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Pyeloplasty, upper tract stone surgery, and renal surgery for congenital anomalies

Introduction Pyeloplasty offers the best long-term cure for patients with pelviureteric junction (PUJ) obstruction. Before the advent of laparoscopic renal surgery, endopyelotomy was the most popular treatment method due to its minimally invasive nature in comparison to an open procedure. However, laparoscopic and now robotic pyeloplasty have surpassed open repair and endopyelotomy to become the gold standard. Many patients with PUJ obstruction have concurrent renal stones…

Nephroureterectomy

Introduction Upper tract urothelial carcinoma (UTUC) accounts for 5% to 10% of urothelial cancer, with approximately 60% muscle invasive at the time of diagnosis. Extirpative surgery, traditionally open nephroureterectomy, was considered the gold standard curative procedure. Robotic-assisted radical nephroureterectomy (RANU) has been shown to have equivalent oncological outcomes while benefiting from the advantages of minimally invasive surgery with reduced blood loss and shorter length of hospital…

Retroperitoneal partial nephrectomy

Introduction Nephron-sparing surgery (NSS) is indicated for the treatment of small renal masses, and the technique for NSS has transitioned from open to the minimally invasive approach. Although the initial experience with minimally invasive NSS used traditional laparoscopy, robotic surgery has evolved as the preferred approach given the benefits of three-dimensional (3D) vision and improved instrument dexterity. Similar to laparoscopy, most early adopters of robotic NSS…

Partial nephrectomy

Introduction Partial nephrectomy is now considered the treatment of choice in all small renal tumors when technically feasible, because long-term oncologic outcomes are equivalent to radical nephrectomy while preserving renal function. Despite its oncologic safety, laparoscopic partial nephrectomy (LPN) is still considered a technically challenging procedure with a prolonged learning curve. Robotic-assisted partial nephrectomy (RAPN) has progressed as a technique that attempts to address the technical…

Robotic renal surgery: Radical nephrectomy (including inferior vena cava thrombectomy)

Introduction This chapter describes techniques for transperitoneal and retroperitoneal robotic-assisted laparoscopic nephrectomy. Robotic assistance facilitates a minimally invasive approach and avoids the need for open surgery particularly for larger and more challenging tumors, including those with inferior vena caval tumor thrombi. Indications/patient selection Indications for robotic nephrectomy include both benign and malignant conditions of the kidney. Benign conditions include those that result in chronic infection, pain…

Robotic simple prostatectomy

Introduction Benign prostatic hyperplasia (BPH) is the most common cause of lower urinary tract symptoms (LUTS) and bladder outlet obstruction (BOO) in men. The prevalence of this pathology increases with male aging. In the fourth decade of life, BPH is demonstrable in 30% to 40% of men, and its prevalence increases almost linearly to 70% to 80% in those older than 80 years. Despite recent advances…

Pelvic lymph node dissection for prostate cancer

Introduction Lymph node status is a primary factor in determining a patient’s prognosis and future therapy for prostate cancer. Lymph node involvement (LNI) is associated with a significant increase in recurrence and mortality. , Pelvic lymph node dissection (PLND) remains the most accurate means of determining lymph node status. Conventional cross-sectional imaging (computed tomography [CT] and magnetic resonance imaging [MRI]) has significant limitations in detecting LNI,…

Nerve sparing in robot-assisted radical prostatectomy: Tips and tricks

Introduction Robot-assisted radical prostatectomy (RARP) is the most common form of treatment for localized prostate cancer. Introduction of robotics has helped to visualize prostatic and periprostatic structures better and improve the ability to perform detailed dissections. Still, a significant number of men experience erectile dysfunction (ED) and urinary incontinence (UI) after RARP. The rates of UI (defined as usage of at least one pad/24 hours) after…

Tips and tricks for continence preservation following robot-assisted radical prostatectomy

Introduction Radical prostatectomy represents a treatment of choice for organ-confined prostate cancer (PCa). However, due to the adjacent anatomical location of the prostate to the neurovascular bundles (NVBs), and the urethral sphincter complex, radical prostatectomy may lead to adverse functional outcomes regarding erectile function and urinary continence. Among them, post-prostatectomy urinary incontinence (UI) still represents a concern, with a current incidence varying between 8% and 77%.…

Robotic prostatectomy: The patel approach

Introduction The first report of robotic-assisted radical prostatectomy (RARP) was performed by Binder and Kramer in 2000, describing 10 patients who underwent surgical treatment for prostate cancer using robotic technology. In this study, the authors combined the Walsh retrograde technique with Campbell’s anterograde approach. Since then, several groups worldwide have described the robotic surgery approach to radical prostatectomy. However, the unpredictable functional and oncological outcomes following…

Radical prostatectomy: Standard approach, retzius sparing, and single port

Standard approach Linda My Huynh, Erica Huang, Thomas Edward Ahlering Introduction Since the introduction of the robot-assisted radical prostatectomy (RARP) in 2001, much has been learned about techniques to improve patient outcomes via tenants of decreased bleeding and improved visualization. The 20-plus-year life history of prostate cancer (PC) following definitive therapy places huge priority on maximizing patient quality of life. Side effects such as urinary incontinence…

The future of robotic surgery

Introduction Surgeons have been at the forefront of integrating robotic systems into routine clinical practice. Radical prostatectomy is now commonly performed using a surgical robot in the majority of large centers in developed nations. Surgeons continue to push the boundaries in integrating new technologies in their clinical practice and training to improve outcomes, safety, and quality in surgery. In this chapter the major new technologies that…

Proficiency performance measures and artificial intelligence in robotic education

Introduction In the past decade, mounting evidence suggests that surgical performance affects postoperative outcomes, as superior quality of surgery reduces the risk of complications, shortens the length of hospital stay, and results in better long-term functional and oncological outcomes. Thus surgical training is the foundation for high-quality surgery. The recent transition in surgical training from Halstead’s traditional apprenticeship model, famously known as “see one, do one,…

Guidance for the safe implementation of telementoring in robotic surgery

Introduction The concept of telepresence has been present since the inception of robotic surgery. The first teleoperated robotic systems developed by SRI International and the Defence Advanced Research Projects Agency (DARPA) resulted in the surgeon console systems we are now familiar with. The impetus to develop these remotely controlled systems was driven by DARPA who identified a need to provide additional expertise in warzones to decrease…

Achieving robotic surgery competency

Introduction Embarking on robotic surgery training can be a daunting task for the robot-naïve surgeon. Robotics has a steep learning curve, and a pathway to robotic surgery competency has not yet been standardized. Surgical colleges have not yet developed credentialing for robotic surgery training. There is no surgical college accredited curriculum for robotics. The result is that training in robotics has been haphazard and is fragmented…

Achieving surgical proficiency by Harnessing nontechnical skills

Introduction “Engine fire,” announced the first officer during the take-off roll. The captain rotated the aircraft and confirmed that the aircraft was climbing away and commanded the landing gear to be retracted. Then the flight deck was silent with no one saying anything until 400 feet above the ground when a carefully choreographed sequence was commenced, identifying the engine that was on fire and shutting it…

Principles of anesthesia and physiology

Introduction The increased use of robotic surgery across multiple surgical disciplines has required anesthesiologists to refine their approach to continue to provide safe and effective anesthesia. The anesthesiologist must consider whether the health status of the patient is adequate to withstand the position, duration and physiological demands required of the chosen robotic surgery approach. The conduct of anesthesia needs to be adapted at certain surgical time…

Assisting in robotic surgery: Surgical skills for the bedside assistant

Introduction The rapid uptake of robotic procedures has necessitated development of new training methods and the establishment of bedside assistants. Taking on the position of bedside assistant for a surgical procedure is a responsible and pivotal task. A skilled bedside assistant is an essential part of an effective robotic surgery team. Importantly, surgeons operating at the console are physically separated from the patient. Therefore, reliance on…

Fundamentals of operating on the console

Introduction Currently available systems for robot-assisted surgery are operator-robot systems that lack operational autonomy. The robotic console is the interface between the surgeon’s hands and the surgical instruments. It is the “cockpit” of the robotic system. The surgical console consists of four main components that are used by the console surgeon: the image interface, the hand controls (surgeon’s), the foot pedals, and the console touchpad. Currently,…

Robot setup

Introduction The focus of this chapter is how to set up the da Vinci Xi robot for surgery. Da Vinci robots are the most widely used surgical robots in the world, with over 5500 machines installed globally, and have been a monopoly system for the past 20 years. The configurations of new and emerging surgical robotics are varied. A brief overview of the setup for some…