■ Routine urologic laparoscopic surgery is no longer futuristic, but actual clinical practice at some institutions. Horizons for expanding the laparoscopic surgical realm are broad (168).

■ Manufacturers, research engineers, optical engineers, roboticists, computer engineers, software engineers, communications specialists, and surgeons must be able to constructively work together in order to minimize the time to perfect new instruments and procedures (169,170).

■ The doctor-patient relationship must always be of foremost concern to the laparoscopic surgeon. The trust in the surgeon for allowing the patient to be the first to have this procedure done cannot be underestimated. Ethically, the laparoscopic surgeon must be forthright in assessing own skills, the mastery of the laparoscopic procedure, the indications of the procedure, and must maintain healthy skepticism of newer procedures until adequate data are available (171-174).

■ The proctor for laparoscopic urologic surgery has to date benefited from unprecedented legal immunity. Proctoring and peer reviews remain mechanisms utilized by physicians to ensure high-quality outcomes, and as such, continue to receive comprehensive legal immunity in order to prevent reprisals (175). The law is clear that the some kind of proctorship is necessary for physicians to begin to practice advanced technologic surgeries, neither legal cases nor the Joint Commission on Accreditation of Hospitals provides much guidance on the process to fulfill this responsibility (176).

■ New technology has an apparent life cycle with five stages: (i) feasibility (technical performance, applicability, safety complications, morbidity, mortality); (ii) efficacy (benefit for the patient demonstrated in centers of excellence); (iii) effectiveness (benefit for the patient under normal conditions, reproducible with widespread application); (iv) costs (benefit in terms of cost effectiveness); (v) gold standard (177).

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