Page 20 - Swsthya Winter Edition Vol 1 Issu 3 DEC 2020 Circulation copy BP

SURGERY

(C) Medtronics approach (26)
Medtronics Hugo RAS (Robotic assisted surgery) is still
awaited to be launched in market. Key features claimed by Partial nephrectomy
Medtronics about this system are flexibility and universal
13)
use for both key hole and open surgeries ( ; apart from this Partial nephrectomy is the surgical modality of choice for
(27)
an open console with the autofocusing monitor. The robotic small renal masses . This procedure involves renal artery
arms are comparable to human arms having of seven joints clamping; hence, time is a crucial factor in the procedure
with serial kinematics. Robotic arms are driven by micro- to minimise the warm ischemia time. Traditional open
motors, with option of tactile feedback via potentiometers approach is more morbid because of large incision and
(9)
can have longer hospital stays and delayed recovery and
problem with the laparoscopic approach is longer warm
Radical prostatectomy ischemia. Robotic surgery is an ideal answer to mitigate
these challenges with a shorter artery clamping time and
(28, 29)
This is a well-known procedure for the treatment of localised early recovery . In fact, the learning curve for the
prostate cancer and the number of surgical procedures is robotic approach is significantly lower than its counterpart

increasing because of increasing diagnosis of prostate cancer (15–25cases compared with 100–150 for laparoscopic) (30) .
thanks to improved awareness and widespread availability
of screening tests. Although, laparoscopic procedures Several modifications have been proposed for robotic partial
have overcome the morbidity associated with the open nephrectomy such as safely omitting cortical renorrhaphy
(31)
procedures, the primary limitation was the limited spaces . Similarly, a new technique using a dye named
in pelvis which leads to difficulties in performing vesico- Indocyanine green (ICG) is a potential aid to robotic partial
urethral anastomosis. Introduction of robotics has overcome nephrectomy as it helps in real-time identification of renal
(32)
the problems associated with restricted manoeuvrability. mass, renal vasculature and tumour margin . By this it can
help in minimizing the ischemia time by allowing selective
With 3D perception and jointed laparoscopic instruments clamping. Some provided evidence that it can be beneficial
(33)
giving 7 degrees of articulation, the da Vinci framework in improved perioperative and oncological outcomes . It
gave the ideal combination of the magnified advantages and can be an adjunct especially in difficult cases with impaired
(34)
minimally invasive feature of laparoscopy with the dexterity renal function or challenging vascularization .
(14)
of an open surgery . The robotic radical prostatectomy
is now a widely accepted and well established surgical Interestingly, the increased cost of the robotic approach
procedure of choice and emerging as a frontrunner for is counter-balanced by the reduced hospitalisation and
(15, 16) (35)
radical prostatectomy in well-resourced nations . complication rates .
Undeniably, the main benefit is a shorter learning curve
(17) Radical cystectomy
compared with laparoscopy is a boon to surgeons .
The technique of robotic prostatectomy has undergone Radical cystectomy and urinary diversion with pelvic lymph
significant improvisation to accomplish superior oncological node dissection is the standard of care for muscle-invasive
and functional results with a better understanding of the and high-risk superficial bladder cancer. Traditionally,
(18)
neurovascular anatomy . Various studies have shown open surgeries remains a highly morbid procedure with a
the benefits of preservation of neurovascular bundle on delayed recovery. Menon et al reported the initial series of
(36)
improved post-operative erectile and orgasmic function nerve spare robotic radical cystectomy in 2003 . Since
(19)
. Gulfano et al has proposed the new technique of then, there are a number of studies have been published on
robotic radical prostatectomy approach named as Retzius- robotic cystectomy but still level 1 evidence confirming the
sparing robotic radical prostatectomy which has recently superiority over conventional approach remains unproven
(20) (37,38,39)
gained popularity . In the Retzius (posterior) approach, . The current evidence states that although the robotic
continence and erectile function can be recovered early; approach achieves better results in terms of blood loss
however, higher positive surgical margin is the main concern and hospital stay, oncological outcomes and good quality
(20, 21)
with the posterior approach . lymphadenectomy are equivalent only as compared to open
(40)
counterpart
Apart from this, several other modifications has been
proposed for robotic prostatectomy to achieve early Although in the initial series of robotic approach,
continence which have been eased by robotic system extracorporeal approach was used for the urinary diversion,
namely- bladder neck preservation/reconstruction, modern surgeries involve the intra-corporeal approach with
(36, 41)
preservation of urethral length, peri-urethral suspension and an equivalent outcome .
reconstruction, pubo-prostatic ligaments preservation and
(22) . Despite this, Level Robot-assisted pyeloplasty
limited endopelvic-fasica dissection
1 evidence comparing robotics surgery and laparoscopic/
open surgeries has been limited. Asimakopoulos etal has The open dismembered pyeloplasty has been the standard
compared laparoscopic and robotic prostatectomy and of care for pelvi-ureteric junction obstruction, with a high
(42)
reported significantly better erectile function recovery success rate (>90 %) . Minimally invasive alternatives
in the robotic arm but no difference in perioperative and have been tried to reduce the morbidity associated with open
(23)
continence outcomes . approach such as balloon dilatation and endopyelotomy but
(43)
success rates of only 60-70% . Laparoscopic pyeloplasy
Follow-up studies also shown similar results in these arms has been proven as a standard treatment for pelvi-ureteric
with some superiority of robotic arm, however, still a robust junction obstruction with less morbidity and good outcome.
(24, 25)
randomised study is required for level 1 evidences . Robotic technique has also been tried for that but the
Although controversial, some studies claim that risk of outcomes were statistically similar as with the laparoscopic
positive surgical margin is less after robotic assisted approach although the learning curve is much shorter with
(44)
radical prostatectomy as compared to laparoscopic or open the robotic technique .
20 Volume: 1 I Issue: 3 I 2020