Laparoscopic orthotopic ileal neobladder

Quality of Life Assessment With Orthotopic Ileal Neobladder Reconstruction After Radical Cystectomy: Results From a Prospective Italian Multicenter Observational Study

OBJECTIVE

To assess health-related quality of life (HRQoL) parameters in patients who received radical cystectomy (RC) with ileal orthotopic neobladder (IONB) reconstruction and to identify clinic-pathologic predictors of HRQoL.

PATIENTS AND METHODS

From January 2010 to December 2013, a multicenter, retrospective on 174 RC-IONB patients was carried out. All patients completed the following questionnaires: the European Organization for Research and Treatment of Cancer (EORTC) generic (QLQ-C30) and bladder cancer-specific instruments (QLQ-BLM30) and the IONB-Patient Reported Outcome (IONB-PRO). Univariate and multivariate analyses were computed to identify clinic-pathologic predictors of HRQoL.

RESULTS

Median age was 66 years (range, 31-83), and 91.4% of patients were men. Median follow-up period was 37 months (range, 3-247). The EORTC QLQ-C30 revealed that age >65 years, absence of urinary incontinence, and absence of peripheral vascular disease were independent predictors of deteriorated body image. A follow-up > 36 months and the presence of urinary incontinence were independent predictors of worsened urinary symptoms, whereas the absence of urinary incontinence was an independent predictor of a worsened body image according to EORTC QLQ-BLM30 results. A follow-up >36 months and the absence of urinary incontinence were independent predictors of better functioning in terms of relational life, emotional life, and fatigue as revealed by the IONB-PRO.

CONCLUSION

Age, presence of urinary incontinence, length of follow-up, and comorbidity status may influence postoperative HRQoL and should all be taken into account when counseling RC-IONB patients.

Emerging role of robotics in urology

Robotic assistance is one of the latest additions to the field of laparoscopic surgery. The most commonly used robotic device in Urology is the da Vinci^® system of which over 200 devices are installed worldwide including 3 in India. This robot consists of three or four arms, one of which is used to hold and manipulate the laparoscopic camera while the others are used to manipulate specialized laparoscopic instruments with endowrist^® technology that allows 7 degrees of freedom.

The robot is currently used primarily for radical prostatectomies where complex dissection and reconstruction can be performed in less than 2 hours with excellent outcomes. There is a progressive increase in the number of surgeries being performed by this device which allows laparoscopy naïve surgeons to offer the benefits of minimally invasive surgery to their patients. The other surgeries where this device has been used to benefit are pyeloplasty, cystectomy with urinary diversion, nephrectomy and ureteric re-implant.

The principal drawbacks of the device are the steep cost of machine and disposables. However, the benefits achieved in terms of improved surgical precision, magnified 3 dimensional vision, scaling of movements, remote surgery and as a teaching tools will help the robot establish a definitive place in the urologic armamentarium.

Laparoscopic radical and partial cystectomy

Radical cystectomy remains the standard treatment for muscle invasive organ confined bladder carcinoma. Laparoscopic radical cystoprostatectomy (LRC) is an advanced laparoscopic procedure that places significant demands on the patient and the surgeon alike. It is a prolonged procedure which includes several technical steps and requires highly developed laparoscopic skills including intra-corporeal suturing. Here we review the development of the technique, the indications, complications and outcomes. We also examine the potential benefits of robotic-assisted LRC and explore the indications and technique of laparoscopic partial cystectomy.

Complete ileal neobladder intracorporeal construction with standard sutured technique and novel technology

PURPOSE

We compared the surgical efficacy and efficiency of a completely suture based procedure with a novel entero-urethral anastomosis device and an EndoGIA stapler to create an ileal neobladder.

MATERIALS AND METHODS

Two groups of 7 pigs each were survived for 8 weeks. In group 1 the neobladder was constructed using a U-shaped segment of ileum sealed with the stapler. The entero-urethral anastomosis was created with a novel sutureless anastomosis device. All other procedures were completed with standard intracorporeal suturing techniques. In group 2 animals completely intracorporeal sutured technique was used. Total procedure, and enteroenteric, ileal neobladder, uretero-enteric and entero-urethral anastomosis times were recorded. Cystograms done immediately postoperatively, at 2 weeks and at sacrifice to evaluate the newly constructed system were rated from 0-no leakage to 3-severe leakage.

RESULTS

In group 1 vs 2 the overall procedure, and enteroenteric, ileal neobladder, uretero-enteric and entero-urethral anastomoses were completed in 285.3, 32.3, 58.8, 54.2 and 5.5 vs 350.1, 29.9, 139.1, 58.0 and 46.3 minutes, respectively. In groups 1 and 2 the average postoperative cystogram rating was 0.83 and 1.6, respectively (p = 0.63). At 2 weeks and at sacrifice cystograms showed no extravasation in either group. The overall surgical procedure, pouch creation and entero-urethral anastomosis were statistically briefer in group 1 (p = 0.036, 0.01 and 0.039, respectively). Average survival in groups 1 and 2 was 30 (range 4 to 56) and 41 days (range 1 to 56), respectively (p = 0.36). All animals had voiding complications within 1 week after ureteral and urethral catheters were removed. One neobladder ruptured in group 1.

CONCLUSIONS

Combining stapled ileal neobladder construction and the entero-urethral anastomosis device significantly decreases operative time, pouch creation and urethral anastomoses.

Totally laparoscopic creation of a novel stapled orthotopic neobladder in the porcine model

PURPOSE

Laparoscopic urinary diversion remains difficult and time consuming even when performed by experienced laparoscopists. Here we describe a novel procedure that quickly creates an ileal orthotopic neobladder with an afferent tubular segment using a laparoscopic stapling device.

MATERIALS AND METHODS

Laparoscopic cystectomy and stapled ileal neobladder were performed in five domestic juvenile pigs. Following cystectomy, 30 to 40 cm of terminal ileum was harvested, and ileal continuity restored. The harvested ileum was made into a J configuration, and three to seven laparoscopic staple firings were used to create a spherical pouch with an afferent limb modeled after the Studer-type neobladder. An aperture was created in the dependent portion of the neobladder, and urethral anastomosis was performed using six interrupted absorbable sutures. Ureterointestinal anastomosis was performed using a Wallace technique. Postoperative cystography and intravenous pyelography were performed. A 1-month survival study was completed in one pig.

RESULTS

All five procedures were completed successfully without conversion to open surgery. The majority of the steps of the procedures were performed by second- and third-year urology residents (PGY 3-4). Neobladder stapling, ureterointestinal anastomosis, and the first three urethral sutures were performed by an endourology fellow. Average time for neobladder creation and entire procedure was 78 and 355 minutes, respectively. Postoperative cystography revealed spherical orthotopic neobladder with minimal or no leakage in all animals. Average neobladder capacity was 100 mL, and no obstruction was visualized on intravenous pyelography immediately after the procedures. One pig successfully survived the 1-month study period. There was excellent neobladder storage, no clinically apparent renal obstruction, and no postoperative complications.

CONCLUSIONS

Total laparoscopic urinary diversion and specifically orthotopic neobladder remains one of the frontiers of minimally invasive urologic surgery. Our technique for stapled ileal neobladder provides substantial advantages in terms of the operative time required for orthotopic neobladder reconstruction. This may offer an avenue to foster the development of more feasible techniques for laparoscopic urinary tract reconstructive surgery.

Modified ureterosigmoidostomy (Mainz Pouch II): a nonrefluxing stented vs unstented laparoscopic porcine model

OBJECTIVE

To describe a rapid and reproducible pure laparoscopic cystectomy and nonrefluxing modified continent urinary diversion (Mainz Pouch II), and to determine whether ureteric stenting decreases ureteric obstruction after surgery.

MATERIALS AND METHODS

After institutional review and approval, six female pigs (51-55 kg) had a laparoscopic cystectomy and urinary diversion using a modified Mainz Pouch II. Imbricating bowel over the extra-intestinal ureteric segment created the nonrefluxing mechanism. All pigs had the same bowel preparation before a standard four-port transperitoneal laparoscopic procedure, but three pigs received bilateral J ureteric stents and three did not. Body weights, radiographic imaging, serum electrolytes and renal function were monitored during the 6-week survival period.

RESULTS

One stented pig developed bilateral pyelonephritis, renal obstruction and was killed. Including this pig, four of 12 renal units were obstructed, occurring more often in the stented pigs. There were no significant differences between the serum electrolytes before and after surgery or between the stented or unstented pigs. The surgery was quicker as experience increased. No pig developed hyperchloraemic metabolic acidosis. The nonrefluxing modification appeared to be effective, as reflux was only present in one renal unit.

CONCLUSIONS

Laparoscopic ureterosigmoidostomy, specifically the modified Mainz Pouch II, represents a viable and reasonable continent urinary diversion. The results suggest that there was no benefit in stenting in this pig model.

Modified Ileal Conduit Stoma: Safety of Freeing the Mesenteric Edge of the Distal Part of Ileal Conduits

PURPOSE

An ileal conduit is created in about half of all urinary diversions. Difficulties in constructing an abdominal stoma in morbidly obese patients can be challenging, especially if the patient has a short mesentery. Excessive traction on the mesentery in an attempt to pass the distal segment of ileum through the thick abdominal wall may result in ischemia of the whole segment blood supply. We evaluated the safety of freeing the terminal portion of the conduit from its mesentery to facilitate easy passage of the conduit through the abdominal wall and decrease the incidence of parastomal hernia.

MATERIALS AND METHODS

Five domestic pigs were used for this study. In each subject a 10 cm segment of ileum was isolated to form the ileal loop and bowel continuity was established. A 3 to 4 cm segment of the distal ileal loop was freed from its mesenteric blood supply. This segment of the loop was passed through the appropriate defect in the abdominal wall to the skin and an everted stoma was constructed. Postoperatively the animals were followed for 1 month and then sacrificed. The ileal loop with its mesentery and surrounding skin were harvested en bloc and sent for gross and histological examination.

RESULTS

Mean postoperative time was 30 days (range 29 to 32). No mortality or perioperative complications were recorded. All animals had an uneventful postoperative course until the scheduled time for specimen collection. At harvesting the stoma remained pink in all animals. Gross examination and calibration demonstrated no evidence of narrowing or stenosis. Histological examination revealed no ischemic changes. The mucosa of the entire ileal loop was uniform and healthy.

CONCLUSIONS

Freeing the mesenteric edge of the ileal loop is safe. This finding has an important application for allowing easy construction of an ileal loop or continent cutaneous diversion stoma in morbidly obese patients. This finding is also applicable when constructing terminal ileostomy or colostomy stoma in select patients.

Laparoscopic radical cystectomy: an Italian survey

BACKGROUND

Radical cystectomy with urinary diversion is the current gold standard procedure for muscle-invasive bladder cancer. However, laparoscopic radical cystectomy (LRC) has evolved rapidly worldwide during the past decade, despite its complexity due to both the demolitive step with management of a highly aggressive cancer and the reconstructive step. The authors performed a survey to assess the Italian experience with LRC and urinary diversion in an effort to point out the volume of the procedure in their country, providing some surgical details.

METHODS

A total of 10 Italian urologic departments with experts in laparoscopic urologic surgery were contacted and asked to participate in a two-page survey concerning indications for cystectomy, laparoscopic technique, intra- and postoperative complications, and follow-up evaluation of the procedure when available.

RESULTS

Five sites elected to participate, and a total of 83 LRCs were collected. All centers used five trocar ports. The mean operative time was 8 h and 40 min, and the estimated blood loss was 376 ml. In two cases, the procedure was converted to open surgery. Postoperative complications consisted of one urinary leakage, one fistula, and one atrium rupture. A retrieval sac was used in all cases. Urinary diversions consisted of 43 ileal conduits, 26 orthotopic diversions, and 14 other techniques. The mean follow-up period was 9 months (range, 1-36 months). No tumor seeding was recorded.

CONCLUSIONS

The LRC procedure is feasible although technically demanding. The morbidity of this procedure is evident, but may be reduced with further experience. Bowel management and reconstruction remain the most challenging part of the procedure.

Laparoscopic radical cystoprostatectomy with bilateral nephroureterectomy: initial report

OBJECTIVES

To present our experience with laparoscopic radical cystoprostatectomy and bilateral nephroureterectomy for organ-confined, muscle-invasive transitional cell carcinoma (TCC) of the bladder in two patients with dialysis-dependent end-stage renal disease (ESRD).

PATIENTS AND METHODS

Two men aged 77 and 65 years with organ-confined, muscle-invasive TCC of the urinary bladder and pre-existing dialysis-dependent ESRD underwent laparoscopic bilateral pelvic lymphadenectomy, radical cystoprostatectomy and bilateral nephroureterectomy. Urine spillage was avoided and en bloc urothelial integrity between the bladder and the two renal specimens was maintained throughout the procedure. The intact, entrapped specimens were removed en bloc via a Pfannenstiel incision at the end of the procedure.

RESULTS

The total operative duration was 573 and 660 min, respectively, including repositioning and re-draping between each major step. Blood loss was 350 and 1000 mL, respectively. Both patients tolerated the procedure well and there were no intraoperative complications. The first patient resumed oral intake 3 days after surgery and was discharged home after 5 days. The second patient's course after surgery was complicated by a prolonged adynamic ileus and infection of the catheter placed for continuous ambulatory peritoneal dialysis. He was discharged 28 days after surgery and died from unknown causes at 30 days.

CONCLUSIONS

To our knowledge, this is the first report of radical urotheliectomy, consisting of bilateral pelvic lymph node dissection, radical cystoprostatectomy, and bilateral nephroureterectomy, using entirely intracorporeal laparoscopic techniques.

Laparoscopic Nephroureterectomy with Bladder-Cuff Resection: Techniques and Outcomes

Advancements in minimally invasive instrumentation and technique have provided the impetus to performing urologic procedures with reduced perioperative morbidity, shorter hospital stays, and, most importantly, efficacious oncologic results. At multiple centers of excellence, laparoscopic nephroureterectomy (LNU) has evolved into a new standard for the management of upper-tract transitional-cell carcinoma (TCC) that is not amenable to endoscopic resection. An LNU may be performed via a transperitoneal or retroperitoneal approach together with excision of the distal ureter and a bladder cuff. Analysis of present-day studies comparing LNU with open techniques demonstrates equivalent oncologic outcomes. In addition, those patients undergoing LNU fare better than their counterparts having open surgery with respect to hospital stay, analgesic requirements, and convalescence. With multiple options for excision of a cuff of bladder, a consensus has not been established. However, LNU has emerged as the new standard of care for the treatment of upper- tract TCC. Review of the techniques and outcomes of LNU from the minimally invasive urology community are described.

Laparoscopic radical cystectomy and urinary diversion

Most of the publications regarding laparoscopic radical cystectomy (LRC) have reported the institutions' initial experience focusing on technique and perioperative results. Increasing experience from major medical centers worldwide indicates increasing interest and expertise with LRC. In this manuscript, initial laboratory experience, contemporary series, current controversies, and future directions of the procedure are discussed. Careful prospective evaluations of oncologic and functional outcomes are awaited to define the role of LRC as a viable alternative to open radical cystectomy.

Clinical Experience of Laparoscopic-Assisted Radical Cystectomy with Continent Ileal Reservoir

INTRODUCTION

Laparoscopic-assisted radical cystectomy with continent ileal reservoir reconstruction is a challenging procedure. We report our experience learned from a hand-assisted laparoscopic technique in our transition to a pure laparoscopic approach.

MATERIALS AND METHODS

Eighteen consecutive patients underwent laparoscopic-assisted radical cystectomy with continent ileal reservoir. Hand-assisted laparoscopy was used for the first 11 patients and pure laparoscopy was performed for the subsequent 7 patients in radical cystectomy. Continent ileal reservoir reconstruction was performed extracorporeally via the hand port wound or trocar extension wound. Surgical outcome was analyzed in a retrospective review of the medical records.

RESULTS

In the hand-assisted and pure laparoscopic groups, the mean operative time for cystectomy was 2.5 and 2.3 h, for continent ileal reservoir reconstruction it was 4.0 and 3.7 h, and for bilateral lymph node dissection it was 0.8 and 0.6 h, respectively. Mean intraoperative blood loss was 286 ml for the hand-assisted and 179 ml for the pure laparoscopic group. There were no major intraoperative complications nor need for conversion in any of the procedures. Bowel movement was regained in a mean of 3 days and the mean length of postoperative hospital stay was 7 days.

CONCLUSIONS

The hand-assisted laparoscopic experience of radical cystectomy learned from the initial 11 patients effectively helped us in the transition to a pure laparoscopic approach. A comparable surgical outcome was found in both groups of patients.

Laparoscopic radical cystectomy with continent urinary diversion

Laparoscopic radical cystectomy with urinary diversion, although challenging even for the skilled laparoscopist, has evolved rapidly throughout the past decade. These advances are attributable to a series of well-designed animal studies transitioned carefully to humans. Short-term data have shown that this is a feasible technique that respects the basic principles of surgical oncology. However, the possibility of decreased blood loss, improved visualization, shorter hospital stay, and less postoperative pain are balanced against technical difficulty, long operative times, and unproved long-term efficacy compared with the open gold standard. The goal of this review is to reflect the available literature with regard to surgical indications, the current technique in evolution, short-term morbidity, and oncologic outcomes.

Laparoscopic radical cystectomy with urinary diversion

PURPOSE OF REVIEW

The laparoscopic approach in urology is now an accepted option for kidney, adrenal, and prostate surgery. We review the current experience with laparoscopic radical cystectomy to identify its role in oncological bladder surgery.

RECENT FINDINGS

Pure laparoscopic techniques are being employed for the extirpative portion of laparoscopic radical cystectomy at multiple institutions. Various extracorporeal and intracorporeal techniques are evolving for the reconstructive procedures necessary for urinary diversion. Worldwide experience continues to accumulate with over 150 cases already having been performed.

SUMMARY

With the gradual growth and experience in laparoscopic radical cystectomy, along with continuing refinements in technique, laparoscopic radical cystectomy is now being performed at many centers worldwide. Long-term oncological and functional outcome data are necessary to determine its proper role for patients with bladder cancer.

Simplified laparoscopic radical cystectomy with orthotopic ileal neobladder creation in a porcine model

BACKGROUND AND PURPOSE

Laparoscopic radical cystectomy with orthotopic ileal neobladder creation is a technically challenging and lengthy surgical procedure. We present our experience with a simplified technique for laparoscopic cystectomy and neobladder creation in the porcine model.

MATERIALS AND METHODS

Ten female minipigs underwent a purely laparoscopic radical cystectomy with orthotopic ileal neobladder creation. Nine ureterointestinal anastomoses were performed using a simplified "dunk" technique, where the ureter was prolapsed 5 mm into the afferent limb and the periureteral tissue was secured to the bowel serosa with three superficial sutures. Six ureters were not stented, and three had indwelling stents inserted. In 11 ureters, the anastomosis was performed using a running mucosa-to-mucosa technique (three with stents, eight without stents). The Lapra-Ty suture clip (Ethicon Endosurgery, Cincinnati, OH) was used to secure the running sutures on the urethra, ureters, and neobladder. Animals were harvested at 3 to 8 weeks (mean 6.5 weeks) after surgery. Serology, static cystogram, intravenous urography, and gross and histopathologic evaluations were performed.

RESULTS

Of six unstented dunked ureterointestinal anastomoses, two (33%) were widely patent, two were strictured but patent, and two were completely obstructed. In the three stented ureters implanted using the dunk technique, one (33%) was widely patent, one was strictured, and one was completely obstructed. All ureterointestinal anastomoses performed with a mucosa-to-mucosa running anastomosis, whether stented (three ureters) or not stented (eight ureters), were widely patent. Lapra-Ty clip migration into the neobladder pouch caused urethral obstruction resulting in delayed bladder perforation in two animals.

CONCLUSIONS

Laparoscopic cystectomy and ileal neobladder creation is technically feasible. Attempts to simplify the ureterointestinal anastomosis require further evaluation and modification. Stent placement appears to be unnecessary in the laparoscopic ureterointestinal anastomosis. Laparoscopic creation of the ileal neobladder remains a technically challenging procedure.

A Combined Technique for Radical Cystoprostatectomy and Orthotopic Ileal Neobladder

After anatomical and surgical studies on cadavers we developed a combined technique for radical cystoprostatectomy with orthotopic ileal neobladder labelled M.I. La. N. (Minimally Invasive Laparoscopic Neobladder). The aim of this technique is to combine the advantages of open and laparoscopic surgery. Between June 2001 and July 2002, 6 men aged 65 to 72 underwent combined radical cystoprostatectomy with orthotopic ileal neobladder for organ-confined bladder cancer.

The M.I. La.N. consists of 3 steps: 1) laparoscopic radical cystoprostatectomy and bilateral pelvic lymph node dissection; 2) external partial fashioning of the neobladder and side-to-side bowel anastomosis; 3) laparoscopic lower urinary tract reconstruction.

The mean time of the overall procedure was 425 minutes (range 360 to 510). Mean estimated blood loss was 312 mL (range 220 to 440). Mean hospital stay was 8.1 days (range 7 to 9). Histopathology revealed 1 pT1N0 G3 plus carcinoma in situ (Cis), 1 pT2aN0 G3 plus Cis, 4 pT2bN0 G2-3. The surgical margins were tumor free. At the time of analysis (October 2003) the mean follow-up is 18.1 months (range 15 to 21). Two patients respectively stage pT1N0 + Cis and pT2bN0 G2-3 died for metastatic disease at 20 and 18 months after the operation. One patient stage pT2aN0 plus Cis died for unrelated causes free from disease after 16 months from the procedure. The remaining 3 patients are alive and free from disease. The combined technique for radical cystoprostatectomy with orthotopic ileal neobladder (“M.I. La. N.”) can reproduce open surgery. Moreover, it provides an anatomic approach, familiar to most urologist and anatomical landmarks are easy to follow. In our opinion, the combined approach does not reduce the advantages of laparoscopy. We know that this technique may require a long learning curve and it is still a pioneristic procedure. A strict follow up is necessary to evaluate the oncological outcome that is still unpredictable for the low number of treated patients and for biology of bladder cancer.

Minimally invasive laparoscopic neobladder

PURPOSE

To our knowledge orthotopic reconstruction after laparoscopic radical cystectomy has not been described in the human. After anatomical and surgical studies on cadavers we developed an original technique and performed the first laparoscopic radical cystectomy with pelvic lymphadenectomy and ileal orthotopic neobladder reconstruction in a patient.

MATERIALS AND METHODS

Our technique has 3 steps, namely laparoscopic pelvic clearance, external reconstruction and laparoscopic reconstruction. After cystoprostatectomy and lymphadenectomy were completed via laparoscopy we removed the surgical specimens through a 5 cm. supraumbilical incision. Through the same incision an ileal loop was extracted from the abdominal cavity, isolated, detubularized and partially reconfigured. Intestinal continuity was restored extracorporeally. All intestinal loops were inserted back into the abdomen and pneumoperitoneum was started again. The ureteroileal (nipple valve) and urethroileal anastomoses were formed via laparoscopy and the neobladder was then completed with an intracorporeal running suture.

RESULTS

Operative time was 450 minutes and blood loss was 350 ml. Postoperatively pain was minimal. The patient was ambulatory, regained bowel activity on postoperative day 2 and began food intake 2 days later. He was discharged home on postoperative day 7 with an indwelling catheter, which was removed after 7 days. Histopathological examination showed organ confined bladder cancer without margin invasion.

CONCLUSIONS

To our knowledge we report the first case of laparoscopic radical cystectomy with ileal orthotopic reconstruction. This original technique combines the advantages of minimally invasive laparoscopy with the speed and safety of open surgery.

Laparoscopic radical cystectomy with urinary diversion: completely intracorporeal technique

Laparoscopic radical cystectomy with urinary diversion performed using intracorporeal techniques exclusively is a new development in the growing field of minimally invasive urology. This report details step by step the completely intracorporeal laparoscopic technique of cystectomy, bilateral pelvic lymphadenectomy, and urinary diversion with creation of an ileal conduit or neobladder, including the isolation of ileum, restoration of bowel continuity, retroperitoneal transfer of the left ureter to the right side, bilateral stented ureteroileal anastomoses, and urethroileal anastomosis in case of orthotopic diversion. Although at present, this is still a technique in development at high-volume medical centers, it holds promise as a minimally invasive yet appropriately radical form of treatment for patients with muscle-invasive bladder cancer. Definition of its true role awaits greater experience and long-term comparisons of the outcomes with those of traditional open surgery.

Laparoscopic surgery in urological pelvic cancer

Laparoscopy has become more widely used in urological practice, both for upper and lower urinary tracts. Improvements in instrumentation, and in surgeons' skills and experience have broadened the applications of laparoscopy. In particular, indications for laparoscopy in urological pelvic oncology have emerged as possible but still theoretical alternatives to conventional surgery. The development of the laparoscopic approach is still under close evaluation. Beyond these 'conventional' forms of laparoscopy, potential technical applications of computer assistance provide a glimpse of what could become the surgery of tomorrow.