Robotics in Urology

Robotics in Urology

Robotics has now become well established for urological surgery. Especially complex urological surgeries which used to be done by open or laparoscopic method is now performed by robotics. Actually in this method a urological surgeon performs the procedure using a robot as an interface between himself and the patient. In addition a patient side surgeon is also present throughout the procedure.

It is generally called Robot assisted Laparoscopic procedures. Like Laparoscopic procedures, small incisions are made and ports and instruments are inserted. However these instruments are connected to a robot which in turn is controlled by the operating surgeon.

The da Vinci surgical robot gives excellent magnification along with 3D vision. This allows the surgeon to remove what needs to be and preserve the vital structures. The robot’s unique EndoWrist instruments offer physicians the dexterity not available to them when using conventional laparoscopic instruments. By taking advantage of the da Vinci robot, surgeons are able to dissect and reconstruct the tissue of interest with relative ease.

At this moment, daVinci robotic system is the most commonly available surgical robot. The advantages of robotic surgery includes less blood loss, less pain for patients, quicker recovery from operation and return to normal activity, quicker functional recovery ( like incontinence , impotence) and slightly better cancer outcomes.

Removal of bladder (with prostate in males and uterus in females) is usually done for cancer of the urinary bladder. Rarely done for non-cancerous conditions as well, this operation would require reconstruction to divert the urine to outside ( ileal conduit diversion) or a reconstruction of a neobladder from intestine. Traditionally done as an open operation or laparoscopic operation, now-a-days could be done with robotics with its added advantages. Benefits of Robotic-Assisted Cystectomy includes minimal damage to vital muscle and delicate nerve tissue as a result of the surgery, shorter hospital stay, faster return to a normal level of activity, minimal blood loss

After performing cystectomy, section of intestine is isolated and reshaped into a new bladder. This could be completely with a robot ( intracorporeal ) or a combined robotic and open method ( combined intra-extracorporeal).

The new bladder is placed in the same location as the original and is joined to the ureters and the urethra. This reconstruction allows you to maintain a functional urinary tract.

As with any bladder substitute, it may take some time until the neobladder functions best. Soon after surgery, many people may have difficulties with urinary incontinence until the neobladder stretches to a normal bladder size.

Robotic assisted laparoscopic radical prostatectomy is a minimally invasive form of robotic surgery to remove the cancerous prostate. This is one of the most commonly done robotic surgeries. 5-6 small incisions are used. The bladder is then mobilised to allow access to the prostate. The prostate and its attachments (vas and seminal vesicles) are disconnected from bladder , urethra and surrounding structures like a sculptor. Great care is taken to preserve what needs to be preserved (like nerves if necessary) and to avoid damage to surrounding structures ( like rectum). The urethra is then joined to the bladder over a catheter.

Patients are discharged with a catheter (a small plastic tube) in place which is usually removed on an appropriate day as determine by your surgeon.

Following catheter removal the rehabilitation phase of treatment begins. This involves rehabilitation of urinary control and sexual function. The urinary continence returns quickly in the majority over the next 3-6 weeks with progressive decrease in the pad usage. Majority of the patients are using one pad for protection at 6 weeks follow up. This recovery is greatly aided by Pelvic Floor Exercises. This could be commenced even before surgery and patients training aids recovery.

The sexual functions recover well with preservation of atleast one neurovascular bundle during the operation and use of PDE 5 inhibitors (oral tablets) after the operation.

Partial nephrectomy (Nephron Sparing Surgery) removes the cancer while preserving the normal and unaffected portion of the kidney, thus preventing the loss of the entire kidney.

The patients with renal tumours usually have special CT scans which helps the surgeon to plan as whether partial nephrectomy could be performed .

During the operation, the kidney and its blood vessels are mobilised; the blood supply to the kidney is stopped for a short while (usually less than 30 min) ; during this time, the tumour with a small margin of normal kidney is cut out; bleeding areas are carefully sutured; any open calyces are sutured; the cut surface is the opposed by a process called renorrhaphy. After the kidney is reconstructed, the blood flow to the kidney is restored by removing the vascular clamps which are on the blood vessels supplying the kidney. The kidney is inspected to ensure there is no bleeding from where the kidney was cut. Generally, the tumour is removed from the body through one of the holes.

Because of the complexity of this surgery, patients may have a higher chance of postoperative complications from a robotic partial nephrectomy instead of a robotic radical nephrectomy, which is a removal of the total kidney.

However partial nephrectomy has an advantage that the patients have a slightly lower incidence of cardiovascular and renal diseases in future.

Postoperatively patients are discharged usually on day 1 or 2 and are back to complete normal activity by 4-6 weeks. Depending upon the nature of the tumour careful follow up is planned.

For some patients with kidney cancer or a benign kidney conditions, removing the whole kidney may be necessary. This is called Nephrectomy, if done for cancer it is called Radical Nephrectomy. This minimally-invasive procedure offers patients many of the same advantages as any other robotic surgery.

In this procedure the whole kidney is mobilised, the blood supply is clipped, the ureter is clipped and the whole kidney with its surrounding structures is removed.

Robotic radical nephrectomy becomes especially advantages in complex situations such as large tumours, proximity to large vessels, need to remove lymphnodes as well etc.

This procedure is done for patients with adrenal tumour; which might be functional ( producing hormones in excess and hence causing symptoms) or non-functioning tumours (including cancers).

Adrenal glands are located just above the kidneys and have a delicate venous drainage. They are responsible for producing a number of important hormones-substances that circulate throughout the bloodstream and help regulate blood pressure, sugar level, salt production and other metabolic functions. These hormones include cortisol, aldosterone, epinephrine (adrenaline), and norepinephrine. An adrenal gland that develops a benign functional tumor (so-called because it affects the way the gland functions) and begins producing too much of any one hormone may require adrenalectomy in order to avoid long-term health problems. In other cases, it may be possible to treat the condition by performing a partial adrenalectomy, in which just the tumor is excised while the rest of the adrenal gland is left intact.

The entire adrenal gland is also removed if doctors diagnose or suspect a malignant tumor in the adrenal cortex (the outer part of the gland)-a rare condition known as adrenocortical carcinoma, adrenal cortex cancer, or simply adrenal cancer.

Robotics is especially useful in adrenal surgery for its visualization and aiding delicate dissection and control of multiple feeding blood vessels during adrenalectomy. This is in addition to the other advantages of robotic surgery including shorter recovery and return back to normalcy.