Robotic-Assisted Urological Surgery and Its Application

Introduction

The history of surgery is almost two thousand years old. Previously large instruments were used for surgical purposes. The traditional way of surgery has its own drawbacks, like excessive blood loss, large incisions, and excessive tissue injury. To overcome such complications, robot-assisted surgeries are introduced.

What Are the Different Robotic Surgical Systems?

The robotic system is based on three types of mechanisms. These are active systems, semi-active systems, and master-slave systems. In active systems, procedures are autonomously under the command of a surgeon. In the semi-active system, both automatic and surgeon-driven controls are present. Most of the systems used in today's practice are master-slave systems. In this technique, the surgeon operates the robotic arms through a workstation by the assisted method.

For urological purposes, different robotic surgical systems are used. These are:

1. Da Vinci Surgical System: The FDA (Food and Drug Administration) approved this system in 2000. Four generations of this system are Vinci 2000, S, Si, and Xi. In 2018, da Vinci Single-Port (SP) was introduced, which can be used in urological procedures. The total system is divided into three parts. The console is a part from which the surgeon controls the robot. The units of the console are 3D binoculars, Endowrist for finger controls, and foot pedals for clutching. Food paddles also control diathermy and other energy sources. The surgeon’s thumb and forefinger mediate the movement of the robotic arm. The patient’s side cart harbors the robotic arms. There are four robotic arms present. In da Vinci Single-Port system, the arms are double-jointed, with a distal (elbow and a proximal shoulder) site of articulation, and provide 7 degrees of freedom of movement. The image processing unit consists of an 8 mm three-dimensional camera unit. In a single-port system, a 12x10 mm three-dimensional -high definition articulating camera is used.
2. Revo-I: This system was approved by the Korean Ministry of Food and Drug Safety in 2017. This instrument has four robotic arms with wristed arms. The degree of freedom of movement is seven degrees with a diameter of 7.4 millimeters. It consists of a 10-millimeter articulating camera.
3. Senhance: The Senhance surgical system was previously known as Telelap ALFX. This system got its approval from the FDA in 2017. However, the clearance includes only gastrointestinal and general surgical procedures. The multisystem unit consists of four separate arms placed in separate carts. The handles are based on laparoscopic instruments with diameters ranging from three to ten millimeters.
4. Versius: This system received its approval in Europe in 2019. The robotic arms of this system are mounted in a portable cart. These arms are divided into parts like the shoulder, elbow, and wrist. The instruments attached to the arms have 5 millimeters in diameter and seven degrees of freedom of movement. The surgeon can operate these arms with the help of a joystick while standing away from the patient.
5. Avatera: This system received its operational approval in the European market in 2019. This device has four robotic arms. Three out of four robotic arms of this device are composed of 5 millimeters of fully articulated instruments, and one arm consists of 10 10-millimeter endoscopes. The instruments have seven degrees of freedom of movement. All instruments attached to the arms are disposable and single-use.
6. Hinotori: This made-in-Japan robotic instrument received approval in 2020 from the Japanese Ministry of Health, Labor, and Welfare. This instrument is made up of three parts. These are the surgeon's cockpit, the operative unit, and the vision unit. There are four robotic arms that are mounted in the operative unit. These arms have multiple joints and eight axes of movement.

What Are the Surgical Techniques for Robotic Surgery?

Currently, there are two surgical techniques that are in robotic urological surgery. The first technique used was the single-site surgery technique that was introduced in 2008. In this procedure, a relatively large skin is made, and several instruments are inserted. One of the main problems associated with the single-site approach was the clashing of instruments. The external clashing of arms can be avoided by the adoption of the chopstick technique. In this technique, arms are placed on both sides of the body and maintain a safe distance. On the other hand, in single-port surgery, a small incision is made on the fascia, and a single port is used for inserting instruments.

What Are the Different Uses of Robotic Surgical Procedures?

Robotic surgeries are used for different types of urological problems. These are:

1. Prostatectomy: Robot-assisted surgeries are most commonly used for the treatment of localized cases of prostate cancer. Robotically assisted laparoscopic radical prostatectomy (RALP) is considered the gold standard technique for such cases. The advantages of this technique are less blood loss, better visualization, precision tissue removal, and fewer postoperative complications.
2. Nephrectomy for Malignant Indications: The tumors of the nephron are removed through this procedure. This procedure was first performed in 2004. Tumors less than 4 centimeters in size are removed without removing the health nephron. That is why it is also known as nephron-sparing surgery.
3. Cystectomy: The first robotic-assisted radical cystectomy (RARC) was performed in the year 2003. In this procedure, the urinary bladder is removed. This is mainly done in cases of muscle-invasive bladder cancer. The robotic surgical approach helps in urinary diversion, which is one of the aspects of these types of surgeries. With the help of robotic techniques, the intracorporeal creation of an orthotopic neobladder can be done.
4. Pyeloplasty: This type of surgical procedure can be used for the removal of ureteropelvic junction obstruction. Such procedures can be done in both adult and pediatric cases. In normal circumstances, open access is done for the removal of obstructions. A close surgical approach with less blood loss causes fewer postoperative complications.
5. Robot-Assisted Ureteroscopy: Ureteroscopy is a procedure that is used to remove stones from the kidney. Due to its difficult anatomical locations, it has often been difficult to remove such stones. Robot-assisted use of flexible ureteroscopy (FURS) can reach difficult anatomical positions and help to remove stones. Also, procedures like percutaneous nephrolithotomy and extracorporeal shockwave lithotripsy can be done with the help of robot-assisted techniques.

What Are the Rationality of Robotic Urological Surgery?

The advantages of robotic urological procedures are three-dimensional high-definition vision, an enhanced degree of freedom, ergonomic positioning, no tremor, and no fatigue during surgical procedures. Small incisions reduce surgical complications and the amount of blood loss. The disadvantages of this procedure are increased operational costs, lack of trained surgeons, and lack of tactile feedback during the procedure.

Conclusion

Over the years, several robotic surgical systems have been introduced for urological procedures. Systems like da Vinci, Revo-I, and Avatera have multiple arms that can be operated by surgeons remotely. Also, these robots have high-definition cameras and wristed arms, which is helpful in providing great freedom of movement and accessibility. Such robots are used in procedures like prostatectomy, cystectomy, and pyeloplasty.