Computer Assisted Robotic Surgery in Urooncology

Abstract

Robotic surgery is a significant advance in the realm of urologic surgery esp. for uro genital cancers and reconstructive procedures. Robotic surgery is associated with precision and ease in dissection, incision and suturing with less steep learning curve in comparison to laparoscopy. It provides all benefits of minimally invasive surgery. At present, cost is a prohibitive factor. Robotic surgery is going to stay and is going to open new avenues for, image guided and telepresence surgery.

Urologists are pioneers in endoscopy and started endoscopic surgery more than 100 years back followed by endourologic, Laparoscopic and now Robotic Urologic Surgery. During the last 10 years, significant progress had been made in robotic assisted laparoscopic surgery and a new standard of care has been set up for many Urologic diseases.

The term robot was first coined by Karel capek in 1921 in his play Rossums Universal Robots. The robot word was derived from the Czech word “Robota” meaning “Industrial worker”. It has gained popularity through science fiction such as Blade Runner & Star Wars. The computers are in use in every walk of our life and now are introduced in our operation theatre.

The first Urologic surgery with the assistance of robot was a transurethral resection of prostate performed by Wickham in 1979, however due to uncontrolled resection and bleeding, this has not become popular. In Italy, robot was used to perform TRUS guided biopsy but did not provide any advantage. At John Hopkins Medical center, Percutaneous access to the Kidney (PAKY) was developed with the assistance of robot and the system is currently being evaluated clinically. Automated Endoscopic System for Optimal Positioning (AESOP) was the first active robotic device approved by the FDA. AESOP is a robotic arm with motorized joints that is controlled by a surgeon through the speech recognition system. Endo-Assist is a similar device, but the arm is controlled by the surgeon’s head movement. These devices have paved the way for Master Slave devices (da Vinci Surgical system), which is at present manufactured only by Intitutive Surgicals, USA. A group of urologist in 1996 in France started robotic radical prostatectomy but it was popularized by Mani Menon from Detroit,USA in 2001. After Radical Prostatectomy, robotic urologic surgery was performed for Bladder ,kidney and Retroperitoneal dissection for testicular tumours. Today, there are more than 1,000 da Vinci robots are installed all over the world and mainly used in Urologic surgery. After seeing the success in Urology, other surgical specialties have started exploring its utility.

Da Vinci Surgical System

The da Vinci surgical system consists of a surgeon’s computer console for surgeon interaction, a surgical cart that houses the video and lighting equipment, and a robotic tower that supports three or four arms. The surgeon’s console provides the user a three-dimensional view through a binocular viewport. Interaction is through “masters” in to which the surgeon inserts his or her hands. The masters allow free movement that is translated intuitively in to seven degrees of freedom at the robotic instruments tips. A double lens laparoscopic system is combined in to a single three dimensional binocular view. The robotic tower supports three or four robotic with one arm controlling the camera. Endowrist instruments come in a wide range of types including graspers, scissors, hook, knives, hot scissors and surgical energy devices.

The master slave system has advantages of an ergonomic environment for performing surgery for the surgeon. Surgeon can make natural hand movements rather than counter intuitive movements. It filters hand tremors and scale movements, by digitizing surgeon’s hand movements. The robotic arms provide additional degree of freedom inside the patient’s body. It provides 3-D view of the surgical field & improves depth perception. With the seven degree of freedom at the instrument tips and 3-D view, suturing becomes much simpler in comparison to laparoscopic surgery.

The Patient’s advantage of robotic surgery is that it is a minimally invasive procedure with less morbidity, shorter hospital stay and early return to work.

The disadvantage of robotic surgery is the initial cost of equipment and cost of reusable robotic instruments. At present, the usage is limited to only 10 per instruments as a result cost of the surgery is too much. This is the biggest limiting factor for robotic surgery in India. It is hoped that the cost will come down in future to make robotic surgery affordable to a large number of patients. As any new procedure, there is a learning curve in the robotic surgery, however in comparison to laparoscopic surgery, there is a short learning curve for the complex urological procedures. The duration of surgery is same as for open surgery and initially longer during the learning. The comparative trials are going on to find out the efficacy and effectiveness of robotic surgery in Urooncology in comparison to open and laparoscopic surgery.

Prostate

Robot-Assisted Radical Prostatectomy (RARP)

RARP seems to have overtaken retropubic radical prostatectomy (RRP) as the treatment of choice due to patient preference for minimally invasive surgical options [1]. Patient intrigue coupled with aggressive marketing of robotic surgery means that the majority of prostatectomies performed in the status quo utilises the da Vinci platform [1]. Robot-assisted radical prostatectomy (RARP) is rapidly gaining acceptance in the urologic community as a safe and efficacious treatment option for localised prostatic adenocarcinoma with comparable oncological outcomes as open and laparoscopic counterparts [2]. RARP has come a long way since the first large series appeared in the literature [3], and a recent analysis by Menon et al. found that RARP provided acceptable rates of biochemical recurrence at 5 years for clinically localised prostate cancer. This study was especially promising as it included a large cohort of patients for analysis and demonstrated that when an experienced and well-trained surgeon performs RARP, adequate long-term oncologic efficacy is obtained. Newly emerging evidence reinforces this point, with RARP having lower rates of positive surgical margins than RRP and laparoscopic radical prostatectomy (LRP).

In one of the largest studies to date, Menon et al. found that their Vattikuti Institute prostatectomy (VIP) technique achieved comparable oncological outcomes to conventional nerve-sparing modalities but offered 84% of patients total urinary control at a mean 12-month follow-up, with a further 8% using liners for reassurance purposes [4]. Furthermore, the VIP technique utilised the increased dexterity of the robot’s wristed instruments and high-magnification 3D view to ensure preservation of the lateral prostatic fascia, which conferred better erectile function postoperatively as compared to conventional open surgery [2, 5]. The aforementioned results were corroborated in a meta-analysis from various high-volume centers, which revealed that RARP had better return of urinary continence and improved sexual function postoperatively than after open and laparoscopic modalities [2]. Patel et al. recently reported that the age of the patient had a significant effect on potency after RARP, with younger men having quicker return to sexual function at 6 weeks, 3, 6 and 12 months postoperatively [6]. Complication rates after RARP in a recent study of 2,500 patients were found to be 5.08%, with the vast majority of complications being either Clavien grade I or II [7]. RARP also seemed to have decreased intraoperative EBL, risk of intraoperative transfusion and anastomotic strictures in comparison with RRP [2]. Coupled with the fact that RARP seems to have a shorter learning curve than LP [8], it appears that the use of robotic surgery in the realm of localised prostatic adenocarcinoma will reach ever greater heights. We have performed about 250 RALP with comparable results with less blood loss, minimum hospital stay.

Bladder

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 [9]. The interest generated since the initial description of RARC [10–12] has been immense and larger case series are now appearing in the literature. Pruthi et al. reported their initial experience with 100 patients who underwent RARC and found that there were no positive surgical margins and that the mean hospital stay was 4.9 days, with mean bowel movement being at 2.8 days [13]. The complication rate appeared to be 36%, with 8% of these being Clavien grade III or higher [13]. In a mean follow-up of 21 months, the authors reported that 15 patients manifest recurrent malignancy with 6 individuals succumbing to their disease [13]. The same group reported the first prospective randomised trial of ORC versus RARC in 41 patients and found that there was no significant difference in postoperative complication rate (33% RARC vs. 50% ORC; P = 0.279) and mean hospital stay (5.1 days RARC vs. 6.0 days ORC; P = 0.239) [14]. The investigators reported that RARC had a longer operative time than ORC (4.2 vs. 3.5 h; P < 0.001 ), but that there was less intraoperative EBL associated with RARC (258 vs. 575 ml; P < 0.001) [14]. RARC also appeared to confer quicker time-to-bowel movement and time to flatus with less use of narcotic analgesics for pain relief [14]. This landmark study used a prospective randomised clinical trial to demonstrate that RARC was not inferior in comparison to ORC and matched up favourably with respect to various intraoperative and postoperative outcomes [14]. While there is still much work that needs to be done to assess long-term 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. We have performed about 30 Robotic Radical cystectomy with extracorporeal urinary diversion.

Kidney

Robot-Assisted Partial Nephrectomy

Robot-assisted partial nephrectomy (RAPN) was first described in 2004 by Gettman et al. [15]. It has since enjoyed widespread adoption at many high-volume centres. 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) [16]. In an analysis of over 100 RAPN and LPN cases, no significant difference was found in the rate of focal positive margins between the two modalities [17]. While it may be too early to assess long-term oncological control in this relatively new surgical technique, early results from a series of 100 RAPN showed no tumour recurrence at 12 months [18]. Intraoperative EBL during partial nephrectomy has been shown to be an accurate predictor of early and late recovery of kidney function [19], and considering that 26% of patients undergoing partial or radical nephrectomy have some degree of renal impairment preoperatively [20], RAPN holds the promise of better long-term nephron preservation. Studies also show that RAPN generally provides shorter WIT as compared to LPN. This seems to hold true even in cases that require calyceal repair, have complex renal tumours or have multiple tumoursNew evidence reveals that RAPN has a relatively short learning curve with regard to parameters such as acceptable WIT and total operative time. All the aforementioned advantages suggest, in our opinion, that RAPN will garner widespread acceptance as the minimally invasive treatment of choice for small renal masses

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 robot-assisted nephroureterectomy with excision of the bladder cuff (RANUT) provides a viable treatment option for this long and technically challenging procedure [21]. Eandi and colleagues reported their initial experience with 11 patients who underwent RANUT for upper tract TCC and showed promising short-term intraoperative and postoperative outcomes with regard to oncological efficacy, hospital stay, EBL and operative time. (22)This was the first case series to utilise a completely robotic approach but required undocking and redocking of the da Vinci system during the procedure to allow for better surgical access. As can be inferred, this increased total operative time by 10–15 min [22]. In what comprised the largest series of RANUT till date, 15 patients underwent RANUT with excision of the bladder cuff for upper tract TCC [23]. The mean operative time was 184 min, average EBL was 103 ml and mean hospital stay was 2.7 days [23]. More importantly, there were no complications, no positive surgical margins and no cancer recurrence on short-term follow-up [23]. Compared to other series of RANUT, Hemal and colleagues reported that their technique was associated with less EBL, shorter operative time and less hospital stay [23]. They attribute this to the strategic placement of ports, which allowed for a seamless transition between the nephrectomy portion and excision of bladder cuff part of the case [23]. Additionally, the careful handling of the ureter and tactical bladder reconstruction were also instrumental in improved intraoperative and postoperative outcomes [23].

Testicular Cancer

Testicular Cancer is not a common cancer, but it effects males between the age of 20–40 years which is a productive age for men and is a cause of great concern. Testicular cancer spread to Retroperitoneal lymphnodes in abdomen. For complete treatment, management is removal of lymphnodes which is known as Retroperitoneal lymph node dissection (RPLND). It is indicated in Stage 1 and 2 in Non seminomatous germ cell tumour (NSGCT) and also post chemotherapy residual lymph nodes.

RPLND is the most challenging operation in urology as lymph nodes surrounds the great vessels aorta and venacava. In the past, this operation was done by open surgery in which full abdomen has to be opened and had significant operation related complications. Recently, in few centers in world , this operation was done by key hole surgery (laparoscopic)and few cases were done robotically in Europe and America [24]. We have performed Robotic RPLND in a case of postchemotherapy residual mass in a case of NSGCT.

Our Experience

The department of Urology at AIIMS, New Delhi installed 4 arm da vinci-S surgical system and started robotic surgery since 19th July, 2006. We have performed more than 550 procedures. The commonly done procedures are Robotic Radical prostatectomy followed by Robotic pyeloplasty. The other procedures done are Radical cystectomy and extracorporeal diversion, Radical Nephrectomy, Partial Nephrectomy, Nephroureterectomy, Ureteric reimplantation, VVF repair, pyelolithotomy etc. etc. Similarly at Medanta medicity hospital, we have performed 240 procedures from 1.4.2010 and all variety of Urooncologic surgeries.

Conclusion

Robotic surgery is a significant advance in the realm of urologic surgery esp. for uro genital cancers and reconstructive procedures. Robotic surgery is associated with precision and ease in dissection, incision and suturing with less steep learning curve in comparison to laparoscopy. It provides all benefits of minimally invasive surgery. At present, cost is a prohibitive factor. Robotic surgery is going to stay and is going to open new avenues for, image guided and telepresence surgery.