Future of robotic surgery in urology Rassweiler, Jens J.; Autorino, Riccardo; Klein, Jan ...
BJU international,
December 2017, Volume:
120, Issue:
6
Journal Article
Peer reviewed
Open access
Objectives
To provide a comprehensive overview of the current status of the field of robotic systems for urological surgery and discuss future perspectives.
Materials and Methods
A non‐systematic ...literature review was performed using PubMed/Medline search electronic engines. Existing patents for robotic devices were researched using the Google search engine. Findings were also critically analysed taking into account the personal experience of the authors.
Results
The relevant patents for the first generation of the da Vinci platform will expire in 2019. New robotic systems are coming onto the stage. These can be classified according to type of console, arrangement of robotic arms, handles and instruments, and other specific features (haptic feedback, eye‐tracking). The Telelap ALF‐X robot uses an open console with eye‐tracking, laparoscopy‐like handles with haptic feedback, and arms mounted on separate carts; first clinical trials with this system were reported in 2016. The Medtronic robot provides an open console using three‐dimensional high‐definition video technology and three arms. The Avatera robot features a closed console with microscope‐like oculars, four arms arranged on one cart, and 5‐mm instruments with six degrees of freedom. The REVO‐I consists of an open console and a four‐arm arrangement on one cart; the first experiments with this system were published in 2016. Medicaroid uses a semi‐open console and three robot arms attached to the operating table. Clinical trials of the SP 1098‐platform using the da Vinci Xi for console‐based single‐port surgery were reported in 2015. The SPORT robot has been tested in animal experiments for single‐port surgery. The SurgiBot represents a bedside solution for single‐port surgery providing flexible tube‐guided instruments. The Avicenna Roboflex has been developed for robotic flexible ureteroscopy, with promising early clinical results.
Conclusions
Several console‐based robots for laparoscopic multi‐ and single‐port surgery are expected to come to market within the next 5 years. Future developments in the field of robotic surgery are likely to focus on the specific features of robotic arms, instruments, console, and video technology. The high technical standards of four da Vinci generations have set a high bar for upcoming devices. Ultimately, the implementation of these upcoming systems will depend on their clinical applicability and costs. How these technical developments will facilitate surgery and whether their use will translate into better outcomes for our patients remains to be determined.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
The coronavirus disease 2019 (COVID-19) pandemic is unlike anything seen before by modern science-based medicine. Health systems across the world are struggling to manage it. Added to this struggle ...are the effects of social confinement and isolation. This brings into question whether the latest guidelines are relevant in this crisis. We aim to support urologists in this difficult situation by providing tools that can facilitate decision making, and to minimise the impact and risks for both patients and health professionals delivering urological care, whenever possible. We hope that the revised recommendations will assist urologist surgeons across the globe to guide the management of urological conditions during the current COVID-19 pandemic.
The coronavirus disease 2019 (COVID-19) pandemic is unlike anything seen before by modern science-based medicine. As a scientific society, the European Association of Urology, via the guidelines, section offices, and the European Urology family of journals, we believe that it is important that we try to support urologists in this difficult situation. We aim to do this by providing tools that can facilitate decision making with the goal to minimise the impact and risks for both patients and health professionals delivering urological care, whenever possible, although it is clear that it is not always possible to mitigate them entirely. We hope that these revised recommendations will fill an important urological practice void and assist urologist surgeons across the globe as they do their very best to deal with the crisis of our generation.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
To update the complications of transurethral resection of the prostate (TURP), including management and prevention based on technological evolution.
Based on a MEDLINE search from 1989 to 2005, the ...2003 results of quality management of Baden-Württemberg, and long-term personal experience at three German centers, the incidence of complications after TURP was analyzed for three subsequent periods: early (1979-1994); intermediate (1994-1999); and recent (2000-2005) with recommendations for management and prevention.
Technological improvements such as microprocessor-controlled units, better armamentarium such as video TUR, and training helped to reduce perioperative complications (recent vs. early) such as transfusion rate (0.4% vs. 7.1%), TUR syndrome (0.0% vs. 1.1%), clot retention (2% vs. 5%), and urinary tract infection (1.7% vs. 8.2%). Urinary retention (3% vs. 9%) is generally attributed to primary detrusor failure rather than to incomplete resection. Early urge incontinence occurs in up to 30-40% of patients; however, late iatrogenic stress incontinence is rare (<0.5%). Despite an increasing age (55% of patients are older than 70), the associated morbidity of TURP maintained at a low level (<1%) with a mortality rate of 0-0.25%. The major late complications are urethral strictures (2.2-9.8%) and bladder neck contractures (0.3-9.2%). The retreatment rate range is 3-14.5% after five years.
TURP still represents the gold standard for managing benign prostatic hyperplasia with decreasing complication rates. Technological alternatives such as bipolar and laser treatments may further minimize the risks of this technically difficult procedure.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background An improved armamentarium has had a significant impact on the emerging role of flexible ureteroscopy (FURS) for the management of nephrolithiasis; however, FURS still represents a ...challenging technique. Objective To examine a robotic device designed for FURS for its impact on ergonomics and outcome of the procedure based on the IDEAL (idea, development, evaluation, assessment, long-term study) framework. Design, setting, and participants Roboflex Avicenna consists of a surgeon's console and a manipulator for the flexible ureterorenoscope. Following experimental evaluation of the prototype (IDEAL stage 1) and receipt of ethical approval, seven surgeons treated 81 patients (mean age: 42 yr range: 6–68) with renal calculi (mean volume: 1296 ± 544 mm3 range: 432–3100 mm3 ) in an observational study (IDEAL stage 2). Surgical procedure Robotic FURS was performed with the Roboflex Avicenna robotic device. Outcome measurements and statistical analysis Numerical data were analysed with the Mann-Whitney test, and categorical variables were analysed using the chi-square test or Fisher exact test. P values <0.05 were considered statistically significant. Results and limitations Mean robot docking time was 59.6 ± 45 s. Mean operative time was 74 min (range: 40–182). Mean fragmentation speed was 29.1 ± 6.1 mm3 /min. Ergonomics based on a validated questionnaire showed significant advantage for robotic FURS (total score: 5.6 vs 31.3; p < 0.01). A 10/12F-access sheath was used in 72 patients. Two cases required secondary FURS, one because of malfunction of the flexible digital ureteroscope and another because of larger residual fragments. In the remaining 79 cases, complete stone disintegration was accomplished. Conclusions Roboflex Avicenna provides a suitable and safe platform for robotic FURS with significant improvement of ergonomics. Future studies should evaluate its impact on the clinical outcome of FURS. Patient summary Robotic flexible ureteroscopy (FURS) was performed with the Roboflex Avicenna robotic device. Results showed that Roboflex Avicenna provides a suitable and safe platform for robotic FURS with significant improvement of ergonomics.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Context Despite the wide diffusion of laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALP), only few studies comparing the results of these ...techniques with the retropubic radical prostatectomy (RRP) are currently available. Objective To evaluate the perioperative, functional, and oncologic results in the comparative studies evaluating RRP, LRP, and RALP. Evidence acquisition A systematic review of the literature was performed in January 2008, searching Medline, Embase, and Web of Science databases. A “free-text” protocol using the term radical prostatectomy was applied. Some 4000 records were retrieved from the Medline database; 2265 records were retrieved from the Embase database;, and 4219 records were retrieved from the Web of Science database. Three of the authors reviewed the records to identify comparative studies. A cumulative analysis was conducted using Review Manager software v.4.2 (Cochrane Collaboration, Oxford, UK). Evidence synthesis Thirty-seven comparative studies were identified in the literature search, including a single, randomised, controlled trial. With regard to the perioperative outcome, LRP and RALP were more time consuming than RRP, especially in the initial steps of the learning curve, but blood loss, transfusion rates, catheterisation time, hospitalisation duration, and complication rates all favoured LRP. With regard to the functional results, LRP and RRP showed similar continence and potency rates. Similarly, no significant differences were identified between LRP and RALP, while a single, nonrandomised, prospective study suggested advantages in terms of both continence and potency recovery after RALP, compared with RRP. With regard to the oncologic outcome, LRP and RALP were associated with positive surgical margin rates similar to those of RRP. Conclusions The quality of the available comparative studies was not excellent. LRP and RALP are followed by significantly lower blood loss and transfusion rates, but the available data were not sufficient to prove the superiority of any surgical approach in terms of functional and oncologic outcomes. Further high-quality, prospective, multicentre, comparative studies are needed.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Summary Background Vascular-targeted photodynamic therapy, a novel tissue-preserving treatment for low-risk prostate cancer, has shown favourable safety and efficacy results in single-arm phase 1 and ...2 studies. We compared this treatment with the standard of care, active surveillance, in men with low-risk prostate cancer in a phase 3 trial. Methods This randomised controlled trial was done in 47 European university centres and community hospitals. Men with low-risk, localised prostate cancer (Gleason pattern 3) who had received no previous treatment were randomly assigned (1:1) to vascular-targeted photodynamic therapy (4 mg/kg padeliporfin intravenously over 10 min and optical fibres inserted into the prostate to cover the desired treatment zone and subsequent activation by laser light 753 nm with a fixed power of 150 mW/cm for 22 min 15 s) or active surveillance. Randomisation was done by a web-based allocation system stratified by centre with balanced blocks of two or four patients. Best practice for active surveillance at the time of study design was followed (ie, biopsy at 12-month intervals and prostate-specific antigen measurement and digital rectal examination at 3-month intervals). The co-primary endpoints were treatment failure (histological progression of cancer from low to moderate or high risk or death during 24 months' follow-up) and absence of definite cancer (absence of any histology result definitely positive for cancer at month 24). Analysis was by intention to treat. Treatment was open-label, but investigators assessing primary efficacy outcomes were masked to treatment allocation. This trial is registered with ClinicalTrials.gov , number NCT01310894. Findings Between March 8, 2011, and April 30, 2013, we randomly assigned 206 patients to vascular-targeted photodynamic therapy and 207 patients to active surveillance. Median follow-up was 24 months (IQR 24–25). The proportion of participants who had disease progression at month 24 was 58 (28%) of 206 in the vascular-targeted photodynamic therapy group compared with 120 (58%) of 207 in the active surveillance group (adjusted hazard ratio 0·34, 95% CI 0·24–0·46; p<0·0001). 101 (49%) men in the vascular-targeted photodynamic therapy group had a negative prostate biopsy result at 24 months post treatment compared with 28 (14%) men in the active surveillance group (adjusted risk ratio 3·67, 95% CI 2·53–5·33; p<0·0001). Vascular-targeted photodynamic therapy was well tolerated. The most common grade 3–4 adverse events were prostatitis (three 2% in the vascular-targeted photodynamic therapy group vs one <1% in the active surveillance group), acute urinary retention (three 2% vs one <1%) and erectile dysfunction (two 1% vs three 1%). The most common serious adverse event in the vascular-targeted photodynamic therapy group was retention of urine (15 patients; severe in three); this event resolved within 2 months in all patients. The most common serious adverse event in the active surveillance group was myocardial infarction (three patients). Interpretation Padeliporfin vascular-targeted photodynamic therapy is a safe, effective treatment for low-risk, localised prostate cancer. This treatment might allow more men to consider a tissue-preserving approach and defer or avoid radical therapy. Funding Steba Biotech.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Artificial intelligence (AI) is the field of computer science that aims to build smart devices performing tasks that currently require human intelligence. Through machine learning (ML), the deep ...learning (DL) model is teaching computers to learn by example, something that human beings are doing naturally. AI is revolutionizing healthcare. Digital pathology is becoming highly assisted by AI to help researchers in analyzing larger data sets and providing faster and more accurate diagnoses of prostate cancer lesions. When applied to diagnostic imaging, AI has shown excellent accuracy in the detection of prostate lesions as well as in the prediction of patient outcomes in terms of survival and treatment response. The enormous quantity of data coming from the prostate tumor genome requires fast, reliable and accurate computing power provided by machine learning algorithms. Radiotherapy is an essential part of the treatment of prostate cancer and it is often difficult to predict its toxicity for the patients. Artificial intelligence could have a future potential role in predicting how a patient will react to the therapy side effects. These technologies could provide doctors with better insights on how to plan radiotherapy treatment. The extension of the capabilities of surgical robots for more autonomous tasks will allow them to use information from the surgical field, recognize issues and implement the proper actions without the need for human intervention.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Abstract Objective This review focuses on a step-by-step approach to percutaneous nephrolithotomy (PNL) and its complications and management. Methods Based on institutional and personal experience ...with >1000 patients treated by PNL, we reviewed the literature (Pubmed search) focusing on technique, type, and incidence of complications of the procedure. Results Complications during or after PNL may be present with an overall complication rate of up to 83%, including extravasation (7.2%), transfusion (11.2 – 17.5%), and fever (21.0 – 32.1%), whereas major complications, such as septicaemia (0.3 – 4.7%) and colonic (0.2 – 0.8%) or pleural injury (0.0 – 3.1%) are rare. Comorbidity (i.e., renal insufficiency, diabetes, gross obesity, pulmonary disease) increases the risk of complications. Most complications (i.e., bleeding, extravasation, fever) can be managed conservatively or minimally invasively (i.e., pleural drain, superselective renal embolisation) if recognised early. Conclusions The most important consideration for achieving consistently successful outcomes in PNL with minimal major complications is the correct selection of patients. A well-standardised technique and postoperative follow-up are mandatory for early detection of complications.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background
Extracorporeal shock wave lithotripsy represents one option for the non-surgical management of Peyronie’s disease. Despite promising results, several questions are still pending. We want ...to present the long-term results of a retrospective study using high-energy extracorporeal shock wave lithotripsy.
Material and methods
We evaluated retrospectively 110 patients treated between 1996 and 2020 at the Department of Urology, SLK Kliniken Heilbronn for chronic phase Peyronie’s disease using two electromagnetic lithotripters (Siemens Lithostar Plus Overhead Module, Siemens Lithoskop) applying high-energy shock waves under local anesthesia and sonographic or fluoroscopic control. A standardized questionnaire focused on the change in pain, curvature, sexual function and the need of penile surgery.
Results
In 85 of the 110 patients (mean age 54 years) we had sufficient data for evaluation. The median follow-up was 228 (6–288) months. There were no significant complications. Pain reduction was achieved in all patients, 65 (76%) patients were free of pain. Improvement of penile curvature was achieved in 43 patients (51%) ranging from 25% improvement (deflected angle < 30°) to 95% (angle 30–60°). 59 patients (69%) reported problems with sexual intercourse, 40 of those (68%) reported improvement. Only 9 (10.5%) patients underwent surgical correction. We did not observe any significant differences between both electromagnetic devices with stable long-term results.
Conclusions
High-energy shock wave therapy delivered by two standard electromagnetic lithotripters is safe and efficient providing stable long-term results. In cases with significant plaque formation, the concept of high-energy ESWT should be considered in future studies.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
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