Robotic surgery

Since its introduction robotic surgery has been used in various procedures and its indications are, even now, continue to expand. Some examples include:

• Cardiothoracic surgery. Robotic technology has been used for mediastinal pathologies, pulmonary pathologies, complex esophageal surgery, coronary arterial bypass, mitral valve repair etc.
• Head and neck surgery. Robots have been used for operations including oncological cases like tonsil and laryngeal cancer as well as benign conditions like chronic tonsilitis.
• General surgery. Procedures like bowel resections, pancreatic and hepatic surgery, gastrectomy and procedures to treat gastroesophageal reflux are now commonly performed with the aid of robotic systems.
• Gynecological surgery. Robotic surgery can be used to treat fibroids, endometriosis, ovarian tumors and female cancers.
• Urological surgery. Urology has been, perhaps the surgical specialty that has taken advantage of robotic surgery more than anyone else. Since the first robotic radical prostatectomy in 2000, robotic-assisted technology has completely changed our practice in the field of major oncologic surgery first, and subsequently complex reconstructive procedures and transplant surgery. Today the vast majority of Urologic oncological surgery in advanced countries are performed robotically due to its intrinsic advantages for the patients. Some examples of robotic operations are: 

1. Radical prostatectomy for prostate cancer
2. Simple prostatectomy for benign prostatic enlargement
3. Reconstruction of the bladder neck in cases of strictures
4. Bladder diverticulectomy
5. Radical cystectomy and urinary diversion for bladder cancer
6. Ureteral reconstruction and reimplantation
7. Prolapse surgery
8. Radical and partial nephrectomy for renal cancer
9. Radical nephroureterectomy
10. Donor nephrectomy and kidney transplantation
11. Pelvic and retroperitoneal lymph node dissection for various cancers like testicular, penile etc

The question, though, patients always ask their surgeons is why they should have a robotic operation instead of a traditional open or laparoscopic and which are the advantages. In this matter the answer is quite straightforward as robotic surgery offers:

• Reduced post-surgery pain. Robotic surgery allows less tissue damage due to the increased precision when handling tissues and less stress put on the abdominal wall when the arms are moving.
• Less blood loss. This results from the accuracy the robot offers as well as the high-definition 3D imaging it offers, making tissue identification, handling and dissection much safer.
• Increased precision. This, can be said, is the core of robotic technology advantages. The robotic instruments are designed after the human wrist, and the technology is called EndoWrist offering a greater range of motion than the human hand, making even difficult or impossible maneuvers during open or laparoscopic surgery easy and allowing rapid and precise suturing, dissection and tissue manipulation. Also, with highly magnified 3D high-definition vision and true depth perception, the surgeon can see the anatomy clearly, identify structures and stay oriented. With magnification being 10-15 times, we can visualize very small details beyond the ability of the naked eye.
• Faster recovery. Increased precision means less pain and complications. This is one of the reasons why robotic surgery is nowadays the standard approach for very complex surgery like oncological and reconstructive procedures.
• Shorter hospital stays. It’s fair to say that even operations for which the patient had to stay in the hospital for many days when an open or laparoscopic procedure was performed, nowadays require a 1–2-day hospitalization or the patient can even go home on the same day.
• Less risk of infection. Smaller incisions and less tissue damage result in lowering the overall risk of postoperative surgical site infections. This comes with a great benefit for the patient and health systems as it reduces antibiotic use and therefore resistant bacteria.

No other surgery has benefited most by robotic technology than radical prostatectomy. The indication for this procedure is for localized or some cases of locally advanced prostate cancer. It is also used for salvage prostatectomy when other modes of treatment have failed. At the same time removal of the pelvic lymph nodes can be performed whenever indicated.

The use of the robotic system in those cases allows very accurate dissection of tissues in a very small space with excellent visibility in an otherwise hard to reach and see space. This combination is unique to robotic surgery as both open and laparoscopic surgery cannot offer both of those due to poor visibility of the open approach and reduced freedom of motion of the instruments in the laparoscopic one. As a result, there are certain benefits for the patient in terms of oncological and functional results as we can reduce the chance of leaving cancer cells behind but at the same time, we can spare the nerves responsible for erection and avoid injuring the sphincteric mechanism, avoiding incontinence.

There are different robotic techniques described depending on the approach we use to remove the prostate including the classic anterior that replicates the open approach and the hybrid anterior-posterior that allows early release from the prostate of the nerves responsible for erection. Great interest has been raised the last decade for the so called Retzius sparing approach that avoids entering the space anterior to the prostate. Each one has its advantages and disadvantages and the decision as to which one will be used depends on the configuration of the prostate, its size, the location and extent of the cancer, previous treatments for prostate cancer, any previous operations in the abdomen and the patient’s medical history. Therefore, a detailed discussion with the surgeon must be done before the operation to explore what is best for the patient.

One special case of radical prostatectomy is when previous treatment for prostate cancer has been given either in the form of external radiotherapy, brachytherapy of focal therapy. That is the so-called salvage prostatectomy that poses certain challenges for the surgeon and puts the patent in higher risk of complications due to fibrosis and poor healing of the area.

In our practice we offer the full range of radical prostatectomy options as well as salvage prostatectomy for recurrent prostate cancer following previous treatment. Patients, if eligible, have also the option to have their operation as a day case and safely go home at the same day because of our carefully designed protocol that allows faster recovery. Every other case has a 1–2-night stay depending on whether they had a lymph node removal or not.

As stated, robotic simple prostatectomy is indicated in cases where the patient has severe urinary symptoms due to an enlarged prostate. Its difference with radical prostatectomy is that we only remove the adenoma responsible for the symptoms and leave the capsule of the prostate intact. It is mainly an alternative to TURIS and HOLEP procedures, especially for very large glands, or when other procedures need to be done at the same time such as removal of a bladder diverticulum.
The whole concept of robotic simple prostatectomy or adenomectomy replicates the traditional open approach which has been largely abandoned, with the main differences being the significantly reduced blood loss, shorter catheterization time and faster recovery. Our practice performs this procedure whenever indicated after exploring all the alternative options like TURIS and HOLEP.

Bladder neck strictures following resection of an enlarged prostate can be very challenging to treat with frequent recurrences and severe impact on the quality of life of the patient. Traditionally they are managed endoscopically with various outcomes. Open reconstruction is extremely challenging in those cases due to the narrow space and poor visibility whereas laparoscopy cannot offer the precision for this type of reconstructive surgery.

Robotic surgery has been now used for more than a decade mainly in cases where everything else failed with excellent outcomes. It involves a plastic reconstruction of the stenotic area using the healthy surrounding tissues.

We have significant experience in this type of surgery and we offer it as one of the options for cases of bladder neck strictures.

Bladder diverticula are pouches that develop in the wall of the bladder because of chronic obstruction from an enlarged prostate or other urethral pathologies or from dysfunction of the bladder secondary to neurologic diseases. Traditionally removal of diverticula was performed with an open surgery and later with laparoscopy. Robotic surgery is applied to the management of this pathology with superior results compared to the other techniques. It can be performed as an isolated surgery or more usually in combination with another procedure such as simple prostatectomy or reconstruction of the bladder neck.

Our practice has shifted from open removal of bladder diverticula to robotic assisted operations due to the superior results and the shorter recovery time for the patient.

Radical cystectomy refers to the removal of the urinary bladder and the pelvic lymph nodes due to bladder cancer. At the same time the prostate and seminal vesicles are removed in men and the uterus with or without the ovaries and part of the vagina in women. There are also cases where the bladder must be removed for other reasons like chronic pelvic sepsis secondary to a non-functional bladder, non-functional bladder after pelvic radiotherapy, total pelvic exenteration for recurrent cervical cancer etc.

Following removal of the bladder, urine must be diverted to either a neobladder or an ileal conduit so that they can exit the body in a safe way. A neobladder refers to making a new urinary bladder, usually at the same anatomic location as the native bladder whereas the ileal conduit is a type of urinary diversion that ends up directly to skin via a urostomy. Both types are constructed using in most of the cases the small bowel. Each one has its unique advantages and disadvantages as well as potential complications and therefore a thorough discussion is necessary with the surgeon before the operation to clarify for which type of diversion someone is suitable for and make a consent decision.

In those cases robotic surgery with the combination of increased accuracy, the ability to perform fine movements and exceptional visibility allows superior oncological and functional results as we are able to spare the nerves responsible for sexual function, if indicated ,in both males and females, something that is almost impossible in open surgery and perform the urinary diversion ,which is a highly complex step requiring very neat suturing ,with extreme precision ,thus lowering potential complications.

Due to its high complexity, robotic radical cystectomy, must be performed by trained surgeons with experience in major oncologic pelvic surgery. Given that radical cystectomy is considered a highly complex procedure even when minimally invasive techniques are used, it is necessary for the patient to stay in the hospital for 4-7 days.

We offer to our patients robotic radical cystectomy, salvage radical cystectomy following failed previous treatments for bladder cancer, simple cystectomy for functional issues as well as pelvic exenterative surgery for advanced or recurrent pelvic cancers.

Ureteral pathologies that cause obstruction can have a significant impact in the wellbeing of the patient and can be the cause of kidney failure, infections, stones etc. They are usually secondary to trauma, inflammatory conditions like bowel diverticulitis, endometriosis and radiotherapy or they can be congenital with the most typical example being the ureteropelvic junction obstruction syndrome.

In this condition the junction between the kidney and the ureter does not allow free passage of urine resulting in dilatation of the kidney. This can be managed by removing the part of the ureter that cause this problem and restoring its continuity by suturing the two edges together, an operation called pyeloplasty. Reconstructive ureteral surgery has benefited from robotic surgery due the ability it gives to the surgeon to perform very precise dissection and suturing, thus reducing the rate of complications and need for further surgery.

We perform whenever necessary all types of ureteral reconstructive surgery according to the patient’s problem.

Pelvic organ prolapse is one of the leading causes of sexual function impairment in otherwise healthy women causing significant disturbance in their quality of life.

Symptoms of POP can vary but often include a visible bulge or lump in or protruding from the vagina, discomfort or numbness during sex, and urinary problems such as a persistent feeling of a full bladder, increased frequency of urination, or leakage when coughing, sneezing, or exercising.

The surgical management of this condition is done by restoring the normal anatomy by placing a mesh either through the vagina or through the abdominal cavity. The first approach is becoming less and less popular due to its higher risk of complications like mesh erosion to the vagina or bladder, infections and higher failure rates. The contemporary approach to this condition is placement of the mesh through the abdominal cavity with an operation called sacrocolpopexy.

Robotic surgery allows accurate identification of the anatomy, which in those cases is significantly altered, precise dissection and placement of the mesh, avoiding problems with recurrences, injuries to the vagina, bladder and rectum, infections and chronic pain. Patients also benefit from shorter hospital stay, which is usually 1 night and earlier return to their daily activities.

Given the superior results of the robotic sacrocolpopexy, which is now the preferred approach in all high volume Uro-gynecology clinics around the world, we have abandoned the traditional transvaginal surgery in favor of the transabdominal robotic approach.

Renal cancer is one of the commonest urological cancers and its main treatment when localized to the kidney is surgical removal of the whole organ for large masses or removal of only the tumor for smaller ones, leaving the healthy kidney undisturbed.

Open surgery had been the mainstay of treatment for many decades but with the advent of laparoscopy this has changed, and minimally invasive techniques are now the preferred approach. Radical nephrectomy refers to removal of the entire kidney along with the tissues surrounding it and sometimes the regional lymph nodes and is indicated in cases where the tumor is large, and preservation of the organ is not feasible.

Laparoscopic and robotic techniques can be employed with equal results unless there is a very large mass, over 20 cm, in which cases an open approach is favored. The real advantage, though, of robotic surgery comes to when a small tumor has to be removed and partial nephrectomy is indicated. In those patients following the removal of the mass the remaining defect must be restored by placing sutures that bring the cut edges of the organ together. This is a time-sensitive step that along with the excision of the mass has to be completed in less than 30 minutes to avoid permanent injury and failure of the kidney. Here, decisive and precise movements are necessary to avoid losing time, and robotic technology with the increased freedom of motion of the robotic arms allows us to complete this crucial step in time, minimizing any potential complications even in circumstances where more than one tumor must be removed.

Furthermore the use of high end robotic ultrasound probes allow the surgeon to perform real time imaging of the lesions and accurately delineate their edges ,minimizing the risk of incomplete cancer removal. Given the advantages of minimally invasive techniques we offer to our patients the ability to treat their problem with the most advanced and safe techniques available.

This procedure is used when the kidney, along with the entire ureter must be removed due to cancer of the renal collecting system. Sometimes the regional lymph nodes are removed as well. The main problem is those cases is the very wide surgical field which is inaccessible from only one incision and indeed in open surgery two or occasionally a single incision, usually over 30 cm long where necessary to complete the operation.

Contemporary robotic technology due to its flexibility offers the advantage of accessing the entire surgical field using only a few small incisions measuring 1 cm each and therefore allowing shorter hospital stay, faster recovery of the patient and with its intrinsic superiority in precision and visibility, better oncological outcomes.

Hence, we employ minimal invasive robotic technology to offer our patients the highest standards of care.

One of the newest indications for urologic robotic surgery is its use in kidney transplantation. With many available studies in the last few years, it has shown its effectiveness in this special type of surgery as well as its excellent outcomes.

Transplant surgery is coordinated from a dedicated team including surgeons, nephrologists, nurses, social workers, psychologists etc. and is offered only from accredited centers.

Malignant conditions of the testis or penis require sometimes further treatment on top of tumor removal. This is usually in the form of lymph node removal in the area around the big vessels like the aorta for testicular tumors or the pelvic area for tumors of the penis.

Robotic surgery has made those procedures much more accurate, reducing the potential complications like nerve or vessel injury and providing superior oncologic outcomes.

Given the rarity of those cases it is advisable to be done by dedicated teams that have experience and perform a high volume of those procedures.