Conclusion

Aside from robot-assisted laparoscopic radical prostatectomy, clinical utilization of robotic systems for a variety of procedures in the upper and lower urinary tract is still in its infancy. Surgical techniques and feasibility of multiple robotic procedures have been described, but the data currently available is limited to small case series with little long-term follow-up. Telerobotic surgical systems were introduced to address the technical limitations of standard laparoscopy. The current robotic systems provide three-dimensional visualization of the operative field, improved dexterity (with tremor filtering and motion scaling software), and increased range of motion compared to standard laparoscopy. The benefit of these performance features appears greatest when performing advanced laparoscopic dissection techniques (i.e., prostatectomy and cystectomy) or intracorporeal suturing (i.e., pyeloplasty, prostatectomy, urinary diversion, and sacrocolpopexy); however, a clinical advantage remains scientifically unproven at this time.

In the skills laboratory, Yohannes et al. have previously shown that learning how to suture is faster with da Vinci than with standard laparoscopy (26). Furthermore, the investigators reported novice laparoscopists learned suturing with the robot quicker than experienced laparoscopists. Clinically, multiple centers have also successfully used robotics to perform complex laparoscopic tasks without any formal training in minimally invasive surgery (8,22,23). For instance, Bentas et al. had no experience with laparoscopic pyeloplasty before successfully embarking on their da Vinci-assisted procedures (8). In general, they concluded that telerobotics enabled inexperienced urologists to perform complex reconstructive procedures with more confidence and better results than could be obtained with standard laparoscopy. Nonetheless, a paucity of prospective randomized trials is currently available to compare outcomes of laparoscopic surgery performed with or without telerobotics (15). This information would be helpful in defining the role of robotics for "trained" and "untrained" laparoscopists.

Limits are also currently present with telerobotics. Critical performance features are lacking with robotic surgery including even gross tissue palpation and force feedback. So, robotic surgery must be performed with increased reliance on visual versus tactile inputs. Telerobotic surgery is also associated with a significant learning curve not only for the operating surgeon but also more significantly for the operating room staff. An attempt should be made to establish a robotics "team" when embarking on these surgical procedures. In contrast to standard laparoscopy, the importance of the surgical assistant is critical to the flow of robotic surgery. Using standard laparoscopic instruments, the assistant surgeon is depended on to provide traction/countertraction, apply hemostatic clips, and introduce and remove suture. For this reason, the assistant surgeon must be proficient with at least basic laparo-scopic tasks. At the present time, robotic surgery also utilizes more resources than standard laparoscopy. For instance, two surgeons are needed when performing robotic surgery: one at the remote control unit and one scrubbed at the operating table. Initial capital expenditures and per case costs are also more expensive at the present time for robotic surgery.

Robotic technologies have been recently introduced with fanfare, but increased clinical application and critical evaluation are needed. Robotics appears best targeted for complex laparoscopic tasks requiring delicate dissection or intracorporeal suturing. Robotics has already succeeded in increasing clinical applicability by permitting "untrained" open surgeons to perform complex laparoscopic tasks (8,22,23). Nonetheless, deficiencies currently exist for robotics, and the learning curve is not insignificant. With the anticipated introduction of improved robotic technologies and other technologies in the information age, the ongoing value of robotics must be carefully evaluated and proven to optimally benefit patient care.

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