Robot-assisted surgery: The time to learn is now

August 15, 2008

The growing use of robot-assisted laparoscopic techniques should cause urologists in the community to sit up and take more immediate notice.

Key Points

In an interview with Urology Times, Dr. McDougall commented on the significance of selected take-home messages on laparoscopy.

Surgery is transitioning from pure laparoscopic to robot-assisted. Robotic assistance in prostate cancer surgery significantly reduces blood loss, hospital stays, and operative time with no difference in surgical results.

Although this new era in urologic laparoscopic surgery was launched by robot-assisted laparoscopic prostatectomy, the technique is also gaining an important role in the surgical treatment of renal cell carcinoma. Looking ahead, further developments in robot-assisted laparoscopic surgery may be anticipated because of what it can offer to surgeons in the ability to perform minimally invasive procedures and to patients in terms of improved recovery.

For urologists who are not already performing robot-assisted laparoscopic surgery, the time to start learning is now.

"Novices should be encouraged to know that while there is a learning curve for these procedures, developing skill is a lot easier than when attempting to learn traditional laparoscopy," she said.

Advances in imaging technology with the daVinci Surgical System (Intuitive Surgical, Sunnyvale, CA) allow additional external image inputs onto the 3-D image of the operative field, including live intraoperative ultrasound, preoperative computed tomography (CT) or magnetic resonance imaging (MRI) images, and computerized hospital records.

Dr. McDougall notes that this take-home message represents an opportunity for advancing robot-assisted surgery. Superimposition of a CT or MRI image over the operative image holds huge potential for improving reconstructive and nephron-sparing types of surgical procedures performed with the robot.

"The ability to identify and isolate vessels so that they can be specifically dissected or to better localize the tumor when performing a partial nephrectomy would represent a huge advance," she said. "Although the imaging techniques are still in development, they are feasible and forthcoming."

Recently, nephrectomies have been performed with single-port Natural Orifice Translumenal Endoscopic Surgery (NOTES) transvaginally and with robotic assistance.

Reports of NOTES and single-port access (SPA) procedures are emerging in the literature, and urologists should be aware of these approaches. However, while both techniques are interesting, only the SPA is currently clinically applicable. NOTES has been performed only in animals and, while it holds promise, whether it becomes clinically viable remains to be seen and will depend on a quantum leap in the technology, Dr. McDougall said.

Representing an outgrowth of NOTES, SPA is being touted for being "less invasive" than traditional laparoscopic surgery. While the ability to perform laparoscopy through a single incision is an interesting concept, existing hype may be a case of "the emperor's new clothes," she said.

She pointed out there is currently no evidence that SPA provides any advantages over what patients are offered by standard laparoscopic surgery: recovery is not faster, pain is not reduced, and there is no reason to expect SPA will provide superior oncologic outcomes. Furthermore, SPA is technically challenging and is being attempted by only very skilled laparoscopic surgeons.

"In essence, SPA is a mini hand-assisted laparoscopic approach, but one that is much more difficult, and that, I doubt, will be applicable to most community urologists," Dr. McDougall said.

New technology is being developed to magnetically anchor instruments to the skin.

This area of research holds exciting promise and probably represents the direction in which minimally invasive surgery will be heading in the future, according to Dr. McDougall.

She envisions accessing the abdomen via a small incision and introducing a small robot that holds a camera, a retractor, or possibly an instrument and that is controlled with the use of external magnets.

"There is still a lot of work to be done on this technology, but it makes a lot of sense and, importantly, it is a concept that can be married to the robot," Dr. McDougall said.

"With its ergonomic advantages and ease, the robot has made laparoscopic surgery doable for just about every open surgeon, and it provides an excellent platform for future developments in imaging and manipulation of instruments."

High-intensity focused ultrasound ablation of tumors is now being applied laparoscopically with ultrasound guidance. The technology, which is still being developed, could offer targeted, homogeneous ablation of tissue.

Dr. McDougall observed that Louis Kavoussi, MD, conducted some of the original work in this area almost a decade ago using percutaneous high-intensity focused ultrasound to ablate tissue in animal models.

While interest in this concept died, this recent research may fuel increased attention toward development of what is a potentially valuable approach for performing less invasive treatment of specific types of tumors.

"Again, this is a direction for the future, but it is of interest because once technology is available for focusing high-intensity ultrasound, the door is opened for a totally incisionless procedure," Dr. McDougall said.