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Developments in the Fields of Endourology and Minimally Invasive Surgery
practice and combines the well-known advantages of laparoscopic performed by various approaches (for example, interfascial versus
procedures with state-of-the-art robotic technology. The most recent da extrafascial, with or without nerve sparing and pre-peritoneal).
Vinci version provides a four-arm robotic system. During the procedure, Other urological procedures such as radical cystectomy, radical
the surgeon is placed at a console in the operation theatre, away from nephr(o-ureter)ectomy, pyeloplasty, ureteral re-implantations and
the patient. A first assistant is placed at the operation table and re-anastomosing procedures after vasectomy are still performed by a
introduces suture material and other instruments through the port sites. specialised but growing group of physicians. About 400 da Vinci
The surgeon’s hand movements are scaled, filtered and translated into systems are installed worldwide, and there is a growing interest in this
the precise movements of the micro-instruments within the operative device among physicians and patients. Thus, the number of robotic-
site. Its optimised, high-resolution, three-dimensional (3-D) image assisted procedures will continue to grow, and further technical
eliminates the surgeon’s tremor and thus provides an optimised development is underway.
visualisation of vital anatomical structures and facilitates a more precise
surgical procedure. Furthermore, more degrees of freedom allow the Natural Orifice Transluminal Endoscopic Surgery
surgeon to make more intuitive manoeuvres. These features are An exciting new approach in minimally invasive treatment options is
considered to be the main advantages of the da Vinci-assisted procedure natural orifice transluminal endoscopic surgery (NOTES). The technique
compared with ‘conventional’ laparoscopic surgery. arose from gastrointestinal endoscopic procedures (e.g. drainage of a
pancreatic pseudocyst by a transgastric approach), but takes the
instrument beyond the confines of the gastrointestinal tract. It offers the
potential to be safer, less invasive and more cost-effective than a
An exciting new approach in minimally
laparoscopic approach. There is no need for transcutaneous access in this
‘incision-less’ technique. The skills of endoscopists and endoscopic
invasive treatment options is natural
surgeons have to be combined for optimal application. Procedures that
orifice transluminal endoscopic surgery.
have already been performed by NOTES include cholecystectomy,
splenectomy and hysterectomy, which were all performed by a
transgastric approach.
32
One group reported a liver biopsy and, in a
porcine model, even thoracoscopy using a transvesical approach.
33,34
The
In the US, the majority of radical prostatectomies are being performed feasibility of various procedures using this approach has now been
using the da Vinci robot, indicating the high acceptance and rapid approved; however, new instruments and further evidence are needed to
expansion of this technique. Radical prostatectomy is the procedure show that this could be applied for use with humans and, most
most often performed using the da Vinci system, and it can be importantly, that it could offer advantages for patients. ■
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EUROPEAN GENITO-URINARY DISEASE 2007 53
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