Robotic Urologic Surgery (eBook)

Vipul Patel, MD, is director of Robotic and Minimally Invasive Urologic Surgery, associate clinical professor of Urology and Bioinformatics at The Ohio State University. He serves as an attending physician at OSU Medical Center and is a member of the OSU James Cancer Hospital prostate cancer treatment team. Patel also is director of the minimally invasive laparoscopic surgery fellowship training program at OSU. Dr. Patel is an internationally recognized expert in minimally invasive laparoscopic and robotic urologic surgery. His clinical interests involve urologic cancer and laparoscopic reconstruction with special emphasis on the care of patients with prostate and kidney cancer. He has performed more than 1,500 open, laparoscopic and robotic surgeries. His experience of almost 1,000 robotic surgeries is one of the largest in the world. He has served on the Board of the American Cancer Society and has led a prostate cancer support group called "Man to Man." This group serves to provide individualized support to patients and the families of men with prostate cancer. Yearly they have an event to raise awareness of prostate cancer called Relay For Life. Dr. Patel is a member of several professional societies including American Urological Association, Society of Laparoscopic Surgeons, Robotic Surgery Society and the American College of Surgeons. He is a reviewer for the professional journal Urology and has received numerous awards for his expertise in laparoscopy and patient care. He has published several articles on urologic cancer, urology and robotics.

Foreword 7
Preface 9
Contents 11
Contributors 15
Robotic Urologic Surgery: An Introduction and Vision for the Future 19
1.1. Definition 19
1.2. A Brief History of Robotics 19
1.3. Instrumentation 20
1.4. Optics 20
1.5. Robotic Arm Design 21
1.6. Console Design 21
1.7. Telecommunications 21
1.8. Tactile Feedback 21
1.9. Access 21
1.10. Miniaturization 22
1.11. Autonomy 22
1.12. Conclusion 22
Robotic Surgical Systems 23
2.1. Introduction 23
2.2. Robotics in Surgery 23
2.3. AESOP System 24
2.4. Telerobotic Surgery 25
2.5. Zeus System 25
2.6. da Vinci® Surgical System 26
2.7. Advantages of Robotic Technology 29
2.8. Telepresence Surgery 29
2.9. Future Designs 30
2.10. Conclusion 30
Multispeciality Applications of Robotic Technology 33
3.1. Cardiothoracic Surgery 33
3.2. General Surgery 35
3.3. Neurosurgery 37
3.4. Orthopedic Surgery 38
3.5. Conclusion 38
An Overview of Adult Robotic Urologic Surgery 41
4.1. Introduction 41
4.2. General Applications of Robotics in Adult Urologic Surgery 41
4.3. Conclusion 43
Essential Elements of Building a Robotics Program 46
5.1. Introduction 46
5.2. Establishment of a Robotic Prostatectomy Team 47
5.3. Training of the Robotic Prostatectomy Team 48
5.4. Operating Room Requirements 48
5.5. Patient Selection 49
5.6. Outcomes Measurement 50
5.7. Financial Considerations 50
5.8. Marketing Strategy 51
5.9. Conclusion 51
Principles and Lessons in a Transition from Open to Robotic-Assisted Laparoscopic Prostatectomy 52
6.1. Technical Differences in Surgical Technique 52
6.2. Patient Selection 54
6.3. Comparative Results 55
6.4. Conclusion 58
Training: Preparing the Robotics Team for Their First Case 59
7.1. The Current Standard 60
7.2. The Decision to Start a Robotic Prostatectomy Program 60
7.3. The Robotic Team 60
7.4. Preparation Before the First Case 61
7.5. Patient Selection 62
7.6. The First Case and the Mentor/ Proctor 63
7.7. Review of Reported Results 63
7.8. Other Thoughts 63
Patient Selection and Perioperative Management 65
8.1. Preoperative Period 65
8.2. Intraoperative Considerations 65
8.3. Robotic Radical Prostatectomy 66
8.4. Robotic Radical Cystectomy 69
8.5. Robotic Distal Ureterectomy with Reimplantation 70
Anesthetic Considerations and Management 72
9.1. Patient Population 72
9.2. Laparoscopic Considerations 74
9.3. Robotic/ Positioning Considerations 75
9.4. Recovery/ Pain Control Issues 76
9.5. Conclusion 77
Patient Positioning for Robotic Urologic Procedures 79
10.1. Robotic-Assisted Laparoscopic Prostatectomy 79
10.2 Robotic-Assisted Laparoscopic Ureterovesical Reimplant 81
10.3. Kidney Surgery 82
10.4. Conclusion 84
Transperitoneal Trocar Placement 85
11.1. General Considerations 85
11.2. Pelvic Operations ( Radical Prostatectomy, Cystectomy, Sacrocolpopexy) 87
11.3. Renal Operations 91
11.4. Special Considerations 92
11.5. Conclusion 92
Extraperitoneal Access 94
12.1. Introduction 94
12.2. Published Series 96
12.3. Comment 96
12.4. Conclusion 97
Robotic Radical Prostatectomy: A Step- by- Step Approach 99
13.1. Robot-Assisted Prostatectomy: A Step- by- Step Approach 99
13.2. Steps of the Robotic Prostatectomy 99
13.3. Evolving Role of Robotic Prostatectomy in Urology Practice 107
Clinical Pearls: The Approach to the Management of Difficult Anatomy and Common Operative and Postoperative Problems 109
14.1. The Obese Patient 109
14.2. Postinguinal Hernia Repair 111
14.3. The Bladder Neck Dissection 112
14.4. Posttransurethral Resection of the Prostate 112
14.5. Median Lobe 113
14.6. The Large Prostate 115
14.7. The Vesicourethral Anastomosis 115
14.8. Immediately Increased Postoperative Drain Output 116
14.9. Postoperative Urinary Retention and Nonunion of the Vesicourethral Anastomosis 117
14.10. Conclusion 117
The French Experience: A Comparison of the Perioperative Outcomes of Laparoscopic and Robot- Assisted Radical Prostatectomy at Montsouris 119
15A. 1. Robotic-Assisted Laparoscopic Prostatectomy 119
15A. 2. Conclusion 121
The French Experience: The St. Augustin Transition from the Laparoscopic to the Robotic Approach 124
15B. 1. Introduction 124
15B. 2. Trocar Position 124
15B. 3. Dissection of the Neurovascular Bundles 125
15B.4. The Anastomosis 126
15B. 5. Conclusion 127
The Oncologic Outcomes of Robotic- Assisted Laparoscopic Prostatectomy 128
16.1. Open Radical Prostatectomy 128
16.2. Robotic-Assisted Laparoscopic Prostatectomy 129
16.3. Techniques to Decrease Positive Margins 130
16.4. Robotic-Assisted Laparoscopic Prostatectomy: Comparison to Open and Laparoscopic Prostatectomies 131
16.5. Conclusion 131
Anatomic Basis of Nerve- Sparing Robotic Prostatectomy 134
17.1. Pelvic Neuroanatomy 134
17.2. Nerve- Sparing Technique of Robotic Prostatectomy 137
17.3. Conclusion 139
Alternative Approaches to Nerve Sparing: Techniques and Outcomes 141
18.1. Introduction 141
18.2. Nerve-Sparing Techniques and Results 141
18.3. Conclusion 147
Management of Postprostatectomy Erectile Dysfunction 149
19.1. Introduction 149
19.2. Approaches to Radical Prostatectomy: Potency Rates 149
19.3. Concept of Early Penile Intervention 155
19.4. Pathophysiology of Nerve Injury: Historical Evidence 156
19.5. Clinical Evidence ( Studies) for Early Intervention 157
19.6. Evolving Role of Robotic- Assisted Laparoscopic Prostatectomy 162
19.7. Is There Any Role of Early Penile Rehabilitation Following Robotic- Assisted Laparoscopic Prostatectomy? 163
19.8. Concept of Chronic Therapy 164
19.9. Conclusion 166
Robotic Pyeloplasty 170
20.1. Ureteropelvic Junction Obstruction 170
20.2. Pathophysiology 170
20.3. Presenting Symptoms 171
20.4. Diagnosis 171
20.5. Indications for Treatment 173
20.6. Therapeutic Options 173
20.7. Robotic-Assisted Pyeloplasty 173
20.8. Patient Positioning 174
20.9. Trocar Placement 174
20.10. Surgical Technique 175
20.11. Clinical Outcomes 175
20.12. Cost 177
20.13. Conclusion 177
Robot- Assisted Radical Cystectomy and Urinary Diversion 179
21.1. Introduction 179
21.2. Surgical Technique 180
21.3. Postoperative Care 183
21.4. Results 183
21.5. Comments 183
21.6. Conclusion 185
Complications of Robotic Surgery and How to Prevent Them 187
22.1. Patient Positioning and Anesthetic Issues 187
22.2. Complications of Access and Port Placement 190
22.3. Complications of Robotic- Assisted Laparoscopic Prostatectomy 191
22.4. Robotic Pyeloplasty 193
22.5. Mastering the Robotic Surgical System 194
Applications of Robotics in Pediatric Urologic Surgery 197
23.1. Pediatric Urologic Procedures 198
23.2. Other Procedures 204
23.3. Conclusion 205
Robotics and Infertility 206
24.1. Current Applications of Robotic Surgery in Reproductive Endocrinology and Infertility 207
24.2. Conclusion 210
Robotic Urogynecologic Surgery 212
25.1. Robotic-Assisted Laparoscopic Sacrocolpopexy Surgical Technique 213
25.2. Results 214
25.3. Complications 214
25.4. Limitations of Robotic-Assisted Sacrocolpopexy 214
25.5. Conclusion 215
25.6. The Future of Robotics in Urogynecology 215
The Future of Telerobotic Surgery 217
26.1. Telementoring 217
26.2. Telepresence Surgery 219
26.3. The Operating Room as a Digital Information Platform: Surgery in Information Space 220
26.4. Surgical Simulation 220
26.5. Augmented Reality Surgery 221
26.6. Preoperative and Intraoperative Teleconsulting for Oncologic Surgery 222
26.7. Surgical Simulation for Surgical Training 222
26.8. Surgical Simulators and Surgical Skills Competency 223
Prostate Images 226
Pyeloplasty Images 232
Index 235