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Dibitetto F, Fede Spicchiale C, Castellucci R, Sansalone S, Akhundov A, Defidio L, De Dominicis M. Extraperitoneal robot assisted laparoscopic prostatectomy with Versius system: single centre experience. Prostate Cancer Prostatic Dis 2024:10.1038/s41391-024-00810-6. [PMID: 38491207 DOI: 10.1038/s41391-024-00810-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 02/04/2024] [Accepted: 02/12/2024] [Indexed: 03/18/2024]
Abstract
INTRODUCTION Versius Surgical System (CMR Surgical, Cambridge, UK) is a novel tele-operated robotic surgical system designed to assist surgeons for minimally invasive surgery which is gaining momentum in the world of robotic surgery. We describe our single centre experience with Versius and report the advantages and challenges posed by this new robotic system in a series of 53 extraperitoneal robotic assisted laparoscopic prostatectomies (eRALP) for prostate cancer (PCa). MATERIALS AND METHODS Data of 53 eRALP performed with Versius in our centre were collected and analysed, Descriptive statistics were used to report our results. RESULTS In 16 months we performed 53 eRALP: 18 (34%) with PLND, 33 (62%) nerve sparing cases. Mean setup time was 15 min, mean console time was 100 min and mean operative time was 130 min. We observed a substantial reduction of console time and set-up time after only 5 procedures. In the first 4 procedures, the dissection of the neurovascular bundle was performed laparoscopically, to switch back to robotic assisted approach afterwards. No major system failures were observed. No major intra-operative and post-operative complications occurred. Mean follow-up time was 9 months (range 3-15 months); no patients experienced biochemical recurrence or metastatic progression over this period, 8 (15%) patients had adjuvant radiotherapy based on unfavourable pathology report (positive surgical margins or positive limphnodes). CONCLUSION This represents to our knowledge the largest extraperitoneal RALP case series with Versius, and it aims to provide solid clinical proof of the safety, effectiveness and versatility of this innovative system. In our experience, this platform represents a good option for every urologic surgeon who wants to start a robotic programme and it appears particularly suitable for urologists with a large laparoscopic expertise.
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Affiliation(s)
- F Dibitetto
- Uroclinic, Casa di Cura Nuova Villa Claudia, Rome, Italy
| | - C Fede Spicchiale
- Department of Urology, University Hospital Monklands, NHS Lanarkshire, Airdrie, UK.
| | - R Castellucci
- Uroclinic, Casa di Cura Nuova Villa Claudia, Rome, Italy
| | - S Sansalone
- Uroclinic, Casa di Cura Nuova Villa Claudia, Rome, Italy
| | - A Akhundov
- Uroclinic, Casa di Cura Nuova Villa Claudia, Rome, Italy
| | - L Defidio
- Uroclinic, Casa di Cura Nuova Villa Claudia, Rome, Italy
| | - M De Dominicis
- Uroclinic, Casa di Cura Nuova Villa Claudia, Rome, Italy
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Molle F, Savastano MC, Giannuzzi F, Fossataro C, Brando D, Molle A, Rebecchi MT, Falsini B, Mattei R, Mirisola G, Poretti E, Cestrone V, D'Agostino E, Bassi P, Scambia G, Rizzo S. 3D Da Vinci robotic surgery: is it a risk to the surgeon's eye health? J Robot Surg 2023; 17:1995-2000. [PMID: 37103772 PMCID: PMC10492867 DOI: 10.1007/s11701-023-01604-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 04/16/2023] [Indexed: 04/28/2023]
Abstract
Da Vinci three-dimensional (3D) system has been increasingly used in customary surgical settings, gaining fundamental relevance for abdominal, urological, and gynecological laparoscopic surgery. The aim of this research is to evaluate the degree of discomfort and potential changes in the binocular vision and ocular motility of surgical operators, who employ 3D vision systems during Da Vinci robotic surgery. Twenty-four surgeons were enrolled in the study, including twelve who typically use the 3D Da Vinci system and twelve who routinely employ 2D system. Routine general ophthalmological and orthoptic examinations were conducted at baseline (T0), the day before surgery, and 30 min after the 3D or 2D surgery (T1). In addition, surgeons were interviewed using a questionnaire of 18 symptoms, with each item containing three questions regarding the frequency, severity, and bothersomeness of the symptoms, in order to evaluate the degree of discomfort. Mean age at evaluation was 45.28 ± 8.71 years (range 33-63 years). Cover test, uncover test, and fusional amplitude showed no statistically significant difference. After surgery, no statistical difference was observed in the Da Vinci group on the TNO stereotest (p > 0.9999). However, the difference in the 2D group resulted statistically significant (p = 0.0156). Comparing participants (p 0.0001) and time (T0-T1; p = 0.0137), the difference between the two groups was statistically significant. Surgeons using 2D systems reported more discomfort than those using 3D systems. The absence of short-term consequences following surgery with the Da Vinci 3D system is a promising conclusion, considering the numerous advantages of this technology. Nonetheless, multicenter investigations and more studies are required to verify and interpret our findings.
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Affiliation(s)
- Fernando Molle
- Ophthalmology Unit, "Fondazione Policlinico Universitario A. Gemelli, IRCCS", Largo A. Gemelli, 8, 00168, Rome, Italy
- Catholic University "Sacro Cuore", 00168, Rome, Italy
| | - Maria Cristina Savastano
- Ophthalmology Unit, "Fondazione Policlinico Universitario A. Gemelli, IRCCS", Largo A. Gemelli, 8, 00168, Rome, Italy
- Catholic University "Sacro Cuore", 00168, Rome, Italy
| | - Federico Giannuzzi
- Ophthalmology Unit, "Fondazione Policlinico Universitario A. Gemelli, IRCCS", Largo A. Gemelli, 8, 00168, Rome, Italy.
- Catholic University "Sacro Cuore", 00168, Rome, Italy.
| | - Claudia Fossataro
- Ophthalmology Unit, "Fondazione Policlinico Universitario A. Gemelli, IRCCS", Largo A. Gemelli, 8, 00168, Rome, Italy
- Catholic University "Sacro Cuore", 00168, Rome, Italy
| | - Davide Brando
- Ophthalmology Unit, "Fondazione Policlinico Universitario A. Gemelli, IRCCS", Largo A. Gemelli, 8, 00168, Rome, Italy
- Catholic University "Sacro Cuore", 00168, Rome, Italy
| | - Andrea Molle
- Ophthalmology Unit, "Fondazione Policlinico Universitario A. Gemelli, IRCCS", Largo A. Gemelli, 8, 00168, Rome, Italy
- Catholic University "Sacro Cuore", 00168, Rome, Italy
| | - Maria Teresa Rebecchi
- Ophthalmology Unit, "Fondazione Policlinico Universitario A. Gemelli, IRCCS", Largo A. Gemelli, 8, 00168, Rome, Italy
- Catholic University "Sacro Cuore", 00168, Rome, Italy
| | - Benedetto Falsini
- Ophthalmology Unit, "Fondazione Policlinico Universitario A. Gemelli, IRCCS", Largo A. Gemelli, 8, 00168, Rome, Italy
- Catholic University "Sacro Cuore", 00168, Rome, Italy
| | - Roberta Mattei
- Ophthalmology Unit, "Fondazione Policlinico Universitario A. Gemelli, IRCCS", Largo A. Gemelli, 8, 00168, Rome, Italy
- Catholic University "Sacro Cuore", 00168, Rome, Italy
| | - Giorgia Mirisola
- Ophthalmology Unit, "Fondazione Policlinico Universitario A. Gemelli, IRCCS", Largo A. Gemelli, 8, 00168, Rome, Italy
- Catholic University "Sacro Cuore", 00168, Rome, Italy
| | - Eleonora Poretti
- Ophthalmology Unit, "Fondazione Policlinico Universitario A. Gemelli, IRCCS", Largo A. Gemelli, 8, 00168, Rome, Italy
- Catholic University "Sacro Cuore", 00168, Rome, Italy
| | - Valentina Cestrone
- Ophthalmology Unit, "Fondazione Policlinico Universitario A. Gemelli, IRCCS", Largo A. Gemelli, 8, 00168, Rome, Italy
- Catholic University "Sacro Cuore", 00168, Rome, Italy
| | - Elena D'Agostino
- Ophthalmology Unit, "Fondazione Policlinico Universitario A. Gemelli, IRCCS", Largo A. Gemelli, 8, 00168, Rome, Italy
- Catholic University "Sacro Cuore", 00168, Rome, Italy
| | - Pierfrancesco Bassi
- Catholic University "Sacro Cuore", 00168, Rome, Italy
- Urology Department, Sacro Cuore Catholic University, A. Gemelli University Hospital, 00168, Rome, Italy
| | - Giovanni Scambia
- Catholic University "Sacro Cuore", 00168, Rome, Italy
- Department of Woman, Child, and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, 00168, Rome, Italy
| | - Stanislao Rizzo
- Ophthalmology Unit, "Fondazione Policlinico Universitario A. Gemelli, IRCCS", Largo A. Gemelli, 8, 00168, Rome, Italy
- Catholic University "Sacro Cuore", 00168, Rome, Italy
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Vasdev N, Charlesworth P, Slack M, Adshead J. Preclinical evaluation of the Versius surgical system: A next‐generation surgical robot for use in minimal access prostate surgery. BJUI COMPASS 2023. [DOI: 10.1002/bco2.233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023] Open
Affiliation(s)
- Nikhil Vasdev
- Hertfordshire and Bedfordshire Urological Cancer Centre Lister Hospital Stevenage UK
- School of Life and Medical Sciences University of Hertfordshire Hertfordshire UK
| | | | | | - Jim Adshead
- Hertfordshire and Bedfordshire Urological Cancer Centre Lister Hospital Stevenage UK
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Wilson RR, Hemal A, Liu S, Craven TE, Petrou S, Pathak RA. Influence of Preoperative and Postoperative Factors on Prolonged Length of Stay and Readmission after Minimally Invasive Radical Prostatectomy. J Endourol 2021; 36:327-334. [PMID: 34549603 DOI: 10.1089/end.2021.0571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The mean length of stay (LOS) following minimally invasive radical prostatectomy (MI-RP) is less than 2 days. Our main objective was to utilize the National Surgical Quality Improvement Program Database (NSQIP) to evaluate preoperative factors that may contribute to prolonged hospital stay and readmission. MATERIALS AND METHODS Utilizing the NSQIP database, records for surgery with the Current Procedural Terminology (CPT) code 55866 (prostatectomy) between 2007 and 2017 were evaluated. Chi-square and t-tests were used to assess the effects of preoperative factors on prolonged LOS and rates of hospital readmission within 30 days. Odds ratios, p-values, and confidence intervals were determined using multivariable logistic regression. RESULTS 40,764 patients underwent MI-RP between 2007 and 2017. Of these, 11.7% reported a LOS of more than 2 days, while 3.9% of patients were readmitted to the hospital within 30 days. Preoperative congestive heart failure within 30 days of surgery was shown to be strongly associated with both prolonged LOS (OR = 6.16) and readmission (OR = 3.28). Bleeding requiring transfusion was demonstrated to be the most significant postoperative factor for prolonged LOS (OR= 23.9), while unplanned intubation was shown to be the most significant postoperative factor for readmission (OR=57.1). BMI over 30 was associated with both prolonged LOS and increase in readmission. CONCLUSIONS Upon NSQIP database analysis, cardiopulmonary factors and BMI were demonstrated to have negative impacts on postoperative quality indicators. Patients with comorbidities should be counselled preoperatively concerning their individual risk factors. Mitigation of these factors is important in ensuring optimal outcomes.
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Affiliation(s)
- Robert Ra Wilson
- University of Kentucky College of Medicine, 12252, Surgery, Lexington, Kentucky, United States;
| | - Ashok Hemal
- Wake Forest University School of Medicine, 12279, Urology, Winston-Salem, North Carolina, United States;
| | - Shuo Liu
- Macquarie University Hospital, 150782, Urology, Sydney, New South Wales, Australia;
| | - Timothy E Craven
- Wake Forest University School of Medicine, 12279, Urology, Winston-Salem, North Carolina, United States;
| | - Steven Petrou
- Mayo Clinic Florida, 23389, Department of Urology, Jacksonville, Florida, United States;
| | - Ram A Pathak
- Wake Forest University School of Medicine, 12279, Medical Center BLVD, Winston-Salem, North Carolina, United States, 27101-4135.,Wake Forest University School of Medicine, 12279, Winston-Salem, United States, 27101-4135;
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Tuna MB, Kilavuzoglu AE, Mourmouris P, Argun OB, Doganca T, Obek C, Ozisik O, Kural AR. Impact of Refractive Errors on Da Vinci SI Robotic System. JSLS 2020; 24:JSLS.2020.00031. [PMID: 32831541 PMCID: PMC7434396 DOI: 10.4293/jsls.2020.00031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Objective To investigate the impact of refractive errors on binocular visual acuity while using the Da Vinci SI robotic system console. Methods Eighty volunteers were examined on the Da Vinci SI robotic system console by using a near vision chart. Refractive errors, anisometropia status, and Fly Stereo Acuity Test scores were recorded. Spherical equivalent (SE) were calculated for all volunteers' right and left eyes. Visual acuity was assessed by the logarithm of the minimal angle of resolution (LogMAR) method. Binocular uncorrected and best corrected (with proper contact lens or glasses) LogMAR values of the subjects were recorded. The difference between these values (DiffLogMAR) are affected by different refractive errors. Results In the myopia and/or astigmatism group, uncorrected SE was found to have significant impact on the DiffLogMAR (p < 0.001) and myopia greater than 1.75 diopter had significantly higher DiffLogMAR values (p < 0.05). Subjects with presbyopia had significantly higher DiffLogMAR values (p < 0.01), and we observed positive correlation between presbyopia and DiffLogMAR values (p = 0.33, p < 0.01). The cut off value of presbyopia that correlated the most with DiffLogMAR differences was found to be 1.25 diopter (p < 0.001). In 13 hypermetropic volunteers, we found significant correlation between hypermetropia value and DiffLogMAR (p > 0.7, p < 0.01). The statistical analysis between Fly test and SE revealed a significant impact of presbyopia and hypermetropia to the stereotactic view of the subject (p = -0.734, p < 0.05). Conclusion Surgeons suffering from myopia greater than 1.75 diopter, presbyopia greater than 1.25 diopter (D), and hypermetropia regardless of grade must always perform robotic surgeries with the proper correction.
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Affiliation(s)
| | - Ayse Ebru Kilavuzoglu
- Department of Ophthalmology, Acibadem Mehmet Ali Aydinlar University Medical Faculty
| | - Panogiotis Mourmouris
- 2nd Department of Urology, National and Kapodistrian University of Athens, Sismanoglio Hospital
| | - Omer Burak Argun
- Department of Urology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | | | - Can Obek
- Department of Urology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | | | - Ali Riza Kural
- Department of Urology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
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Thomas BC, Slack M, Hussain M, Barber N, Pradhan A, Dinneen E, Stewart GD. Preclinical Evaluation of the Versius Surgical System, a New Robot-assisted Surgical Device for Use in Minimal Access Renal and Prostate Surgery. Eur Urol Focus 2020; 7:444-452. [PMID: 32169362 DOI: 10.1016/j.euf.2020.01.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/17/2020] [Accepted: 01/28/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Minimal access surgery (MAS) is well-established in urological surgery. However, MAS is technically demanding and associated with a prolonged learning curve. Robot-assisted laparoscopy has made progress in overcoming these challenges. OBJECTIVE The aim of this study was to evaluate the feasibility of a new robot-assisted surgical system (the Versius Surgical System; CMR Surgical, Cambridge, UK) for renal and prostate procedures in a preclinical setting, at the IDEAL-D phase 0. DESIGN, SETTING, AND PARTICIPANTS Cadaveric sessions were conducted to evaluate the ability of the system to complete all surgical steps required for a radical nephrectomy, prostatectomy, and pelvic lymph node dissection. A live animal (porcine) model was also used to assess the surgical device in performing radical nephrectomy safely and effectively. Procedures were performed by experienced renal and prostate surgeons, supported by a full operating room team. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Surgical access and reach were evaluated by the lead surgeon using a visual analogue scale. The precise surgical steps conducted to make the assessment that the procedures could be completed fully were recorded, as well as instruments used (including manual laparoscopic instruments) and endoscope angle. RESULTS AND LIMITATIONS In total, all 24 procedures were completed successfully in cadavers by eight different lead surgeons. Positioning of the ports and bedside units reflected the lead surgeon's preferred laparoscopic set-up and enabled good surgical access and reach, as quantified by a median visual analogue score of ≥6.5. Radical nephrectomies performed in pigs were all completed successfully, with no device- or non-device-related intraoperative complications recorded. Testing in human cadavers and pig models balances the bias introduced by each model; however, it is impossible to completely replicate the experience and performance of the robot for surgery in live humans. CONCLUSIONS This is the first preclinical assessment of the Versius Surgical System for renal and prostate procedures. The safety and effectiveness of the system have been demonstrated and warrant progressive assessment in a clinical setting utilising the IDEAL-D framework. PATIENT SUMMARY In this report, we looked at the usability of a new robot-assisted surgical device for renal and prostate surgery by testing the system in cadavers and pigs. We found that a number of different surgeons and operating team personnel were able to use the system to successfully complete the procedures under evaluation. We conclude that the system is ready to be tested in live human studies.
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Affiliation(s)
- Benjamin C Thomas
- Department of Urology, The Royal Melbourne Hospital, Melbourne, Australia; Australian Medical Robotics Academy, Melbourne, Australia
| | | | - Muddassar Hussain
- Frimley Renal Cancer Centre, Frimley Health NHS Foundation Trust, Surrey, UK
| | - Neil Barber
- Frimley Renal Cancer Centre, Frimley Health NHS Foundation Trust, Surrey, UK
| | - Ashish Pradhan
- Department of Urogynaecology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Eoin Dinneen
- Division of Surgical and Interventional Sciences, University College London, London, UK
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge, UK; Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
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Lone Z, Hussein AA, Jing Z, Elsayed AS, Aldhaam NA, Sniadecki K, Guru KA. Optimizing the Financial Burden of the Approach to Robot-Assisted Radical Prostatectomy. J Endourol 2020; 34:456-460. [PMID: 31973577 DOI: 10.1089/end.2019.0869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objectives: The robot-assisted approach to radical prostatectomy (RARP) has been adopted worldwide as an acceptable alternative to open prostatectomy owing to improved visualization and dexterity for surgeons, with improved recovery and convalescence for patients. However, the associated cost of installation of robot as well as running costs may hamper its utilization. We sought to investigate and identify the drivers of cost at our institution and implement changes that could reduce costs. Methods: We retrospectively reviewed the annual cost data of all RARPs performed by a single surgeon between April 1, 2017 and March 31, 2018. A cost analysis was performed investigating the variable costs associated with RARP: anesthesia related, operative time, and medical supplies. We then prospectively implemented a cost reduction plan that included reducing the number of robotic instruments used per surgery, surgical supplies, and changing the type of trocars. We also investigated whether these changes impacted cost as well as operative outcomes. Results: Forty retrospective procedures were compared with 32 prospective procedures after implementation of cost reduction plan. There were no differences in clinical characteristics. Cost savings per case were $705 for variable costs (95% CI $662, $748, p < 0.01): $36 for anesthesia related (95% CI $5, $67, p = 0.03), $198 for operative time (95% CI $145, $251, p < 0.01), and $471 for medical supplies (95% CI $438, $504, p < 0.01). There was no statistically significant difference in operative time or estimated blood loss between the two groups. Conclusion: Cost reduction plan can reduce total cost associated with RARP without compromising patient safety or operating room efficiency.
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Affiliation(s)
- Zaeem Lone
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA.,Applied Technology Laboratory for Advanced Surgery (ATLAS), Buffalo, New York, USA
| | - Ahmed A Hussein
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA.,Applied Technology Laboratory for Advanced Surgery (ATLAS), Buffalo, New York, USA.,Department of Urology, Cairo University, Cairo, Egypt
| | - Zhe Jing
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA.,Applied Technology Laboratory for Advanced Surgery (ATLAS), Buffalo, New York, USA
| | - Ahmed S Elsayed
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA.,Applied Technology Laboratory for Advanced Surgery (ATLAS), Buffalo, New York, USA.,Department of Urology, Cairo University, Cairo, Egypt
| | - Naif A Aldhaam
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA.,Applied Technology Laboratory for Advanced Surgery (ATLAS), Buffalo, New York, USA
| | - Karen Sniadecki
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Khurshid A Guru
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA.,Applied Technology Laboratory for Advanced Surgery (ATLAS), Buffalo, New York, USA
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Design and Prototyping of Miniaturized Straight Bevel Gears for Biomedical Applications. MACHINES 2019. [DOI: 10.3390/machines7020038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This paper presents a semi-automated design algorithm for computing straight bevel gear involute profiles. The proposed formulation is based on the Tredgold approximation method. It allows the design of a pair of bevel gears with any desired number of teeth and relative axes inclination angles by implementing additive manufacturing technology. A specific case study is discussed to calculate the profiles of two straight bevel gears of a biomedical application. Namely, this paper illustrates the design of the bevel gears for a new laparoscopic robotic system, EasyLap, under development with a grant from POR Calabria 2014–2020 Fesr-Fse. A meshing analysis is carried out to identify potential design errors. Moreover, finite element-based tooth contact analysis is fulfilled for determining the vibrational performances of the conjugate tooth profiles throughout a whole meshing cycle. Simulation results and a built prototype are reported to show the engineering feasibility and effectiveness of the proposed design approach.
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Cheung H, Wang Y, Chang SL, Khandwala Y, Del Giudice F, Chung BI. Adoption of Robot-Assisted Partial Nephrectomies: A Population-Based Analysis of U.S. Surgeons from 2004 to 2013. J Endourol 2017; 31:886-892. [DOI: 10.1089/end.2017.0174] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Hoiwan Cheung
- Department of Pathology, Stanford University School of Medicine, Stanford, California
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Ye Wang
- Division of Urology and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Steven L. Chang
- Division of Urology and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Yash Khandwala
- Department of Urology, Stanford University School of Medicine, Stanford, California
- University of California San Diego School of Medicine, La Jolla, California
| | - Francesco Del Giudice
- Department of Gynecological-Obstetrics Sciences and Urological Sciences, Sapienza Rome University, Policlinico Umberto I, Rome, Italy
| | - Benjamin I. Chung
- Department of Urology, Stanford University School of Medicine, Stanford, California
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Robot-Assisted Laparoscopic Surgery for the Treatment of Urological Malignancy. Indian J Surg Oncol 2017; 8:343-347. [DOI: 10.1007/s13193-016-0582-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 07/11/2016] [Indexed: 11/27/2022] Open
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Jacobs BL, Lai JC, Seelam R, Hanley JM, Wolf JS, Hollenbeck BK, Hollingsworth JM, Dick AW, Setodji CM, Saigal CS. Variation in the Use of Open Pyeloplasty, Minimally Invasive Pyeloplasty, and Endopyelotomy for the Treatment of Ureteropelvic Junction Obstruction in Adults. J Endourol 2017; 31:210-215. [PMID: 27936909 DOI: 10.1089/end.2016.0688] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Ureteropelvic junction obstruction is a common condition that can be treated with open pyeloplasty, minimally invasive pyeloplasty, and endopyelotomy. While all these treatments are effective, the extent to which they are used is unclear. We sought to examine the dissemination of these treatments. PATIENTS AND METHODS Using the MarketScan® database, we identified adults 18 to 64 years old who underwent treatment for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was ureteropelvic junction obstruction treatment (i.e., open pyeloplasty, minimally invasive pyeloplasty, endopyelotomy). We fit a multilevel multinomial logistic regression model accounting for patients nested within providers to examine several factors associated with treatment. RESULTS Rates of minimally invasive pyeloplasty increased 10-fold, while rates of open pyeloplasty decreased by over 40%, and rates of endopyelotomy were relatively stable. Factors associated with receiving an open vs a minimally invasive pyeloplasty were largely similar. Compared with endopyelotomy, patients receiving minimally invasive pyeloplasty were less likely to be older (odds ratio [OR] 0.96; 95% confidence interval [CI], 0.95, 0.97) and live in the south (OR 0.52; 95% CI, 0.33, 0.81) and west regions (OR 0.57; 95% CI 0.33, 0.98) compared with the northeast and were more likely to live in metropolitan statistical areas (OR 1.52; 95% CI 1.08, 2.13). CONCLUSIONS Over this 9-year period, the landscape of ureteropelvic junction obstruction treatment has changed dramatically. Further research is needed to understand why geographic factors were associated with receiving a minimally invasive pyeloplasty or an endopyelotomy.
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Affiliation(s)
- Bruce L Jacobs
- 1 Department of Urology, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Julie C Lai
- 2 RAND Corporation , Santa Monica, California
| | | | | | - J Stuart Wolf
- 3 Dell Medical School of the University of Texas , Austin, Texas
| | - Brent K Hollenbeck
- 4 Department of Urology, Division of Health Services Research, University of Michigan , Ann Arbor, Michigan.,5 Department of Urology, Division of Oncology, University of Michigan , Ann Arbor, Michigan
| | - John M Hollingsworth
- 4 Department of Urology, Division of Health Services Research, University of Michigan , Ann Arbor, Michigan.,6 Department of Urology, Division of Endourology, University of Michigan , Ann Arbor, Michigan
| | | | | | - Christopher S Saigal
- 2 RAND Corporation , Santa Monica, California.,7 Department of Urology, David Geffen School of Medicine, University of California , Los Angeles, California
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Lieberman L, Barod R, Tapper A, Kumar R, Rogers C. Robotic nephrectomy for central renal tumors with intraoperative evaluation of tumor histology. J Robot Surg 2016; 10:261-5. [PMID: 27146858 DOI: 10.1007/s11701-016-0596-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 04/26/2016] [Indexed: 11/30/2022]
Abstract
Patients undergoing nephrectomy for central renal tumors suspicious for renal cell carcinoma (RCC) may carry a small risk of having transitional cell carcinoma (TCC) on final pathology, even in the absence of filling defects or abnormal cytology. We describe outcomes in such patients undergoing robotic nephrectomy for suspected RCC, with intraoperative specimen assessment to guide completion ureterectomy if TCC is present. Between September 2010 and August 2015, ten patients had central renal masses suspicious for RCC, which were not amenable to nephron-sparing surgery. Patients underwent a four-arm robotic nephrectomy technique using a GelPOINT(®) access port. Following hilar ligation, the ureter was divided between adjacent hem-o-lok clips, placed in an endocatch bag, and extracted through the GelPOINT incision for the frozen section analysis. If intraoperative assessment confirmed TCC, a robotic completion ureterectomy and a bladder cuff excision were performed. Of the ten patients with central tumors who underwent robotic nephrectomy for suspected RCC, four (40 %) had TCC on the frozen section analysis and underwent completion ureterectomy. Five patients had RCC, and one patient had an oncocytoma. Mean age was 63.1 years (49-76) and mean tumor size was 4.0 cm (1.9-7.6). Mean operating time was 246 min (135-328). All patients had negative margins. Mean length of stay was 2.5 days. No recurrences were documented at median 8.5 months follow-up. For patients undergoing robotic nephrectomy for central renal tumors, intraoperative specimen evaluation can help determine the need for minimally invasive completion ureterectomy.
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Affiliation(s)
- Leedor Lieberman
- Wayne State University School of Medicine, 540 E. Canfield Rd, Detroit, MI, USA
| | - Ravi Barod
- Vattikuti Urology Institute, Henry Ford Health Systems, 2799 W. Grand Blvd, Detroit, MI, USA
| | - Alex Tapper
- Wayne State University School of Medicine, 540 E. Canfield Rd, Detroit, MI, USA
| | - Ramesh Kumar
- Vattikuti Urology Institute, Henry Ford Health Systems, 2799 W. Grand Blvd, Detroit, MI, USA
| | - Craig Rogers
- Vattikuti Urology Institute, Henry Ford Health Systems, 2799 W. Grand Blvd, Detroit, MI, USA.
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Hamed OH, Gusani NJ, Kimchi ET, Kavic SM. Minimally invasive surgery in gastrointestinal cancer: benefits, challenges, and solutions for underutilization. JSLS 2016; 18:JSLS.2014.00134. [PMID: 25489209 PMCID: PMC4254473 DOI: 10.4293/jsls.2014.00134] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background and Objectives: After the widespread application of minimally invasive surgery for benign diseases and given its proven safety and efficacy, minimally invasive surgery for gastrointestinal cancer has gained substantial attention in the past several years. Despite the large number of publications on the topic and level I evidence to support its use in colon cancer, minimally invasive surgery for most gastrointestinal malignancies is still underused. Methods: We explore some of the challenges that face the fusion of minimally invasive surgery technology in the management of gastrointestinal malignancies and propose solutions that may help increase the utilization in the future. These solutions are based on extensive literature review, observation of current trends and practices in this field, and discussion made with experts in the field. Results: We propose 4 different solutions to increase the use of minimally invasive surgery in the treatment of gastrointestinal malignancies: collaboration between surgical oncologists/hepatopancreatobiliary surgeons and minimally invasive surgeons at the same institution; a single surgeon performing 2 fellowships in surgical oncology/hepatopancreatobiliary surgery and minimally invasive surgery; establishing centers of excellence in minimally invasive gastrointestinal cancer management; and finally, using robotic technology to help with complex laparoscopic skills. Conclusions: Multiple studies have confirmed the utility of minimally invasive surgery techniques in dealing with patients with gastrointestinal malignancies. However, training continues to be the most important challenge that faces the use of minimally invasive surgery in the management of gastrointestinal malignancy; implementation of our proposed solutions may help increase the rate of adoption in the future.
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Affiliation(s)
- Osama H Hamed
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan
| | - Niraj J Gusani
- Department of Surgery, Penn State Cancer Center, Hershey, PA, USA
| | - Eric T Kimchi
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Stephen M Kavic
- Department of Surgery, University of Maryland, Baltimore, MD, USA
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Di Gregorio M, Botnaru A, Bairy L, Lorge F. Passing from open to robotic surgery for dismembered pyeloplasty: a single centre experience. SPRINGERPLUS 2014; 3:580. [PMID: 25332880 PMCID: PMC4201660 DOI: 10.1186/2193-1801-3-580] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Accepted: 09/19/2014] [Indexed: 12/02/2022]
Abstract
BACKGROUND The treatment of symptomatic uretropelvic junction obstruction (UPJO) has evolved towards minimal invasive endourologic and laparoscopic techniques. Robotic assisted laparoscopic pyeloplasty has achieved outcomes comparable to those corresponding to open and laparoscopic techniques. The objective of this work is to demonstrate that the transition between open to robotic surgeries is straightforward. We analysed retrospectively "our initial results" in robotic assisted UPJ reconstruction procedures. Technical and convalescence aspects for 17 reconstructive robotic procedures performed by 2 surgeons in a 5 years period have been evaluated. Success consisted of no postoperative symptoms, no evidence of obstruction on mercaptoacetyltriglycine-3 diuretic renal scan or computed tomography (CT) and non-further treatment. STATISTICS mean ± standard deviation, median and range. FINDINGS From 17 patients who underwent Da Vinci Robot procedure, 15 followed the complete treatment (2 were converted to laparotomy). Two patients had post-operative urine leakage; the stent was changed under sedation without further sequelae. The mean operative time was 189 minutes. The average hospital stay was 4 days. The average follow-up was 25 months. There was only one patient with UPJ stenosis at 6 months and he was treated by balloon dilation. All patients were followed with MAG 3 lasix renal scan, CT or urography. Except the patient with recurrent stenosis, all patients were asymptomatic without objective evidence of obstruction at the present time. CONCLUSIONS Robotic pyeloplasty technique is feasible and gives good results without previous laparoscopic experience.
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Affiliation(s)
- Marcelo Di Gregorio
- />Urology Department, Cliniques universitaires UCL Dinant-Godinne, Université Catholique de Louvain, 1 Av Gaston Thérasse, Yvoir, Belgium
| | - Andrei Botnaru
- />Urology Department, Cliniques universitaires UCL Dinant-Godinne, Université Catholique de Louvain, 1 Av Gaston Thérasse, Yvoir, Belgium
| | - Laurent Bairy
- />Aenesthesia Department, Cliniques universitaires UCL Dinant-Godinne, Université Catholique de Louvain, 1 Av Gaston Thérasse, Yvoir, Belgium
| | - Francis Lorge
- />Urology Department, Cliniques universitaires UCL Dinant-Godinne, Université Catholique de Louvain, 1 Av Gaston Thérasse, Yvoir, Belgium
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15
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Khemees TA, Nasser SM, Abaza R. Clinical pathway after robotic nephroureterectomy: omission of pelvic drain with next-day catheter removal and discharge. Urology 2014; 83:818-23. [PMID: 24529589 DOI: 10.1016/j.urology.2013.10.078] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Revised: 10/14/2013] [Accepted: 10/26/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine the feasibility of applying a postoperative clinical pathway after robotic nephroureterectomy (RNU) targeting safe omission of a pelvic drain and removal of the bladder catheter on the day after surgery with hospital discharge on postoperative day 1 (POD#1). METHODS We reviewed a prospectively collected database of all RNUs performed by a single surgeon (R.A.) since institution of our clinical pathway in 2008 that includes pelvic drain omission, bladder catheter removal the morning after surgery, and discharge on POD#1. Patient demographics, and perioperative and postoperative outcomes were evaluated. Ability to adhere to the pathway and achieving the described parameters and whether any resulting complications occurred were determined. RESULTS RNU was performed in 29 patients with mean age and body mass index of 69 years (50-90 years) and 30 kg/m(2) (19-41 kg/m(2)), respectively. No patient required a pelvic drain, and 2 were discharged with a catheter. All but 2 patients (93%) were discharged on POD#1. Overall, successful pathway application was achieved in 26 of 29 patients (90%) including no drain, catheter removal on the morning after surgery, and discharge on POD#1. No patient developed urine leak or other complications related to early catheter removal. CONCLUSION Our clinical pathway after RNU allows safe omission of a pelvic drain with early discontinuation of the bladder catheter and discharge on the POD#1 in most patients. To our knowledge, similar pathways have not been previously achieved with nephroureterectomy by any approach, but should be considered by surgeons treating urothelial carcinoma of the upper urinary tract.
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Affiliation(s)
- Tariq A Khemees
- Department of Urology, The Ohio State University Wexner Medical Center & James Cancer Hospital, Columbus, OH.
| | - Samiha M Nasser
- Department of Urology, The Ohio State University Wexner Medical Center & James Cancer Hospital, Columbus, OH
| | - Ronney Abaza
- Department of Urology, The Ohio State University Wexner Medical Center & James Cancer Hospital, Columbus, OH
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De Lorenzis E, Palumbo C, Cozzi G, Talso M, Rosso M, Costa B, Gadda F, Rocco B. Robotics in uro-oncologic surgery. Ecancermedicalscience 2013; 7:354. [PMID: 24101943 PMCID: PMC3788173 DOI: 10.3332/ecancer.2013.354] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Indexed: 01/31/2023] Open
Abstract
In urology, the main use for the robotic technique has been in radical prostatectomy for prostate cancer. Robotic surgery for other organs, such as the kidneys and bladder, has been less explored. However, partial nephrectomy or radical nephroureterectomy can be difficult for inexperienced laparoscopic surgeons. The advent of the da Vinci robot, with multijointed endowristed instruments and stereoscopic vision, decreases the technical difficulty of intracorporeal suturing and improves the reconstructive steps. The objective of this article is to offer an overview of all robotic procedures recently developed in the field of urology. We evaluate the feasibility of these procedures and their potential advantages and disadvantages. We also describe perioperative, postoperative, and oncologic outcomes of robot-assisted surgery as well as perform a comparison with open and laparoscopic techniques. Comparative data and an adequate follow-up are needed to demonstrate equivalent oncologic outcomes in comparison with traditional open or laparoscopic procedures.
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Affiliation(s)
- Elisa De Lorenzis
- Department of Specialist Surgical Sciences, University of Milan, Urology Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Cozzi G, Lorenzis ED, Palumbo C, Acquati P, Albo G, Dell'orto P, Grasso A, Rocco B. Robotic prostatectomy: an update on functional and oncologic outcomes. Ecancermedicalscience 2013; 7:355. [PMID: 24101944 PMCID: PMC3788169 DOI: 10.3332/ecancer.2013.355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Indexed: 11/25/2022] Open
Abstract
Since the first procedure performed in 2000, robotic-assisted radical prostatectomy (RARP) has been rapidly gaining increasing acceptance from both urologists and patients. Today, RARP is the dominant treatment option for localised prostate cancer (PCa) in the United States, despite the absence of any prospective randomised trial comparing RARP with other procedures. Robotic systems have been introduced in an attempt to reduce the difficulty involved in performing complex laparoscopic procedures and the related steep learning curve. The recognised advantages of this kind of minimally invasive surgery are three-dimensional (3D) vision, ten-fold magnification, Endowrist technology with seven degrees of freedom, and tremor filtration. In this article, we examine this technique and report its functional (in terms of urinary continence and potency) and oncologic results. We also evaluate the potential advantages of RARP in comparison with open and laparoscopic procedures.
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Affiliation(s)
- Gabriele Cozzi
- Department of Specialist Surgical Sciences, University of Milan, Urology Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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18
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Santoro E, Pansadoro V. Robotic surgery in Italy national survey (2011). Updates Surg 2012; 65:1-9. [DOI: 10.1007/s13304-012-0190-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 11/23/2012] [Indexed: 02/02/2023]
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Goldman RE, Bajo A, MacLachlan LS, Pickens R, Herrell SD, Simaan N. Design and performance evaluation of a minimally invasive telerobotic platform for transurethral surveillance and intervention. IEEE Trans Biomed Eng 2012; 60:918-25. [PMID: 23144027 DOI: 10.1109/tbme.2012.2226031] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Bladder cancer, a significant cause of morbidity and mortality worldwide, presents a unique opportunity for aggressive treatment due to the ease of transurethral accessibility. While the location affords advantages, transurethral resection of bladder tumors can pose a difficult challenge for surgeons encumbered by current instrumentation or difficult anatomic tumor locations. This paper presents the design and evaluation of a telerobotic system for transurethral surveillance and surgical intervention. The implementation seeks to improve current procedures and enable development of new surgical techniques by providing a platform for intravesicular dexterity and integration of novel imaging and interventional instrumentation. The system includes a dexterous continuum robot with access channels for the parallel deployment of multiple visualization and surgical instruments. This paper first presents the clinical conditions imposed by transurethral access and the limitations of the current state-of-the-art instrumentation. Motivated by the clinical requirements, the design considerations for this system are discussed and the prototype system is presented. Telemanipulation evaluation demonstrates submillimetric RMS positioning accuracy and intravesicular dexterity suitable for improving transurethral surveillance and intervention.
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Affiliation(s)
- Roger E Goldman
- College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA.
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21
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Rabah DM, Al-Abdin OZ. The development of robotic surgery in the Middle East. Arab J Urol 2012; 10:10-6. [PMID: 26557999 PMCID: PMC4442898 DOI: 10.1016/j.aju.2011.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2011] [Revised: 12/02/2011] [Accepted: 12/03/2011] [Indexed: 12/03/2022] Open
Abstract
Objectives We provide an overview of the development of robotic surgery in the Middle East since its first introduction in April 2003 in the Kingdom of Saudi Arabia (KSA). Methods We searched MEDLINE using 20 keywords/phrases and identified 44 reports, of which only 15 were relevant. Five of these articles were duplicated when using two different keywords. Therefore, no more than 10 articles were found that were relevant to the scope of this review. Results After completing the MEDLINE search to identify articles related to robotic surgery in the Middle East, we noted that all of the nine case series (Level of evidence 3a) reported took place in the KSA, with no other reported series from other Middle-Eastern countries. To the best of our knowledge, there are no operating robotic surgery systems (da Vinci, Intuitive Surgical, CA, USA) in the Middle East other than in the KSA, Qatar and Egypt. The number of robotic surgery cases and newly adapted robotic procedures is increasing. Two major institutions in the KSA have expanded to robotic-assisted pyeloplasty in all of their cases since January 2005. Conclusion There are 10 da Vinci robots in the KSA, with over 35 trained surgeons, yet very few index cases. The cancer incidence rate, lack of practitioners’ referrals, and demographic age distribution are all factors that contribute significantly to the few index cases reported. By consolidating the robotic surgery procedures in high-volume speciality centres, hospitals can increase their case loads by promoting the multidisciplinary use of the robotic system. Even though growth is relatively slow, we believe that robotic surgery is gaining momentum, and its benefits and innovation will soon be grasped in other countries in the Middle East.
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Affiliation(s)
- Danny M Rabah
- Division of Urology, Department of Surgery, King Saud University, Princess Jouhara Al-Ibrahim Cancer Research Centre, King Khaled University Hospital, PO Box 7805, Riyadh 11472, Kingdom of Saudi Arabia
| | - Osman Zin Al-Abdin
- Division of Urology, Department of Surgery, King Saud University, Princess Jouhara Al-Ibrahim Cancer Research Centre, King Khaled University Hospital, PO Box 7805, Riyadh 11472, Kingdom of Saudi Arabia
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Abstract
• Robotics of the current day have advanced significantly from early computer-aided design/manufacturing systems to modern master-slave robotic systems that replicate the surgeon's exact movements onto robotic instruments in the patient. • Globally >300,000 robotic procedures were completed in 2010, including ≈98,000 robot-assisted radical prostatectomies. • Broadening applications of robotics for urological procedures are being investigated in both adult and paediatric urology. • The use of the current robotic system continues to be further refined. Increasing experience has optimized port placement reducing arm collisions to allow for more expedient surgery. Improved three-dimensional camera magnification provides improved intraoperative identification of structures. • Robotics has probably improved the learning curve of laparoscopic surgery while still maintaining its patient recovery advantages and outcomes. • The future of robotic surgery will take this current platform forward by improving haptic (touch) feedback, improving vision beyond even the magnified eye, improving robot accessibility with a reduction of entry ports and miniaturizing the slave robot. • Here, we focus on the possible advancements that may change the future landscape of robotic surgery.
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Affiliation(s)
- Alexei Wedmid
- Division of Urology, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, PA 19104, USA
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Yates DR, Vaessen C, Roupret M. From Leonardo to da Vinci: the history of robot-assisted surgery in urology. BJU Int 2011; 108:1708-13; discussion 1714. [DOI: 10.1111/j.1464-410x.2011.10576.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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