OBJECTIVES: By addressing the performance limitations of standard laparoscopy, robotics has developed a role in urology. While greatest use has been in pelvic prostatectomy, the role of robotics is expanding to other retroperitoneal surgeries. We review the feasibility of robotic radical and partial nephrectomy.METHODS: Medline literature search of robotic nephrectomy and partial nephrectomy was performed. Data was compiled for the review as well as personal experience.RESULTS: Multiple studies have demonstrated the feasibility and safety of robotic assisted laparoscopic nephrectomy and partial nephrectomy. Operative time is increased with the robotic system compared to pure laparoscopic surgery. Although complication rates are low, robotic renal surgery requires two skilled surgeons.CONCLUSION: While the use of robotics in renal surgery may enhance suturing abilities, currently, this system requires two skilled surgeons and significant operative time. The exact role of robotics in extirpative renal surgery remains unclear and may require technical and surgical advancements before robotic renal surgery is widely accepted.

OBJECTIVES: To describe a technique of Robot Assisted Radical Prostatectomy (RAP) for localized carcinoma of the prostate, the Vattikuti Institute Prostatectomy (VIP) and an innovative incremental nerve preservation technique, the Veil of Aphrodite. We also report complications, oncolgical and functional outcomes in a cohort of the patient operated during 2001-2006.METHODS: 2.652 patients with localiced carcinoma of prostate underwent VIP at our centre between 2001- 2006. Our current technique involves: early division of the bladder neck, preservation of the lateral pelvic fascia and control of the dorsal vein complex after apical dissection of the prostate. Oncological, functional and follow-up information was obtained through “ROBOSURG”® data base, which is managed by an independent group not involved in the patient care.VIP, as it has evolved in our hands over a period of 5 years, has given excellent outcomes in terms of cancer control, continence and erectile function. Our modifications of the surgical technique had a singular focus on consistent improvement of the so called “Trifecta”, taking radical retropubic prostatectomy (RRP) published data as a reference standard. We present our current technique of VIP with preservation of the lateral prostatic fascia (“Veil of Aphrodite”).RESULTS: In this report we include 2077 patients with follow-up ranging from 4 weeks to 260 weeks (median 68 weeks). We have a low incidence (1.5%) of perioperative complications. 97.6% of our patients had a hospital stay of less than 48 hours. There were 5.8% unscheduled postoperative visits. With the PSA cut-off limit of 0.4ng/ml, the overall biochemical recurrence rate was 3.9%. Median duration of incontinence was 4 weeks; 0.8% patients had total incontinence at 12 months. The intercourse rate was 93% in men with no pre-operative erectile dysfunction undergoing veil nervesparing surgery, although only 51% returned to baseline function. CONCLUSION: Vattikuti Institute Prostatectomy offers excellent patient recovery with significant reduction in first 30 days morbidity and provides excellent oncological and functional outcomes. The preservation of the “Veil of Aphrodite” helps in postoperative return of erectile function in patients with normal preoperative erectile function.

Robotic radical prostatectomy is fast gettingpopular as an alternative to the open and laparoscopic radical prostatectomy. Planning for port placement and the assistant’s role are the two crucial yardsticks for the success of this procedure. Ideal port placement for radical robotic prostatectomy is not only crucial for the surgeon at the console but also for the patient sideassistant. A better assistance could enhance the functionaloutcome of the procedure and at the same time could increase the comfort level of the surgeon at the console. This article describes the role of an assistant in robotic radical prostatectomy.

Robotic surgery is expanding little by little in urology. At present only few centers have incorporated this new technology in Spain but it is predictable that this number will exponentially increase in a near future. We described the experience of our center establishing and developing a program of robotic surgery that it is operating since July 2006. It is important to know some basic premises that it is compulsory to fulfill to reach optimal results.

The treatment of ureteropyelic junction (UPJ) obstruction offers a perfect sketch of the parallel evolution of the availability of technology and changes in surgical proceedings. From the open Anderson-Hynes pyeloplasty, passing through percutaneous or retrograde endopyelothomy with various instruments, to the laparoscopic approach, technology and human talent have found a field for development in this reconstructive procedure. Robotic surgery is young and starts to define its role in urology surgery. There are established procedures such as radical prostatectomy; it remains to be established what operations will benefit from the robotic technology, so results are under continuous evaluation. The non stopping advance of computer technology guarantees future achievements of robotic technology. The objective is to achieve that surgeons could perform difficult surgical procedures with a level of accuracy and clinical results that would be difficult to achieve with conventional methods. We analyze the technical features, results and comparative studies of the robotic pyeloplasty from the medical literature. Robotic surgery has demonstrated its usefulness in the performance of pyeloplasties, with good results in primary and secondary UPJ stenosis in children and adults, in various aetiologies. Robotics enables to diminish the difficulties of intracorporeal suture and the learning curve for surgeons without laparoscopic experience. Nevertheless, although initial clinical experience with robotic pyeloplasty is favourable, continuous evaluation of results is necessary to determine if the surgical procedure is as effective in the long-term as laparoscopic and open pyeloplasty.

Laparoscopic colposacropexy has become a substitute for open surgery in the treatment of pelvic organ prolapse. In the same way, robotic assisted surgery is a new step in the evolution of the procedure. In this paper we intend to show our surgical technique and preliminary results. From November 2006 to date, 10 patients have undergone this procedure at the Hospital Clínico San Carlos. The main indication for the operation was existence of symptomatic pelvic prolapse. Both patients with or without hysterectomy have been operated, without making significant differences between them. Preoperative evaluation workout included: cystogram, urinary tract ultrasound and urodynamics in all cases; urinary tract MRI was performed only in selected cases. All patients underwent surgery under general anesthesia, with at least three robotic trocars (8 mm) and one conventional trocar for the assistant; 2 accessory trocars were necessary in some cases, mainly at the beginning of the series. Most procedures in our series were associated with a transobturator suburethral sling for the treatment of stress urinary incontinence or prevention of its appearance after prolapse repair. Our results are comparable to those reported in other larger series in terms of operative time, hospital stay and early or late complications. Pending an evaluation on the long term with larger series, we can include robot assisted colposacropexy among the therapeutic options for symptomatic pelvic floor prolapse repair.

OBJECTIVES: Most advances in Surgery can now be seen to have been preceded by the invention of new instruments. Conventional surgery progressed as new instruments became available. Transurethral resections became routine following the introduction 80 years ago of the resectoscope: a highly revolutionary instrument at that time. Ureterorenoscopes and nephroscopes opened new windows of opportunity for urologists. When the therapeutic potential of extracorporeal lithotripsy, was first mentioned in the literature most surgeons thought it was mere science-fiction fantasy. Very soon however, this new technique, the fruit of close collaboration between urologists and engineers, became a common-place reality. Laparoscopy met with similar disbelief and the early applications gave rise to controversy and even consternation, yet only a few years later most of our urological surgical procedures have adopted this technique.METHODS: At the beginning of the 20th century the astounding advances in engineering led many to forecast that before its end those systems might mimic human intelligence. However, many attempts to construct a rational thinking device revealed that even today this ambitious project was a still an unattainable dream. Consequently, attempts to design an autonomous urological surgical robot that might carry out unsupervised transurethral resections were unfruitful because the inherent and unpredictable complexity of surgical procedures obliges close and rigorous control by the surgeon. This important limitation led to the creation of ‘master-slave’ systems similar to those designed by our team in 1998 for transurethral resection. These are relatively simple tools and are infi-nitely safer than autonomous robots because they aim to effectively help the surgeon rather than replace him.RESULTS/CONCLUSIONS: The oft-repeated argument about whether or not a robot might ever replace the surgeon now has little sense because today it is merely a tool, an instrument for the surgeon’s hands. The devices available today lack the all-important tactile feedback and to use them effectively, the surgeon is obliged to serve a new and arduous apprenticeship and the learning curve is unavoidably steep. Consequently, many prestigious authors understandably feel unable to recommend their use. Our accumulated experience with master-slave manipulators stimulates us to confidently predict that sooner than later, whether we like it or not, surgical robots will evolve to become indispensable tools that enhance the surgeon’s skill, precision and speed in many surgical procedures.

The surgery robotics is in full expansion. The objective of all new sanitary new technology is to improve the results in the treatment of the different pathologies. We believe that our of future perspective both in the development of the current generation of surgical robots and in the improvements that could be incorporated to short and half term.

We review the evolution and current status of robotic equipment and technology in urology. We also describe future developments in the key areas of virtual reality simulation, mechatronics and nanorobotics.The history of robotic technology is reviewed and put into the context of current systems. Experts in the associated fields of nanorobotics, mechatronics and virtual reality simulation simulation review the important future developments in these areas.

Robotic is an antique concep. The first robots used in surgery were precise path systems in the 80´s. Stereotactic neurosurgery was the first field applying this devices. Based on these more complex devices were built: AESOP and Endoassist help the surgeon during the surgery. The surgical assistant will not fatigue and there will be no tremor of the camera. Finally the master-slave devices were developed. They are the most commenly used all around the world. They are involved many types surgery in. To evaluate the cost- effectiviness of robotics in surgery is our responsability. Robotics provides many advantages but also has a few disadvantages including expense.

OBJECTIVES: The last decade has seen tremendous growth of surgical robotics. Popularized for radical prostatectomy, robotic techniques are now increasingly being applied to radical cystectomy. Herein, we review the development and current status of robotic radical cystectomy (RRC) in contemporary urological practice. METHODS: Between 1995 and 2007 published literature was reviewed using the National Library of Medicine database and the following key words: robotic, robot-assisted, laparoscopic and cystectomy. Since the first report in 2003, nine published original reports were identified. These were evaluated with regards to the technique, advantages and disadvantages, perioperative and oncological outcomes. Our initial experience, as yet unpublished, is also described. RESULTS: At this writing, all published papers on RRC are based on small number of patients with short-term followup. Nevertheless, they have demonstrated the technical feasibility of RRC with encouraging perioperative outcomes. Compared to open radical cystectomy (ORC), RRC appears to be associated with decreased blood loss, hospital stay and analgesic requirement. These advantages are also found with laparoscopic radical cystectomy (LRC) and are a function of the minimally invasive approach. The operating time is longer, markedly so when the bowel work is performed intracorporeally. CONCLUSIONS: RRC is in evolution. Technical feasibility has been demonstrated. Initial perioperative outcomes are encouraging. Oncological outcomes are awaited to identify the role of RRC in the management of bladder cancer. Multi-center prospective randomized trials comparing ORC with RRC and LRC are necessary.

Over the last 20 years there has been a move in all surgical specialties towards less invasive surgical procedures. The most recent step is robotic surgery or better described as surgical telemanipulation technology which has slowly been adapted worldwide for many reasons including: cost, learning curve, available technology, and applicability to the different surgical specialties. Nonetheless, its use continues to grow in all surgical fields. Our center has been a pioneer in the use and training of robotic surgical techniques. In this manuscript, we describe the organization and experience of our training program.

OBJECTIVES: Laparoscopic surgery has demonstrated that it is a good alternative to conventional surgery for the treatment of localized prostate cancer. Robotic surgery could be a therapeutic option. We try to evaluate both techniques, analyzing a series of pa-rameters that allow us to describe the advantages and disadvantages of both techniques.METHODS: We performed a MEDLINE search and re-viewed the main series of laparoscopic radical prosta-tectomy (LRP) and robotic radical prostatectomy (RRP). The parameters analyzed for each techniques were: oncological results, functional results, blood loss, transfu-sion rates, surgical times, complications rates, learning curve and cost.RESULTS: Both techniques have the advantage of being minimally invasive, which results in better recovery and aesthetic results. The learning curve of the robotic pros-tatectomy is shorter, 10 to 20 cases in comparison with 50 to 60 for the LRP. Cost analysis is more favourable for LRP, with a single-use instrument expenditure of 533 dollars per patient in comparison with 1.705 dollars with the robot. The cost of the robot is 1.200.000 do-llars plus 100.000 dollars of annual maintenance (1). Operative time was 182 minutes [141-250] for robotic surgery and 234 min. [151-453] for LRP. Within the same institution, like Montsouris, times are very similar: 155 min. for the RRP and 181 min. for the (LRP). Mean operative blood loss was 234 ml [75-500] for the robot and 482 ml [185-859] for the LRP, depending on the technique employed and the institution. Complication rate is similar for both techniques. The percentage of positive surgical margins is 20.6% for LRP and 19.24% for RRP. Long term results on the biochemical PSA re-currence cannot be given due to the short life of both techniques. Continence rates are 56-100% for LRP and 70-98% for RRP. Potency rates are 25-82% for LRP and 79-100% for RRP. It is difficult to evaluate hospital stay because it depends on the politics of the medical insti-tutions; nevertheless, it seems there are not significant differences between techniques.CONCLUSIONS: Intraoperative and postoperative ad-vantages are comparable with both techniques. Robotic prostatectomy has a shorter learning curve. Prospective studies with longer follow-up are necessary to compare oncological and functional results. The cost of LRP is lower than RRP.

We present in this chapter our Athermal Radical Robotic Prostatectomy technique developed in the Cornell University and the Urology Institute, Innsbruck University from 2004. Up to date, we have performed surgery in more than 600 patients diagnosed with clinically localized cancer of prostate. We describe most important technical steps, emphasizing in NVB dissection avoiding using any thermical energy not to injury the cavernous nerves. Additionally we present the pathological and functional outcomes (urinary continence and potency) of our cohort of 215 patients that underwent surgery during year 2005.

The evolution of surgical therapy has been vertiginous, from the classical principles of open surgery to laparoscopy and currently to robotic surgery, in which the principles of robotic engineering have been successfully applied to the surgeon’s daily work. The development of minimally invasive surgery, initially led by conventional laparoscopy, was a fertile field for the development of surgical techniques with the robot. The use of automatized systems for surgery is not as new as one could think, but the robots today participating in the main operative rooms worldwide are an example of the newest and most advanced available technology. Urology has become the leading surgical speciality in the application of technologies for diagnosis and treatment of its diseases, and robotic surgery is not an exception. We present our vision about the state of the art in automatized surgery, in the setting of its close relationship with conventional laparoscopic surgery, which originated it.

OBJECTIVES: To present a contemporary review of the functional outcomes following robotic-assisted radical prostatectomy based on published postoperative erectile function and urinary continence data.METHODS: A review of the available literature on Medline and PubMed databases was performed.RESULTS: Factors affecting erectile function include age, preoperative SHIM scores, co-morbidities and nerve sparing techniques. Large robotic-assisted laparoscopic radical prostatectomy (RALP) series like the Vattikuti Institute’s and Ohio State University’s demonstrate early potency outcomes: 70% and 80% of patients, respectively, who underwent bilateral nerve sparing and had a pre-operative SHIM score >17, regained potency after a follow-up of 12 months. This has also been reproduced by smaller series, where 43% of patients achieved potency within 3 months postop and 68%, 79% of patients who underwent unilateral or bilateral nerve sparing, respectively, were able to have intercourse with or without PDE5 inhibitors after 12 months follow-up. Postoperative continence rates after RALP for larger series are 76%-92% and 95.2%-98% while that for smaller series range from 76% and 89% at 3 and 12 months, respectively.CONCLUSIONS: RALP is a safe, minimally invasive procedure that produces functional outcomes comparable to contemporary results of both open and laparoscopic prostatectomy.

OBJECTIVES: To review the current literature on oncologic outcomes following robot-assisted laparoscopic radical prostatectomy. METHODS: A systematic MEDLINE search was performed to retrieve articles relating to oncologic outcomes with robot-assisted laparoscopic prostatectomy. Two reviewers independently selected studies, assessed their methodological quality and extracted data. RESULTS: Positive surgical margin rates in RALP are commensurate to contemporary open and standard laparoscopic series. Surgical experience and refinement of technique helped decrease positive margins. Long-term biochemical disease-free survival (PSA <0.1 ng/ml) following RALP is currently unknown, with only 2 series reporting data with>12 month follow-up.CONCLUSIONS: RALP is a safe and reproducible treatment modality for organ-confined prostate cancer and provides excellent short-term oncological control. Larger studies with long-term oncologic follow-up are needed to establish the efficacy compared to more traditional surgical approaches.

OBJECTIVES: To review the use of robotic surgery in pediatric urology and provide a platform from which discussions regarding this technology can arise. METHODS: The available literature and the experience at the author’s institution were reviewed to examine the applications of robotic surgery in pediatric urology. MEDLINE was queried using the following key words: robot, robotic, laparoscopy, surgery, child, and pediatrics.RESULTS: The available literature is comprised mainly of case reports and case series. Two groups have published small analyses comparing robotic assisted laparoscopic pyeloplasty and open pyeloplasty. At our institution, we have utilized the daVinci robotic surgical system to perform the following surgical procedures: orchidopexy of the intraabdominal testis, total and partial nephrectomy, dismembered pyeloplasty, pyelolithotomy, excision of calyceal diverticula, ureteroureterostomy, ureteropyelostomy, intra- and extravesical ureteral reimplantation, megaureter tapering and reimplantation, adrenelectomy, creation of a Mitrofanoff continent catheterizable channel, and resection of pelvic Mullerian remnants. CONCLUSIONS: Robotic surgery in pediatric urology is an evolving technology that holds promise for application to most urological surgeries. Refinements in equipment will improve the efficiency of these systems. Ultimately, the efficacy and role of robotic surgical systems need to be defined with rigorous prospective studies that provide comparisons to gold standard techniques, be they open surgery or conventional laparoscopy.