Defining the pros and cons of open, conventional laparoscopy, and robot-assisted pyeloplasty in a developing nation

Robotic reconstruction for benign upper urinary tract obstruction: a review of the current literature

The field of reconstructive urology has seen a paradigm shift in the surgical approach for intra-abdominal cases, resulting in an increased preference for minimally invasive techniques. The introduction of the surgical robot has led to exponential growth in innovative approaches, reflecting the ongoing efforts to improve patient outcomes and address the limitations of open and laparoscopic surgery. This review article summarizes the knowledge gained in the last 10 years about adult robotic ureteral reconstruction. A non-systematic literature review was conducted on February 18, 2024 using Medline, PubMed, Web of Science, and Embase libraries. Studies published in English since 2014 reporting at least five robotic ureteral reconstructive cases for the management of benign ureteral obstruction in adults were included. A narrative review focusing on robotic ureteral reconstructive techniques, their associated success and complication rates, and how the robotic approach compares to open and laparoscopic reconstruction was performed. The current literature demonstrates increased utilization of the robotic platform in reconstructive urological procedures. Robotic surgery has been shown to be associated with shorter learning curves, lower surgeon fatigue, better visualization and equivalent results to those seen with laparoscopic surgery. While the literature is limited by a lack of comparative data, well-designed randomized controlled trials, and standardized criteria for defining and measuring success, this review demonstrates the safety, feasibility, and efficacy of robotic ureteral reconstruction for managing benign ureteral strictures, confirming it as a viable alternative to open and laparoscopic surgery.

Robot-assisted ureteric reconstructive surgeries for benign diseases: Initial single-center experience with point of technique

INTRODUCTION

We present our initial experience with robot-assisted reconstructive surgeries with the Da Vinci Xi robotic system for benign ureteric pathologies.

MATERIALS AND METHODS

This is a retrospective review of prospectively collected data of patients who underwent robot-assisted reconstructive procedures for benign diseases of the ureter at our department from April 2018 to November 2022. Demographic and perioperative details were recorded. Patients were followed up and surgical success was evaluated on the basis of symptomatic, functional, and radiological improvement.

RESULTS

A total of 34 patients underwent robot-assisted reconstructions for benign ureteric pathologies by various techniques. Mean age, body mass index (BMI), hospital stay and follow-up duration were 36 years, 24.1 kg/m2, 5.29 days, and 7.08 months respectively. Procedures included pyeloplasty in eight, primary ureteroneocystostomy (UNC) in seven, Psoas hitch UNC in five, Boari flap UNC in six, Ureteroureterostomy in four, ureterocalicostomy in two and ileal ureteral transposition in two patients. Mean docking time, total operative time, and estimated blood loss were 31.5 min, 178 min, and 64.3 ml, respectively. All patients had radiologic or functional improvement on follow-up after 6 months.

CONCLUSION

Robot-assisted reconstructive surgery for benign ureteric and bladder pathologies imparted excellent short-term outcomes without major complications with all the advantages of a minimally invasive approach.

Nano-embedded medical devices and delivery systems in interventional radiology

Nanomaterials research has significantly accelerated the development of the field of vascular and interventional radiology. The incorporation of nanoparticles with unique and functional properties into medical devices and delivery systems has paved the way for the creation of novel diagnostic and therapeutic procedures for various clinical disorders. In this review, we discuss the advancements in the field of interventional radiology and the role of nanotechnology in maximizing the benefits and mitigating the disadvantages of interventional radiology theranostic procedures. Several nanomaterials have been studied to improve the efficacy of interventional radiology interventions, reduce the complications associated with medical devices, improve the accuracy and efficiency of drug delivery systems, and develop innovative imaging modalities. Here, we summarize the recent progress in the development of medical devices and delivery systems that link nanotechnology in vascular and interventional radiology. This article is categorized under: Diagnostic Tools > Diagnostic Nanodevices Diagnostic Tools > In Vivo Nanodiagnostics and Imaging Therapeutic Approaches and Drug Discovery > Nanomedicine for Cardiovascular Disease.

Laparoscopic Versus Robot-Assisted Pyeloplasty in Adults-A Single-Center Experience

Background: Laparoscopic (LP) and robot-assisted pyeloplasty (RAP) are minimally invasive techniques for correcting uretero-pelvic junction obstruction (UPJO). We retrospectively compared the clinical outcomes of all adults who underwent RAP (n = 41) to those who underwent LP (n = 24) for UPJO at our institution between 2003−2022. Methods: Age, sex, body mass index, surgical side, past abdominal/endoscopic surgeries, pre- and postoperative renal scans, pre- and postoperative serum creatinine levels, operative time (OT), presence of crossing vessels, estimated blood loss, postoperative complications, length of hospital stay, time to JJ stent removal, follow-up length, and postoperative hydronephrosis were analyzed. Results: The groups were demographically comparable. The mean total and skin-to-skin OTs (minutes) were significantly longer in the RAP group than in the LP group (242.4 ± 55 vs. 161.4 ± 40 p < 0.001; 163.7 ± 41.8 vs. 124.3 ± 30.3 p = 0.006, respectively). Hospital stay (days) was shorter in the RAP group (3.3 ± 2.1 vs. 7.3 ± 2.5 p < 0.001). Postoperative complication rates were identical for both groups. The LP group had a significantly longer follow-up period (85.2 ± 73 vs. 19 ± 14 months p < 0.001). The success rates for the LP and RAP groups were 87.5% and 90.6% (p = 0.708). Conclusions: RAP achieves equivalent results to LP, in adult patients. A longer OT may be expected with the robotic system since it can handle more complicated cases.

Role of laparoscopy in the era of robotic surgery in urology in developing countries

With the rapid expansion of robotic platforms in urology, there is an urgent and unmet need to review its cost and benefits in comparison to the traditional laparoscopy, especially in reference to a developing country. A nonsystematic review of the literature was conducted to compare the outcomes of pure laparoscopic and robot-assisted urologic procedures. Available literature over the past 30 years was reviewed. Robot-assisted surgery and laparoscopy were found to have similar outcomes in the areas of radical prostatectomy, partial and radical nephrectomy, radical cystectomy, retroperitoneal lymph node (LN) dissection, inguinal LN dissection, donor nephrectomy, and kidney transplantation. Robot-assisted surgery was found to be significantly costlier than pure laparoscopy. In the absence of a clear advantage of robot-assisted surgery over pure laparoscopy, lack of widespread availability and the currently prohibitive cost of robotic technology, laparoscopic urological surgery has a definite role in the developing world.

The robot-assisted ureteral reconstruction in adult: A narrative review on the surgical techniques and contemporary outcomes

Despite the rapid increase in the use of robotic surgery in urology, the majority of ureteric reconstruction procedures are still performed using laparoscopic or open approaches. This is primarily due to uncertainty regarding the advantages of robotic approaches over conventional ones, and the unique difficulty in identifying the specific area of interest due to the lack of tactile feedback from the current robotic systems. However, with the potential benefits of minimal invasiveness, several pioneering reports have been published on robotic surgery in urology. By reviewing the literature on this topic, we aimed to summarize the techniques, considerations, and consistent findings regarding robotic ureteral reconstruction in adults. Robotic applications for ureteral surgery have been primarily reported for pediatric urology, especially in the context of relieving a congenital obstruction in the ureteral pelvic junction. However, contemporary studies have also consistently demonstrated that robotic surgery could be a reliable option for malignant, iatrogenic, and traumatic conditions, which generally occur in adult patients. Nevertheless, the lack of comparative studies on heterogeneous hosts and disease conditions make it difficult to determine the benefit of the robotic approach over the conventional approach in the general population; thus, qualified prospective trials are needed for wider acceptance. However, contemporary reports have demonstrated that the robotic approach could be an alternative option for ureteral construction, even in the absence of haptic feedback, which can be compensated by various surgical techniques and enhanced three-dimensional visualization.

Single-Port Robot-Assisted Dismembered Pyeloplasty With Mini-Pfannenstiel or Peri-Umbilical Access: Initial Experience in a Single Center

OBJECTIVE

To assess the feasibility and describe the surgical technique for single-port robotic-assisted laparoscopic pyeloplasty using the new da Vinci SP surgical platform (Intuitive Surgical Inc., Sunnyvale, CA), and to describe the approach through a mini-pfannenstiel incision.

METHODS

Data from a prospectively maintained single-institution database on all patients undergoing single-port robotic-assisted pyeloplasty between November 2018 and November 2019 were reviewed. Pyeloplasty was performed with the da Vinci SP system through a pure single site approach (except for the first patient). The initial procedures were performed through a midline incision and the technique evolved to a mini-pfannenstiel incision. Patient demographics, intraoperative data, post-operative data and surgical outcomes were collected.

RESULTS

Overall, 10 patients were included and underwent the procedure without intraoperative complications or conversion to an alternate approach. The patients' ages ranged between 11 and 75 years. Mean operative time was 166 minutes (interquartile range [IQR] 146-181) and EBL was minimal. Pfannenstiel incision was performed for 6 patients and 4 patients had a vertical midline incision. The only complication recorded was a postoperative urinary tract infection treated with antibiotics. The median postoperative hospital stay was 21 hours (7-24). Postoperative pain management after discharge was managed exclusively with non-opioid medication. Overall success rate defined as the absence of pain and renal obstruction on post-operative imaging at 3 months after surgery was 100%.

CONCLUSION

Single-port robotic-assisted laparoscopic pyeloplasty is a safe and feasible procedure through a mini-pfannenstiel incision.

Surgical approaches for treatment of ureteropelvic junction obstruction - a systematic review and network meta-analysis

BACKGROUND

Multiple surgical treatment options are available for the treatment of ureteropelvic junction obstruction (UPJO). The aim of this study is to compare the most frequently used technics in a comprehensive network approach.

METHODS

A systematic literature search of the EMBASE, MEDLINE and COCHRANE libraries was conducted in January 2018. Publications were included that evaluated at least two of the following surgical techniques: open pyeloplasty (OP), endopyelotomy (EP), laparoscopic (LP) and robot assisted pyeloplasty (RP). Main outcomes were operative success, complications, urinary leakage, re-operation, transfusion rate, operating time, and length of stay. Network meta-analyses with random effects models simultaneously assessed effectiveness of all surgical techniques.

RESULTS

A total of 26 studies including 3143 patients were analyzed. Compared with RP, EP and LP showed lower operative success rates (EP: OR = 0.09, 95%CI:0.05-0.19; p < 0.001; LP: OR = 0.51, 95%CI:0.31-0.84; p = 0.008). Compared with OP, LP and RP had lower risk for complications (LP: OR = 0.62; 95%CI:0.41-0.95; p = 0.027; RP: OR = 0.41; 95%CI:0.22-0.79; p = 0.007). Compared with RP, no significant differences were detected for urinary leakage or re-operation, transfusion rates. Compared with EP, RP yielded longer operating time (mean = 102.87 min, 95%CI:41.79 min-163.95 min, p = < 0.001). Further significant differences in operating times were detected when comparing LP to EP (mean = 115.13 min, 95%CI:65.63 min-164.63 min, p = < 0.001) and OP to EP (mean = 91.96 min, 95%CI:32.33 min-151.58 min, p = 0.003).

CONCLUSIONS

Multiple surgical techniques are available for treatment of UPJO. RP has the highest rates of operative success and as well as LP lower complication rates than OP. Although surgical outcomes are worse for EP, its operating time is shorter than OP, RP, and LP. Surgeons should consider these findings when selecting the optimal treatment method for individual patients.

Robot-assisted laparoscopic pyeloplasty versus laparoscopic pyeloplasty for pelvi-ureteric junction obstruction in the paediatric population: a systematic review and meta-analysis

Background

Owing to the improved vision and instrument manipulation in robot-assisted procedures, we sought to evaluate the comparative outcomes of robot-assisted laparoscopic pyeloplasty (RALP) and laparoscopic pyeloplasty (LP) in a paediatric patients with pelvi-ureteric junction obstruction (PUJO).

Methods

We conducted a systemic literature search of online sources, including PubMed, MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials, and respective bibliographic reference lists. Success rate, operative time, hospital length of stay, postoperative complication rate and re-intervention rate were our primary outcomes. Combined overall effect sizes were calculated using fixed-effect or random-effects models.

Results

We identified 14 observational studies reporting a total of 2254 paediatric patients with PUJO, who underwent LP (n = 1021) or RALP (n = 1233). Our analysis demonstrated that RALP was associated with a significantly higher success rate [odds ratio (OR) 2.51; 95% confidence interval (CI) 1.08-5.83, p = 0.03] and shorter length of hospital stay [mean difference (MD) -1.49; 95% CI -2.22 to -077; p < 0.0001] compared with LP. Moreover, nonsignificant reductions in postoperative complications (OR 0.61; 95% CI 0.36-1.02; p = 0.06) and re-intervention (OR 0.43; 95% CI 0.15-1.21; p = 0.11) were found in favour of RALP. There was no difference in procedure time between the two approaches (MD -0.15; 95% CI -30.22 to 29.93, p = 0.99).

Conclusions

Our meta-analysis of observational studies demonstrated that RALP is safe and may have higher success rate compared with the more traditional laparoscopic approach in a paediatric population. Moreover, it may be associated with lower postoperative complications and re-intervention rates. Evidence from randomized trials is required.

Development of stereo endoscope system with its innovative master interface for continuous surgical operation

Background

Although robotic laparoscopic surgery has various benefits when compared with conventional open surgery and minimally invasive surgery, it also has issues to overcome and one of the issues is the discontinuous surgical flow that occurs whenever control is swapped between the endoscope system and the operating robot arm system. This can lead to problems such as collision between surgical instruments, injury to patients, and increased operation time. To achieve continuous surgical operation, a wireless controllable stereo endoscope system is proposed which enables the simultaneous control of the operating robot arm system and the endoscope system.

Methods

The proposed system consists of two improved novel master interfaces (iNMIs), a four-degrees of freedom (4-DOFs) endoscope control system (ECS), and a simple three-dimensional (3D) endoscope. In order to simultaneously control the proposed system and patient side manipulators of da Vinci research kit (dVRK), the iNMIs are installed to the master tool manipulators of dVRK system. The 4-DOFs ECS consists of four servo motors and employs a two-parallel link structure to provide translational and fulcrum point motion to the simple 3D endoscope. The images acquired by the endoscope undergo stereo calibration and rectification to provide a clear 3D vision to the surgeon as available in clinically used da Vinci surgical robot systems. Tests designed to verify the accuracy, data transfer time, and power consumption of the iNMIs were performed. The workspace was calculated to estimate clinical applicability and a modified peg transfer task was conducted with three novice volunteers.

Results

The iNMIs operated for 317 min and moved in accordance with the surgeon’s desire with a mean latency of 5 ms. The workspace was calculated to be 20378.3 cm³, which exceeds the reference workspace of 549.5 cm³. The novice volunteers were able to successfully execute the modified peg transfer task designed to evaluate the proposed system’s overall performance.

Conclusions

The experimental results verify that the proposed 3D endoscope system enables continuous surgical flow. The workspace is suitable for the performance of numerous types of surgeries. Therefore, the proposed system is expected to provide much higher safety and efficacy for current surgical robot systems.

A development of assistant surgical robot system based on surgical-operation-by-wire and hands-on-throttle-and-stick

BACKGROUND

Robot-assisted laparoscopic surgery offers several advantages compared with open surgery and conventional minimally invasive surgery. However, one issue that needs to be resolved is a collision between the robot arm and the assistant instrument. This is mostly caused by miscommunication between the surgeon and the assistant. To resolve this limitation, an assistant surgical robot system that can be simultaneously manipulated via a wireless controller is proposed to allow the surgeon to control the assistant instrument.

METHODS

The system comprises two novel master interfaces (NMIs), a surgical instrument with a gripper actuated by a micromotor, and 6-axis robot arm. Two NMIs are attached to master tool manipulators of da Vinci research kit (dVRK) to control the proposed system simultaneously with patient side manipulators of dVRK. The developments of the surgical instrument and NMI are based on surgical-operation-by-wire concept and hands-on-throttle-and-stick concept from the earlier research, respectively. Tests for checking the accuracy, latency, and power consumption of the NMI are performed. The gripping force, reaction time, and durability are assessed to validate the surgical instrument. The workspace is calculated for estimating the clinical applicability. A simple peg task using the fundamentals of laparoscopic surgery board and an in vitro test are executed with three novice volunteers.

RESULTS

The NMI was operated for 185 min and reflected the surgeon's decision successfully with a mean latency of 132 ms. The gripping force of the surgical instrument was comparable to that of conventional systems and was consistent even after 1000 times of gripping motion. The reaction time was 0.4 s. The workspace was calculated to be 8397.4 cm(3). Recruited volunteers were able to execute the simple peg task within the cut-off time and successfully performed the in vitro test without any collision.

CONCLUSIONS

Various experiments were conducted and it is verified that the proposed assistant surgical robot system enables collision-free and simultaneous operation of the dVRK's robot arm and the proposed assistant robot arm. The workspace is appropriate for the performance of various kinds of surgeries. Therefore, the proposed system is expected to provide higher safety and effectiveness for the current surgical robot system.

Impact of 3D vision on mental workload and laparoscopic performance in inexperienced subjects

OBJECTIVE

To assess the effect of vision in three dimensions (3D) versus two dimensions (2D) on mental workload and laparoscopic performance during simulation-based training.

MATERIALS AND METHODS

A prospective, randomized crossover study on inexperienced students in operative laparoscopy was conducted. Forty-six candidates executed five standardized exercises on a pelvitrainer with both vision systems (3D and 2D). Laparoscopy performance was assessed using the total time (in seconds) and the number of failed attempts. For workload assessment, the validated NASA-TLX questionnaire was administered.

RESULTS

3D vision improves the performance reducing the time (3D = 1006.08 ± 315.94 vs. 2D = 1309.17 ± 300.28; P < .001) and the total number of failed attempts (3D = .84 ± 1.26 vs. 2D = 1.86 ± 1.60; P < .001). For each exercise, 3D vision also shows better performance times: "transfer objects" (P = .001), "single knot" (P < .001), "clip and cut" (P < .05), and "needle guidance" (P < .001). Besides, according to the NASA-TLX results, less mental workload is experienced with the use of 3D (P < .001). However, 3D vision was associated with greater visual impairment (P < .01) and headaches (P < .05).

CONCLUSION

The incorporation of 3D systems in laparoscopic training programs would facilitate the acquisition of laparoscopic skills, because they reduce mental workload and improve the performance on inexperienced surgeons. However, some undesirable effects such as visual discomfort or headache are identified initially.