From Leonardo to da Vinci: the history of robot-assisted surgery in urology

Association between bladder cancer treatment and female sexual function

INTRODUCTION

Bladder cancer ranks 17th in prevalence of cancer types among women, and the trend is rising. The increased risk of female sexual dysfunction (FSD) after radical cystectomy (RC) underscores the need for greater focus on preserving and mitigating FSD.

OBJECTIVES

To place greater emphasis on the importance of female sexual function (FSF) in the treatment of bladder cancer and stimulate additional research to discover more effective solutions for enhancing the overall quality of life.

METHODS

This review used a narrative approach. Previous reviews on FSF after RC have provided limited and 1-sided solutions due to the lack of research. What makes this review unique is its innovative approach: it includes all available measures curing FSD as well as comparative analyses based on experimental data, thus making the findings more comprehensive. A detailed perspective of treatments for female bladder cancer is provided, including nerve- and organ-sparing RC, robot-assisted RC, and radiotherapy. We also analyze the impact of treatments for female bladder cancer on postoperative FSD. Additionally, solutions for addressing or alleviating postoperative FSD are summarized, such as urinary diversion, vaginal reconstruction, and drug and nondrug treatment.

RESULTS

Research has suggested that robot-assisted nerve- and organ-sparing RC is promising. Moreover, orthotopic neobladder among urinary diversions without a stoma helps to maintain a positive female body image. If part of the anterior vaginal wall must be removed during RC, vaginal reconstruction can restore the dimensions with synthetic grafts and biologic scaffolds. Additionally, postoperative measures, such as vaginal laser and hormone therapy, and use of vaginal dilators and lubricants have a significant role in reducing distress caused by FSD to provide maximum relief.

CONCLUSIONS

To support FSF after RC, various interventions are needed, and urologists must focus on patient recovery while minimizing treatment impact on FSF as much as possible.

Suitability of the MP1000 Platform for Robot-assisted Prostatectomy: A Prospective Randomised Controlled Trial

Background and objective

Robot-assisted radical prostatectomy (RARP) is widely used because of the many advantages of a robotic approach. The da Vinci Si robot is one of the most commonly used surgical robot systems, but it may be associated with higher costs owing to the use of consumable surgical supplies. Our aim was to conduct a preliminary investigation of the capability of the MP1000 system for RARP.

Methods

In this prospective, multicentre, single-blinded study, we randomly assigned 42 patients scheduled to undergo RARP between April and September 2021 to a da Vinci Si group (control) or an MP1000 group (intervention). Patients underwent RARP performed using the assigned robotic system and were followed up at 3-mo intervals. The primary outcome was the rate of conversion to open/laparoscopic surgery. Secondary outcomes were installation and operation times, intraoperative blood loss, postoperative surgical margin status, hospital stay, incontinence, complications, safety indicators, and surgeon ergonomics.

Key findings and limitations

All procedures were successfully completed without conversion to open/laparascopic surgery or major complications. Secondary outcomes, including oncological and ergonomic indicators, did not differ significantly between the groups over the study period. One patient in the control group experienced dysuria (Clavien-Dindo grade 3). No patients had incontinence at 3 mo. A limitation of the study is the small sample size.

Conclusions and clinical implications

RARP with the MP1000 system is feasible, safe, and effective in the management of localised prostate cancer.

Patient summary

We assessed the effectiveness and safety of the new MP1000 robot system for robot-assisted removal of the prostate in comparison to the da Vinci Si robot. We found no difference in effectiveness or safety among 42 patients with prostate cancer who were assigned randomly to one of the two systems. We conclude that the MP1000 is a suitable robot for this surgery.

Evaluating the utility of robotic axillary lymph node dissection in patients with invasive breast cancer: a systematic review

Robot-assisted axillary lymph node dissection (RALND) has been proposed to improve surgical and oncological outcomes for patients with breast cancer. To perform a systematic review of current literature evaluating RALND in patients with invasive breast cancer. A systematic search was performed in accordance with the PRISMA guidelines. Studies outlining outcomes following RALND were included. Two studies involving 92 patients were included in this review. Of these, 41 underwent RALND using the da Vinci© robotic system (44.57%), and 51 underwent conventional axillary lymph node dissection (CALND) (55.43%). There was no significant difference observed with respect to intra-operative blood loss or duration of procedure in those undergoing CALND and RALND (P > 0.050). One study reported a significant difference in lymphoedema rates in support of RALND (6.67% vs 26.67%, P = 0.038). Overall, data in relation to postoperative fat necrosis (10.00% vs 33.33%, P = 0.028), wound infection rates (3.33% vs. 20.00%, P = 0.044), and wound ≤ 40 mm in length (63.63% vs. 19.05%, P = 0.020) supported RALND. Oncological outcomes were only reported in one of the studies, which concluded that there was no local or metastatic recurrence in either group at 3-month follow-up. These provisional results support RALND as a safe alternative to CALND. Notwithstanding, the paucity of data limits the robustness of conclusions which may be drawn surrounding the adoption of RALND as the standard of care. Further high-quality studies are required to ratify these findings.

The downtrending cost of robotic bariatric surgery: a cost analysis of 47,788 bariatric patients

The surgical robot is assumed to be a fixed, indirect cost. We hypothesized rising volume of robotic bariatric procedures would decrease cost per patient over time. Patients who underwent elective, initial gastric bypass (GB) or sleeve gastrectomy (SG) for morbid obesity were selected from Florida Agency for Health Care Administration database from 2017 to 2021. Inflation-adjusted cost per patient was collected. Cost-over-time ($/patient year) and change in cost-over-time were calculated for open, laparoscopic, and robotic cases. Linear regression on cost generated predictive parameters. Density plots utilizing area under the curve demonstrated cost overlap. Among 76 hospitals, 11,472 bypasses (223 open, 6885 laparoscopic, 4364 robotic) and 36,316 sleeves (26,596 laparoscopic, 9724 robotic) were included. Total cost for robotic was approximately 1.5-fold higher (p < 0.001) than laparoscopic for both procedures. For GB, laparoscopic had lower total ($15,520) and operative ($6497) average cost compared to open (total $17,779; operative $9273) and robotic (total $21,756; operative $10,896). For SG, laparoscopic total cost was significantly less than robotic ($10,691 vs. $16,393). Robotic GB cost-over-time increased until 2021, when there was a large decrease in cost (-$944, compared with 2020). Robotic SG total cost-over time fluctuated, but decreased significantly in 2021 (-$490 compared with 2020). While surgical costs rose significantly in 2020 for bariatric procedures, our study suggests a possible downward trend in robotic bariatric surgery as total and operative costs are decreasing at a higher rate than laparoscopic costs.

Reappraisal of surgical and survival outcomes of 500 consecutive cases of robotic pancreaticoduodenectomy

BACKGROUND

The role of the robotic approach for pancreaticoduodenectomy has not been well established with robust data. This study aimed to reappraise feasibility and justification of robotic pancreaticoduodenectomy (RPD) over time.

METHODS

A total of 500 patients undergoing RPD were enrolled and divided into early (first 250 patients) and late (last 250 patients) groups for a comparative study.

RESULTS

The conversion rate was 8.8% overall and was significantly lower in the late group (5.6% vs. 12.0%; p = .012). The overall median intraoperative blood loss was 130 mL. Radicality of resection was similar between early and late groups. The overall surgical mortality after RPD was 1.3%. The overall surgical morbidity and major complication was 44.1% and 13.2%, respectively, and similar between early and late groups. Chyle leakage was the most common complication after RPD (25.0%), followed by postoperative pancreatic fistula (POPF). The POPF rate was 8.6% overall, with 5.9% in the early group and 11.0% in the late group, p = .051. The overall delayed gastric emptying rate was 3.5%. The late group had better survival outcomes than those of the early group after RPD for ampullary adenocarcinoma (p = .027) but not for pancreatic head adenocarcinoma.

CONCLUSIONS

Reappraisal of this study has confirmed that RPD is not only technically feasible without increasing surgical risks but also oncologically justified without compromising survival outcomes for both pancreatic head and other periampullary cancers over time. Moreover, RPD is associated with the benefits of low surgical mortality, blood loss, and delayed gastric emptying.

Transitioning from Da Vinci Si to Xi: assessing surgical outcomes at a high-volume robotic center

PURPOSE

In the emerging field of robotics, only few studies investigated the transition between different robotic platforms in terms of surgical outcomes. We aimed at assessing surgical outcomes of patients receiving robot-assisted radical prostatectomy (RARP) and robot-assisted partial nephrectomy (RAPN) at a high-volume robotic center during the transition from Si to Xi Da Vinci surgical systems.

METHODS

We analyzed data of 1884 patients undergoing RARP (n = 1437, 76%) and RAPN (n = 447, 24%) at OLV hospital (Aalst, Belgium) between 2011 and 2021. For both procedures, we assessed operative time, estimated blood loss, length of stay, and positive surgical margins. For RARP, we investigated length of catheterization and PSA persistence after surgery, whereas warm ischemia time, clampless surgery, and acute kidney injury (AKI) were assessed for RAPN. Multivariable analyses (MVA) investigated the association between robotic platform (Si vs. Xi) and surgical outcomes after adjustment for patient- and tumor-related factors.

RESULTS

A total of 975 (68%) and 462 (32%) patients underwent RARP performed with the Si vs. Xi surgical system, respectively. Baseline characteristics did not differ between the groups. On MVA, we did not find evidence of a difference between the groups with respect to operative time (estimate: 1.07) or estimated blood loss (estimate: 32.39; both p > 0.05). Median (interquartile range [IQR]) length of stay was 6 (3, 6) and 4 (3, 5) days in the Si vs. Xi group, respectively (p < 0.0001). On MVA, men treated with the Xi vs. Si robot had lower odds of PSM (Odds ratio [OR]: 0.58; p = 0.014). A total of 184 (41%) and 263 (59%) patients received RAPN with the Si and Xi robotic system, respectively. Baseline characteristics, including demographics, functional data, and tumor-related features did not differ between the groups. On MVA, operative time was longer in the Xi vs. Si group (estimate: 30.54; p = 0.006). Patients treated with the Xi vs. Si system had higher probability of undergoing a clampless procedure (OR: 2.56; p = 0.001), whereas the risk of AKI did not differ between the groups (OR: 1.25; p = 0.4). On MVA, patients operated with the Xi robot had shorter length of stay as compared to the Si group (estimate: - 0.86; p = 0.003), whereas we did not find evidence of an association between robotic system and PSM (OR: 1.55; p = 0.3).

CONCLUSION

We found that the Xi robot allowed for improvements in peri-operative outcomes as compared to the Si platform, with lower rate of positive margins for RARP and higher rate of off-clamp procedures for RAPN. Hospital stay was also shorter for patients operated with the Xi vs. Si robot, especially after robot-assisted partial nephrectomy. Awaiting future investigations-in particular, cost analyses-these results have important implications for patients, surgeons, and healthcare policymakers.

Surgical Risks and Survival Outcomes in Robotic Pancreaticoduodenectomy for the Aged Over 80: A Retrospective Cohort Study

Aim

Whether to execute pancreaticoduodenectomy or not for older people could pose a dilemma. This study clarifies the safety and justification of robotic pancreaticoduodenectomy (RPD) for older individuals over 80.

Methods

A total of 500 patients undergoing RPD were divided into group O (≥ 80 y/o) and group Y (< 80 y/o) for comparison.

Results

There were 62 (12.4%) patients in group O. Surgical mortality was 1.6% for overall patients and higher in group O, 6.5% vs 0.9%; p = 0.001. The surgical complication was comparable between groups O and Y. Delayed gastric emptying and bile leakage were higher in group O, 9.7% vs 2.5%; p = 0.004, and 6.5% vs 0.9%; p = 0.001, respectively. Length of stay was also longer in group O, with a median of 26 vs 19 days; p = 0.001. Survival outcome after RPD was poorer in group O for overall periampullary adenocarcinomas, with a 5-year survival of 48.1% vs 51.2%; p = 0.025 and also for the subgroup of pancreatic head adenocarcinoma, with a 3-year survival of 27.4% vs 42.5%; p = 0.030.

Conclusion

RPD is safe and justified for the selected octogenarians and even nonagenarians, whoever is fit for a major operation. Nevertheless, pancreatic head cancer and higher mortality risk for the aged over 80 with advanced ASA score ≥ 3 should be informed as part of counselling in offering RPD.

Metanephric stromal tumor in an adult with PDGFRA mutation: a case report

BACKGROUND

Metanephric stromal tumors (MST) are rare benign renal tumors that mainly occur in infants and children. Approximately 72% of MST in children have the B-Raf proto-oncogene serine/threonine kinase (BRAF) V600E mutation. To date, only five cases of adult MSTs have been reported and no clear genetic alterations have been found.

CASE PRESENTATION

We report a case of MST in a 45-year-old woman who complained of left lower back pain for a week, accompanied by hypertension (150/79 mmHg). Magnetic resonance imaging (MRI) showed an abnormally enhanced nodule (1.1 cm in the middle of the left kidney), which was histopathologically consistent with an MST. The BRAF V600E mutation was not detected in tumor cells using PCR and next-generation sequencing (NGS). However, a platelet-derived growth factor receptor alpha (PDGFRA) mutation was detected in this case using NGS. The patient showed no recurrence or metastasis nine months after partial nephrectomy, and her blood pressure was consistently normal.

CONCLUSION

This is the first report of alterations in PDGFRA in MSTs. This result advances our knowledge of genetic variations in adult MSTs, which may have different gene alterations from MSTs in children.

Robotically-assisted neuro-endovascular procedures: Single-Center Experience and a Review of the Literature

INTRODUCTION

Robotics could expand treatment of rapidly progressive pathologies such as acute ischemic stroke, with the potential to provide populations in need prompt access to neuro-endovascular procedures.

METHODS

Robotically-assisted (RA) neuro-endovascular procedures (RANPs) performed at our institution were retrospectively examined (RA-group, RG). A control group of manual neuro-endovascular procedures was selected (manual group, MG). Total operating room (OR) time, procedural time, contrast media use, fluoroscopy time, conversion from RA to manual control, procedural success, and complication rates were compared. A learning curve was identified.

RESULTS

Forty-one (41) RANPs were analyzed. Ages ranged from 20-82 y.o. Indications included diagnostic cerebral angiography (37), extracranial carotid artery stenting (3), and transverse sinus stent (1). Total OR time was longer in RG (median 86 vs. 71 min, p < 0.01). Procedural time (median 56 vs. 45 min, p = 0.12), fluoroscopy time (median 12 vs. 12 min, p = 0.69) and contrast media usage (82 vs. 92 ml, p = 0.54) were not significantly different. Patient radiation exposure was similar, considering similar fluoroscopy times. Radiation exposure and lead apron use were virtually absent for the main surgeon in RG. Procedural success was 83% and conversion from RA to manual control was 17% in RG. No treatment-related complications occurred. A learning curve showed that, after the fifth procedure, procedural times reduced and stabilized.

CONCLUSIONS

This series may contribute to further demonstrating the safety and feasibility of RANPs. RANPs can potentially reduce radiation exposure and physical burden for health personnel, expand acute cerebrovascular treatment to underserved areas, and enhance telementoring. Prospective studies are necessary for results to be generalized.

A review on tele-manipulators for remote diagnostic procedures and surgery

With modern medicine and healthcare services improving in leaps and bounds, the integration of telemedicine has helped in expanding these specialised healthcare services to remote locations. Healthcare telerobotic systems form a component of telemedicine, which allows medical intervention from a distance. It has been nearly 40 years since a robotic technology, PUMA 560, was introduced to perform a stereotaxic biopsy in the brain. The use of telemanipulators for remote surgical procedures began around 1995, with the Aesop, the Zeus, and the da Vinci robotic surgery systems. Since then, the utilisation of robots has steadily increased in diverse healthcare disciplines, from clinical diagnosis to telesurgery. The telemanipulator system functions in a master–slave protocol mode, with the doctor operating the master system, aided by audio-visual and haptic feedback. Based on the control commands from the master, the slave system, a remote manipulator, interacts directly with the patient. It eliminates the requirement for the doctor to be physically present in the spatial vicinity of the patient by virtually bringing expert-guided medical services to them. Post the Covid-19 pandemic, an exponential surge in the utilisation of telerobotic systems has been observed. This study aims to present an organised review of the state-of-the-art telemanipulators used for remote diagnostic procedures and surgeries, highlighting their challenges and scope for future research and development.

Strategies to improve cost effectiveness of robotic assisted laparoscopic radical prostatectomy in emerging economies

To assess the cost-effectiveness of the robotic-assisted laparoscopic radical prostatectomy (RALRP) compared to open radical prostatectomy (ORP) for localized prostate cancer from a healthcare perspective in Colombia. A systematic review was conducted in Embase, Scopus, Web of Science, PubMed, and Cochrane CENTRAL databases, to identify relevant publications up to January 2020 to summarize clinical outcomes related to effectiveness of robot-assisted and open radical prostatectomy. A tree decision model was designed given the clinical outcomes and possibilities of complication and success. Outcomes were defined as complications according to Clavien - Dindo classification and success measured as urethral stricture rate. Cost was divided into two categories: surgical procedure and complications. Incremental cost-effectiveness ratio (ICER) was calculated and a deterministic sensitivity analysis was performed to evaluate the impact of the uncertainty on the conclusions of the model. A 90-day horizon was defined. Direct medical costs associated with RALRP were $6.511 ($ 5.127- $8.138), and for ORP were $4.476 ($2.170-$ 6.511). The average cost for complication management was rated at $ 327 for RALRP and $ 382 for ORP, based on an augmented risk of post-operative urethral stricture in the ORP group (2.4% vs 10.8%). ICER was calculated in USD $18.987. The cost of RALRP has to be reduced to around USD 5.345 to achieve an ICER under 1 GDP making the intervention feasible. Using a 3 GDP per capita threshold, the implementation of RALRP could be cost-effective for the treatment of localized prostate cancer in emerging economies. Bolder measures including the use of one needle carrier, three robotic arms, and a shorten hospitalization program of 24 h, can save around $1000 for each patient, achieving the goal cost of $5345 needed for a favorable ICER.

Integration of Reinforcement Learning in a Virtual Robotic Surgical Simulation

Background. The revolutions in AI hold tremendous capacity to augment human achievements in surgery, but robust integration of deep learning algorithms with high-fidelity surgical simulation remains a challenge. We present a novel application of reinforcement learning (RL) for automating surgical maneuvers in a graphical simulation.Methods. In the Unity3D game engine, the Machine Learning-Agents package was integrated with the NVIDIA FleX particle simulator for developing autonomously behaving RL-trained scissors. Proximal Policy Optimization (PPO) was used to reward movements and desired behavior such as movement along desired trajectory and optimized cutting maneuvers along the deformable tissue-like object. Constant and proportional reward functions were tested, and TensorFlow analytics was used to informed hyperparameter tuning and evaluate performance.Results. RL-trained scissors reliably manipulated the rendered tissue that was simulated with soft-tissue properties. A desirable trajectory of the autonomously behaving scissors was achieved along 1 axis. Proportional rewards performed better compared to constant rewards. Cumulative reward and PPO metrics did not consistently improve across RL-trained scissors in the setting for movement across 2 axes (horizontal and depth).Conclusion. Game engines hold promising potential for the design and implementation of RL-based solutions to simulated surgical subtasks. Task completion was sufficiently achieved in one-dimensional movement in simulations with and without tissue-rendering. Further work is needed to optimize network architecture and parameter tuning for increasing complexity.

The Atlantic divide: contrasting surgical robotics training in the USA, UK and Ireland

The uptake of robotic surgery is rapidly increasing worldwide across surgical specialties. However, there is currently a much higher use of robotic surgery in the United States of America (USA) compared to the United Kingdom (UK) and Ireland. Reduced exposure to robotic surgery in training may lead to longer learning curves and worse patient outcomes. We aimed to identify whether any difference exists in exposure to robotic surgery during general surgical training between trainees in the USA, UK and Ireland. Over a 15-week period from September 2021, a survey was distributed through the professional networks of the research team. Participants were USA, UK or Irish trainees who were part of a formal general surgical training curriculum. 116 survey responses were received. US trainees (n = 34) had all had robotic simulator experience, compared to only 37.93% of UK (n = 58) and 75.00% of Irish (n = 24) trainees (p <  0.00001). 91.18% of US trainees had performed 15 or more cases as the console surgeon, compared to only 3.44% of UK and 16.67% of Irish trainees (p <  0.00001). Fifty UK trainees (86.21%) and 22 Irish trainees (91.67%) compared to 12 US trainees (35.29%) do not think they have had adequate robotics training (p <  0.00001). Surgical trainees in the USA have had significantly more exposure to training in robotic surgery than their UK and Irish counterparts.

Robotics and cochlear implant surgery: goals and developments

PURPOSE OF REVIEW

Cochlear implantation (CI) is a viable option for patients with severe sensorineural hearing loss. Advances in CI have focused on minimizing cochlear trauma to improve hearing preservation outcomes, and in doing so expanding candidacy to patients with useful cochlear reserve. Robotics holds promise as a potential tool to minimize intracochlear trauma with electrode insertion, improve surgical efficiency, and reduce surgical complications. The purpose of this review is to summarize efforts and advances in the field of robotic-assisted CI.

RECENT FINDINGS

Work on robotics and CI over the past few decades has explored distinct surgical aspects, including image-based surgical planning and intraoperative guidance, minimally invasive robotic-assisted approaches mainly through percutaneous keyhole direct cochlear access, robotic electrode insertion systems, robotic manipulators, and drilling feedback control through end effector sensors. Feasibility and safety have been established and many devices are undergoing clinical trials for clinical adoption, with some having already achieved approval of national licensing bodies.

SUMMARY

Significant work has been done over the past two decades that has shown robotic-assisted CI to be feasible and safe. Wider clinical adoption can potentially result in improved hearing preservation and quality of life outcomes to more CI candidates.

[Trends in upper urinary tract reconstruction surgery over a decade based on a multi-center database]

OBJECTIVE

To study the trend of surgical type, surgical procedure and etiological distribution of upper urinary tract repair in recent 10 years.

METHODS

The preoperative and perioperative variables and follow-up data of upper urinary tract reconstruction surgery in RECUTTER (Reconstruction of Urinary Tract: Technology, Epidemiology and Result) database from 2010 to 2021 were searched, collected and analyzed. The surgical type, surgical procedure, duration of hospitalization, time of operation, incidence of short-term complications, and proportion of the patients undergoing reoperations were compared between the two groups of 2010-2017 period and 2018-2021 period.

RESULTS

A total of 1 072 patients were included in the RECUTTER database. Congenital factors and iatrogenic injuries were the main causes of upper urinary tract repair. Among them, 129 (12.0%) patients had open operation, 403 (37.6%) patients had laparoscopic surgery, 322 (30.0%) patients had robot-assisted laparoscopic surgery and 218 (20.3%) patients had endourological procedure. In the last decade, the total number of surgeries showed a noticeable increasing annual trend and the proportion of robot-assisted laparoscopic surgery in 2018-2021 was significantly higher than that in 2010-2017 (P < 0.001). The 1 072 patients included 124 (11.6%) cases of ileal ureter replacements, 440 (41.1%) cases of pyeloplasty, 229 (21.4%) cases of balloon dilation, 109 (10.2%) cases of ureteral reimplantation, 49 (4.6%) cases of boari flap-Psoas hitch surgery, 60 (5.6%) cases of uretero-ureteral anastomosis, 61 (5.7%) cases of lingual mucosal onlay graft ureteroplasty or appendiceal onlay flap ureteroplasty. Pyeloplasty and balloon dilatation had been the main types of surgery, while the proportion of lingual mucosal onlay graft ureteroplasty plus appendiceal onlay flap ureteroplasty had increased significantly in recent years (P < 0.05). In addition, the time of operation was significantly increased (P < 0.05) after 2018, which was considered to be related to the sharp increase in the proportion of robot-assisted laparoscopic surgery. We found that minimally invasive surgery (endourological procedure and robot-assisted laparoscopic surgery) as an independent risk factor (P=0.050, OR=0.472) could reduce the incidence of short-term post-operative complications.

CONCLUSION

We have justified the value of the RECUTTER database, created by the Institute of Urology, Peking University in data support for clinical research work, and provided valuable experience for the construction of other multi-center databases at home and abroad. In recent 10 years, we have observed that, in upper urinary tract reconstruction surgery, the surgery type tends to be minimally invasive and the surgery procedure tends to be complicated, suggesting the superiority of robot-assisted laparoscopic surgery.

Robotics in laparoscopic surgery - A review

Because of the increasing use of laparoscopic surgeries, robotic technologies have been developed to overcome the challenges these surgeries impose on surgeons. This paper presents an overview of the current state of surgical robots used in laparoscopic surgeries. Four main categories were discussed: handheld laparoscopic devices, laparoscope positioning robots, master–slave teleoperated systems with dedicated consoles, and robotic training systems. A generalized control block diagram is developed to demonstrate the general control scheme for each category of surgical robots. In order to review these robotic technologies, related published works were investigated and discussed. Detailed discussions and comparison tables are presented to compare their effectiveness in laparoscopic surgeries. Each of these technologies has proved to be beneficial in laparoscopic surgeries.

Contemporary techniques of da Vinci SP radical prostatectomy: multicentric collaboration and expert opinion

Background

The da Vinci SP robot consists of an innovative single port trocar that houses a flexible camera and three biarticulated arms, which minimizes the number of incisions to assess the surgical site, allowing a less invasive procedure. However, due to its recent release in the market, the current literature reporting SP-RARP is still restricted to a few centers. In this scenario, after performing a literature search with all available techniques of SP-RARP, our objective is to report a multicentric opinion of referral centers on different techniques to approach SP-RARP.

Results

The SP literature is provided by only a few centers due to the limited number of this new console in the market. Five different approaches are available: transperitoneal, extraperitoneal, Retzius-Sparing, transperineal and transvesical. None of the current studies describe long-term functional or oncological outcomes. However, all approaches had satisfactory operative performance with minimum complication rates.

Conclusions

Several techniques of SP-RARP have been reported in the literature. We performed a multicentric collaboration describing and illustrating the most challenging steps of this surgery. We believe that the details provided in this article are useful teaching material for new centers willing to adopt the SP technology.

A Historical Perspective of The Evolution of Laparoscopic Surgeries in Urology

Recent decades have seen the rapid progression of minimally invasive surgery in urology with continuing developments in robotic technology paving ways into a new era. In addition to these technological innovations, interests from urologists in developing and embracing new techniques have become a forefront in the ongoing evolution of the field allowing for improvement intraoperative experience as well as morbidity and mortality outcomes. This article aims to provide an overview of the historical development of laparoscopic surgery in urology whilst also providing a brief look into its future.

Impact of blood transfusion on survival after nephrectomy for localized or locally advanced renal cancer

OBJECTIVE

Several studies have reported blood transfusion were associated with a decrease of survival after oncological surgery. For kidney cancer, the effect of blood transfusion is still debated. The objective of this study was to determine the effect of blood transfusion after oncological nephrectomy on overall, specific and recurrence-free survival in a retrospective cohort of localized or locally advanced kidney cancer.

MATERIAL AND METHODS

We performed a monocentric retrospective analysis of all patients managed by surgery for localized or locally advanced renal cancer between January 2000 and December 2016. We compared overall and specific survival and recurrence-free survival between two groups: patients transfused and not transfused. Demographic, surgical and tumor characteristics were compared. Survival analyses were performed using univariate Cox regression and multivariate Cox proportional regression test.

RESULTS

We included 382 patients in this study: 320 (83.8%) were not transfused and 62 (16.2%) were transfused. Transfused patients were significantly older (P=0.001) and had a lower pre-operative hemoglobin level (P=0.008). Operative and oncological characteristics were also different between both groups. In univariate analysis, we showed that blood transfusion was associated with lower overall survival (P<0.001), specific survival (P<0.001), and recurrence-free survival (P<0.001). In multivariate analysis, we found that blood transfusion was not associated with overall survival, or specific survival, but it was associated with lower recurrence-free survival (HR: 1.967, CI95% [1.024-3.780], P=0.042).

CONCLUSIONS

Perioperative blood transfusion is an independent risk factor that increases tumor recurrence among patients treated with nephrectomy for renal cancer.

Cone-beam CT-guided tagging of endophytic renal tumors with indocyanine green via trans-arterial selective delivery in patients undergoing robot-assisted partial nephrectomy with near infrared fluorescence imaging

PURPOSE

To evaluate the safety, efficacy, and clinical impact of pre-operative cone-beam CT (CBCT)-guided selective embolization of endophytic renal tumors with the fluorescent dye indocyanine green (ICG) and lipiodol in patients undergoing robot-assisted partial nephrectomy (RAPN) using near infrared fluorescent imaging (NIFI).

MATERIALS AND METHODS

Patients with renal endophytic tumors eligible for RAPN and trans-arterial embolization with ICG and lipiodol were prospectively included. Technical success was defined as the completion of the embolization procedure. Radiographic success, defined as the lipiodol accumulation into the nodule, was classified as poor, moderate, good, and optimal based on post-embolization CBCT. Surgical visibility of the tumors during RAPN with the use of NIFI was classified as: not visible, visible with poorly defined margins, and visible with well-defined margins.

RESULTS

Forty-one patients underwent pre-operative selective embolization. Technical success was 100%. Lipiodol accumulation at CBCT was poor in 2/41 (4.9%), moderate in 6/41 (14.6%), good in 25/41 (61.0%), and optimal in 8/41 patients (19.5%). During RAPN with NIFI, tumors were visible with well-defined margins in 26/41 (63.4%), visible with blurred margins in 14/41 (34.1%) and not visible in 1/41 (2.4%) of cases. There were no adverse events following endovascular embolization.

CONCLUSION

Pre-operative trans-arterial super-selective embolization of endophytic renal tumors with ICG and lipiodol in patients undergoing RAPN is safe and effective, allowing accurate intraoperative visualization and resection of endophytic tumors.

Robot-assisted surgery in horseshoe kidneys: A safety and feasibility multi-centre case series

Objective:

We assessed the safety and feasibility of minimally invasive robot-assisted surgery for horseshoe kidney (HSK).

Method:

A prospectively maintained data set for consecutive patients undergoing robotic kidney surgery was reviewed for patients with HSK. Cases were performed by experienced robotic surgeons, across two high-volume centres between 2016 and 2020.

Results:

Seven patients underwent robotic surgery for HSK, comprising three partial nephrectomies for renal masses, one nephroureterectomy and three benign nephrectomies for non-functioning kidneys. The median age was 53 (interquartile range (IQR) = 47–60) years and median body mass index (BMI) was 25 (IQR = 25–26.5). Median console time was 120 (IQR = 118–215) minutes and median estimated blood loss was 150 (IQR = 125–250) mL. The median pre- and post-operative estimated glomerular filtration rate (eGFR) was 76 (IQR = 72–90) and 71 (IQR = 60–81), respectively. There were no higher-grade complications (Clavien–Dindo III–IV) and one Clavien–Dindo grade II complication (wound infection treated with IV antibiotics). Median length of stay (LOS) was 2 days and there were no 30-day readmissions. Negative margins were achieved in 75% of tumour resections.

Conclusion:

We report one the largest series of robot-assisted surgery on HSK. Robotic surgery is safe and feasible for HSK in centralised high-volume centres with acceptable perioperative outcomes. Established benefits of minimally invasive surgery, such as reduced LOS and low complication rates, were demonstrated.

Level of evidence:

4

Robotic Diagnosis and Management of Acute Cholecystocolonic Fistula

Cholecystocolonic fistula (CCF) is a rare complication of biliary tract disease. Increased use of imaging has aided in diagnosing these fistulae preoperatively and has established laparoscopy as a safe alternative to laparotomy. Here, we present a 79-year-old male who presented to the emergency room with abdominal pain and was diagnosed with choledocholithiasis. CT scan revealed a CCF, and he underwent endoscopic retrograde cholangiopancreatography (ERCP). He was followed closely to allow maturation of the fistula, and then, da Vinci® Xi robotic cholecystectomy and ligation were performed. Although current comparisons to laparoscopy have yet to demonstrate a clinical advantage, robotic assistance enhances dexterity, visualization, and ergonomics. Our case is one of the first documented successful operative management of CCF using the da Vinci^® Xi robot.

Understanding the surgeon's behaviour during robot-assisted surgery: protocol for the qualitative Behav'Robot study

INTRODUCTION

Robot-assisted surgery is spreading worldwide, accounting for more than 1.2 million procedures in 2019. Data are sparse in the literature regarding the surgeon's mechanisms that mediate risk-taking during a procedure, especially robot-assisted. This study aims to describe and understand the behaviour of the surgeons during robot-assisted surgery and the change in their behaviour with increasing experience in using the robot.

METHODS AND ANALYSIS

This is a qualitative study using semistructured interviews with surgeons who perform robot-assisted surgery. An interview guide comprising open questions will be used to ensure that the points to be discussed are systematically addressed during each interview (ie, (1) difference in behaviour and preparation of the surgeon between a standard procedure and a robot-assisted procedure; (2) the influence of proprioceptive modifications, gain in stability and cognitive biases, inherent in the use of a surgical robot and (3) the intrinsic effect of the learning curve on the behaviour of the surgeons. After transcription, interviews will be analysed with the help of NVivo software, using thematic analysis.

ETHICS AND DISSEMINATION

Since this project examines professional practices in the field of social and human sciences, ethics committee was not required in accordance with current French legislation (Decree no 2017-884, 9 May 2017). Consent from the surgeons is implied by the fact that the interviews are voluntary. Surgeons will nonetheless be informed that they are free to interrupt the interview at any time.Results will be presented in peer-reviewed national and international congresses and submitted to peer-reviewed journals for publication. The communication and publication of the results will be placed under the responsibility of the principal investigator and publications will be prepared in compliance with the ICMJE uniform requirements for manuscripts.

TRIAL REGISTRATION NUMBER

NCT04869995.

In their own words: A narrative analysis of illness memoirs written by men with prostate cancer

By drawing on a narrative analysis of 11 autobiographical illness memoirs, this article investigates the complexities of what it means to live with prostate cancer over a period of time. Acknowledging how cancer disrupts everyday life, we focus on the day-to-day experiences and struggles that take place inside and outside the hospital. By building on illustrative quotes from the memoirs, we discuss different facets of cancer as a lived experience. Our findings show that men reconstruct their identity in the memoirs in response to the disruptive nature of cancer by including various identities from previous times. They describe a relationship with their cancer that is fluid and fitful and often depends on place, time and circumstances. We also found that the 'not knowing' of prostate cancer creates uncertainty, which can take different forms, transcends time and is shaped through medical technologies, continual testing and disagreeing doctors. Prostate cancer is often seen as easily treatable, but our findings call for a different way of looking at its impact. We argue that memoirs, written by men themselves, make it palpable what it means to live with cancer. As such, illness memoirs offer a way to advance our sociological understanding of cancer-as-a-lived experience.

Roboethics principles and policies in Europe and North America

Robotics and artificial intelligence (AI) are revolutionizing all spheres of human life. From industrial processes to graphic design, the implementation of automated intelligent systems is changing how industries work. The spread of robots and AI systems has triggered academic institutions to closely examine how these technologies may affect the humanity—this is how the fields of roboethics and AI ethics have been born. The identification of ethical issues for robotics and AI and creation of ethical frameworks were the first steps to creating a regulatory environment for these technologies. In this paper, we focus on regulatory efforts in Europe and North America to create enforceable regulation for AI and robotics. We describe and compare ethical principles, policies, and regulations that have been proposed by government organizations for the design and use of robots and AI. We also discuss proposed international regulation for robotics and AI. This paper tries to highlight the need for a comprehensive, enforceable, and agile policy to ethically regulate technology today and in the future. Through reviewing existing policies, we conclude that the European Unition currently leads the way in defining roboethics and AI ethical principles and implementing them into policy. Our findings suggest that governments in Europe and North America are aware of the ethical risks that robotics and AI pose, and are engaged in policymaking to create regulatory policies for these new technologies.

Partial nephrectomy through retroperitoneal approach with a new surgical robot system, KD-SR-01

BACKGROUND

To present our experiences with partial nephrectomy (PN) through retroperitoneal approach (RP) with the Kangduo robotic system.

METHODS

From December 2020 to February 2021, the perioperative data of 11 patients underwent PN through RP with the Kangduo robotic system were collected prospectively.

RESULTS

For the R.E.N.A.L. nephrometry score, 72.7% of patients had a low score (4-6) and 27.3% of patients had a medium score (7-9). Seven tumours were posterior (P), four tumours were on the midline (X). All procedures were completed successfully. The median warm ischemia time was 18.5 (IQR, 13.7-21.0) min. None of the patients had positive surgical margins at definitive histology (all pT1a). No high-grade perioperative complications or device-related adverse events occurred. At a mean follow-up of 8 ± 0.8 months, no complications occurred in all patients.

CONCLUSIONS

RPPN using the novel Kangduo robotic system is a safe and effective option for managing posterior and lateral renal tumours with R.E.N.A.L. nephrometry scores ≤9.

Development and validation of the metric-based assessment of a robotic vessel dissection, vessel loop positioning, clip applying and bipolar coagulation task on an avian model

The evolution of robotic technology and its diffusion does not seem to have been adequately accompanied by the development and implementation of surgeon training programs that ensure skilled and safe device use at the start of the learning curve. The objective of the study is to develop and validate performance metrics for vessel dissection, vessel loop positioning, clip applying and bipolar coagulation using an avian model. Three robotic surgeons and a behavioral scientist characterized the performance metrics of the task according to the proficiency-based progression methodology. Fourteen experienced robotic surgeons from different European countries participated in a modified online Delphi consensus. Eight experienced surgeons and eight novices performed the robotic task twice. In the Delphi meeting, 100% consensus was reached on the performance metrics. Novice surgeons took 26 min to complete the entire task on trial 1 and 20 min on trial 2. Experts took 10.1 min and 9.5 min. On average the Expert Group completed the task 137% faster than the Novice Group. The amount of time to reach the vessel part of the task was also calculated. Novice surgeons took 26 min on trial 1 and 20 min on trial 2. Experts took 5.5 min and 4.8 min. On average the experts reached the vessel 200% faster than the novices. The Expert Group made 155% fewer performance errors than the Novice Group. The mean IRR of video-recorded performance assessments for all metrics was 0.96 (95% confidence intervals (CI) lower = 0.94-upper = 0.98). We report the development and validation for a standard and replicable basic robotic vessel dissection, vessel loop positioning, clip applying and bipolar coagulation task on an avian model. The development of objective performance metrics, based on a transparent and fair methodology (i.e., PBP), is the first fundamental step toward quality assured training. This task developed on the avian model proved to have good results in the validation study.

Robotic radical prostatectomy: difficult to start, fast to improve? Influence of surgical experience in robotic and open radical prostatectomy

Purpose

The assistance of robotic systems raises the concern of whether there is an improved learning in robotic-assisted radical prostatectomy (RARP) compared to open retropubic radical prostatectomy (ORP).

Methods

We retrospectively analyzed data from 1438 patients who underwent ORP (n = 735) or RARP (n = 703). For each procedure, the level of experience of three different surgeons was summarized. Perioperative and pathological parameters reflecting surgical performance were compared between both learning curves. RARP data were influenced by new introduction of the robotic system.

Results

The median patient age at surgery was 66 years (IQR 42–80). Patients in the RARP group were younger (p < 0.001) and had a lower oncological risk (p < 0.001). Inexperienced RARP surgeons had a higher pT2-PSM rate and lower lymph node yield (13.8 ± 4.7 vs. 14.7 ± 4.8; p = 0.03) than inexperienced ORP surgeons. After 100 procedures, RARP and ORP surgeons had the same pT2-PSM rate (8% vs. 8%; p = 0.8) and lymph node yield (15.4 ± 5.4 vs. 15.4 ± 5.1; p = 1.0). In multivariate analysis for ORP, surgical inexperience (≤ 100 cases) was an independent predictor of a longer operating time (OR 9.0; p < 0.001) and higher amount of blood loss (OR 2.9; p < 0.001). For RARP, surgical inexperience (≤ 100 cases) was a predictor of a longer operating time (OR 3.9; p < 0.001), higher amount of blood loss (OR 1.9; p = 0.004), higher pT2-PSM rate (OR 1.6; p = 0.03), and lower lymph node yield (OR 0.6; p = 0.001).

Conclusions

Surgical experience has a relevant impact on perioperative and pathological parameters RARP has a higher initial pT2-PSM rate and lower lymph node yield than ORP. This is relevant for patient selection for novice teaching in RARP.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03763-w.

Transdiaphragmatic single-port video-assisted thoracoscopic surgery; a novel approach for pulmonary metastasectomy through laparotomy incision - case series

Background

Pulmonary metastasectomy was performed in the early twentieth century and ever since, it has evolved to be one of the main treatment options for certain metastatic malignancies. The advancement of minimally invasive procedures enabled new techniques to minimize morbidity and improve patient quality of care and overall outcome.

Cases presentation

Herein we present three patients, aged 53, 48, and 27 years, known to have sigmoid, rectal, and non-seminomatous germ cell tumors respectively. All patients were diagnosed to have metastatic lung nodules and underwent laparotomy to excise abdominal tumors followed by trans-diaphragmatic single-port video-assisted thoracoscopic pulmonary metastasectomy. All patients achieved complete surgical tumor excision, and none had pulmonary related complications on follow-up.

Conclusion

Our prescribed novel trans-diaphragmatic single-port video-assisted thoracoscopic surgery (VATS) technique for synchronous pulmonary metastasectomy and intra-abdominal tumor resection is safe and can achieve complete resection with negative margins.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01393-2.

LigaSure versus the standard technique (Hem-o-lok clips) for robot-assisted radical prostatectomy: a propensity score-matched study

The aim of the study is to compare the utility and efficacy of the LigaSure system and standard surgical clips for robot-assisted radical prostatectomy. The medical records of 473 patients who underwent robot-assisted radical prostatectomy between May 2011 and 2018 were retrospectively reviewed and analyzed. The patients were divided into the LigaSure (n = 125) and Hem-o-lok (n = 348) groups, based on the device used to ligate the vascular pedicle. Owing to differences in the patient characteristics, a 1:2 propensity score matching was performed. In the final matched cohort, 375 patients were included for analysis. The median initial prostate-specific antigen level was not significantly different between the two groups. The median surgical and console times were significantly shorter for the LigaSure group than for the Hem-o-lok group (p < 0.001 and 0.003, respectively). The number of specimens with positive surgical margins was significantly lower in the LigaSure group than in the Hem-o-lok group (24.8 vs 40.8%, p = 0.002). The number of specimens with positive surgical margins for pathological stage T2 cases was also significantly lower in the LigaSure group than in the Hem-o-lok group (17.0 vs 37.5%, p < 0.001). However, non-focal positive surgical margins and biochemical recurrence-free survival rates at 1 year postoperatively were not significantly different (11.2 vs 18.4%, p = 0.075 and 91.2 vs 92.8%, p = 0.565, respectively). The LigaSure system was associated with fewer positive surgical margins and shorter operation time, indicating that it could be a useful alternative to Hem-o-lok clips for controlling the prostatic pedicle in robot-assisted radical prostatectomy, despite its high costs.

The nephroureterectomy: a review of technique and current controversies

The nephroureterectomy (NU) is the standard of care for invasive upper tract urothelial carcinoma (UTUC) and has been around for well over one hundred years. Since then new operative techniques have emerged, new technologies have developed, and the surgery continues to evolve and grow. In this article, we review the various surgical techniques, as well as present the literature surrounding current areas of debate surrounding the NU, including the lymphatic drainage of the upper urinary tract, management of UTUC involvement with the adrenals and caval thrombi, surgical management of the distal ureter, the use of intravesical chemotherapy as well as perioperative systemic chemotherapy, as well as various outcome measures. Although much has been studied about the NU, there still is a dearth of level 1 evidence and the field would benefit from further studies.

Transition from open and laparoscopic to robotic pancreaticoduodenectomy in a UK tertiary referral hepatobiliary and pancreatic centre - Early experience of robotic pancreaticoduodenectomy

BACKGROUND

Pancreaticoduodenectomy is performed using an open technique (OPD) as the gold standard. An increase in those performed laparoscopically (LPD) and robotically (RPD) are now reported. We compared the short-term outcomes of RPD cases with LPD and OPD.

METHODS

A retrospective review of a prospectively collected database was undertaken of our first consecutive RPD, our first LPD and consecutive OPD cases. Those requiring venous and/or arterial resection were excluded.

RESULTS

RPD (n = 25) had longer median operating times (461 (IQR 358-564) mins) than LPD (n = 41) (330 (IQR 262.5-397.5) mins) and OPD (n = 37) (330 (IQR 257-403) mins, p < 0.0001). Estimated blood loss and transfusion requirement was less after RPD and LPD compared to OPD (p = 0.012 and p < 0.0001 respectively). No RPD cases required conversion to open operation compared to 24.4% of LPD. Morbidity was comparable with a Clavien Dindo score ≥3 in 20.00%, 24.39% and 18.92% for RPD, LPD and OPD respectively (p = 0.83). Post-operative pancreatic fistula rates were seen in 16.00%, 29.27% and 21.62% of our RPD, LPD and OPD cohorts respectively (p = 0.81). 90-day mortality was seen in 0.97% of the total cohort. Length of hospital stay (LOS) was shorter for RPD compared to both LPD (p = 0.030) and OPD (p = 0.002).

CONCLUSION

RPD is safe to perform with comparable outcomes to LPD and OPD. Further evidence is provided that a randomised controlled trial for PD techniques is required.

Training in robot-assisted surgery

PURPOSE OF REVIEW

The aim of this narrative review is to identify the currently available training programs in the field of robotic-assisted surgery.

RECENT FINDINGS

The lack of well trained robotic surgeons represents the main obstacle facing robotic surgery. This calls for development of structured robotic training programs in order to improve patient safety and outcomes. Structured curriculum should consist of theoretical training (e-learning, case observation), preclinical simulation-based training (virtual reality simulation, dry and wet lab), clinical modular training, and final evaluation. Tele-mentoring might reveal mandatory in future curricula development. To date, several training programs are currently available for robotic surgery. However, the majority lack of clinical modular training that consists of progressive, proficiency-based training through surgical steps with increasing levels of complexity. Moreover, many of these curricula lack validation.

SUMMARY

This recent literature analysis suggests that there is an urgent need to develop and validate new structured training curricula for robotic surgery. This allows to improve the skills of the surgeons and of their team and to prevent patients from being used as a training module optimizing their safety.

Laparoscopic Robotic Surgery: Current Perspective and Future Directions

Just as laparoscopic surgery provided a giant leap in safety and recovery for patients over open surgery methods, robotic-assisted surgery (RAS) is doing the same to laparoscopic surgery. The first laparoscopic-RAS systems to be commercialized were the Intuitive Surgical, Inc. (Sunnyvale, CA, USA) da Vinci and the Computer Motion Zeus. These systems were similar in many aspects, which led to a patent dispute between the two companies. Before the dispute was settled in court, Intuitive Surgical bought Computer Motion, and thus owned critical patents for laparoscopic-RAS. Recently, the patents held by Intuitive Surgical have begun to expire, leading to many new laparoscopic-RAS systems being developed and entering the market. In this study, we review the newly commercialized and prototype laparoscopic-RAS systems. We compare the features of the imaging and display technology, surgeons console and patient cart of the reviewed RAS systems. We also briefly discuss the future directions of laparoscopic-RAS surgery. With new laparoscopic-RAS systems now commercially available we should see RAS being adopted more widely in surgical interventions and costs of procedures using RAS to decrease in the near future.

Preclinical Evaluation of the Versius Surgical System, a New Robot-assisted Surgical Device for Use in Minimal Access Renal and Prostate Surgery

BACKGROUND

Minimal access surgery (MAS) is well-established in urological surgery. However, MAS is technically demanding and associated with a prolonged learning curve. Robot-assisted laparoscopy has made progress in overcoming these challenges.

OBJECTIVE

The aim of this study was to evaluate the feasibility of a new robot-assisted surgical system (the Versius Surgical System; CMR Surgical, Cambridge, UK) for renal and prostate procedures in a preclinical setting, at the IDEAL-D phase 0.

DESIGN, SETTING, AND PARTICIPANTS

Cadaveric sessions were conducted to evaluate the ability of the system to complete all surgical steps required for a radical nephrectomy, prostatectomy, and pelvic lymph node dissection. A live animal (porcine) model was also used to assess the surgical device in performing radical nephrectomy safely and effectively. Procedures were performed by experienced renal and prostate surgeons, supported by a full operating room team.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Surgical access and reach were evaluated by the lead surgeon using a visual analogue scale. The precise surgical steps conducted to make the assessment that the procedures could be completed fully were recorded, as well as instruments used (including manual laparoscopic instruments) and endoscope angle.

RESULTS AND LIMITATIONS

In total, all 24 procedures were completed successfully in cadavers by eight different lead surgeons. Positioning of the ports and bedside units reflected the lead surgeon's preferred laparoscopic set-up and enabled good surgical access and reach, as quantified by a median visual analogue score of ≥6.5. Radical nephrectomies performed in pigs were all completed successfully, with no device- or non-device-related intraoperative complications recorded. Testing in human cadavers and pig models balances the bias introduced by each model; however, it is impossible to completely replicate the experience and performance of the robot for surgery in live humans.

CONCLUSIONS

This is the first preclinical assessment of the Versius Surgical System for renal and prostate procedures. The safety and effectiveness of the system have been demonstrated and warrant progressive assessment in a clinical setting utilising the IDEAL-D framework.

PATIENT SUMMARY

In this report, we looked at the usability of a new robot-assisted surgical device for renal and prostate surgery by testing the system in cadavers and pigs. We found that a number of different surgeons and operating team personnel were able to use the system to successfully complete the procedures under evaluation. We conclude that the system is ready to be tested in live human studies.

The impact of tiredness on virtual reality robotic surgical skills

Introduction

The effect of tiredness has been proved for the surgeons’ musculature performing laparoscopic or robotic procedures (physical stress). Mental stress after robotic surgery has been reported as well. It is still unclear how much the surgical skills are altered and which types of skills are more affected at the final steps of long, complex robotic surgical procedures.

Aim

To evaluate to what extent the surgeon’s skills are influenced by long procedures, using the objective assessment of different surgical skills by a virtual reality robotic simulator.

Material and methods

Fifteen surgeons were asked to perform a continuous 4 h virtual robotic surgical simulator training session. At the beginning of simulator training and at the end of each of the 4 h of training, three exercises of increasing difficulty were selected to be performed in order to assess the surgeons’ skills.

Results

There were statistically significant differences between the initial and final overall scores for all the three exercises, the final outcomes being inferior. The specific metrics for each exercise slightly improved within 1 h from the beginning and thereafter decreased to a statistically significantly inferior value.

Conclusions

The specific metrics on the virtual reality robotic surgical simulator were altered after a 4-hour console training period. Further larger and more complex studies are necessary to evaluate the translation from the simulator to real-life robotic surgery.

The current state and the future of robotic surgery in female pelvic medicine and reconstructive surgery

In this article, we review the current uses and future directions of robotic surgery in the field of female pelvic medicine and reconstructive surgery. Pelvic surgery is ideal for the use of surgical robots, which provide improved visualization and ease of suturing deep within the pelvis. Robots have been successfully used for the treatment of pelvic organ prolapse, in procedures such as sacrocolpopexy, sacrohysteropexy, and uterosacral ligament plication. Surgeons have used the robotic successfully to treat various etiologies of female pelvic pain including fibroids, endometriosis, and nerve entrapment. Robotic repair of iatrogenic injury has been described with excellent outcomes and avoidance of conversion to open surgery in the event of an injury caused using the robotic platform. While more data is needed on this topic, there has been increasing interest in using the robot for urologic reconstruction including repair of vesico-vaginal fistula, cystectomy, augmentation cystoplasty, and continent and non-continent diversions. Recently the use of the robot has been described in the treatment of stress urinary incontinence in females, with robotic placement of an artificial urinary sphincter. While robotic surgery is associated with increased cost, the outcomes of robotic surgery in female urology are promising. More studies that properly evaluate the benefits of robotic surgery as compared to open and laparoscopic approaches are needed.

Utilizing da Vinci® surgical system to treat challenging urinary stones

Introduction:

A worldwide mounting in the incidence and prevalence of urolithiasis has been observed. The standard treatment of urologic stone disease (USD) has changed from open surgery to extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy (PCNL), or ureteroscopy depending on the size and location of the stone. We are sharing our experience in utilizing Da Vinci^® robotic surgical system to treat patient with urolithiasis instead of open surgical approach.

Patients and Methods:

We reviewed prospectively collected data of 19 patients who underwent robotic-assisted stone surgery (RSS) between January 2010 and March 2018 at our institute for USD involving 22 nephroureteral units.

Results:

A total number of 22 RSS were accomplished with no conversion to open. Three patients had bilateral stone and needed to have RSS on each side separately. Eleven RSS were performed on the right. The indications for RSS included as follows: morbid obesity (n = 8, mean body mass index 56.4 kg/m²), need for concurrent renal surgery (n = 3) severe contractures limiting positioning for retrograde endoscopic surgery or PCNL (n = 2), symptomatic calyceal diverticular stone with failed endoscopic approach (n = 4), and after failed PCNL (n = 2). Twenty nephrouretral unit (91%) were rendered stone free on the first attempt with complication occurring after four cases (18%).

Conclusion:

RSS is viable options in the treatment of challenging urologic stone with high success rate and low risk of complication. The need for open stone surgery was eliminated by RSS at our center.

The dawn of robotic surgery in otolaryngology-head and neck surgery

Transoral robotic surgery (TORS) utilizing the da Vinci robotic system has opened a new era for minimally-invasive surgery (MIS) in Otolaryngology-Head and Neck Surgery. Awareness of the historical steps in developing robotic surgery (RS) and understanding its current application within our field can help open our imaginations to future of the surgical robotics. We compiled a historical perspective on the evolution of surgical robotics, the road to the da Vinci surgical system, and conducted a review of TORS regarding clinical applications and limitations, prospective clinical trials and current status in Japan. We also provided commentary on the future of surgical robotics within our field. Surgical robotics grew out of the pursuit of telerobotics and the advances in robotics for non-medical applications. Today in our field, cancers and diseases of oropharynx and supraglottis are the most common indications for RS. It has proved capable of preserving the laryngopharyngeal function without compromising oncologic outcomes, and reducing the intensity of adjuvant therapy. TORS has become a standard modality for MIS, and will continue to evolve in the future. As robotic surgical systems evolve with improved capabilities in visual augmentation, spatial navigation, miniaturization, force-feedback and cost-effectiveness, we will see further advances in the current indications, and an expansion of indications. By promoting borderless international collaborations that put 'patients first', the bright future of surgical robotics will synergistically expand to the limits of our imaginations.

Project INSIDE: towards autonomous semi-unstructured human-robot social interaction in autism therapy

This paper describes the INSIDE system, a networked robot system designed to allow the use of mobile robots as active players in the therapy of children with autism spectrum disorders (ASD). While a significant volume of work has explored the impact of robots in ASD therapy, most such work comprises remotely operated robots and/or well-structured interaction dynamics. In contrast, the INSIDE system allows for complex, semi-unstructured interaction in ASD therapy while featuring a fully autonomous robot. In this paper we describe the hardware and software infrastructure that supports such rich form of interaction, as well as the design methodology that guided the development of the INSIDE system. We also present some results on the use of our system both in pilot and in a long-term study comprising multiple therapy sessions with children at Hospital Garcia de Orta, in Portugal, highlighting the robustness and autonomy of the system as a whole.

Robotic surgery trends in general surgical oncology from the National Inpatient Sample

BACKGROUND

Robotic surgery is offered at most major medical institutions. The extent of its use within general surgical oncology, however, is poorly understood. We hypothesized that robotic surgery adoption in surgical oncology is increasing annually, that is occurring in all surgical sites, and all regions of the US.

STUDY DESIGN

We identified patients with site-specific malignancies treated with surgical resection from the National Inpatient Sample 2010-2014 databases. Operations were considered robotic if any ICD-9-CM robotic procedure code was used.

RESULTS

We identified 147,259 patients representing the following sites: esophageal (3%), stomach (5%), small bowel (5%), pancreas (7%), liver (5%), and colorectal (75%). Most operations were open (71%), followed by laparoscopic (26%), and robotic (3%). In 2010, only 1.1% of operations were robotic; over the 5-year study period, there was a 5.0-fold increase in robotic surgery, compared to 1.1-fold increase in laparoscopy and 1.2-fold decrease in open surgery (< 0.001). These trends were observed for all surgical sites and in all regions of the US, they were strongest for esophageal and colorectal operations, and in the Northeast. Adjusting for age and comorbidities, odds of having a robotic operation increased annually (5.6 times more likely by 2014), with similar length of stay (6.9 ± 6.5 vs 7.0 ± 6.5, p = 0.52) and rate of complications (OR 0.91, 95% CI 0.83-1.01, p = 0.08) compared to laparoscopy.

CONCLUSIONS

Robotic surgery as a platform for minimally invasive surgery is increasing over time for oncologic operations. The growing use of robotic surgery will affect surgical oncology practice in the future, warranting further study of its impact on cost, outcomes, and surgical training.

An automatic skill evaluation framework for robotic surgery training

BACKGROUND

To provide feedback to surgeons in robotic surgery training, many surgical skill evaluation methods have been developed. However, they hardly focus on the performance of the surgical motion segments. This paper proposes a method of specifying a trainee's skill weakness in the surgical training.

METHODS

This paper proposed an automatic skill evaluation framework by comparing the trainees' operations with the template operation in each surgical motion segment, which is mainly based on dynamic time warping (DTW) and continuous hidden Markov model (CHMM).

RESULTS

The feasibility of this proposed framework has been preliminarily verified. For specifying the skill weakness in instrument handling and efficiency, the result of this proposed framework was significantly correlated with that of manual scoring.

CONCLUSION

The automatic skill evaluation framework has shown its superiority in efficiency, objectivity, and being targeted, which can be used in robotic surgery training.

Validity evidence for procedural competency in virtual reality robotic simulation, establishing a credible pass/fail standard for the vaginal cuff closure procedure

BACKGROUND

The use of robotic surgery for minimally invasive procedures has increased considerably over the last decade. Robotic surgery has potential advantages compared to laparoscopic surgery but also requires new skills. Using virtual reality (VR) simulation to facilitate the acquisition of these new skills could potentially benefit training of robotic surgical skills and also be a crucial step in developing a robotic surgical training curriculum. The study's objective was to establish validity evidence for a simulation-based test for procedural competency for the vaginal cuff closure procedure that can be used in a future simulation-based, mastery learning training curriculum.

METHODS

Eleven novice gynaecological surgeons without prior robotic experience and 11 experienced gynaecological robotic surgeons (> 30 robotic procedures) were recruited. After familiarization with the VR simulator, participants completed the module 'Guided Vaginal Cuff Closure' six times. Validity evidence was investigated for 18 preselected simulator metrics. The internal consistency was assessed using Cronbach's alpha and a composite score was calculated based on metrics with significant discriminative ability between the two groups. Finally, a pass/fail standard was established using the contrasting groups' method.

RESULTS

The experienced surgeons significantly outperformed the novice surgeons on 6 of the 18 metrics. The internal consistency was 0.58 (Cronbach's alpha). The experienced surgeons' mean composite score for all six repetitions were significantly better than the novice surgeons' (76.1 vs. 63.0, respectively, p < 0.001). A pass/fail standard of 75/100 was established. Four novice surgeons passed this standard (false positives) and three experienced surgeons failed (false negatives).

CONCLUSION

Our study has gathered validity evidence for a simulation-based test for procedural robotic surgical competency in the vaginal cuff closure procedure and established a credible pass/fail standard for future proficiency-based training.