The history of robotics in urology

Despite being an ancient surgical specialty, modern urology is technology driven and has been quick to take up new minimally invasive surgical challenges. It is therefore no surprise that much of the early work in the development of surgical robotics was pioneered by urologists. We look at the relatively short history of robotic urology, from the origins of robotics and robotic surgery itself to the rapidly expanding experience with the master–slave devices. This article credits the vision of John Wickham who sowed the seeds of robotic surgery in urology.     

State of the art in surgical robotics: clinical applications and technology challenges.

Although it has been over 15 years since the first recorded use of a robot for a surgical procedure, the field of medical robotics is still an emerging one that has not yet reached a critical mass. Although robots have the potential to improve the precision and capabilities of physicians, the number of robots in clinical use is still very small. In this review article, we begin with a short historical review of medical robotics, followed by an overview of clinical applications where robots have been applied. The clinical applications are then discussed; they include neurosurgery, orthopedics, urology, maxillofacial surgery, radiosurgery, ophthalmology, and cardiac surgery. We conclude with a listing of technology challenges and research areas, including system architecture, software design, mechanical design, imaging compatible systems, user interface, and safety issues.     

Flexible robotics: a new paradigm

PURPOSE OF REVIEW: The use of robotics in urologic surgery has seen exponential growth over the last 5 years. Existing surgical robots operate rigid instruments on the master/slave principle and currently allow extraluminal manipulations and surgical procedures. Flexible robotics is an entirely novel paradigm. This article explores the potential of flexible robotic platforms that could permit endoluminal and transluminal surgery in the future. RECENT FINDINGS: Computerized catheter-control systems are being developed primarily for cardiac applications. This development is driven by the need for precise positioning and manipulation of the catheter tip in the three-dimensional cardiovascular space. Such systems employ either remote navigation in a magnetic field or a computer-controlled electromechanical flexible robotic system. We have adapted this robotic system for flexible ureteropyeloscopy and have to date completed the initial porcine studies. SUMMARY: Flexible robotics is on the horizon. It has potential for improved scope-tip precision, superior operative ergonomics, and reduced occupational radiation exposure. In the near future, in urology, we believe that it holds promise for endoluminal therapeutic ureterorenoscopy. Looking further ahead, within the next 3-5 years, it could enable transluminal surgery.     

Twenty-first century surgery using twenty-first century technology: surgical robotics

INTRODUCTION: The "Nintendo" surgery revolution, which began in 1987, has impacted every surgical specialty. However, our operating rooms remain isolated worlds where surgeons use awkward, primitive, rigid instruments with suboptimal visualization. We need "smart instruments," "smart technology," and "smart imaging." Is surgical robotics the answer? METHODS: We provide an analysis of current surgical technology and skills, propose criteria for what the next generation of surgical instruments and technology should achieve, and then examine the evolution and current state of surgical robotic solutions, assessing how they answer future surgical needs. Finally we report on the U.S. Military's early experience with surgical robotics and the lessons learned therein. RESULTS: Current surgical robotic technology has made remarkable progress with miniaturization, articulating hand-imitating instruments, precision, scaling, and three-dimensional vision. The specialty-specific early clinical applications reviewed are promising, but they do have limitations. Surgical robotics offers enormous military application potential. Needed future refinements are identified, including haptics, communications, infrastructure, and information integration. CONCLUSIONS: Laparoscopic surgery is a transition technology, constrained by instrument, equipment, and skill limitations. Surgical robotics or, more properly, computer-assisted surgery may be the key to the future. The operating room of the future will be an integrated environment with global reach. Surgeons will operate with three-dimensional vision, use real-time three-dimensional reconstructions of patient anatomy, use miniaturized minimally invasive robotic technology, and be able to telementor, teleconsult, and even telemanipulate at a distance, thus offering enhanced patient care and safety.     

Robotics in plastic surgery, a review

Robotic surgery is an emerging technology that is conquering the surgery field by storm. It has found solid applications in general surgery, gynecological surgery, vascular surgery, and especially in urology and cardiothoracic surgery. Its application is however restricted in the various fields of plastic surgery. There is no doubt that robots have a potential to become an important toll in reconstructive plastic surgery, but the extent of their use in aesthetic surgery is constrained. A review of the literature showed that several centers are currently using surgical robots for reconstructive and microsurgery. Robotic surgery is feasible and technically advantageous, though very costly. There is a paucity of data however concerning the long-term benefits of robotics versus conventional techniques, and none regarding aesthetic surgery applications. We strongly believe that, without ignoring the tremendous potential benefits of robotic technology in many fields of plastic surgery, no machine, no matter how sophisticated it is, will ever succeed at replacing the artistic sense, feeling, and touch necessary to achieve beauty with harmonious proportions.     

Role of robotics in laparoscopic urologic surgery

Robotic surgery is in its infancy. Small series of cases are emerging from various centers that indicate a strong role for robotics in the future of urology, surgery, and general medicine. Robotic technology is progressing on every level and will continue to be a driving force in the progress of science and medicine.     

Robotics in urologic surgery: An evolving new technology

Rapid technological developments in the past two decades have produced new inventions such as robots and incorporated them into our daily lives. Today, robots perform vital functions in homes, outer space, hospitals and on military instillations. The development of robotic surgery has given hospitals and health care providers a valuable tool that is making a profound impact on highly technical surgical procedures. The field of urology is one area of medicine that has adopted and incorporated robotic surgery into its armamentarium. Innovative robotic urologic surgical applications and techniques are being developed and reported everyday. Increased utilization and development will ultimately fuel the discovery of newer applications of robotic systems in urologic surgery. Herein we provide an overview of the history, development, and applications of robotics in surgery with a focus on urologic surgery.     

Robotic and telesurgery: will they change our future?

In urology, at the end of the last millennium, there was an increasing use of computerized technology, extracorporeal shock wave lithotripsy, microwave therapy and high-energy focused ultrasound. However, experience with manipulating robots in urological surgery is still very limited. Laparoscopic surgery is handicapped by a reduction of the range of motion because of the fixed trocar position. The da Vinci system is the first surgical system to address all these problems adequately. The system consists of two main components: the surgeon's viewing and control console with three-dimensional imaging and the surgical arm unit that positions and manoeuvres detachable surgical instruments. The surgeon performs the procedure seated at the console holding specially designed instruments. Telerobotic laparoscopic radical prostatectomy provides advantages such as stereovision, dexterity and tremor filtering, but there is a learning curve with the device, mainly because of the magnification, the three-dimensional image and the lack of tactile feedback. However, after only a short period of time, the experienced surgeon is able to become familiar with the device. The impact of robotics in urological surgery is therefore very promising, and we are convinced that it will totally change the future of urological surgery.     

El impacto de la cirugía robótica en Urología

IntroductionMore than a decade ago, robotic surgery was introduced into urology. Since then, the urological community started to look at surgery from a different angle. The present, the future hopes, and the way we looked at our past experience have all changed.MethodsBetween 2000 and 2011, the published literature was reviewed using the National Library of Medicine database and the following key words: robotic surgery, robot-assisted, and radical prostatectomy. Special emphasis was given to the impact of the robotic surgery in urology. We analyzed the most representative series (finished learning curve) in each one of the robotic approaches regarding perioperative morbidity and oncological outcomes.ResultsThis article looks into the impact of robotics in urology, starting from its background applications before urology, the way it was introduced into urology, its first steps, current status, and future expectations. By narrating this journey, we tried to highlight important modifications that helped robotic surgery make its way to its position today. We looked as well into the dramatic changes that robotic surgery introduced to the field of surgical training and its consequence on its learning curve.ConclusionBasic surgical principles still apply in Robotics: experience counts, and prolonged practice provides knowledge and skills. In this way, the potential advantages delivered by technology will be better exploited, and this will be reflected in better outcomes for patients.     

Robotic surgery

The industrial revolution demonstrated the capability of robotic systems to facilitate and improve manufacturing. As a result, robotics extended to various other domains, including the delivery of health care. Hence, robots have been developed to assist hospital staff, to facilitate laboratory analyses, to augment patient rehabilitation, and even to advance surgical performance. As robotics lead usefulness and gain wider acceptance among the surgical community, the urologist should become familiar with this new interdisciplinary field and its “URobotics” subset: robotics applied to urology. This article reviews the current applications and experience, issues and debates in surgical robotics, and highlights future directions in the field.     

Robotics in colorectal surgery: telemonitoring and telerobotics

Surgery has just passed through the laparoscopic surgery revolution, with validation of the advantages for the patient evaluated painstakingly; however, laparoscopy is a transition phase to fully information-based surgery, which only can be accomplished when hand motions are converted to information through robotic surgery systems. The main advantage is using such systems to integrate the entire surgical process. The components that will allow such a transition exist in other industries that use robotics, so it is more a matter of applying these engineering principles to surgery, rather than inventing new technologies. Robotics cannot only improve the performance of surgery, but is providing access to surgical expertise in remote and underserved areas through telementoring, teleconsultation, and telesurgery. Colorectal surgeons should seize the opportunity to begin to use surgical robotic systems in those niche areas and procedures that have proven to be of significant benefit to the patient and are cost-effective. Over time, with the development of even more advanced systems it will become more advantageous to use robotics on a routine basis.     

Preparedness in robotically assisted interventions

For many years, robots have been used in manufacturing to perform a variety of delicate tasks. Their use is now being generalized to other fields, such as biology, domestic applications, and especially medicine, in which they are poised to make a significant contribution. This evolution comes from the progress made in the field of robotics and from recent changes in medical and surgical techniques, namely, developments in medical imaging and a new desire for minimally invasive interventions. This emerging combination of high-precision robotic manipulators, new medical diagnostic techniques, and efficient minimally invasive surgery has not yet been perfected. After a brief discussion of state-of-the-art robotic systems used in urology, this article discusses new challenges presented by robotic minimally invasive surgery. A computer-integrated approach aimed at increasing the efficiency of such interventions through better preparedness is presented. This approach is illustrated by a case study in human nephrectomy and a cardiac animal experiment.     

Robotic and navigation systems: surgical practicability and benefit for the patient?

The use of robotics and navigated systems to prepare, perform and reinforce surgical interventions is described by the term "computer aided surgery" (CAS). CAS is expected to make surgery even more precise, safer and cheaper. It comprehends computer based supporting systems (e. g. therapy planning, simulation, navigation), assisting systems, programmable automates and the so called master-slave-systems. When introducing technical innovations, the potential benefit of the patient is the essential issue. Then only practicability under clinical conditions, and additional aspects can be discussed. Conclusively, less spectacular applications of CAS like computer based supporting or assisting systems are more relevant for current practical use than visionary robotic systems.     

Establishing a robotics program

Establishing a successful robotics program requires consideration of several issues, including the surgical procedures to be performed, training and personnel, facilities, finance, and marketing. This article considers these factors from an academic health center standpoint and evaluates the benefits and risks of this new technology for urology departments.     

Emerging technologies for surgery in the 21st century.

Laparoscopic surgery is a transition technology that marked the beginning of the information age revolution for surgery. Telepresence surgery, robotics, tele-education, and telementoring are the next step in the revolution. Using computer-aided systems such as robotics and image-guided surgery, the next generation of surgical systems will be more sophisticated and will permit surgeons to perform surgical procedures beyond the current limitations of human performance, especially at the microscale or on moving organs. More fundamentally, there will be an increased reliance on 3-dimensional images of the patient, gathered by computed tomography, magnetic resonance imaging, ultrasound, or other scanning techniques, to integrate the entire spectrum of surgical care from diagnosis to preoperative planning to intraoperative navigation to education through simulation. By working through the computer-generated image, first with preoperative planning and then during telepresence or image-guided procedures, new approaches to surgery will be discovered. These technologies are complemented by new educational opportunities, such as tele-education, surgical simulation, and a Web-based curriculum. Telementoring will permit further extension of the educational process directly into the operating room.     

ROBOTIC TECHNOLOGY IN SURGERY: CURRENT STATUS IN 2008

There is increasing patient and surgeon interest in robotic‐assisted surgery, particularly with the proliferation of da Vinci surgical systems (Intuitive Surgical, Sunnyvale, CA, USA) throughout the world. There is much debate over the usefulness and cost‐effectiveness of these systems. The currently available robotic surgical technology is described. Published data relating to the da Vinci system are reviewed and the current status of surgical robotics within Australia and New Zealand is assessed. The first da Vinci system in Australia and New Zealand was installed in 2003. Four systems had been installed by 2006 and seven systems are currently in use. Most of these are based in private hospitals. Technical advantages of this system include 3‐D vision, enhanced dexterity and improved ergonomics when compared with standard laparoscopic surgery. Most procedures currently carried out are urological, with cardiac, gynaecological and general surgeons also using this system. The number of patients undergoing robotic‐assisted surgery in Australia and New Zealand has increased fivefold in the past 4 years. The most common procedure carried out is robotic‐assisted laparoscopic radical prostatectomy. Published data suggest that robotic‐assisted surgery is feasible and safe although the installation and recurring costs remain high. There is increasing acceptance of robotic‐assisted surgery, especially for urological procedures. The da Vinci surgical system is becoming more widely available in Australia and New Zealand. Other surgical specialties will probably use this technology. Significant costs are associated with robotic technology and it is not yet widely available to public patients.     

Robotic surgery versus laparoscopy; a comparison between two robotic systems and laparoscopy

Laparoscopy has found a role in standard urologic practice, and with training programs continuing to increase emphasis on its use, the division between skill sets of established non-laparoscopic urologic practitioners and urology trainees continues to widen. At the other end of the spectrum, as technology progresses apace, advanced laparoscopists continue to question the role of surgical robotics in urologic practice, citing a lack of significant advantage to this modality over conventional laparoscopy. We seek to compare two robotic systems (Zeus and DaVinci) versus conventional laparoscopy in surgical training modules in the drylab environment in the context of varying levels of surgical expertise. A total of 12 volunteers were recruited to the study: four staff, four postgraduate trainees, and four medical student interns. Each volunteer performed repeated time trials of standardized tasks consisting of suturing and knot tying using each of the three platforms: DaVinci, Zeus and conventional laparoscopy. Task times and numbers of errors were recorded for each task. Following each platform trial, a standardized subjective ten-point Likert score questionnaire was distributed to the volunteer regarding various operating parameters experienced including: visualization, fluidity, efficacy, precision, dexterity, tremor, tactile feedback, and coordination. Task translation from laparoscopy to Zeus robotics appeared to be difficult as both suture times and knot-tying times increased in pairwise comparisons across skill levels.     

Minimally Invasive Techniques for Bladder Reconstruction

Purpose of Review

Bladder reconstruction surgery is a key component of neurogenic lower urinary tract dysfunction (nLUTD) management. Traditionally, given the complexity and unpredictable operative challenges of bladder reconstruction in this patient population, little consideration has been given to performing lower urinary tract reconstruction in a minimally invasive approach.

Recent Findings

We describe the innovative minimally invasive surgical techniques in four major categories of reconstructive procedures for nLUTD: (A) ileal bladder augmentation, the use of a low morbidity open Pfannenstiel incision and the use of laparoscopy and robotics; (B) creation of a catheterizable channel, the use of laparoscopy and robotics for Mitrofanoff procedures; (C) creation of both a bladder augmentation and catheterizable channel, the use of a hand-assisted approach for the creation of a continent cutaneous ileocystoplasty; and (D) bladder neck artificial urinary sphincter implantation: the use of a robotics.

Summary

Patients with nLUTD need surgical solutions that can improve their quality of life over several decades. As experience with robotics increases and as technology provides us with new tools to ease minimally invasive bladder reconstruction, we can expect that the field will continue to grow and improve.