectomy:

Robot-assisted partial cystectomy (RAPC) for the treatment of malignant bladder lesions was recently performed in three patients and found to be technically feasible with acceptable intraoperative and postoperative outcomes. The procedure seems to confer satisfactory short-term oncological outcomes and provides a bladder sparing surgical option in select patients.

 

KIDNEY:

Robot-assisted partial nephrectomy:

Robot-assisted partial nephrectomy (RAPN) was first described in 2004 by Gettman et al. Recent evidence suggests that RAPN offers equivalent oncological control to open partial nephrectomy (OPN) and laparoscopic partial nephrectomy (LPN) while providing the additional benefit of shorter hospital stay, less intraoperative EBL and shorter warm ischaemia time (WIT).

 

Robot-assisted pyeloplasty:

Robot-assisted pyeloplasty (RAP) provides a viable alternative to the current gold standard open approach for the treatment of ureteropelvic junction (UPJ) obstruction. Gettman et al. reported one of the earlier comparisons of RAP with the laparoscopic approach and found that the robotic method was associated with less operating time.

 

Robot-assisted nephroureterectomy with excision of the bladder cuff:

Upper tract transitional cell carcinoma (TCC) is treated in the status quo with open nephroureterectomy with excision of the bladder cuff. Early feasibility studies show that robotassisted nephroureterectomy with excision of the bladder cuff (RANUT) provides a viable treatment option for this long and technically challenging procedure.

 

Robotic management of urolithiasis:

 Percutaneous nephrolithotomy is the current treatment of choice for large renal stones but robot-assisted extended pyelolithotomy (REP) provides an appealing option in cases of staghorn calculi and in patients undergoing concurrent RAP.

 

 

Figure: Stepwise demonstration of robot assisted partial nephrectomy; (a) Dissected renal hilum demonstrating renal artery (RA) and renal vein (RV); (b) Dissected renal tumor and renal scoring performed prior to clamping the RA; (c) View showing the renal parenchyma after tumor excision; (d) Repair of pelvicalyceal system (PCS) and small renal vessels; (e) Renal parenchyma reconstruction (renorrhaphy); and (f) final view showing closure of Gerota’s fascia.

 

FEMALE UROLOGY:

The robotic repair of primary vesicovaginal fistula was first described in five patients by Sundaram et al. in 2006 and was associated with acceptable postoperative outcomes. In a matched comparative analysis of open versus robotic repair of recurrent vesicovaginal fistula, robot-assisted techniques were found to be more effective in regard to better morbidity related outcomes while providing similar postoperative success rates.

 

URETER:

Robot-assisted ureteral surgery:

Robotic assistance is increasingly being utilised in a variety of urologic procedures and is furthering the applicability of this exciting technology. Hemal and colleagues recently reported the feasibility of robotic intracorporeal or extracorporeal ureteric tapering with ureteroneocystostomy for primary symptomatic obstructive megaureter. Various ureteral pathologies seem to be especially amenable to robotic repair in the hands of an experienced surgeon with Hemal et al. demonstrating the feasibility of robotic ureteroneocystostomy, ureteroureterostomy, ureteral stump excision and ureterosciatic hernia repair.⁴

 

CONCLUSION:

Robot assistance is emerging as a significant adjunct to pure laparoscopy. It has to be viewed as a tool for laparoscopy rather than as independent surgical modality. The main advantages for this technology are its enhanced dexterity, precision and ergonomics. It has also enabled availability of laparoscopy to patients who would otherwise be candidates for open surgery. The lack of significant experience and training opportunities for pure laparoscopy makes it imperative that easier learning tools such as robotic assistance are available to surgeons. There are increasing demands for minimally invasive surgery, despite the controversy over whether patients benefit from minimally invasive procedures as compared to open surgery. Robotic surgery has demonstrated some clear benefits. It remains to be seen whether these benefits will outweigh the associated costs over the long term. In the future, surgical robots will be smaller, less expensive, easier to operate, and should seamlessly integrate emerging technologies from a number of different fields. Such advances will enable continued advancements in surgical instrumentation and, ultimately, surgical care for the whole world.

 

REFERENCE:

1.     Jeffrey S Berger et al. Anesthetic Considerations for Robot-Assisted Gynecologic and Urology Surgery. J Anesth Clin.2013; 54 (6): 546-60.

2.     Buckingham RA, Buckingham RO. Robots in operating theatres. BMJ.1995; 311: 1479.

3.     Prem N Kakar et al. Robotic invasion of operation theatre and associated anaesthetic issues. A review. Indian journal of Anaesthetia;55 (1):18-25.

4.     Reynolds W, Jr. The first laparoscopic cholecystectomy. JSLS 2001;5 (1):89-94.

 

 

 

 

Accepted on 04.12.2019            © A&V Publications All right reserved