Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 48, Num. 1, 2002, pp. 39-41

Journal of Postgraduate Medicine, Vol. 48, Issue 1, 2002 pp. 39-41

Laparoscopy, Robot, Telesurgery and Urology: Future Perspective

Hemal AK, Menon M

Vattikuti Urology Institute, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA.
Address for Correspondence: A. K. Hemal, Department of Urology, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA E-mail: akhemal@hotmail.com

Code Number: jp02012

During the last 25 years, probably urology was the surgical speciality that presented the most extraordinary technological development. The evolution has ranged from open surgery to minimally invasive surgery at dawn of the third millennium. The development has ranged from techniques to technology.¹

Laparoscopic urologic surgery has increasingly become accepted as an alternative to open urological surgical techniques. Recent advances in laparoscopic surgery are largely attributable to technological improvements. Advances in imaging technologies, virtual reality and teleconsultation have allowed a broadening of laparoscopic applications, improved training, decrease morbidity, increase urologist acceptance and patients interest.

Laparoscopy

Laparoscopy offers significant advantages over conventional open surgery.² Although initially slow to pick up, urologists now rely on them to perform an ever-increasing variety of procedures. It includes adrenalectomy, adrenal cyst excision, all kinds of nephrectomy, nephroureterectomy, treatment of stone disease, orchidopexy and orchidectomy, prostatectomy, pyeloplasty, renal biopsy, ureteroneocystostomy, urethropexy, varicocelectomy, cystectomy and lymphadenectomy.^3-8 The major impediment to widespread application of laparoscopy in urology has been the complexity and technical demands of urological procedures.⁴ The low volume of laparoscopic urologic cases makes it difficult for surgeons to progress beyond the steep portion of this learning curve and may place patients at unacceptable risk. In the 1970's Cortessi et al in Italy first introduced laparoscopy into urology with his report of Laparoscopic exploration for the cryptorchid testicle.⁵ It look almost 20 years when Schuessler et al performed first laparoscopic pelvic lymphadenectomy in a patient with prostate cancer. The first laparoscopic nephrectomy was performed by Clayman et al,⁶ whereas the credit for development of retroperitoneal space by balloon goes to Gaur.⁷

Despite substantial progress in retroperitoneoscopy it is still considered significantly more challenging as disorientation can plague inexperienced surgeon. With increasing experience, skill, and improved instrumentation, laparoscopy is continuing to move further into surgical domain of urology.⁸ The recent developments of newer techniques like donor nephrectomy,⁹ laparoscopic radical prostatectomy by Guilloneau and Vallancien¹⁰ and Robotic anatomical radical prostatectomy by Menon et al,¹¹ have changed entire scenario and bar has been set further high to other speciality to match development in the field of urology. Another perfect example of ablative and reconstructive procedures beside radical prostatectomy are radical cystectomy and ileal conduit diversion.¹²

Thus, laparoscopy has succeeded in providing surgical cure and less morbidity to the patients. However, for laparoscopy to spread more, need better and more training courses and improved instrumentation, such as hand assistance.¹³

Robotics

There is fundamental question to be asked of a technologically advanced society, which is: "once a machine has been designed to perform a task, should man be removed from the equation?". The painful and unequivocal answer to this question whether it be in folk song of John Henry and the steam engine or the economical practicalities of the automobile industries is a mournful but unwavering yes.¹ And so robotics are coming to an operating room to assist and to replace to an extent. Surgical robots were initially used in neurosurgery and orthopaedics and have since been applied to urologic surgery. Robotic systems have been developed to assist percutaneous renal access, transperineal prostate biopsy, radio active seed delivery into prostate and TURP.³ In a study, use of AESOP to hold camera during laparoscopy has been found to be more steadier and effective than their human counterpart.¹⁴ The next logical step was to implement active robotic instruments that can be controlled remotely. Laparoscopic instruments are well suited for automation given their inherent simplicity and limited degrees of freedom. Zeus (Computer motion, Goleta, CA) has been used to perform lymphadenectomy.¹⁵ The versatile da Vinci system (Intuitive surgical, Maintain view, CA) has been used to perform robotic radical prostatectomy.^11,16 To operate these robotic system the surgeon manipulates controls at a work station known as console that are directly used to a surgical robot at the operating table. These are going to be modified soon for complex robotic telesurgery.

Telesurgery

It is a new exciting branch of medicine concerned with the integration of multimedia, telecommunications and robotic technologies to provide surgical care at a distance. It has potential to reach to surgeon in any part of the world. Laparoscopic surgery is well suited for this purpose. Urological Laparoscopic procedures in urology are complex and learning curve is steep as there is no easy learning procedure like lap. Cholecystectomy, hence advanced laparoscopic skills and familiarity with laparoscopic anatomy related to urological organs for both access transperitoneal and retroperitoneal are essential. The steep learning curve translates into long operative times and an unacceptably high rate of complication for inexperienced laparoscopic surgeons. Through telesurgical mentoring, less experienced surgeons with basic laparoscopic skills could receive training in advanced technique from a world expert without the need for travel. These systems could also be used to proctor laparoscopic cases for credentialing purposes and to provide a uniform standard.

The first telesurgical urologic procedure a percutaneous renal access was carried out between Baltimore and Rome in 1998 using surgical robot PAKY (Percutaneous access to the Kidney).¹⁷

Substantial progress is made in developing first-generation telesurgical systems that allow telementoring and limited active surgical assistance over great distances; however, several significant technical and legal barriers must be surmounted before telesurgery can be widely accepted and incorporated into general urologic practice.

Non-invasive Surgery

There has been significant demonstration in the field of urology from open wound to non-invasiveness. The advent of extracorporeal shock wave lithotripsy (ESWL) turned out to be boon for stone disease patients as without invasion patients are enjoying treatment for urolithiasis all over the world including developing countries. The non-invasive techniques such as Pyrotech (a piezoelectric source for destruction) and High Intensity focused ultrasound (HIFU) for treating tumours and most recently it is being tried for obliteration of vas in canine and the potential clinical impact of this device on population control is indeed, significant. However, all of this non-invasive technology is expensive to develop and deploy.¹

Nonetheless, the future is bright; machines are going to help surgeons more and more giving non-invasive tools for treating cancer of bladder, kidney and prostate.

Robotic surgery for prostate cancer

Laparoscopic radical prostatectomy is perfect example of most advanced laparoscopic procedure in the field of urology. In a world of rapid innovation, at the dawn of the third millennium, radical prostatectomy has changed hands from laparoscopic surgeon to robotic assisted surgeon. As we all know the laparoscopic technique has provided 4 degree of movements, lack of tactile feedback, and one need to realise unique anatomical perspective, hand to eye dissociation and to operate without 3 dimensional orientation, needless to say all this led to steep learning curve, beside the cost.

To overcome these drawbacks to an extent robotic assistance is turning out to be a big boon as it has certain unique qualities i.e. six degree of movements like human hand, filter the tremor and provide stability beside superior visualization due to three chips camera one for each eye along with 3-D environment for better depth perception. This method has few drawbacks like lack of touch sensation, hand to eye dissociation and of course the cost factor at this stage.

In personal experience (MM) of 60 cases of robotic assisted anatomical radical prostatectomy (RAP), though it takes marginally longer time than open surgery but has advantages of less blood loss, less pain, less analgesia and shorter hospital stay [unpublished data]. It was also appreciated that there is no difference in terms of shorter hospital stay, oncological completeness and surgical outcome in terms of providing excellent anastomosis and preservation of neurovascular bundle as in open surgery along with superb cosmesis. Thus, RAP has made its way in the management of localised carcinoma of the prostate, as robot facilitate the execution of complex surgical manoeuvres flawlessly particularly during dissection of neurovascular bundle and anastomosis, which are often considered as difficult steps. Not only this it opens new vistas for telementoring and telerobotic surgery. It is also likely to reduce learning curve with telesurgery in remote areas.

Conclusions

Advances in technology, instrumentations, technique and deployment of these skills have changed complete management of patients in this era. Our therapy should harm to the patients from minimal to not at all. Hence, let us continue to move with the development in the third millennium, to provide for those who seek our counsel and our skill with a resolution of their maladies in the most humane, least disruptive manner.

References

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