Urologic Applications

Urologic applications have also begun (135-146). In work by Kavoussi's group at Johns Hopkins University, AESOP has been utilized for telementoring and teleproctoring advanced laparoscopic procedures (135). In 1998, Bowersox and Cornum first used a robotic surgical telemanipulator to perform an open urological surgery in swine (136). Sung et al. in 1999 performed robotic-assisted laparoscopic pyeloplasties in a porcine model utilizing the Zeus system (138). Guillonneau's group in Paris began a program in utilizing the Zeus system in the animate laboratory and started to accrue patients into clinical applications performing laparoscopic pelvic lymphadenectomies in 20 consecutive patients with stage T3MO disease (139). They noted no need for open conversions and the average operative time was 2.1 hours, one full hour longer than their usual laparoscopic times. They noted that the time for robotic setup was 30 minutes. Abbou et al. from Creteil, France have also been exploring urologic applications (140). They recently reported the use of the da Vinci robotic system to perform a laparoscopic radical prostatectomy in a 63-year-old man with Gleason's sum score of six prostatic adenocarcinoma, clinically staged T1c and a prostate specific antigen of 7 ng/mL. They utilized five trocars (one 12 mm umbilical camera port, two 8 mm trocars located at the lateral rectus sheath, and two lateral 5 mm trocars at the iliac position for the assistant). Robotic instruments used were the Cadiere and DeBakey forceps, two needle drivers, long and round tip forceps, scalpel, electrocautery, and a prototype bipolar forceps. The operating time was 420 minutes, well in excess of their standard operative times of 240 minutes. Assembly of the robot took 30 minutes and disengaging the unit took 15 minutes. The vesicourethral running 3-0 polyglactin suture anastomosis took 30 minutes. These authors mention that the three-dimensional imaging system and the full six degrees of freedom of the daVinci robotic system made in vitro training on animals streamlined to the point that they could proceed to clinical applications quickly. Drawbacks of the system were pointed out to include, lack of tactile feedback, the high cost of the robotic equipment, the cost of disposables (US$1800) for this radical prostatectomy case), and the time lost to replace the surgical instruments. Guillonneau and the Montsouris group have recently published the first case of robot-assisted laparoscopic nephrectomy (304). They utilized their Zeus™ robotic system in a 77-year-old female with a nonfunctioning, hydronephrotic right kidney secondary to a ureteropelvic junction obstruction. They performed a transabdominal nephrectomy utilizing three robotic arms (Zeus™ and AESOP™). A10 mm trocar was placed at the right pararectal line for the camera port and AESOP™. Two 5 mm trocars in the right flank in a triangular fashion for the robotic instruments (mainly a forceps in the left and monopolar scissors in the right). A 5 mm trocar was placed at the umbilicus and a 12 mm trocar was placed in the right subcostal region for suction/irrigation, retraction, and application of clips and/or endovascular gastrointestinal stapler. The operative time was 200 minutes, anesthesia time was 245 minutes, blood loss was less than 100 mL and the patient's postoperative course was uneventful (141).

The probable proliferation of computer-enhanced robotic surgery is beginning to materialize in urologic practice. From robotic-assisted adrenalectomies, retroperitoneal lymphadenectomies, to robotic sacrocolpoplasty; all urologic applications are beginning to be reported (142-144). As with surgical applications these are mostly anecdotal case reports. One group's pioneering efforts deserves special attention, from Creteil France. Hoznek et al. have been attempting to use the daVinci robot to perform kidney transplant surgery (145). A 26-year-old male received a cadaver donor transplant performed with a hybrid open/robotic technique. The operative time was 178 minutes with a robotic vascular anastomosis time of 57 minutes. The authors present several interesting features of eliminating the surgeon from contact with the patient including reduction in the risk of infectious transmission to the surgeons.

There are two urologic surgeries that are begging the attention of the computer-enhanced robotic application, pyeloplasty and radical prostatectomy with urethrovesi-cal reanastomosis. Guilloneau et al. first published on robotic techniques for pyeloplasty in 2000 (146). Currently series are beginning to be reported. Gettman et al. have presented preliminary work on nine patients using the da Vinci robotic system to perform four Anderson-Hynes and two Fengerplasty ureteropelvic junction repairs (147). The estimated blood loss was <50 cc, the mean overall operating room time was 140 minutes, and the mean suture times were 70 minutes. There were no open conversions. They have subsequently updated their Anderson-Hynes-dismembered pyelo-plasty series to nine with a mean operating room time of 138.8 minutes (range, 80-215 minutes). The mean suturing time 62.4 minutes (range, 40-115 minutes) (148). Other groups with the available technology can be expected to rapidly follow with series (149). Radical prostatectomy with urethrovesical anastomosis is the next frontier. Abbou et al. first reported a case in 2001 as noted previously (140). They have expanded their series and have been performing the entire robotic surgery extraperitoneally. This prefaces the astounding data beginning to flow from the Vattikuti Urology Institute at Henry Ford Hospital in Detroit (150-152). The number of reported robotic radical prostatectomies is over 400 cases currently with rigid follow-up strategies for solving operative problems that are constantly associated with this surgery, incontinence, and impotence (152). The remarkable aspect of this experience is that innovations are already being reported that might enhance the operative technique even more, such as the single knot, two-color running suture (153). Ahlering et al. at University of California Irvine have shown that open surgical skills might be rapidly transferred into the laparoscopic environment with the use of the da Vinci robot (154). They report on 12 robotic radical prostatectomies all completed successfully with no open conversions and no blood transfusions. They have been able to equate this skill transfer to approximately the equivalent of a laparoscopic surgeon performing >100 laparoscopic radical prostatectomies. The questions remaining is how good can this operation be performed, what is the learning curve, can the complications of radical prostatectomy be minimized? All of these are approaching the event horizon. Menon's group has estimated that the operative time for a robotic radical prostatectomy is below 150 minutes (155). As their series expands and follow-up times accrue, data regarding impotence, incontinence, bladder neck contractions will all be reported. Others should be able to confirm these findings rapidly and the much anticipated results of brightly illuminated, magnified controlled environment will materialize (156). No one seriously should doubt these possibilities. It has been estimated that about 700 da Vinci robotic-assisted prostatectomies were performed in 2003. By the end of 2004, this number is anticipated to be 7000 or a logarithmic increase in the numbers of these cases.

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