Urological Surgery •


RALP cannot overcome the difficulties experienced when dealing with obese patients, large prostates, middle lobes or previous prostatic surgery (TURP); and


• the economic burden of RALP is a major concern to the healthcare system.99


Talking about the burden on (European) healthcare systems, one has to look critically at the direct and indirect costs of RALP. A recently published study by Bolenz et al.100


focused on the comparison of


costs associated with RALP, RRP and LRP. Six hundred and forty-three patients who underwent radical prostatectomy between September 2003 and April 2008 were included in the analysis (262 RALP, 220 LRP and 161 RRP). All three groups were similar regarding disease characteristics. Nerve-sparing procedure was reported in 85% of RALP cases, 96% of LRP cases and 90% of RRP procedures (p


1. Guillonneau B, et al., Laparoscopic radical prostatectomy: technical and early oncological assessment of 40 operations, Eur Urol, 1999;36(1):14–20.


2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 76


Shah J, et al., ‘Urobotics’: robots in urology, BJU Int, 2001;88(4):313–20.


Nedas TG, et al., Robotics in urology: an update, Int J Med Robot, 2005;1(2):13–18.


Eichel L, et al., Role of robotics in laparoscopic urologic surgery, Urol Clin North Am, 2004;31(4):781–92.


Challacombe BJ, et al., The history of robotics in urology, World J Urol, 2006;24(2):120–27.


Kwoh YS, et al., A robot with improved absolute positioning accuracy for CT guided stereotactic brain surgery, IEEE Trans Biomed Eng, 1988;35(2):153–60.


Davies BL, et al., A surgeon robot prostatectomy – a laboratory evaluation, J Med Eng Technol, 1989;13(6): 273–7.


Thiel DD, Winfield HN, Robotics in urology: past, present, and future, J Endourol, 2008;22(4):825–30.


Unger SW, et al., AESOP robotic arm, Surg Endosc, 1994;8(9):1131.


Kavoussi LR, et al., Comparison of robotic versus human laparoscopic camera control, J Urol, 1995;154(6):2134–6.


Miyake O, et al., Urological robotic surgery: preliminary experience with the Zeus system, Int J Urol, 2005;12(10): 928–32.


Marescaux J, et al., Transatlantic robot-assisted telesurgery, Nature, 2001;413(6854):379–80.


Himpens J, Leman G, Cadiere GB, Telesurgical laparoscopic cholecystectomy, Surg Endosc, 1998;12(8): 1091.


Kaul S, Menon M, Robotics in laparoscopic urology, Minim Invasive Ther Allied Technol, 2005;14(2):62–70.


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Gregory WT, Nygaard I, Childbirth and pelvic floor disorders, Clin Obstet Gynecol, 2004;47(2):394–403.


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purchase and maintenance of the robot (US$340,000 per year when amortised over a seven-year period), which would result in US$2,698 extra per patient undergoing RALP (results calculated from 126 RALP cases per year).100


Looking at these figures it is quite clear that better evidence for the functional and oncological superiority of RALP over conventional methods is needed to justify the additional costs. Furthermore, it has to be clearly stated that the monopoly of Intuitive Surgical is definitely a drawback in robotic surgery. The lack of any competitor on the market is a very bad thing from an economic perspective. Another major financial issue is the limitation of the use of robotic instruments (usually to 10 procedures).


Conclusion


Robot-assisted surgery has revolutionised the urological world. There is no doubt about the efficacy and safety of robotic procedures nowadays. However, it has to be kept in mind that there are some drawbacks, especially concerning cost. With regard to prostatectomy, it has to be stated very clearly that until now, no publication has proved the superiority of RALP over conventional methods, and therefore there is still a big question mark over this procedure. Current results in the field of robotic surgery are promising and future developments will show whether the robotic revolution will proceed. Last but not least, successful surgeries depend on the competence and experience of the operating surgeon, whether the surgery is performed with robotic assistance, laparoscopically or conventionally (open). n


sacrocolpopexy compared with abdominal sacrocolpopexy, Obstet Gynecol, 2008;112(6):1201–6.


19.


Kho RM, et al., Incidence and characteristics of patients with vaginal cuff dehiscence after robotic procedures, Obstet Gynecol, 2009;114(2 Pt 1):231–5.


Beste TM, et al., Total laparoscopic hysterectomy utilizing a robotic surgical system, JSLS, 2005;9(1):13–15.


Fiorentino RP, et al., Pilot study assessing robotic laparoscopic hysterectomy and patient outcomes, J Minim Invasive Gynecol, 2006;13(1):60–63.


Kho RM, et al., Robotic hysterectomy: technique and initial outcomes, Am J Obstet Gynecol, 2007;197(1):113.


Lenihan JP, et al., What is the learning curve for robot- assisted gynecologic surgery?, J Minim Invasive Gynecol, 2008;15(5):589–94.


Payne TN, Dauterive FR, A comparison of total laparoscopic hysterectomy to robotically assisted hysterectomy: surgical outcomes in a community practice, J Minim Invasive Gynecol, 2008;15(3):286–91.


Hemal AK, et al., Robotic reconstruction for recurrent supratrigonal vesicovaginal fistulas, J Urol, 2008;180(3):981–5.


Hemal AK, et al., Robotic repair of complex vesicouterine fistula with and without hysterectomy, Urol Int, 2009;82(4):411–15.


Menon M, et al., Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion, BJU Int, 2003;92(3):232–6.


Beecken WD, et al., Robotic-assisted laparoscopic radical cystectomy and intra-abdominal formation of an orthotopic ileal neobladder, Eur Urol, 2003;44(3):337–9.


Ng CK, et al., A comparison of postoperative complications in open versus robotic cystectomy, Eur Urol, 2010;57(2):274–81.


Pruthi RS, Wallen EM, Is robotic radical cystectomy an appropriate treatment for bladder cancer? Short-term oncologic and clinical follow-up in 50 consecutive patients, Urology, 2008;72(3):617–20.


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Hubert J, et al., Initial experience with successful totally robotic laparoscopic cystoprostatectomy and ileal conduit construction in tetraplegic patients: report of two cases, J Endourol, 2006;20(2):139–43.


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Pruthi RS, et al., Robotic-assisted laparoscopic intracorporeal urinary diversion, Eur Urol, 2010; in press.


Nunez-Mora C, Garcia-Mediero JM, Cabrera-Castillo PM, Radical laparoscopic salvage prostatectomy: medium-term functional and oncological results, J Endourol, 2009;23(8):1301–5.


Butt ZM, et al., Impact of body mass index on robot- assisted radical cystectomy, JSLS, 2008;12(3):241–5.


Herr H, et al., Standardization of radical cystectomy and pelvic lymph node dissection for bladder cancer: a collaborative group report, J Urol, 2004;171(5):1823–8.


Martin AD, et al., Robot-assisted radical cystectomy: intermediate survival results at a mean follow-up of 25 months, BJU Int, 2010;105(12):1706–9.


Hayn MH, et al., The learning curve of robot-assisted radical cystectomy: results from the international robotic cystectomy consortium, Eur Urol, 2010; in press.


Herr HW, et al., Impact of the number of lymph nodes retrieved on outcome in patients with muscle invasive bladder cancer, J Urol, 2002;167(3):1295–8.


Leissner J, et al., Extended radical lymphadenectomy in patients with urothelial bladder cancer: results of a prospective multicentre study, J Urol, 2004;171(1): 139–44.


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42. 43.


Hautmann RE, The oncologic results of laparoscopic radical cystectomy are not (yet) equivalent to open cystectomy, Curr Opin Urol, 2009;19(5):522–6.


Schumacher MC, et al., Does extended lymphadenectomy preclude laparoscopic or robot- assisted radical cystectomy in advanced bladder cancer?, Curr Opin Urol, 2009;19(5):527–32.


44.


Nix J, et al., Prospective randomised controlled trial of robotic versus open radical cystectomy for bladder cancer: perioperative and pathologic results, Eur Urol, 2010;57(2):196–201.


45.


Richards KA, et al., Robot Assisted Laparoscopic Pelvic Lymphadenectomy at the Time of Radical Cystectomy Rivals That of Open Surgery: Single Institution Report,


EUROPEAN UROLOGICAL REVIEW


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