1. Robotic surgery in urology
Departamento de Urologia – CUF
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Robotic surgery in urology
European perspective
I express my gratitude to the scientific committee of this workshop for give the opportunity to present this communication on robotic surgery in urology . European perspective.
Estevao Lima
2017

2. HISTORY OF UROLOGIC ROBOTIC SURGERY
Departamento de Urologia – CUF
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HISTORY OF UROLOGIC ROBOTIC SURGERY
The da Vinci Surgical System was released
The da Vinci surgical system was approved by the FDA
Robotic surgeries are increasing in number and are becoming more popular
The da Vinci surgical system is the most widely used robotic surgical system. It was approved by the FDA of the United States in Robotic surgeries are increasing in number and are becoming more popular. We can see in this slide the use of a robot for camera control at the Hospital de Santo Antonio in 2004, the robot-assisted.

3. Are robots more effective than laparoscopic surgery?
Departamento de Urologia – CUF
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Are robots more effective than laparoscopic surgery?
The question most often is done is: Are robots more effective than laparoscopic surgery? The advantage of the robotic surgery, less invasive, shorter hospital stay, less pain, less scaring and less blood loss is similar to laparoscopy because it uses minimally invasive accesses that in robotic surgery is slightly larger, the trocars are all of 8 mm.

4. Are robots more effective than laparoscopic surgery?
Departamento de Urologia – CUF
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Are robots more effective than laparoscopic surgery?
Robotic 3D Vision is not an added advantage
Real Advantages of robots
Robotics makes surgeries extremely precise mainly the suture.
Robots reduce the learning curve for laparoscopic surgery
Robotic surgeries are ergonomically superior and cause less fatigue for surgeons
The real advantages of the robot is not the quality of the image, nor the 3D but the following aspects: Robotics makes surgeries extremely precise mainly the suture. Robots reduce the learning curve for laparoscopic surgery. Robotic surgeries are ergonomically superior and cause less fatigue for surgeons.

5. Departamento de Urologia – CUF
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Nowadays the image of laparoscopy is as good or better than robotics, since there is already a 3D and 4K image. In this study we also demonstrated with skilled surgeons the 3D image makes no difference in quality of surgery.

6. Oncologic outcome of robot-assisted radical prostatectomy
Departamento de Urologia – CUF
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Oncologic outcome of robot-assisted radical prostatectomy
What European guidelines show us in relation to robotic surgery. Robot-assisted radical prostatectomy has gained widespread acceptance and has become part of the standard armamentarium in the management of prostate cancer. But the recommendation is Robotic surgery does not improve oncologic outcomes but the surgical expertise does.

7. Departamento de Urologia – CUF
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Conclusions and recommendations on incontinence outcomes of robot-assisted radical prostatectomy
 The reason for these conclusions is the ease of suturing with the robot, mostly in surgeons with no experience in laparoscopy.
Conclusions and recommendations on incontinence outcomes of robot-assisted radical prostatectomy. Experienced robotic surgeons achieve good early continence results. There is a trend towards faster recovery of continence after robotic prostatectomy in comparison with open and laparoscopic prostatectomies. To achieve better early continence results, the use of robotic technique is recommended. The reason for these conclusions is the ease of suturing with the robot, mostly in surgeons with no experience in laparoscopy.

8. Departamento de Urologia – CUF
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Conclusions and recommendations on potency outcomes of robot-assisted radical prostatectomy
Regarding potency outcomes. To achieve better early potency results, the use of laparoscopy or robotic techniques are recommended.

9. NEWER FRONTLINES IN RADICAL PROSTATECTOMY
Departamento de Urologia – CUF
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NEWER FRONTLINES IN RADICAL PROSTATECTOMY
 retzius-sparing prostatectomy - posterior approach
In 2010 Bocciardi group form Italy developed the idea of how to avoid the anatomic structures of Retzius space by passing through a posterior plane with the aim to get a better early continence.

10. Departamento de Urologia – CUF
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Beyond the theoretical point of view the functional results was excellent. In fact, more than 90% of the patient were immediately continents after the surgery, more similar to simple prostatectomy than radical prostatectomy.

11.  This surgical approach requires the use of robot.
Departamento de Urologia – CUF
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More recently this group from Korea validated the excellent continence outcomes reported by Bocciardi group. In this study this group compared Retzius-sparing robotic prostatectomy with conventional radical prostatectomy and this study demonstrated that retzius-sparing might indeed lead to early recovery of continence. But this surgical approach needs the use of robot.
 This surgical approach requires the use of robot.

12. Robot-assisted radical nephrectomy
Departamento de Urologia – CUF
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Robotic in kidney surgery?
Robot-assisted radical nephrectomy
Described by the first time in 2000
Limitations:
Increased operative time - robot docking time
higher cost per procedure
No significant improvement in clinical outcomes
Robotic in kidney surgery makes sense? Robot-assisted radical nephrectomy was introduced in 2000 but the limited benefit offered with the approach has reduced its widespread adoption. The main limitations of the approach are the increased technical effort associated with robot docking time and the considerably higher cost per procedure, without significant improvement in clinical outcomes compared with standard laparoscopic surgery

13. Robotic in partial nephrectomy?
Departamento de Urologia – CUF
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Robotic in partial nephrectomy?
The outcomes of selected studies on robot-assisted partial nephrectomy compared with laparoscopic partial nephrectomy
Robotics in partial nephrectomy make sense? A recently published systemic meta-analysis on robotic partial nephrectomy versus Laparoscopic partial nehrectomy incorporating data from 717 patients reported a significantly lower warm ischaemia time in the robotic arm. Complication rates associated with robotic are comparable with Laparoscopic approaches.

14. Use laparoscopy for simple or radical nephrectomy. laparoscopic
Departamento de Urologia – CUF
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Conclusions and recommendations on robot-assisted radical nephrectomy and robot-assisted partial nephrectomy
Use laparoscopy for simple or radical nephrectomy. laparoscopic
Use robot-assisted or surgery for partial or reconstructive renal surgery if technically feasible.
Use of minimal invasive techniques should not compromise nephron-sparing surgery.
This is the raison for the recommendations on robot-assisted radical nephrectomy and robot-assisted partial nephrectomy of European association of urology. Use laparoscopy for simple or radical nephrectomy. Use robot-assisted or laparoscopic surgery for partial or reconstructive renal surgery if technically feasible. Use of minimal invasive techniques should not compromise nephron-sparing surgery.

15. Departamento de Urologia – CUF
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Perioperative data, complications rates and oncologic outcomes of robot-assisted radical cystectomy
Robotic approach can achieve a similar oncologic surgical quality to open approach and this depends more of the surgeon than the technology used.
For radical cystectomy there are data support that robotic approach can achieve a similar oncologic surgical quality to open approach and this depends more of the surgeon than the technology used.

16. it is only possible with the use of robot
Departamento de Urologia – CUF
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Robot-assisted radical cystectomy
with urinary diversion performed intracorporeally
But if we want to perform a urinary diversion intracorporeally in a quick and safe way, it is only possible with the use of a robot.
it is only possible with the use of robot

17. Robot-assisted kidney transplantation
Departamento de Urologia – CUF
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Robot-assisted kidney transplantation
Recently, several groups started reporting excellent results with robot-assisted kidney transplantation. This technique provide exceptional patients outcomes by reducing operative morbidity and time to recovery.
Promising technique that provides exceptional patients outcomes by reducing operative morbidity, immobilization and time to recovery.

18. Departamento de Urologia – CUF
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Take home message
For a majority of surgeries, robot don´t offers real patient benefits in terms of surgical outcomes
Main advantage of robotic surgery  the learning curve and quality of the suture (surgical stitches) when compared to laparoscopy
Main indications for robotic surgery:
- Partial nephrectomy,
- Retzius-sparing prostatectomy,
- Cystectomy with urinary diversion performed intracorporeally,
- Kidney transplantation
Take home message. For a majority of surgeries, robot don´t offers real patient benefits in terms of surgical outcomes. The main advantage of the robot is the ease and quality of suture (surgical stitches) with this technology when compared to laparoscopy. Main indications for robotic surgery: Partial nephrectomy, Retzius-sparing prostatectomy, Cystectomy with urinary diversion performed intracorporeally, Kidney transplantation.

19. Departamento de Urologia – CUF
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Future perspectives
Robotic surgery continues to evolve into newer techniques and refine the past techniques such as single-port surgery and reconstructive endoscopy being the robotic the obvious solution.
Robotic surgery continues to evolve into newer techniques and refine the past techniques.

20. Robotic surgery in urology
Departamento de Urologia – CUF
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Robotic surgery in urology
European perspective
Many thanks.
Estevao Lima
2017