University of Central Florida Undergraduate Research Journal - A Practicality Analysis Pertaining to Minimally <br/> Invasive Robot-Assisted Urologic Surgery
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Robot-Assisted Radical Prostatectomy (RARP) Robot-assisted radical prostatectomy (RARP) is a procedure used to remove the prostate gland and the seminal vesicle, most often performed to treat localized prostate cancer.16 Robot-assisted prostatectomy is easily the most common robotic procedure performed today; it has experienced exponential growth in the years following its approval by the Food and Drug Administration (FDA) in 2000.16 Between 2003 and 2004 the number of surgeries increased threefold, and statistics indicate that robot-assisted prostatectomy is gaining popularity throughout the United States.17 Although robot-assisted prostatectomy is gaining popularity, some practitioners remain skeptical, mainly due to the limited long-term research currently available. However, robotic prostatectomy is widely associated with several peri-operative and post-operative benefits, including decreased blood loss, decreased post-operative pain, and shorter hospitalizations when compared with retropubic or traditional laparoscopic prostatectomy.18-22 While Ficarra's 2009 meta-analysis shows similar blood loss between the two techniques,22 a 2005 study shows that RARP displayed far less EBL when compared to traditional laparoscopy (206 vs 299 ml).19 It also seems that midterm recovery is a benefit of robot-assisted prostatectomy. Comparisons with traditional laparoscopic radical prostatectomy (LRP) surgeries showed that while patients from both methods regained their continence in the long-term, those who underwent robotic prostatectomy were more likely to do so within the first six months (68-96% compared to 43-80%).22 Additionally, a comprehensive study by Patel et al displayed increased trifecta (continence, potency, and prostate specific antigen) outcome rates at six weeks, three, six, twelve and eighteen months after RARP (42.8%, 65.3%, 80.3%, 86% and 91% respectively).23 Another benefit of da Vinci® System is that it appears to minimize the learning curve for new surgeons due to the added dexterity, which is so vital within the pelvis.12

Currently, most of the disadvantages associated with robot-assisted prostatectomy seem to be monetary. To this point, LRP continues to be more affordable than RARP by around $1200, mostly due to the initial purchase of the equipment.21, 24, 25 While the initial purchase and maintenance costs of a da Vinci® surgical System are quite high, they do not seem to be prohibitive given the increase in the amount of robot-assisted prostatectomy procedures being performed at many locations. An additional factor that must be evaluated is total operative time. While robot-assisted prostatectomy initially seems to have a longer total operative time in the early phase, operative duration decreases with experience.26 Several recent studies have found RARP to have a shorter average duration.22, 27 Due to the growth and popularity of robot-assisted prostatectomy, some experienced surgeons at high-volume centers are now able to complete the procedure within 90 minutes.22 Long-term oncologic outcomes are limited, but the existing literature seems encouraging. A 2011 study evaluating 3625 patients over eight years concluded that RARP offers effective long-term biochemical control.28 Currently, with cost being one of the only barriers, it seems that the frequency of RARP will continue to rise in the future due to the procedure's successes.

Robot-Assisted Pyeloplasty

Pyeloplasty has become the standard surgical treatment for ureteropelvic junction obstruction (UJO) to allow urinary flow from the renal pelvis into the ureter.12 The first robot-assisted pyeloplasty was performed on a swine model by Sung and co-authors using the Zeus® surgical System in 1999. The team concluded that robot-assisted laparoscopic pyeloplasty is a feasible and effective procedure that may enhance surgical dexterity and precision.29 With the increasing use of da Vinci® System, the frequency of robot-assisted pyeloplasty has continued to grow. It appears that both laparoscopic pyeloplasty and robotic pyeloplasty have similar outcomes in terms of their success rates. As of 2006, Bhayani and co-authors concluded that robot-assisted pyeloplasty had no distinct advantage when compared with traditional laparoscopic pyeloplasty performed by an experienced surgeon.30 However, since then the robotic method has continued to improve, and results point to several common advantages in decreasing mean estimated blood loss (50 vs. 158 ml) and mean hospital stay (1.54 vs. 1.98 days). 31-33 In addition, a comprehensive comparison of two large-scale literature reviews found that robot-assisted pyeloplasty has shorter operating time (194 vs 224 mins) when compared to the laparoscopic method.31, 33 The enhanced suturing ability often associated with the robotic platform is ideal for the efficient reconstruction needed for the procedure. Those with advanced robotic laparoscopy skills have completed the procedure in as few as 60 minutes.34 Further benefits of robot-assisted pyeloplasty include the potential to reduce technical challenges of laparoscopic pyeloplasty, which is considered a challenging procedure even for most skilled laparoscopic surgeons.35 Although evaluation of costs shows that robot-assisted pyeloplasty can be more costly ($10,635 vs $9,065) than laparoscopic or open methods,33 the procedure will likely continue to gain in popularity due to these documented advantages.

Robot-Assisted Partial Nephrectomy (RAPN)

Nephrectomy is the surgical removal of all or part of the kidney, which is often performed in patients with renal cell carcinoma.36 The application of robotics to partial nephrectomy is a recent technique in the field, with the first robot-assisted partial nephrectomy performed by Gettman in 2004.37 Currently robot-assisted partial nephrectomy (RAPN) is a viable option for patients who desire a minimally invasive option for the performance of nephron-sparing surgery.38 Most of the benefits of RAPN, such as less EBL and shorter hospital stay, 36, 39 can be attributed to enhanced suturing dexterity when compared to laparoscopic techniques.40 Moreover, RAPN is associated with a shorter total operative time 36, 41 as well as a decreased learning curve.42, 43 Benway suggests RAPN is a safe and viable alternative to laparoscopic partial nephrectomy, " may provide maximal renal nerve preservation," 43 which is vital in the sympathetic regulation of the nephron and renin-angiotensin System.44 Much like what is seen in both RARP and robot-assisted pyeloplasty, the cost of RAPN is greater than that of Laparoscopic methods by roughly $1,500 per surgery.39 An additional limitation related to the cost of RAPN is the need for a bedside assistant, a factor that presents further challenges in robot integration. Similar to many robot-assisted procedures, the long-term oncologic effects of RAPN have yet to be seen. It requires further exploration since the first recorded procedure was performed in 2004. As surgeons' experience increases, patients will experience the benefits of RAPN, and the use of robotics for partial nephrectomy should continue to grow.

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