Case Studies: The Role of Minimally Invasive Robot-Assisted Surgery in Urology

Robotics have been used to perform endoscopic radical prostatectomies since the turn of this century. Also known as telemanipulation devices, the robotic systems allow delicate and precise movement in spaces too tight to accommodate hands. Advances in technology now enable surgeons to use a minimally invasive approach for a multitude of more complex surgeries that previously required a large incision.

“Thanks to recent improvements in robotics technology, even advanced surgeries, including those involving the removal of multiple organs, can now safely be performed with a minimally invasive approach,” says Jayram Krishnan, DO, MBA, a urologist with Cleveland Clinic’s Glickman Urological & Kidney Institute, and a proponent of advancing the use of robotics for minimally invasive urologic surgery.

Because of the expense of the system and the specialized training needed to operate it, robotic-assisted surgery is generally available only in major medical centers and large hospitals. The system consists of four jointed (“wristed”) arms with 7 degrees of freedom. The surgeon manipulates the controls using a processor that filters, scales and relays his or her exact actions, correcting for tremors, and allowing for more precise movement and better range of motion than the human hand.

The arms are controlled from a console, typically in the same room as the patient, although they can be operated remotely. The console allows procedures conducted from a seated position while viewing the target area magnified in 3-D in a single line of sight, unlike in conventional procedures in which the surgeon must stand and continually look away from the surgical area to view a video monitor. A recent development is that all four quadrants can now be operated on without repositioning either the patient or the robot.

Two of Dr. Krishnan’s recent cases are described below.

Case 1

A 62-year-old man presented with high-grade transitional cell carcinoma of the bladder. A year before, he had a left nephrectomy for renal carcinoma, performed with traditional open surgery. His remaining kidney functions poorly, making him dependent on dialysis.

At this time, the patient required resection of the bladder, and because of the risk of future cancer to the prostate and the malfunctioning kidney, he was advised to have them removed at the same time.

The entire procedure was done with a minimally invasive, robotic-assisted procedure through five 1-cm incisions and one larger incision to remove the organs. All three organs could be removed in one piece along with the ureter.

The minimally invasive approach offers major advantages over a traditional open approach. Since there is no need to cut through muscle, recovery time is faster. The patient returned home in two days (compared with one and a half weeks required for open surgery), and he experienced less pain and a faster return to normal activity. Other advantages include less blood loss, risk of infection and scarring.

More than a year later, the patient is doing well and remains cancer-free.

Case 2

A 67-year-old man presented with transitional cell carcinoma of the bladder and ureter in addition to adenocarcinoma of the prostate.

He required removal of the prostate, one-third of the bladder, the distal one-third of the ureter, and the right kidney. Reconstruction was required with ureteral reimplantation on the right side. The entire surgery was performed in a single robotics-assisted, minimally invasive procedure in six hours, about the same time one would expect for a traditional open approach.

Nine months later, the patient is doing well. Follow-up every three months postoperatively with CT and cystoscopy has revealed no evidence of cancer recurrence.

Discussion

Before incorporating the new technology into a surgical practice, Dr. Krishnan emphasizes the need for specialized training in robotic techniques, which he acquired through a fellowship with Cleveland Clinic. He estimates that he has used robotics in about 400 cases over the past three years.

“New advances allow us to constantly push the limits of robotic surgery,” said Dr. Krishnan, who uses a minimally invasive approach for all bladder, prostate, and kidney surgeries whenever feasible and warranted. “It is important for the medical community to be aware of the possibilities of this technology.”