Herrell, S. Dukea,b
aDepartment of Urologic Surgery, Vanderbilt University Medical Center
bDepartment of Biomedical Engineering, Vanderbilt University, Vanderbilt Initiative in Surgical Engineering (VISE), Nashville, Tennessee, USA
Correspondence to S. Duke Herrell, MD, Department of Urologic Surgery, A1302 Medical Center North, Nashville, TN 37232, USA. Tel: +1 615 343 1317; e-mail: firstname.lastname@example.org
Technology has defined many of the changes to surgery and the operating room over the last several decades. We have been promised many cures by the biologic advancements of ‘-omics’ and ‘personalized medicine’ and vast sweeping changes to the practice of surgery, but, in reality, the majority of the recent changes in surgical operative practice have come in the form of advancements of our ‘tools’ and our knowledge of how to apply these tools to benefit our patients. Examples of such paradigm-changing technology and tools are familiar to urologists and examples include shock wave lithotripsy, endoscopy, and the modern era of laparoscopy and robotics. All of these advancements have been in visionary approaches, by both surgeons and engineers, to improve on ‘gold standards’ that were at the time considered by the majority to be unchallengeable. Central to these paradigm shifts was adaptation or creation of tools to augment and allow the new approaches. In lectures, I have explained this to young surgeons and engineers as the ‘bovie vs. biology’ paradox, in that the electrocautery unit has in many instances and operating room cases resulted in as much or more impact for the practicing surgeon, their patient, and outcomes than any progress made in ‘biologically’ curing many surgical disease processes. Although an oversimplification, there is no doubt that technology has and will continue to dominate and revolutionize the operative care of the surgical patient.
The invited articles in this edition of Current Opinion in Urology were chosen to review some emerging surgical technologies and research that hold promise to potentially revolutionize the practice of operative urologic surgery. Many of these are not limited to only the field of urologic surgery.
Laparoscopic endoscopic single-site (LESS) surgery and natural orifice transluminal endoscopic surgery (NOTES) hold promise to further decrease the invasiveness and incisions associated with standard laparoscopy and robotics. Morgan et al. review a variety of information on new instrumentation platforms created to overcome many of the challenges, such as instrument clashing, of these new approaches. Promising technologies such as magnetically actuated and controlled camera systems and instrumentation may restore surgical tenets such as triangulation, while allowing for placement through a single small incision. Robotics has rapidly been adapted to help overcome the difficulty with performance and ergonomics in LESS. Although true valuation of the benefits of LESS awaits procedure-specific robotic development, such as the Insertable Robotic Effector Platform (IREP) and Korean robotic systems covered in other articles, perhaps the greatest contribution to date has been the increased interest in new equipment and platform development.
Surgeons have long dreamed of the ability to augment standard optical visualization in the operating room with new methods of imaging, guidance, and visualization of critical structures. Several articles in this edition explore the cutting-edge technologies that are in development and early use. Hsu et al. (pp. 66–74) give an excellent review of the status of a number of current and future intraoperative tissue interrogation and optical diagnostic technologies. Photodynamic diagnosis (PDD) is gaining traction in bladder cancer treatment, and near-infrared and newer technologies, such as optical coherence tomography (OCT) and confocal laser endomicroscopy (CLE), may employ the ability to very specifically intraoperatively image tissue and cellular architecture at unprecedented levels in the hope of improved diagnosis, and decreasing positive margins, residual disease, and recurrence. One might also ask whether the future disease evaluation may be done in the operating room using these or other techniques or whether in some distant future pathology will simply be done via computerized cellular image analysis software. Ultrasound has long been part of the Urologist's imaging armamentarium and has moved from a diagnostic to intraoperative therapeutic tool. Combining ultrasound with the accuracy, precision, and stability of robotics as discussed by Stoianovici and Han (pp. 75–80) allows for potential improvements in prostate imaging, biopsy, and radiation seed placement. In one of the most interesting applications, a secondary robotic system was used for real-time image guidance during the performance of robotic prostatectomy to improve neurovascular bundle identification. Whether this will improve preservation of potency and reduce side-effects and positive margins is unclear at present, but the future may involve multiple robotic platforms interacting in surgery, perhaps to even exert combined control or guide each other during the surgery.
Intraoperative surgical navigation, also known as image-guided surgery (IGS), has already become a standard of care in a number of surgical fields such as neurosurgery, otolaryngology, and orthopedics. Rassweiler and colleagues review (pp. 81–97) the contributions of their collaborative research group. Certain types of intraoperative imaging, such as ultrasound and fluoroscopy, are familiar to urologic surgeons, but methods to leverage three-dimensional, segmented, preoperative, axial, patient-specific imaging models and provide surgeons spatially accurate guidance are in development for kidney and other soft-tissue organs. Our research group has also done work in this area, bringing the application of IGS technology to robotic partial nephrectomy and a clinical trial grant is in design. However, IGS is a complex engineering challenge and terms such as segmentation, registration, and target error for soft-tissue organs will need to be understood by urologic surgeons in order to properly apply this tool.
Ablation is growing in popularity using standard modalities such as cryoablation and radiofrequency for multiple urologic disease processes. Leveillee et al. (pp. 98–103) discuss several newer needle-based modalities for tumor ablation including microwave and irreversible electroporation, which may bring significant advantages in larger lesions and preservation of critical structures. Histotripsy, which does not require a needle or even incision, and does not have the disadvantage of surrounding tissue thermal damage, is a fascinating new technology being developed by Dr William Roberts and discussed in his article (pp. 104–110). Although initial use is being focused at benign prostatic hyperplasia, the potential of this technology to destroy tumors is obvious. For urologic surgeons, involvement in developing, understanding, and applying these new technologies, many of which require concurrent imaging such as computed tomography and MRI, will determine whether treatment of disease processes such as prostate cancer and the small renal cell carcinoma stay in the wheelhouse of the urologic surgeon of the future. To those urologists who would give up these ‘image-guided procedures’, we always ask a question: ‘Do you think the cardiac surgeons would like to have coronary stenting back if they could go back in time?’
Finally, two articles explore new platform developments in robotic surgery. Tuliao et al. describe the myriad of contributions made by Korean engineers, surgeons, and developers toward new robotic surgical instruments and platforms. There was palpable excitement at the 2012 American Urologic Association with the initial reports of a procedure-specific LESS robot under development with Samsung. Finally, we describe three new robotic platforms under development at Vanderbilt. Our bladder robot is designed to take advantage of robotic architecture and computer control to potentially improve on the diagnostic and therapeutic efficiency and efficacy of bladder tumor resection. Although some would criticize the potential of increasing equipment cost, the cost of inadequate staging, repeat resection, avoidable recurrence, etc., would need to be factored into any economic analysis. We also continue to develop a robotic platform for LESS, the IREP. Finally, robotically controlled, steerable, cannula-based needles robots may allow for continued miniaturization and new applications in not only urologic surgery, but also in a variety of surgical specialties.
In summary, surgeons and engineers working together continue to fundamentally change the technology, ‘tools’, and practice of urology and all of surgery. Although there are and will be continued challenges in this era of healthcare and urology, one cannot help but be excited about the possibilities that new technology will bring to the care of our patients.
Source of funding: none.
Conflicts of interest
There are no conflicts of interest.