Robotic Surgery in Urology: The Golden Choice of Treatment with Scientific Proof

Robotic Surgery in Urology: The Golden Choice of Treatment with Scientific Proof

By Dr. Stavros I. Tyritzis, Surgeon - Urologist of the Center for Minimally Invasive Urological Surgery of Athens Medical Center, Assistant Professor of Urogenetic Oncology and Robotics, University of Karolinska, Sweden and Doctor of Medicine at University of Athens.

 

Robotic surgery in Urology is in its 15th year since the first time it was used in urologic surgery (radical prostatectomy) and is now undergoing a full maturation phase. A surgical approach combining human qualities with technological excellence has succeeded in providing the patient with significant advantages, such as:

  • Zoom x 15
  • Ergonomics
  • Absolute transport of surgical movements
  • Terror filtering
  • Less blood loss
  • Less pain
  • Less hospitalization
  • Less chance of complications, hernia
  • Faster return to activities
  • Better operating results (maintaining consistency, erection)

Robotic surgery is one millimeter precision surgery, causing minimal internal and external trauma. It is not only the large, unsightly, painful cuts of the skin that are avoided, but also the minimization of injury to the internal anatomical structures. This reduces surgical stress, internal inflammation, adhesions and of course blood loss leading to transfusions and possible complications.

But what robotic surgery is still being blamed for by its adversaries, as is the case with any new technique, is its aggressive marketing, numerous advertisements and excessive web promotion, as the means of technique over open surgery.

But if one looks at the big picture coldly and study the scientific facts, one will understand that the superiority of robotics is clear and that is why it is also recommended by all the guidelines of the European and American Urological Society.

On the other hand, given the existing monopoly on robotic surgery (Intuitive Surgical, Sunnyvale CA), it is a given that marketing will be aggressive. However, it is up to us surgeons to prove to our patients this superiority of robotics by honestly updating and using scientific data.

Being a robotic surgeon and active clinical researcher, supporting robotics in debates with foreign and Greek colleagues, participating in important clinical trials and collaborating with the best robotic surgeons in Europe and America, I constantly seek the “truth”, studying the published scientific researches.

This "truth" is evident from our daily surgical experience, but also from published scientific articles that analyze the results from all existing clinical data (systematic analyzes), which provide the highest level of scientific evidence.

Robotic surgery in Urology has many indications (Table 1). Almost all urologic procedures can become robotic today. But that does not mean that everything must be made robotic.

However, robotic oncology indications in particular, namely prostate cancer, kidney cancer and bladder cancer, enjoy significant advantages over the corresponding open interventions.

In summary, the proven scientific advantages over open surgery, published in the best and most reliable foreign language medical journals are:

 

Robotic radical prostatectomy

In the US, over 85% of radical prostatectomies are performed robotically. Robotic radical prostatectomy is the most common robotic urological procedure, with more than 4,500 operations performed in Greece over the past five years, despite the financial crisis.

Robotic radical prostatectomy is:

  • Better blood loss, transfusion rate, hospitalization time, rate of postoperative complications, rate of re-admission or re-intervention, functional outcome (erection, continence), lymphadenectomy (removal of more lymph nodes)
  • Less likely postoperative venous thrombosis after lymphadenectomy
  • It has a comparable oncologic effect (survival, positive surgical margins, relapse)
  • It has similar surgical time

 

Robotic radical cystectomy

Although we have been talking about a technique that is much newer from open surgery by many decades, robotic radical cystectomy has reached and surpassed open cystectomy in just 10 years and after more than 2.000 operations worldwide.

Why?

Robotic radical cystectomy:

  • Is better in blood loss, transfusion rate, hospitalization time, postoperative complication rate, lymphadenectomy (removal of more lymph nodes).
  • It has a comparable oncologic effect (survival, positive surgical margins and relapse).

There are no major studies that give us reliable data on functional outcomes, but evidence from robotics speaks of excellent rates of erection and urinary continence and despite the radicality of the operation.

 

Robotic partial nephrectomy

  • Better blood loss, transfusion rate, hospital stay, postoperative complication rate.
  • Better preservation of postoperative renal function.
  • Better than the conventional laparoscopic approach at the time of ischemia (due to the blockage of blood flow to the kidney, usually necessary during surgery), resulting in less damage to the normal remaining kidney, a lower rate of turning to an open surgery.

Applying my very own scientific opinion, I think that our patient has a lot to gain by choosing the robotic technique. Not so for the best oncologic outcome, but for the less likely postoperative complication, early or late, and the best functional outcome. After all, that is EXACTLY where robotics EXCELS, as a MINIMALLY INVASIVE TECHNIQUE.

It is also no coincidence that many of the best open surgeons became even better after using robotic technology because they learned to appreciate the patient's anatomy better (because of the huge magnification provided by the robotic console) and because they began to apply techniques in the open surgery that were first applied with the robot.

Finally, it should be noted that robotics is the basis for the development and application of new technologies in surgery (FIREFLY ™ imaging, mini-scopes, image-guided surgery, molecular imaging etc.).

In conclusion, robotic surgery is here to stay, deliver better results, reduce our patient morbidity and further improve our technical competence. However, it is absolutely necessary to inform the patient honestly and to describe all aspects of a surgical or non-surgical treatment, as well as to respect the patient's personal desire before making a final treatment decision.

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