ROBOTICS: Edited by Jim Hu
The advent of robotic-assisted urologic surgery has dramatically altered urologic training, practice patterns and outcomes. Due to the high incidence of prostate cancer among US men, radical prostatectomy served as the Trojan horse for hospital acquisition of the robot. In this issue, we describe robotic-assisted technology to improve the accuracy of prostate needle biopsy, expansion to the treatment of pediatric urologic conditions, assess its efficacy for lymphadenectomy during oncologic procedures and present tips and tricks to facilitate a retroperitoneal approach to posterior renal masses, master robotic-assisted radical cystectomy and improve continence and potency outcomes during radical prostatectomy.
Marks et al. (pp. 43–50) describe exciting advances surrounding the use of US-MRI fusion targeted prostate needle biopsies. The fusion device employed by the investigators is comprised of a robot-like mechanical arm used to scan and digitize the prostate; the needle and probe positions are tracked by angle-sensing encoders built into each joint of the arm. Given the overscreening and overtreatment of indolent, clinically insignificant prostate cancers, this exciting technology holds the promise of improving the accuracy of active surveillance biopsies and may facilitate and track the outcomes of focal therapies.
The early dissemination of robotic-assisted urologic oncologic surgeries paralleled a greater emphasis on surgical technique, particularly in regard to yield and oncologic outcomes for pelvic lymph node dissection during robotic-assisted versus open surgery. Prasad et al. (pp. 57–64) critically assesses the past, present and future of robotic-assisted approaches for lymphadenectomy, including inguinal lymph node dissection for penile cancer.
Although less blood loss, fewer transfusions and fewer anastomotic strictures may be attributed to carbon dioxide insufflation and better visualization, comparisons of open versus robotic postprostatectomy recovery of urinary and sexual function outcomes remain sparse. However, the question of comparative effectiveness is less relevant as robotic-assisted approaches presently account for the majority of US radical prostatectomies. Although learning curves have been demonstrated for improvement in operative time, cancer control and subjective surgeon comfort with robotic-assisted surgery, fewer studies have detailed the learning curve and technical refinement to improve recovery of continence and erectile function outcomes. In this issue, Carter et al. (pp. 88–94) present anatomic concepts and critical maneuvers to attenuate neurapraxia and achieve earlier and better recovery of erectile function. Additionally, Kowalczyk et al. (pp. 78–87) highlight the body of evidence for preservation of postprostatectomy urinary continence.
In summary, robotic surgery has rapidly become the standard of care for many urologic conditions, and the advent of novel imaging, instrumentation and communication technologies will profoundly change urologic surgery.
Conflicts of interest
There are no conflicts of interest.