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Emergence of robotic assisted surgery in gynecologic oncology: American perspective

  • AdventHealth Cancer Institute

Abstract and Figures

To discuss the emergence of robotic surgery in gynecologic oncology and describe the growth of robotic surgery in a university medical center and a community based practice. In addition to the historical evolution of the robotic assisted surgery medicine, a survey of robotic cases was performed on two robotic programs since the inception of the programs. A review of the current literature on the use of the da Vinci robot in gynecologic oncology was also performed. The robotic surgery programs at UNC Hospital and Florida Hospital are growing steadily since the inception of the programs in 2005 and 2006, respectively. Since 2005 there have also been numerous publications detailing the effectiveness, safety, and efficiency of the robot. Robotic surgery is gaining acceptance and is rapidly growing as evidenced by an increased number of publications on the topic; these publications demonstrate the safety, efficacy, and improved outcomes compared to open surgery and conventional laparoscopy.
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Emergence of robotic assisted surgery in gynecologic oncology: American perspective
Alberto Mendivil
, Robert W. Holloway
, John F. Boggess
University of North Carolina, Chapel Hill, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, 101 Manning Drive, CB 7572, Chapel Hill,
NC 27599-7572. USA
Gynecologic Oncology Program, Florida Hospital Cancer Institute, 2501 N. Orange Avenue, Suite 689, Orlando, FL 32804, USA
abstractarticle info
Article history:
Received 21 November 2008
Endometrial cancer
Cervical cancer
da Vinci
Objectives. To discuss the emergence of robotic surgery in gynecologic oncology and describe the growth
of robotic surgery in a university medical center and a community based practice.
Methods. In addition to the historical evolution of the robotic assisted surgery medicine, a survey of
robotic cases was performed on two robotic programs since the inception of the programs. A review of the
current literature on the use of the da Vinci robot in gynecologic oncology was also performed.
Results. The robotic surgery programs at UNC Hospital and Florida Hospital are growing steadily since the
inception of the programs in 2005 and 2006, respectively. Since 2005 there have also been numerous
publications detailing the effectiveness, safety, and efciency of the robot.
Conclusions. Robotic surgery is gaining acceptance and is rapidly growing as evidenced by an increased
number of publications on the topic; these publications demonstrate the safety, efcacy, and improved
outcomes compared to open surgery and conventional laparoscopy.
© 2009 Published by Elsevier Inc.
Introduction ................................................................ S25
Evolution of surgical robotics ........................................................ S25
Historical perspectives.......................................................... S25
The da Vinci surgical system ......................................................... S26
Da Vinci surgical applications in gynecologic oncology ............................................ S26
Rationale and strategic approach to program building a tale of two programs ................................ S27
Program initiation.............................................................. S27
Cost .................................................................. S27
Public institution experience ....................................................... S27
Private setting ............................................................. S27
Training ................................................................ S28
Teaching residents, fellows, and colleagues .................................................. S28
Surgical skill-set requirements and strategies for acquisition and development ................................. S29
Concept of a minimally invasive surgical team ................................................ S29
Institutional commitment ........................................................ S29
Strategies for building a robotic surgery team ................................................. S29
Establishing guidelines ........................................................... S29
Patient selection ............................................................ S29
Protocols, algorithms, clinical pathways.................................................. S30
Clinical outcomes ............................................................ S30
Summary .................................................................. S30
Conict of interest statement ........................................................ S30
References ................................................................. S30
Gynecologic Oncology 114 (2009) S24S31
Corresponding author. Fax: +1 919 843 5387.
E-mail address: (J.F. Boggess).
Fax: +1 919 843 5387.
Fax: +1 407 303 2435.
0090-8258/$ see front matter © 2009 Published by Elsevier Inc.
Contents lists available at ScienceDirect
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Surgery is a controlled injury. In order to treat disease, surgeons
balance complications and invasiveness with clinical outcomes in
order to determine which techniques are best. Minimally invasive
surgery (MIS) is a method to reduce the morbidity of surgery and has
been shown in general to reduce blood loss, complications, post-
operative pain and length of hospital stay compared with traditional
laparotomy [1]. While laparoscopic tools have evolved signicantly
over the last three decades, there has not been widespread adoption in
gynecology and gynecologic oncology [2,3]. The development and
introduction of robotic assisted MIS addresses many of the limitations
of traditional laparoscopy instruments by restoring dexterity and
intuitive instrument movement, 3-D vision, ergonomics and auton-
omy. Although robotic surgery in gynecology is in its infancy, the use of
the da Vinci surgical system is quickly becoming an integral tool for
treating gynecologic malignancies [4]. Since 2005, robotic surgery has
emerged as an effective MIS tool in gynecologic oncology that in early
feasibility studies appears to decrease surgical morbidity beyond that
seen with traditional laparoscopy [512] . The following review will
outline the development of robotic surgical applications in gynecologic
oncology and will describe the development of two successful robotic
surgical programs one university based and the other private practice
based in order to illustrate the specic issues inherent to both
academic and private practice robotic surgery program development.
Evolution of surgical robotics
Historical perspectives
The rst surgical robots were utilized in the 1980s. The rst surgical
robots were industrial robots that were modied to assist with surgical
procedures. In 1984 the PUMA-560, a revamped industrial robot,
assisted with a stereotactic brain biopsy under CT guidance [13].After
the PUMA was used to assist with prostate surgery, further, specialized
surgical robots were developed [14]. The PROBOT was developed in
England specically to assist in transurethral prostate surgery. The
PROBOT had an ultrasonic tip, which allowed for reconstruction of the
prostate and adequate removal of the organ [15]. Thus, prostatectomy
is considered the rst truly robotic operation. In the late 1980s, the
ROBODOC was developed by Integrated Surgical Supplies, Inc. to
specically perform hip replacements (Fig. 1). ROBODOC was the rst
surgical robot approved by the FDA.
Robotic surgery and tools for broader applications were further
developed in the 1990s. Abdominal robotic assisted procedures
became possible with the advent of Computer Motion's AESOP
(Automatic Endoscopic System for Optimal Positioning). In 1994, the
rst FDA approval of a robotic device for intra-abdominal surgery was
granted. AESOP was a robotic arm that allowed surgeons to control the
orientation of a traditional laparoscope via foot pedal and later voice
command (Fig. 2). AESOP was the rst voice-controlled robot to
receive FDA approval. Four years later, Computer Motion introduced
ZEUS, a second-generation robotic system. Zeus was the rst robotic
system to provide instrument control in addition to camera control.
Zeus was composed of three robotic arms one for a 2-dimensional
laparoscope and two arms to control surgical instruments. The camera
was operated with voice commands similar to AESOP while the
surgeon controlled the instrument arms from a remote console. A
computer translated the surgeon's movements into the laparoscopic
instruments, which were scaled according to surgeon preference. The
Zeus system had a 2D video screen identical to laparoscopy (Fig. 3).
Fig. 1. ROBODOC developed by Integrated Surgical Supplies, Inc.
Fig. 2. Computer Motion's AESOP (Au tomatic Endoscopic System f or Optimal
Positioning) has allowed surgeons to control the orientation of the laparoscope via
foot pedal and later voice commands, freeing both hands for surgery.
Fig. 3. ZEUS robotic system; rst robotic system to combine instrument and camera
S25A. Mendivil et al. / Gynecologic Oncology 114 (2009) S24S31
Using the ZEUS robotic system, a remote-site robotic surgery was rst
performed by a surgeon in New York who performed a cholecystect-
omy on a patient in Strasbourg, France. This surgery utilized a
dedicated ber optic network and was performed after several similar
trans-Atlantic surgeries had been performed on pigs [16]. Telesurgery
has been limited due to bandwidth restraints and cost limitations.
However, DARPA, the Defense Advanced Research Projects Agency,
and TATRC, the U.S. Army Telemedicine and Advanced Technology
Research center have led advancements in robotic telesurgery given
the Congressional mandate to transform the Army to one-third
unmanned vehicles by 2015. Around the time that ZEUS was being
developed, Intuitive Surgical introduced the da Vinci robotic surgical
system. The rst telesurgery using the da Vinci robotic system was
conducted via public-use internet between the University of Cincin-
nati and Intuitive Surgical in California in March 2006 [17]. The da
Vinci surgical system is the only FDA approved robotic surgical system
on the market currently, and will be further described below.
The da Vinci surgical system
The da Vinci surgical system is the most sophisticated of the
surgical robotic systems. The da Vinci has three components: the
patient side surgical cart, the vision system and the surgical console
(Fig. 4). The patient side cart has three to four arms for controlling a
12 mm 3-dimensional camera and two or three robotic surgical
instruments. The vision cart processes the video signal from the
camera and the image displayed on the surgeon console and two
separate monitors for the surgical assistant. Each eyepiece on the
surgical console receives a different feed allowing reconstruction of
the internal 3-dimensional view of the operative eld. The surgeon
sits remotely from the patient at the surgical console. The robotic
instruments are controlled via the surgeon's ngers in two hand
pieces or masters. The surgeon's movements are translated into the
robotic surgical instruments, decreasing tremor and enhancing
precision. Robotic instruments are uniquely wristed allowing seven
degrees of freedom as opposed to the four degrees of freedom offered
by traditional laparoscopic instruments. Foot controls allow the
console surgeon to adjust the camera independently and activate
monopolar and bipolar energy sources. A surgical assistant stands
patient side to assist via traditional laparoscopic instruments. There
are two da Vinci systems currently available; the standard and S-
systems. The standard system was developed rst and has 3 or an
optional 4th arm. The S-system was the next upgrade and has 3-
dimensional, high denition vision, a wider panoramic view, and a
digital zoom that was developed to prevent instrument interference.
An integrated touch screen LCD monitor is available with the S-system
that allows the bedside assistant to see what the surgeon sees. The
monitor has a telestration feature (nger writing feature viewable by
both the bedside assistant and the console surgeon) that allows for
better proctoring and communication between the bedside assistant
and the surgeon.
Da Vinci surgical applications in gynecologic oncology
In 1999, the cardiothoracic surgery team of Loulmet and colleagues
performed one of the rst procedures using the da Vinci surgical
system. They described the use of robotic assistance in performing
coronary artery bypass grafts and showed that patients who under-
went robotic assistance had shorter length of stays in the hospital, and
less time in the intensive case unit after surgery compared with
sternotomy [18]. The use of the da Vinci robotic-assisted laparoscopic
radical prostatectomy (RALP) was pivotal in bringing about the
subsequent wide spread use of the tool in gynecology. In 2001, Binder
et al. [19] published their rst 10 cases of RALP. Since then, RALP has
quickly moved to an accepted method treatment for prostate cancer.
Most recently, a case series of 1500 patients of RALP they concluded
that the procedure was safe, feasible, and efcacious [20].
Based upon the pioneering work of Advincula and Reynolds who
reported on the use of the robot for myomectomies followed by their
preliminary experience in staging gynecologic cancers the United
States Food and Drug Administration (FDA) approved the use of the da
Vinci in gynecologic procedures in April 2005 [2124]. In February,
2006, Boggess performed the rst live telecast demonstrating a
technique for performing robotic assisted radical hysterectomy and
subsequently presented data for a series of 13 radical hysterectomies
at the Society of Gynecologic Oncologists annual meeting in March of
the same year [25]. Since this initial demonstration of feasibility and
technique, the interest in robotic assisted gynecologic oncology
procedures has rapidly spread. Tables 1 and 2summarize the current
literature detailing experiences of robotic procedures for the
Fig. 4. Da Vinci Surgical System, Intuitive Surgical, Inc., Sunnyvale, CA.
Table 1
Robotic-assisted radical hysterectomy cases; N/A = not available
Article Year # pts Median operative
time (min)
EBL (mL)
Median lymph
node count
Marchal, et al. [29] 2005 7 N/A N/A N/A
Sert, et al. [28] 2006 1 N/A N/A N/A
Sert, et al. [27] 2007 15 241 71 N/A
Kim, et al. [8] 2008 10 207 355 28
Magrina, et al. [9] 2008 18 226 175 26
Fanning, et al. [26] 2008 20 390 300 18
Boggess, et al. [6] 2008 51 211 97 32
S26 A. Mendivil et al. / Gynecologic Oncology 114 (2009) S24S31
treatment of cervical and endometrial cancer. While these series are
relatively small and non-randomized, they consistently demonstrate
safety and efcacy with respect to complications, blood loss, operative
time and patient convalescence compared with laparotomy and
laparoscopy [8,9,2628].
Rationale and strategic approach to program building a tale of
two programs
Early adopters of robotic surgery have not only faced challenges in
procedure development, but also in program development. There are
inherent differences in program building based on the type of practice
involved. As more gynecology oncologists begin to adopt robotic
surgery, these early experiences can serve as a roadmap to establish-
ing a successful program.
Program initiation
Program initiation is based on two key players: surgeons and
administrators. Surgeon interest and commitment to a robotic
program is key in the successful implementation, whereas adminis-
trators are paid to protect the nancial interests of an institution and
thus must be convinced that robotics offers benets and is marketable.
The upfront capital investment for an institution is between
$1,000,000 and $1,500,000 per da Vinci
surgical system and requires
a 10% annual maintenance fee for repair and service as well as
software upgrades to the system. There are also costs associated for
each case that include robotic instrument use cost of $200 per use.
Second, additional costs include drapes for the actual system, robot
specic ports (depending on the type of system), and any other
accessories necessary for the particular case. Third, there is the cost of
training personnel to set up the system; initially there may be delays
due to the novel nature of the process and may lead to additional
operating room time and costs. Finally, there is the cost for proctoring
newly involved surgeons in a program [4]. In the end, an institution
must view the system as an investment that requires continued
support by multiple services to ensure the program's success. The
xed cost of the system can be justied and distributed when utilized
to a maximum number of cases by multiple surgical services.
Public institution experience
At the publicly funded, University of North Carolina, surgeons
pursued a robotic surgery program based on extensive experience in
advanced laparoscopic surgery [4]. The University administration was
interested in the nancial aspects of establishing a robotic program;
one key factor was use of the system by multiple surgical de-
partments. At UNC, Urology offered initial interest, followed by
pediatric and gynecologic oncology surgery. As a leading University-
based academic program questions regarding the advantages of
robotic assistance over laparoscopic techniques with regard to patient
outcomes and learner experience were considered. Ultimately,
surgeons and administration agreed that a robotic program would
be benecial and the initial system, a standard 3-arm robot was
installed in February 2005.
At the University of North Carolina, the Urology service was the
rst to use the robot. In 2005, the gynecologic oncology service
performed the institution's rst robotic hysterectomy and bilateral
salpingoophorectomy. Since then, the number of gynecologic proce-
dures performed has exceeded 700 cases. The initial success of the
program led to the purchase of a second system (S-system); both
systems are used virtually every day with access by ve different
surgical services. Robotic surgical procedures by the gynecology and
gynecologic oncology services have grown progressively since the
inception of the program in 2005 (Figs. 5 and 6), and the majority of
staging for endometrial cancer and radical hysterectomy for cervical
cancer are currently performed via robotic assistance.
Private setting
In contrast, the development of the robotics program at Florida
Hospital in Orlando began in 2006 soon after seeing a live broadcast of
a robotic radical hysterectomy [25]. As with many gynecology
practices, a da Vinci system was already in place at the medical center
being utilized by the Urology service. The evolution to robotics was
viewed as particularly challenging by the attending surgeons since the
gynecologic oncology program was not routinely performing mini-
mally invasive surgical techniques for treatment gynecologic malig-
nancies. Despite the ability to perform an open radical hysterectomy
in 97 min and an endometrial staging in 84 min on average [7], the
group decided to explore robotics in order to improve surgical
outcomes for their patients. It was postulated that the quicker patient
Table 2
Robotic-assisted staging of endometrial cancer; N/A = not available
Article Year # pts Median operative
time (min)
EBL (mL)
Mean total lymph
node counts
Reynolds, et al. [24] 2005 2 N/A N/A 23
Marchal, et al. [29] 2005 5 N/A N/A N/A
Bell, et al. [30] 2008 40 184 166 17
Denardis, et al. [7] 2008 56 177 105 19
Boggess, et al. [5] 2008 103 191 75 33
Fig. 5. Growth of robotic assisted cases for the gynecology and gynecologic oncology
services at UNC since the inception of the program in 2005; 2008represents data
compiled through October 2008.
Fig. 6. Cases performed by the gynecologic oncology service at UNC from 20052008;
data from 2008 is compiled up to 6/30/20 08.
S27A. Mendivil et al. / Gynecologic Oncology 114 (2009) S24S31
recovery times combined with less pain and complications would
justify any anticipated increases in operative times. The purchase price
of a da Vinci
system is signicant to the budget of any hospital;
however, it was anticipated that conversion of complicated gyneco-
logic laparotomy cases to MIS would shorten length of stay, thus
freeing up inpatient bed-days to satisfy the admission needs of the
hospital. Ultimately, the potential improvement in patient outcomes
from MIS compared to the standard laparotomy justied the hospital
investment irrespective of the best and worst case economic
projections. Since the program's inception, the number of cases
performed robotically continues to grow each quarter, approaching
400 robotic procedures annually at present (Fig. 7).
Regardless of setting, training of multiple team members must
occur prior to procedure initiation. In both public and private
experiences, a dedicated team of nurses and operating room support
staff were trained on the operation of the system. Designated surgeons
were oriented to the system in a dry labsetting and then attended a
porcine lab for a one-day comprehensive training and certication
In the academic setting, the rst case was a simple hysterectomy
and bilateral oophorectomy. The technique used was based upon a
modied KOH ring method for performing total laparoscopic
hysterectomy [29]. Port placement strategy for this rst case was
derived from the robotic assisted prostatectomy literature. The
primary surgeon's perception was that the ergonomics and intuitive
movements of the instruments combined with the 3-dimensional
immersive vision were major improvements over traditional laparo-
scopy and that the system would be adequate for performing more
complex procedures. Based upon this initial success, a robotic assisted
endometrial cancer staging was performed the following week and a
radical hysterectomy performed as case number three. Since this
initial experience, the author has performed and/or instructed on over
600 robotic procedures with the emphasis being on hysterectomy,
simple or radical, and lymph node dissection.
Since the inception of the robotics program in gynecologic
oncology at Florida Hospital, there has been consistent growth in
the number of robotic cases performed each year (Fig. 8). Further-
more, there has been a shift in the trend of approach to endometrial
cancer staging cases with now more than half of the cases being
performed via robotic assistance (Fig. 9).
Teaching residents, fellows, and colleagues
Training of additional surgeons in robotic surgery has been crucial
to the success of both public and private gynecologic oncology
programs. The most successful training programs have utilized a
process involving progressive involvement. At the start of both
programs, a single surgeon developed procedures at the console
with assistants at the bedside. Cases were scheduled according to the
surgeon's level of comfort. With time, the involvement of assistants
(residents and fellows) on the console increased.
The observation of robotic cases by residents and fellows is
important to familiarize them to the instrument. At UNC, residents/
fellows begin by learning the placement of trocars necessary for the
particular case, followed by docking the robotic arms to the ports. It is
also a goal for learners to gain the ability to trouble shoot the device/
arms during the case as this can make a major difference in the ability
of the console surgeon to the effectively complete the case. Becoming
familiar with the robot as the bedside surgeon also serves to teach the
anatomy, surgical boundaries, and surgical procedures with vivid
visualization. After case observation, residents and fellows train in the
Fig. 7. Quarterly growth of robotic cases during the rst two-years of robotics program
at Florida HospitalOrlando (6/30/066/30/08).
Fig. 8. Growth of gynecologic oncology robotic cases at Florida Hospital during the years
20062008 (= 8-month data).
Fig. 9. Changes in the pattern of surgery for endometrial cancer during the rst two-
years of the program at Florida Hospital (20072008).
Table 3
Robotic surgical curriculum (adapted from Chitwood, et al. [32])
1. Didactic overview
Understanding robotic instrumentation
2. Inanimate lab
Master console (actuators/pedals)
3. Animal lab
Console surgeonmaster suturing, tissue manipulation
Patient side surgeonmaster instrument changes, trocar positioning
4. Cadaver lab
Master trocar placement
Apply acquired skills to cadaver
5. Operative observation
6. Performance live case
S28 A. Mendivil et al. / Gynecologic Oncology 114 (2009) S24S31
(dry) laboratory and practice specictasksontherobot.The
completion of such pre-surgical preparation is followed by perfor-
mance of appropriate surgical procedures for patients under direct
supervision. The da Vinci
S system has an LCD with writing feature
allowing the bedside surgeon (attending) an opportunity to observe,
teach, and guide the resident/fellow at the same time. Table 3 outlines
a stepwise training strategy for robotic surgery.
Surgical skill-set requirements and strategies for acquisition and
The robotic surgical system is a tool set and, therefore, a successful
procedure is dependent upon the surgeon's abilities. The primary goal
when transitioning to robotics is to develop comfort and familiarity
with the tools in order to have safe and efcient procedures. In our
experience, there are multiple ways to obtain the skills necessary to
become a successful robotic surgeon. One way is to participate in a dry
(inanimate) lab session practicing suturing, and performing simple
dexterity skills with the robotic surgical system. Furthermore, it is
useful to participate in a formal porcine training lab in order to practice
handling tissue, tissue dissection, cautery, and tissue resection to
become procient with the instrumentation. However, this has proven
nancially impractical for multiple residents. Finally, console experi-
ence with simple hysterectomies and salpingo-oophorectomy are the
necessary predecessors to more complicated procedures. Thus far, at
UNC, attending surgeons have logged over 400 h on the console since
2005 and fellows have logged almost 200 console hours.
Teaching other physicians the use of the da Vinci surgical system
can take several forms. Traditionally, educating other physician on
surgical techniques involves direct case observation in the operating
room. Direct case observation can prove very useful for surgeons who
have never seen robotic surgery performed in a live setting. Intuitive
Surgical has promotional material in DVD format of both an
endometrial cancer staging operation and a radical hysterectomy
with pelvic lymphadenectomy for cervical cancer that were developed
by the senior author. Surgical symposia are another way to educate
other physicians and ancillary personnel about robotic surgery. In
2007, UNC hosted the rst International Gynecologic Oncology
Robotic Symposium (IGORS). During this conference, attendees had
the opportunity to see two live cases, hear a series of lectures on
robotic surgery, experience and technique, and participate in discus-
sion forums on previous experiences in robotics (difcult cases,
complications, trouble-shooting tips etc.).
Concept of a minimally invasive surgical team
Institutional commitment
There are currently over 600 da Vinci surgical systems installed in
the United States; and over 900 systems around the world [30].Since
most gynecology robotics programs will be implemented at an
institution already performing Urology or General Surgery cases,
surgical teams familiar with the system typically already exist. There
are, however, differences in gynecology that need to be taught. In this
situation, the xed cost of the system can be justied and distributed
throughout the difference services and is determined according to the
number of cases performed in total by all services using the robot. As
previously mentioned, there is an up from cost through a capital
investment between $1,000,000 and $1,500,000 per da Vinci surgical
system in addition to the 10% annual maintenance fee for repair and
service. There are also periodic software upgrades that are required to
maintain the uid function of the system. At $200 per use, the
instruments also add a signicant cost to the individual procedure and
to the program as a whole. Furthermore, additional costs include drapes
for the actual system, robot specic ports (depend on type of system),
and any other accessories necessary for the particular case. There is the
cost of training personnel to set up the system; initially there may be
delays due to the novel nature of the process and may lead to additional
operating room duration and costs. Finally, there is the cost for
proctoring newly involved surgeons in a program [4]. In the end, an
institution must view the system as an investment that requires
continued support by multiple services to ensure the program's success.
Strategies for building a robotic surgery team
Building a professional sports team requires money, a good head
coach, and talented players. The same can be said about starting a
robotic surgery program. Once the institution has decided to make the
initial investment in a system, the next key step is to nd a physician
or small group of physicians within the institution who will take
charge in building the program: a surgical champion. This individual
should not only have the training necessary to operate the robot, but
also the support of their respective departments. Often the start of a
robotic program is met with resistance because initially the cases may
take longer to complete, there may be high rates of conversion from
robotic to open surgery, or there may be a lack of support from the
operating room staff. Regardless, it is important for the robot program
leader to assemble a team that will feel invested in the program and
feel that the success of the program depends upon them. The robot
team should consist of individuals that are open to change, are willing
to learn a whole new instrument, and don't mind enduring the
growing pains of implementing a new system.
Establishing guidelines
Patient selection
Several considerations are involved when selecting the route of
surgical intervention in patients with gynecologic malignancies.
Factors to consider when choosing a robotic surgical approach may
include disease type, extent of disease, preoperative imaging, stage,
patient age, body mass index, parity, size of lesion(s), and equipment
availability. There are currently no published guidelines on patient
selection as it relates to robotic surgery in gynecology. In general, our
institution has developed some general considerations when deter-
mining the use of robotics for patients with uterine or cervical cancer.
In the preoperative period, patients receive imaging studies such as
CT scans to assess for metastatic disease (as in the case of grade III or
atypical uterine cancer), or MRI (to assess for parametrial involve-
ment in the case of cervical cancer with large lesions). The size and
weight of the patient often plays a limited role in the decision to
proceed with robotic surgery. The main factor is the ability of the
patient to tolerate steep Trendelenberg, which is necessary to
complete the surgery. Patients with multiple (non-pulmonary) co-
morbidities need not be excluded from a robotic surgical approach if
anesthesia clears them.
Table 4
Abbreviated clinical pathway for robotic surgery in gynecologic oncology
Endometrial cancer Cervical cancer
Bowel preparation Golytely
Preoperative Cefoxitin 2gm IV, no anticoagulant Same
Post operative laboratory Hemoglobin/hematocrit on POD 1 Same
Post-op diet Clear liquid when fully awake,
regular diet after 8 h
Analgesia Oral narcotics preferred PRN,
no standing order for IV narcotics
post PACU
Ambulation Within 4 h Same
Catheter removal When able to ambulate if no
bladder trauma
POD 47
Can substitute magnesium citrate (POD= post operative day, PACU= post
anesthesia care unit).
S29A. Mendivil et al. / Gynecologic Oncology 114 (2009) S24S31
Protocols, algorithms, clinical pathways
Clinical pathways are used to streamline and standardize post-
operative care. These pathways are prevalent in the general surgery
literature for MIS operations such as appendectomy, cholecystectomy,
and increasingly gastric bypass [3133]. At UNC, our clinical pathway
since 2005 allows patients to quickly recover after anesthesia,
ambulate, eat, and be discharged from the hospital within 24 h
(Table 4). The clinical pathway was duplicated at Florida Hospital
with similar success. In both institutions this has led to more efcient
utilization of hospital resources without compromising patient care.
Patients do not have a standing order for intravenous narcotics once
they leave the post anesthesia care unit (PACU). Patients requesting
intravenous pain medication are assessed by a physician then given
the appropriate medication to provide the appropriate analgesia. We
nd this is important since excessive and inappropriate pain after
minimally invasive surgery may potentially be a sign of an acute
abdominal process.
Clinical outcomes
Since 2005 there has been an increase in the published literature
describing outcomes for robotic surgery in gynecologic oncology.
Marchal et al.[34] in 2005 rst described their experience with
hysterectomy, endometrial cancer staging, and radical hysterectomy
Piver type II for cervical cancer. They reported only one conversion to
laparotomy out of 30 cases; 17% post-operative complication rate, less
intra-operative bleeding, less pain, and a shorter hospital stay.
Reynolds has since echoed these outcomes as they reported on their
initial 7 cases. Post operative results demonstrated excellent lymph
node retrieval (average 15 lymph nodes), a blood loss of 50 mL, and a
median length of stay of 2 days and no conversions to laparotomy [24].
Sert and Abeler published the results on a series of 15 patients relating
to outcomes from robotic assisted radical hysterectomy compared to
laparoscopy. In their cohort, the robotic assisted group has less
operative times, less bleeding, and a shorter hospital stay compared to
traditional laparoscopy [27]. Another paper dealing with outcomes
was from Kim et al. where they reported on 10 patients who
underwent robotic radical hysterectomy. The average estimated
blood loss for the 10 cases was 355 mL and their complication rate
was low [8]. Magrina [9] and Fanning [26] have also reported their
outcomes with robotic radical hysterectomy. In both studies the
median case blood loss was less than 300 mL and the median lymph
count was 26 and 18 total pelvic lymph nodes, respectively. In the
current largest series by Boggess et al. [6], 51 patients underwent
robotic assisted radical hysterectomy with pelvic lymphadenectomy.
This cohort of patients had low median blood loss (97 mL), operative
time, and a high lymph node count. One of the most distinguishing
ndings was that the median length of stay was 1 day in robotic cohort
compared to 3 days for the comparable open cohort.
Staging for endometrial cancer via robotic assistance is also gaining
acceptance. Laparoscopic surgical staging has generally led to lower
blood loss, less post-operative pain, and shorter length of stay. There
has been a single prospective randomized trial assessing the feasibility
of laparoscopy for endometrial cancer staging (Gynecologic Oncology
Group Lap-2). In this study of over 2000 women, the results showed
the procedure was feasible with an average hospital stay of 3 days and a
conversion rate of 23% [35]. Since 2005 there have been reports
detailing the use of the robot for the staging of endometrial cancer. All
reports described shorter operative times, shorter length of stays, and
lower estimated blood loss [6,36]. To date, Boggess and colleagues have
reported on the largest cohort of patients undergoing robotic
endometrial cancer staging (see Table 2). The reported median
lymph node retrieval of 33 nodes was also the largest count achieved
to date. In their rst year's experience, the Florida Hospital group
reported a signicant reduction in peri-operative morbidity with the
initiation of robotic surgery compared to laparotomy [7]. These studies
point the reproducibility and feasibility of the procedure.
The development of surgical robots is revolutionizing surgery in
gynecologic oncology just as it has done for urology and cardiothoracic
surgery. With improvements in operative times, decreased blood loss,
and decrease in length of stay after surgery, the robot has allowed
surgeons to perform more and more complex procedures, while
providing patients the benets of minimally invasive surgery. Endo-
metrial cancer staging and radical hysterectomy have emerged as the
most common gynecologic oncology procedures performed using
robotic assistance. Over 1000 systems have been installed worldwide
and the use of the robot continues to increase. Community based
practices and university based institutions are increasingly adopting the
use of the robot and its use continues to expand. In this review, we have
outlined templates for the successful initiation of a robotic surgery
program in both an academic and private setting, and have discussed
many facets of program development and surgeon training. Today,
robotic surgery has introduced precision, autonomy, ergonomics and
efciency to minimally invasive surgery. Tomorrow, with development,
computers and robots will enhance our abilities beyond what can be
achieved or imagined today. It will be our responsibility as surgeons to
critically evaluate these new developmentsin the context of ourpatients
to ensure the best clinical outcomes.
Conict of interest statement
Alberto Mendivil, MD has no conict of interest to declare.
Robert W. Holloway, MD is a consultant for Intuitive Surgical.
John F. Boggess, MD is a consultant for Intuitive Surgical.
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... 20 PROBOT was developed in England and utilized in prostate reconstruction and transurethral prostate resection surgeries. 21,22 In 1992, the ROBODOC, developed by the Integrated Surgical Supplies, Inc., became the first US Food and Drug Administration (FDA) approved surgical robot. The ROBODOC was developed to perform hip replacements, specifically. ...
... The ROBODOC was developed to perform hip replacements, specifically. 21,[23][24][25] Through the late 1980s and early 1990s, Computer Motion developed their robotic system named AESOP, Automatic Endoscopic System for Optimal Positioning. AESOP assisted surgeons by providing a steady operating field without the risk of a fatigued or inexperienced scope holder. ...
... AESOP received FDA approval for intra-abdominal surgeries in 1994 and became the first FDA-approved robotic device for intra-abdominal procedures. 21,26 ZEUS was the second-generation robotic system introduced by Computer Motion. It provided instrument and camera control, had three robotic arms and a 2D video screen. ...
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Background The field of robotic surgery has seen significant advancements in the past few years and it has been adopted in many large hospitals in the United States and worldwide as a standard for various procedures in recent years. However, the location of many hospitals in urban areas and a lack of surgical expertise in the rural areas could lead to increased travel time and treatment delays for patients in need of robotic surgical management, including cancer patients. The fifth generation (5G) networks have been deployed by various telecom companies in multiple countries worldwide. Our aim is to update the readers about the novel technology and the current scenario of surgical procedures performed using 5G technology. In this article, we also discuss how the technology could aid cancer patients requiring surgical management, the future perspectives, the potential challenges, and the limitations, which would need to overcome prior to widespread real‐life use of the technology for cancer care. Recent findings The expansion of 5G technology has enabled some countries to conduct remote surgical procedures, tele‐mentored and real‐time interactive procedures on animal models, cadavers, and humans, demonstrating that 5G networks could offer a potential solution to previously experienced latency and reliability hurdles during the remote surgeries performed in the 2000s. Conclusion New technological advancements could serve as a ground for emerging novel therapeutic applications. While limitations and challenges related to the 5G infrastructure, cost, compatibility, and security exist; researching to overcome the limitations and comprehend the potential benefits of integrating the technology into practice would be imminent before widespread clinical use. Remote and tele‐mentored 5G‐powered procedures could offer a new tool in improving the care of patients requiring robotic surgical management such as prostate cancer patients.
... However, laparoscopic hysterectomy (LH) has some drawbacks. Robotic hysterectomy (RH) overcomes the disadvantages of laparoscopy because of the three-dimensional view, wide range motion with wristed instruments, and the stability of surgeon's operation [7,8]. Therefore, robotic surgery is likely to become popular but only if its safety and effectiveness are verified. ...
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Objective The aim of this study was to compare the safety and effectiveness of robotic hysterectomy (RH) with conventional laparoscopic hysterectomy (LH) for the treatment of cervical cancer using multivariate regressions. Methods We designed a retrospective single-center study and consecutively collected patients with cervical cancer from February 2014 to October 2017. Data extraction was performed by two independent researchers. The surgical outcomes include operative time, estimated blood loss, number of lymph nodes, time to first flatus, time to a full diet, time to remove drainage tube, length of hospital stay, and postoperative complication. Results A total of 152 patients with cervical cancer were collected in our study including 92 patients who underwent RH and 60 patients who underwent LH. Both groups have similar characteristics. The RH group showed shorter operative time (Coe − 42.89; 95% CI − 74.39 to 11.39; P = 0.008) and more number of lymph nodes (Coe 6.06; 95% CI 2.46–9.66; p = 0.001) than the LH group. As for the postoperative parameters, the RH group showed shorter time to remove drainage tube (Coe − 0.89; 95% CI –1.62 to –0.15; p = 0.019) and length of hospital stay (Coe − 6.40; 95% CI − 10.19 to − 2.95; p = 0.001). No significant difference was found between the groups in estimated blood loss (Coe 34.64; 95% CI − 33.08 to 102.37; p = 0.314), time to first flatus (Coe 0.11; 95% CI − 0.38 to 0.61; p = 0.652), time to a full diet (Coe − 0.24; 95% CI − 0.54 to 0.06, p = 0.118), and postoperative complication (OR 0.84; 95% CI 0.35–1.98; p = 0.685). Conclusion The results from this study suggest that RH is safe and effective as LH but robotic surgery significantly contributed to the feasibility of alternative treatment options for cervical cancer patients.
Since Food and Drug Administration approval in 2005, use of the robotic device in gynecologic surgery has continued to increase. There has been a growing number of applications in various surgical specialties including gynecology, and the surgical robot has been established as an additional surgical tool for performing minimally invasive gynecologic surgery. In this article, the authors review the development of robotic gynecologic surgery, clinical considerations, and future directions.
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This paper presents the modeling and control process of recently developed manipulator with 3 limbs having prismatic-universal-universal (3-PUU) joints. It has 3 degrees of freedom (3-DOF), consisting of 2 rotational DOFs and 1 translational DOF (2R1T). To avoid the computational complexity of solving the manipulator’s kinematics in real-time application, two artificial neural networks (ANNs) are trained to estimate the forward and inverse kinematics solutions. Training and testing results show that the developed ANNs have great prediction capabilities. The manipulator’s dynamic model is deduced using MATLAB Simscape environment. Control schemes are investigated starting with motor control, first using PID controller, and then adding feed-forward control which greatly improved the motors’ response. Closed-loop trajectory control based on Cartesian space feedback of the manipulators’ position and orientation and inverse kinematics ANN is then studied. The closed-loop control scheme can enhance the system’s performance, eliminating the error resulting from any change in the manipulator’s actual model due to manufacturing or assembly defects. Simulation results of a defected manipulator model show that the closed-loop control scheme improved the manipulator’s trajectory tracking capability, reducing the z-axis position error by 89.23% and the orientation error by 86.76% and 82.83% about x-axis and y-axis directions respectively.
Surgical technique is paramount in achieving desirable surgical outcomes. This statement holds true across all surgical disciplines, including plastic, urologic, and gynecologic surgery. Currently, surgical skills acquisition during training in several subspecialties (including plastic surgery and urology) is graded in accordance with the ACGME’s (Accredited Council of Graduate Medical Education) milestone projects. This method of assessment is predicated upon the subjective evaluation of individual observers. Thus, significant potential for observer bias exists in these systems. Furthermore, at most hospitals in the United States, the credentialing process is based upon peer recommendations or case currency. These methods result in a system of assessment that lacks in efficiency, cost-effectiveness, and standardization. The creation of structed tools for the assessment of surgical skill, such as Objective Structured Assessment of Technical Skills (OSATS), provided a framework to produce validated assessments of technical skill. OSATS provided a set of parameters by which many types of surgery could be analyzed on their technical merits. However, while a validated system of assessment, grading a surgeon using systems such as OSATS is often a time-consuming and resource-intensive process – still performed by individual expert surgeons with all the associated costs. As such, these methods have been adopted only within certain subfields where they can be deployed in an efficient manner. Currently, within plastic and reconstructive surgery, few of these methods have been adopted. This chapter presents the current use of a crowd-sourced platform for surgical skills assessment – the Crowd-Sourced Assessment of Technical Skill (CSATS). The platform has successfully been applied to several procedures in both robotic and endoscopic urologic and general surgery. This novel platform of surgical assessment provides a cost-effective, timely, and validated method of surgical skills assessment. While the platform has not been widely adopted within plastic surgery, the authors point to possible opportunities for an analogous system used by plastic surgeons.
Abstract In traditional nasal surgery, surgeons are prone to fatigue and jitter by holding the endoscope for a long‐time. Some complex operations require assistant surgeon to assist with holding the endoscope. To address the above problems, the authors design a remote centre of motion based nasal robot, and propose a voice‐based robot control method. First, through the operation space analysis of nasal surgery, the design scheme of the robot based on RCM mechanism is proposed. On this basis, the design parameters of the robot are analysed to complete the entire design of robot. Then, considering that the surgeon's hands are occupied by surgical instruments during complex surgical operations, a voice‐based robot control method is proposed. This method obtains direction instructions from surgeons by analysing the movement of the endoscopic image. Afterward, a commercial speech recognition interface is used to realise the offline grammar controlwords lib compatible with both Chinese and English, and the overall strategy of robot control is proposed. Finally, an experimental platform for virtual robot control is established, and the voice‐based robot control experiment is performed. The results show that the proposed voice‐based control method is feasible, and it provides guidance for the subsequent development and control of the actual robot system.
Objectives : Some hospitals have invested in robotic surgery platforms to stimulate the uptake of minimally invasive surgery (MIS) and offer its benefits to more patients. The objectives were to determine the clinical and financial effects, as well as the policy implications, of a robotics program in an academic gynecologic oncology division over time. Methods : Patients treated for endometrial, cervical, and ovarian cancer within a gyn-oncology division between 2003 and 2016 were included in the current study. Clinical outcomes were described in function of surgical approach (laparotomy, laparoscopy, and robotic surgery) and tumor site. The net present value and the return on investment of the robotics program were approximated using previously reported treatment costs from our center. Results : The use of MIS soared from a high of 15% to 91% before and after the introduction of robotics in December 2007, respectively. Across all tumor sites, MIS procedures were associated with diminished blood loss and a shorter hospital stay (p<0.0001). The use of robotics in gyn-oncology resulted in cost savings. Conclusions : Robotic surgery was instrumental in catalyzing the shift from open surgery to MIS and amplifying the number of patients who benefited from less invasive surgery. Continued investments in robotics and the digitization of surgery could help further drive innovation and expand its applications.
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Robotlar, bilgisayar tarafından programlanabilen, otomatik olarak karmaşık bir dizi eylem gerçekleştirebilen makineler olarak tanımlanabilir. Robotlar insan for-munu almak için inşa edilebilmektedir ancak robotların çoğu, nasıl göründüklerine bakılmaksızın bir görevi gerçekleştirmek için tasarlanmış makinelerdir. Tıp alanında robotların kullanılmasındaki temel amaç, hassasiyeti arttırarak in-san kaynaklı hataları en aza indirgemektir. Tıbbi robotlar özellikle cerrahi alanlarda kendilerine yer bulmuştur. Bu robotlar, cerrahın kontrolü ile gerekli robot parçaları-nı müdahale edilecek alanlarda hareket ettirmek ve ihtiyaç duyulan müdahaleleri farklı manipülatörler ile gerçekleştirmek için kullanılmaktadır. Ülke genelinde çok yakın süre içerisinde robotlar tıbbi personelin yardımcısı olacaktır. Hastanın nabzını ölçerek, hayati belirtilerini tarayarak, fotoğraf çekerek ve hatta vaka notlarını oku-yarak tanı ve sonrasında da tedavi yapacak hâle gelebilecektir. Sonuç olarak, tıbbi ortamdaki çeşitli rollerde hizmet vermek için çok çeşitli robotlar geliştirilmektedir. İnsan tedavisinde uzmanlaşmış robotlar, cerrahi robotları ve rehabilitasyon robotları bunlara örnektir. İlerleyen bölümlerde cerrahi robotlar başta olmak üzere tıp alanın-da kullanılan robotlar hakkında daha ayrıntılı bilgiler paylaşılacaktır.
Robotic laparoendoscopic single-site (R-LESS) seems to be the next route in advancing minimal invasive surgery, with the potential for better cosmetic results and reduced patient morbidity compared with multi-port surgery. This review describes the history and development of (R-LESS) gynecologic surgery and outlines the latest advancements in the realm of gynecology. The review was conducted according to the PRISMA guidelines. Pubmed and ( were the main search engines utilized for retrieval of study data (1990 – present). The following subject headings and keywords were searched: “robotic laparoscopic single incision”, “robotic laparoendoscopic single site”, “single incision robotic surgery” and “single-port robotic surgery”. All original research articles including randomized, non-randomized controlled trials, cohort studies, patient series, and case reports were included. The search produced a total of 1127 results. After duplicate removal, 452 remained, and each title and abstract was reviewed by 2 reviewers. Subsequently, 56 full texts were selected for full review and an additional 20 excluded, leaving 36 studies that were included in the final review. Based on the data gathered we reached the conclusion that R-LESS surgery is feasible, safe and has equivalent surgical outcomes as conventional LESS surgery; in addition to shorter recovery times, less postoperative pain and better cosmetic outcomes than robotic multi-port surgery. To conclude, R-LESS is a feasible approach with low complication rates, minimal blood loss and postsurgical pain, fast recovery, and virtually scar-free results. However, the lack of large comparative prospective randomized controlled studies prevents drawing absolute conclusions.
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Robotic surgical platforms were first developed with telesurgery in mind. Conceptualized by NASA and the military to provide surgical expertise to remote locations, some telesurgical success has been documented, but progress has been held back by communication bandwidth limitations. Telepresence surgery, where the surgeon is in proximity to the patient but is provided with an ergonomic console equipped with three-dimensional vision and autonomous control of wristed laparoscopic surgical instruments and energy sources, has shown efficacy first in cardiac and then urologic cancer surgery. Interest is currently focused on the application of this technology in the field of gynecology, with techniques being described to perform simple hysterectomy, myomectomy, tubal anastomosis, and pelvic reconstruction procedures. This article will review the application of robotic- and computer-assisted surgery in the specialty of gynecologic oncology.
Objective. To describe the current role of laparoscopy in the clinical practice of gynecologic oncology, and to summarize the most recent published data. Methods. A PubMed search was conducted from 1965 to the present with the following keywords: “laparoscopy”, “gynecology”, “oncology”, “cancer”, “hysterectomy”, “lymphadenectomy”, “ovary”, “cervix”, “endometrial” and “uterus”. Results. Laparoscopy has gained wide acceptance in gynecologic oncology, despite a paucity of data from prospective randomized trials. Retrospective reviews and cohort studies have demonstrated consistent patient benefit in the form of decreased morbidity with equivalent cancer outcomes. Simple and radical hysterectomy have shown to be feasible, as have pelvic and para-aortic lymph node dissection. Conclusion. Laparoscopy is a promising adjunct in the treatment of gynecologic malignancies, and its safety and efficacy as a surgical method have been well documented. However, more prospective data on survival is needed to ensure its widespread acceptance as an equivalent cancer treatment.
Objective: To compare surgical morbidity and clinical-pathologic factors for patients with endometrial cancer (EC) undergoing robotic-assisted laparoscopic hysterectomy (RALH) versus total abdominal hysterectomy (TAH) with aortic and/or pelvic lymphadenectomy (LA). Methods: During the first 14 months of a robotics surgical program, 56 patients with EC were scheduled to undergo RALH with LA. Cases were analyzed for operative (op) time, estimated blood loss (EBL), transfusion, intra- and post-op complications, surgical-pathologic data, patient demographics and length of stay (LOS). Data was compared to 106 serially treated patients with EC who underwent TAH with LA immediately prior to initiation of our robotics program. Results: Three robotic cases (5.4%) were converted to TAH secondary to intra-op factors. FIGO stages for RALH vs. TAH were: stage I (82 vs. 69%), stage II (7 vs. 7.5%) and stage III (11 vs. 21.5%). Patients' mean age was 59+/-10 vs. 63+/-11 years (p=0.05) and body mass index (BMI) was 29+/-6.5 vs. 34+/-9 kg/m(2) (p=0.0001) for the robotic and open groups, respectively. Severe medical co-morbidities affected 5.4% of robotic patients compared to 8.5% of open cases (p>0.05). Comparing RALH and TAH, mean op time was 177+/-55 vs.79+/-17 min (p=0.0001), EBL was 105+/-77 vs. 241+/-115 ml (p<0.0001), transfusion was 0 vs. 8.5% (p=0.005), and LOS was 1.0+/-0.5 vs. 3.2+/-1.0 days (p<0.0001). Robotic patients incurred a 3.6% major peri-operative complication rate while women undergoing open procedures had an incidence of 20.8% (p=0.007). Total lymph node count was 19+/-13 nodes for robotic cases vs. 18+/-10 nodes obtained from open hysterectomy patients. Conclusions: Patients with EC who underwent RALH with LA during the first year of our robotics program were younger, thinner and had less cardio-pulmonary illness than patients previously treated with TAH and LA. LOS, EBL and peri-op complication rates were significantly lower for the robotic cohort.
The purpose of this study was to compare outcomes in women who underwent endometrial cancer staging by different surgical techniques. Three hundred twenty-two women underwent endometrial cancer staging: 138 by laparotomy (TAH); 81 by laparoscopy (TLH) and 103 by robotic technique (TRH). The TRH cohort had a higher body mass index than the TLH cohort (P = .0008). Lymph node yield was highest for TRH (P < .0001); hospital stay (P < .0001) and estimated blood loss (P < .0001) were lowest for this cohort. Operative time was longest for TLH (213.4 minutes) followed by TRH (191.2 minutes) and TAH (146.5 minutes; P < .0001. Postoperative complication rates were lower for TRH, compared with TAH (5.9% vs 29.7%; P < .0001). Conversion rates for the robotic and laparoscopic groups were similar. TRH with staging is feasible and preferable over TAH and may be preferable over TLH in women with endometrial cancer. Further study is necessary to determine long-term oncologic outcomes.
The purpose of this study was to compare robotically assisted hysterectomy (RAH) with open (ORH) type III radical hysterectomy in the treatment of early-stage cervical cancer. The outcomes of 51 consecutive patients who underwent RAH were compared with the outcomes of 49 patients who underwent ORH. There were no differences with regard to patient demographics. There were significant differences between the groups with regard to operative blood loss (P < .0001), operative time (P = .0002), and lymph node retrieval (P = .0003), all of which were in favor of the RAH cohort. All patients with RAH were discharged on postoperative day 1, compared with a 3.2-day average hospitalization for the cohort with ORH. The incidence of postoperative complications was 7.8% and 16.3% for the RAH and ORH cohorts, respectively (P = .35). Robotic type III radical hysterectomy with pelvic node dissection is feasible and may be preferable over open radical hysterectomy in patients with early-stage cervical cancer. Further study will determine procedure generalizability and long-term oncologic outcomes.
Robot-assisted laparoscopic radical prostatectomy (RALP) is an evolving minimally invasive treatment of for localized prostate cancer. We present our experience of 1500 consecutive cases with an analysis of perioperative outcomes. Fifteen hundred consecutive RALPs were performed by a single surgeon (VRP). Following Institutional Review Board approval, clinical coordinators performed prospective intraoperative and postoperative data collection. Functional outcomes were assessed using validated self-administered questionnaires. Mean OR time from skin incision to fascial closure (the time that the surgeon was present) was 105 minutes (55-300). Mean EBL was 111 cc (50-500). Ninety-seven percent of patients were discharged home on postoperative day 1. The overall complication rate was 4.3% with no mortalities. The positive margin rate (PMR) was 9.3% overall. PMR was 4% for pT2, 34% for T3 and 40% for pathologic stage T4. Our initial series represents one of the largest published series for perioperative outcomes of robotic assisted prostatectomy. Our data demonstrates the feasibility, safety and efficacy of the procedure.
Robotic-assisted surgery leverages the advantages of standard laparoscopy while restoring three-dimensional vision, ergonomic, intuitive controls, and wristed instruments that approximate the motion of the human hand. Robotic-assisted surgery has already shown feasibility and in many cases superiority to standard laparoscopy in urology and general and cardiothoracic surgery. The applications of robotic-assisted surgery are rapidly being incorporated into the field of gynecologic oncology.
The removal of prostatic tissue through transurethral resection of the prostate (TURP) is an operation that can require considerable skill from a surgeon as well as being a lengthy procedure. The potential for using robotic techniques was investigated in a preliminary feasibility study using a standard six axis 'Puma' robot. This led to the construction of a manually operated 'safety frame' which has been shown to be effective through clinical trials on 30 patients. A special-purpose robot, based on the design of the manual frame, has now been constructed. Some of the safety issues are discussed which make this procedure an ideal candidate for a robotic device.
The use of a Unimation Puma 200 robot, properly interfaced with a computerized tomographic (CT) scanner and with a probe guide mounted at its end effector for CT-guided brain tumor biopsis is discussed. Once the target is identified on the CT picture, a simple command allows the robot to move to a position such that the end-effector probe guide points toward the target. This results in a procedure faster than one using a manually adjustable frame. Probably the most important advantage, as is shown, is the improved accuracy that can be achieved by proper calibration of the robot.