Innovations in Urologic Robotic Surgery: Beyond Prostatectomy to Partial Nephrectomy

Points to Remember

• Advanced robotic technologies were first used in urologic surgical procedures in 2000. In 2007, some 63% of prostatectomies were performed robotically.
• A new application for robotic surgery is partial nephrectomy for the removal of renal tumors.
• Robotic surgery offers technical advantages, especially the ease of suturing in the challenging angles of the kidneys.

A robotic workstation console

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State of the Art

Advanced robotic technologies were first used in urologic surgical procedures in 2000 as alternatives to minimally invasive laparoscopic techniques and conventional open surgery. Since then, the advantages of robotic surgery have rapidly fueled its use.

At Mayo Clinic, prostatectomy remains the most frequently performed urologic robotic procedure. For example, physicians at a single Mayo Clinic campus, in Rochester, Minnesota, have 4 robotic devices in clinical use. Mayo Clinic in Jacksonville, Florida, also has a robotic device, and Mayo Clinic in Scottsdale/Phoenix, Arizona, will soon have 2 devices.

The current focus is on refining the robotic partial nephrectomy to treat renal tumors. This procedure has been used experimentally at advanced robotic centers to remove small renal tumors, including complex tumors such as hilar, endophytic, and multiple tumors.

Robotic endoscopic surgical instruments

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About Robotics

During robotic procedures, the surgeon manipulates controls operating instruments from inside a workstation console several feet from the operating table. While looking through binoculars equipped with a high-resolution 3-D stereoscopic imaging system, the surgeon guides the robotic endoscopic instruments docked at the operating table. The controls relay the exact movements of the surgeon's hand and fingers to the instruments and filter out any hand tremor. This sensitivity enhances a surgeon's ability to navigate challenging anatomy, to deftly perform microdissection, and to precisely place sutures.

Robotics yields technical advantages, such as ease of suturing in the challenging angles of the kidneys—an efficiency that is needed to minimize warm ischemia time and preserve organ function. Combined, these attributes translate into more effective and faster surgical procedures when performed by high-volume, experienced practitioners.

Five or six incisions created for ports for cameras and the robotic instrument arms

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Partial Nephrectomy

Demand for robotic partial nephrectomy is driven by both the successes and limitations of its minimally invasive precursor, laparoscopy. Laparoscopy's successes include clinical effectiveness in terms of oncologic outcomes and renal function. Limitations include difficulty achieving swift intracorporeal suturing, needed to reconstruct the organ after tumor dissection when blood flow is disrupted.

Magnification of surgical field

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Swift suturing is key to minimize warm ischemia times, which will preserve organ function. Robotic partial nephrectomy overcomes the limits of laparoscopy while maintaining its minimally invasive strengths. Early results with the robotic partial nephrectomy suggest it is a safe and feasible approach for select patients.

Robotics Advantages

Reduced blood loss is among the most notable advantages of robotic urologic surgery. Nation-wide, data show that from 5% to 15% of patients require transfusions when undergoing traditional open surgeries for prostatectomy. By comparison, less than 1% of patients undergoing robotic prostatectomy in experienced hands require transfusion. Reduced blood loss promotes faster recovery.