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.     

A history of robots: from science fiction to surgical robotics

Surgical robotics is an evolving field with great advances having been made over the last decade. The origin of robotics was in the science-fiction literature and from there industrial applications, and more recently commercially available, surgical robotic devices have been realized. In this review, we examine the field of robotics from its roots in literature to its development for clinical surgical use. Surgical mills and telerobotic devices are discussed, as are potential future developments.     

Multiservice laparoscopic surgical training using the daVinci surgical system

BACKGROUND: The daVinci surgical system affords surgeons a magnified three-dimensional videoscopic view of the operative field and precise articulating laparoscopic instruments. The learning curve for this advanced surgical robotics system is poorly characterized. METHODS: Twenty-three surgeons representing seven surgical subspecialties participated in a surgical robotics training program consisting of standardized daVinci system training (phase 1) followed by self-guided learning in a porcine model (phase 2). RESULTS: The average number of recorded procedures performed per surgeon during phase 2 was 5.5. The mean daVinci system set-up time was 45 minutes and decreased by an average of 56.1% by the third successive set-up (r = -0.702, P <0.005). Operative times decreased 39.0% by the third successive practice operation (r = -0.860, P <0.0005). CONCLUSIONS: New use of the daVinci robot is associated with a rapid learning curve and preclinical animal model training is effective in developing surgical robotics skills.     

Evolution of robotic arms

The foundation of surgical robotics is in the development of the robotic arm. This is a thorough review of the literature on the nature and development of this device with emphasis on surgical applications. We have reviewed the published literature and classified robotic arms by their application: show, industrial application, medical application, etc. There is a definite trend in the manufacture of robotic arms toward more dextrous devices, more degrees-of-freedom, and capabilities beyond the human arm. da Vinci designed the first sophisticated robotic arm in 1495 with four degrees-of-freedom and an analog on-board controller supplying power and programmability. von Kemplen’s chess-playing automaton left arm was quite sophisticated. Unimate introduced the first industrial robotic arm in 1961, it has subsequently evolved into the PUMA arm. In 1963 the Rancho arm was designed; Minsky’s Tentacle arm appeared in 1968, Scheinman’s Stanford arm in 1969, and MIT’s Silver arm in 1974. Aird became the first cyborg human with a robotic arm in 1993. In 2000 Miguel Nicolalis redefined possible man–machine capacity in his work on cerebral implantation in owl-monkeys directly interfacing with robotic arms both locally and at a distance. The robotic arm is the end-effector of robotic systems and currently is the hallmark feature of the da Vinci Surgical System making its entrance into surgical application. But, despite the potential advantages of this computer-controlled master–slave system, robotic arms have definite limitations. Ongoing work in robotics has many potential solutions to the drawbacks of current robotic surgical systems.     

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.

     

Neurosurgical robotics: a review of brain and spine applications

Neurosurgery has traditionally been at the forefront of advancing technologies, adapting new techniques and devices successfully in an effort to increase the safety and efficacy of brain and spine surgery. Among these adaptations are surgical robotics. This paper reviews some of the more promising systems in neurosurgical robotics, including brain and spine applications in use and in development. The purpose of the discussion is twofold—to discuss the most promising models for neurosurgical applications, and to discuss some of the pitfalls of robotic neurosurgery given the unique anatomy of the brain and spine.     

Surgical robotics for patient safety in the perioperative environment: realizing the promise

Surgery is at a crossroads of complexity. However, there is a potential path toward patient safety. One such course is to leverage computer and robotic assist techniques in the reduction and interception of error in the perioperative environment. This white paper attempts to facilitate the road toward realizing that promise by outlining a research agenda. The paper will briefly review the current status of surgical robotics and summarize any conclusions that can be reached to date based on existing research. It will then lay out a roadmap for future research to determine how surgical robots should be optimally designed and integrated into the perioperative workflow and process. Successful movement down this path would involve focused efforts and multiagency collaboration to address the research priorities outlined, thereby realizing the full potential of surgical robotics to augment human capabilities, enhance task performance, extend the reach of surgical care, improve health care quality, and ultimately enhance patient safety.     

Use of robotics and novel technologies in spine surgery in elderly patients

As our global population ages, the demand for surgical treatment of spinal disorders in elderly patients has increased. The elderly population poses a unique challenge to spine surgeons due to multiple medical comorbidities and increased likelihood of complications. Robotics are being used for pedicle screw placement to enhance accuracy of placement and minimize surgical invasiveness. Although the use of robotics has not been studied specifically in elderly patients, this population may benefit significantly from the use of robotics as a minimally invasive technique to minimize blood loss, decrease operative time, and lessen postoperative pain—ultimately reducing complications.     

Robotic bariatric surgery: a systematic review

BackgroundObesity is a nationwide epidemic, and the only evidence-based, durable treatment of this disease is bariatric surgery. This field has evolved drastically during the past decade. One of the latest advances has been the increased use of robotics within this field. The goal of our study was to perform a systematic review of the recent data to determine the safety and efficacy of robotic bariatric surgery. The setting was the University Hospitals Case Medical Center (Cleveland, OH).MethodsA PubMed search was performed for robotic bariatric surgery from 2005 to 2011. The inclusion criteria were English language, original research, human, and bariatric surgical procedures. Perioperative data were then collected from each study and recorded.ResultsA total of 18 studies were included in our review. The results of our systematic review showed that bariatric surgery, when performed with the use of robotics, had similar or lower complication rates compared with traditional laparoscopy. Two studies showed shorter operative times using the robot for Roux-en-Y gastric bypass, but 4 studies showed longer operative times in the robotic arm. In addition, the learning curve appears to be shorter when robotic gastric bypass is compared with the traditional laparoscopic approach. Most investigators agreed that robotic laparoscopic surgery provides superior imaging and freedom of movement compared with traditional laparoscopy.ConclusionThe application of robotics appears to be a safe option within the realm of bariatric surgery. Prospective randomized trials comparing robotic and laparoscopic outcomes are needed to further define the role of robotics within the field of bariatric surgery. Longer follow-up times would also help elucidate any long-term outcomes differences with the use of robotics versus traditional laparoscopy.     

Transition from open to robotic-assisted radical prostatectomy: 7 years experience at Hackensack University Medical Center

Background and objective Open radical prostatectomy (ORP) is the standard approach for the surgical management of localized prostate cancer. The steep learning curve for laparoscopic prostatectomy poses a challenge for surgeons with minimal laparoscopic experience. As robotic-assisted surgery becomes more prevalent in the urologic community, there appears to be an increasing interest in robotic-assisted radical prostatectomy (RARP) among urologists throughout the United States. We report on the impact of robotics on practice patterns in the treatment of localized prostate cancer at a single institution. Methods A retrospective review was conducted of radical prostatectomies performed between January 2000 and December 2006 at Hackensack University Medical Center (Hackensack, N.J.). Over this time period, our medical center acquired four da Vinci™ Surgical Systems. The trends for open and robotic-assisted prostatectomies were analyzed. Results Over a 7-year period (2000–2006), a total of 1252 radical prostatectomies were performed by 17 urologists: 469 (37%) ORPs and 783 (63%) RARPs. The total number of prostatectomies increased annually during this time period. The robotic-assisted procedure was predominantly performed by three (18%) urologists from 2001–2003, seven (41%) in 2004, nine (53%) in 2005, and 11 (65%) in 2006. As more urologists became trained in robotic-assisted surgery, the trend gradually shifted towards robotic-assisted prostatectomy. In 2001, only 9.6% of all radical prostatectomies at our institution were performed with robotic assistance; in 2006, this had risen to 92.8%. Conclusion The acquisition of the da Vinci™ Surgical System has allowed robotic-assisted surgery to be an available alternative to open surgery at a single institution. The implementation of robotic technology has led to the gradual adoption of robotic-assisted radical prostatectomy by many of the urologists that surgically treat prostate cancer. As a result, the percentage of open prostatectomies has steadily decreased over time, while trends in robotic-assisted prostatectomies have increased. The impact of robotics also appears to have had an influential effect on the total number of prostatectomies performed annually.     

The evolution of robotic thyroidectomy: from inception to neck dissection

Over the past decade, the application of surgical robotics is bringing about dramatic changes in various surgical fields. Robotic thyroidectomy has achieved safe and accurate management of thyroid disease with remarkable cosmetic and functional benefits. As experiences with robotic techniques accumulate, its indications will expand to include more advanced cases with higher levels of difficulty.     

The end of robot-assisted laparoscopy? A critical appraisal of scientific evidence on the use of robot-assisted laparoscopic surgery

Background

Robot-assisted laparoscopy has been used in a wide variety of surgical fields; however, the financial costs involved are high and convincing proof of superiority in terms of quality of life, cost effectiveness and survival is often lacking. Possibly, there might be small benefits for the patient or for the surgeon’s health that might warrant the use of robotics in limited fields of surgery.

Methods

We performed a critical appraisal of the literature, searching for scientific evidence supporting the use of robotics in daily laparoscopic surgery.

Results

Convincing evidence supporting the use of robotics is lacking.

Conclusion

In an era of worldwide economic crisis, it is about time to start a critical discussion as to whether we should drastically limit, or even abandon, the use of robot-assisted laparoscopic surgery and focus on more cost-effective strategies of healthcare improvement. We suggest the use of robotics should be limited to well-powered, randomized clinical trials in a limited field of research.     

Minimally invasive surgical management of ureteropelvic junction obstruction: laparoscopic and robot-assisted laparoscopic pyeloplasty

Ureteropelvic junction (UPJ) obstruction is characterized by a functionally significant impairment of urinary transport caused by an intrinsic or extrinsic obstruction in the area where the ureter joins the renal pelvis. The majority of cases are congenital in origin; however, acquired conditions at the level of the ureteropelvic junction may also present with symptoms and signs of obstruction. Until recently, open pyeloplasty and endoscopic techniques have been the main surgical options, with the intent of complete excision or incision of the obstruction. The introduction of laparoscopy and robot-assisted applications has allowed for minimally invasive reconstructive surgery that mirrors open surgical techniques. These techniques offer substantial benefits to patients by reducing morbidity, hastening postoperative recovery, and improving cosmetic outcome. During the last decade, laparoscopic pyeloplasty has garnered much interest. However, because of the technically challenging nature of this procedure, it is performed only at select medical centers by surgeons with advanced laparoscopic training. The recent introduction of robotics to the field of minimally invasive surgery may facilitate this procedure and allow for more widespread implementation by surgeons of varying skill levels. This review is limited primarily to the treatment of congenital or acquired UPJ obstruction via laparoscopic and robot-assisted laparoscopic pyeloplasty. Herein, we report the early results, ongoing evolution, and potential future role for these novel surgical procedures.     

Surgical robotics: the early chronicles: a personal historical perspective

The use of robotics has been emerging for approximately 75 years, but only during the past 5 years has the potential of robotics been recognized by the surgical community as a whole. This personal perspective chronicles the development of robotics for the general surgical community, the role of the military medical research effort, and many of the major programs that contributed to the current success of robotics.     

机器人和计算机辅助骨科手术

本文旨在介绍计算机辅助外科手术在术前计划、手术模拟和术中导航的应用,以及医用自动化机械臂的引入和手术导航系统的基本原理等。手术导航要求很高的精确度,因此引入和发展医用自动化机械臂十分必要。我们简要地回顾了目前的医用机器人系统,同时也介绍了在香港中文大学所发展的机械臂系统以及在手术中的应用。导航指引下远端置入髓内钉的实验室测定显示机械臂的使用可以获得更好地可重复性和准确性。手术导航机械臂已经广泛应用于远端髓内钉的置入,经皮置入骶髂关节螺钉、髂骨螺钉、髋螺钉等骨科治疗中。医用机械臂无疑将是计算机辅助手术未来发展的主要技术之一。     

The evolution of robotic urologic surgery

The incorporation of robotics into surgical technology is a relatively recent development. Robotic surgical systems can be classified as master-slave systems, precise-path systems, or intern-replacement systems. Master-slave systems, the most familiar type, were developed from initial experiments in "telepresence" surgery funded by the US Department of Defense. Urology has embraced the use of commercial robotic surgical systems in a growing number of clinical applications. Although drawbacks and limitations exist for the use of surgical robotics, the systems are developing rapidly and an expanded role for this technology in the future of urology is inevitable. This article reviews the history of the use of robotics in surgery, focusing on its specific application to urology.     

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.     

Gestonurse: a robotic surgical nurse for handling surgical instruments in the operating room

While surgeon–scrub nurse collaboration provides a fast, straightforward and inexpensive method of delivering surgical instruments to the surgeon, it often results in “mistakes” (e.g. missing information, ambiguity of instructions and delays). It has been shown that these errors can have a negative impact on the outcome of the surgery. These errors could potentially be reduced or eliminated by introducing robotics into the operating room. Gesture control is a natural and fundamentally sound alternative that allows interaction without disturbing the normal flow of surgery. This paper describes the development of a robotic scrub nurse Gestonurse to support surgeons by passing surgical instruments during surgery as required. The robot responds to recognized hand signals detected through sophisticated computer vision and pattern recognition techniques. Experimental results show that 95% of the gestures were recognized correctly. The gesture recognition algorithm presented is robust to changes in scale and rotation of the hand gestures. The system was compared to human task performance and was found to be only 0.83 s slower on average.     

Robotic pediatric urology

Robotic-assisted minimally invasive surgery is penetrating pediatric urology. The freedom afforded by the “surgical actuators” has led to the expanding adoption of robotics, and it is unlikely that much of laparoscopy will not trend toward some iteration of robotic influence. The da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA) provides delicate telemanipulation, coalesced with three-dimensional visualization and superior magnification. It has bridged the gap between laparoscopy and open surgery. Nonetheless, a confident understanding of pure laparoscopy is paramount in the event that mechanical malfunction is experienced. Robotic pediatric urologic procedures such as pyeloplasty, ureteral reimplantation, abdominal testis surgery, and partial or total nephrectomy with or without ureteral stump removal are routinely performed at select centers offering robotic expertise. Complex reconstructive surgeries such as appendicovesicostomy, antegrade continent enema creation, and augmentation cystoplasty can be performed but are still in their infancy.