Hemal / Menon Robotics in Genitourinary Surgery

1. Auflage 2011
ISBN: 978-1-84882-114-9
Verlag: Springer
Format: PDF
Kopierschutz: 1 - PDF Watermark

E-Book, Englisch, 685 Seiten

Robotics in Genito-Urinary Surgery fills the void of information on robotic urological surgery; a topic that is currently highly in demand and continuously increasing. This book provides detailed information on the utility of robotic urological surgery and how to use it most effectively.  Robotics in Genito-Urinary Surgery comprehensively covers specialist areas such as female urology, pelvic floor reconstructions and holds a strong focus on pediatric urology. It also presents the main operative techniques through the use of high quality images and drawings. Compiled by expert authors from the USA, Europe and Asia, this book provides an international perspective on the basic knowledge and clinical management required for the optimal care of patients.

Ashok K. Hemal, MS, DipNB, MCh, MAMS, FICS, FACS, FAMS, FRCS (Glasg): Professor, Department of Urology, Director, Robotics and Minimally Invasive Surgery, Wake Forest University School of Medicine, Wake Forest University Health Sciences, Medical Center Boulevard, Winston-Salem, NC. Dr Hemal has also contributed to several robotic programs worldwide.Dr. Mani Menon, MD: the Director of Vattikuti Urology Institute, Chairman of Urology at the Henry Ford Health System in Detroit is a well known figure in urologic academia for many years. He is widely published and renowned for his impeccable literary style. As the pioneer of robotic radical prostatectomy - did the first major study to compare open and robotic prostatectomies, published in the BJU Ints in 2003 - he has performed the largest number of such surgeries and has published his impressive results in the Journal of Urology and BJU Intl. He has also organized international workshops on robotic urology and made many presentations on this topic.

Autoren/Hrsg.

Menon, Mani

Hemal, Ashok Kumar

Inhaltsverzeichnis

1;Preface;5
2;Contents;7
3;Contributors;12
4;Part I History, Basics, and Development of Program;19
4.1;1 The History of Robotic Surgery;20
4.1.1;1.1 Introduction;20
4.1.2;1.2 History of Robotics;21
4.1.3;1.3 Western Robotics;21
4.1.4;1.4 Eastern Robotics;24
4.1.5;1.5 Engineering Modern Robots;26
4.1.5.1;1.5.1 From Greek Myths to Reality;26
4.1.5.2;1.5.2 World's Fair Robots;28
4.1.5.3;1.5.3 The Legacy of Raymond C. Goertz;29
4.1.5.4;1.5.4 The University of Robotics;30
4.1.5.5;1.5.5 Out of the Laboratory;31
4.1.6;1.6 Surgical Robotics;32
4.1.6.1;1.6.1 Complete Robotic Surgery;33
4.1.6.2;1.6.2 Microrobotic Surgery;35
4.1.6.3;1.6.3 Autonomous Microrobotic Surgery;35
4.1.6.4;1.6.4 Nano-robotic Surgery;35
4.1.7;1.7 HumanRobot Interface (Cyborgs);35
4.1.8;1.8 Future Considerations (Nanotechnology);37
4.1.9;1.9 Conclusions;38
4.1.10;References;39
4.2;2 Robotic Instrumentation and Operating Room Setup;42
4.2.1;2.1 Robotic Instrumentation;42
4.2.1.1;2.1.1 da Vinci® Surgical System;42
4.2.1.1.1;2.1.1.1 Surgeon Console;42
4.2.1.1.2;2.1.1.2 Patient Cart;45
4.2.1.1.3;2.1.1.3 Vision Cart;46
4.2.1.1.4;2.1.1.4 EndoWrist® Instruments;48
4.2.2;2.2 Surgical Team;48
4.2.3;2.3 Operating Room Setup;49
4.2.4;2.4 Robotic-Assisted Surgery;49
4.2.4.1;2.4.1 Patient Cart Docking;51
4.2.4.2;2.4.2 System Shutdown;52
4.2.5;2.5 Conclusions;52
4.2.6;References;52
4.3;3 Port Placement in Robotic Urologic Surgery;54
4.3.1;3.1 Introduction;54
4.3.2;3.2 General Principles of Port Placement;54
4.3.2.1;3.2.1 Establishing Pneumoperitoneum and Primary Access;55
4.3.2.2;3.2.2 Types of Trocars Used for Robotic Surgery Port Placement;57
4.3.2.3;3.2.3 Port Placement Troubleshooting;57
4.3.3;3.3 Robotic-Assisted Laparoscopic Radical Prostatectomy (RALP);58
4.3.3.1;3.3.1 Port Site Closure;59
4.3.4;3.4 Robotic-Assisted Radical Cystectomy (RARC) and Urinary Diversion;60
4.3.5;3.5 Robotic-Assisted Renal Procedures;61
4.3.5.1;3.5.1 Robotic-Assisted Radical Nephrectomy (RARN) and Partial Nephrectomy;61
4.3.5.2;3.5.2 Robotic-Assisted Pyeloplasty and Pyelolithotomy;64
4.3.6;3.6 Robotic-Assisted Laparoscopic Sacrocolpopexy (RALSC);65
4.3.7;References;66
4.4;4 Achieving Efficiency in the Operating Room: Step by Step;67
4.4.1;4.1 Introduction;67
4.4.1.1;4.1.1 Efficiency Improves Quality, Revenue, and Success;67
4.4.1.1.1;4.1.1.1 Quality;67
4.4.1.1.2;4.1.1.2 Revenue;67
4.4.1.1.3;4.1.1.3 Success;68
4.4.2;4.2 Operating Room Efficiency Defined;68
4.4.3;4.3 Myths and Realities of Operating Room Efficiency;68
4.4.3.1;4.3.1 Myth #1: You Need More Manpower to Increase Efficiency;68
4.4.3.1.1;4.3.1.1 Reality #1;68
4.4.3.2;4.3.2 Myth #2: You Need More Instrument Sets to Improve Your Efficiency;68
4.4.3.2.1;4.3.2.1 Reality #2;69
4.4.3.3;4.3.3 Myth #3: Our Room Turnover Times Are as Good as It Gets;69
4.4.3.3.1;4.3.3.1 Reality #3;69
4.4.4;4.4 Efficiency Theory and Implementation;69
4.4.4.1;4.4.1 The Big Picture;69
4.4.4.1.1;4.4.1.1 External Activities;69
4.4.4.1.2;4.4.1.2 Internal Activities;69
4.4.4.1.3;4.4.1.3 Convert Internal to External Tasks;69
4.4.4.1.4;4.4.1.4 Create Task Overlap;69
4.4.5;4.5 The Operating Room Efficiency Model;70
4.4.5.1;4.5.1 Implementing This Operating Room Efficiency Model;75
4.4.5.2;4.5.2 Everyone Must Play an Active Role;76
4.4.5.3;4.5.3 You Need a Coach;77
4.4.6;4.6 Conclusion;78
4.5;5 Laparoscopy vs. Robotics: Ergonomics – Does It Matter?;79
4.5.1;5.1 Introduction;79
4.5.1.1;5.1.1 Limitations of Laparoscopy;80
4.5.1.2;5.1.2 Mental Stress;80
4.5.1.3;5.1.3 Physical Stress;81
4.5.1.4;5.1.4 The Role of Questionnaires;82
4.5.1.5;5.1.5 Geometrical Compensation;82
4.5.1.6;5.1.6 Technological Compensation;84
4.5.1.7;5.1.7 Telemanipulators;84
4.5.1.8;5.1.8 Telepresence Surgery;85
4.5.1.9;5.1.9 The Surgeon's Console;85
4.5.1.10;5.1.10 The Surgical Arm Unit;86
4.5.1.11;5.1.11 The 3D Imaging System;87
4.5.1.12;5.1.12 Ergonomic Advantages of the da Vinci System;87
4.5.1.13;5.1.13 Ergonomic Disadvantages;87
4.5.1.14;5.1.14 Comparative Studies on Ergonomics of Laparoscopy and Robotics;88
4.5.1.15;5.1.15 The Impact of the Type of Procedure;88
4.5.2;5.2 Discussion;89
4.5.2.1;5.2.1 Interpretation of Magnified Anatomy;89
4.5.2.2;5.2.2 Lack of Tactile Feedback;90
4.5.2.3;5.2.3 Coordinated Interaction Between Surgeon and Assistants;90
4.5.2.4;5.2.4 Prerequisites for a Successful Operation;90
4.5.2.5;5.2.5 Perspectives;91
4.5.3;5.3 Conclusions;93
4.5.4;References;93
4.6;6 Anesthetic Considerations for Robotic Urologic Surgery;95
4.6.1;6.1 Introduction;95
4.6.2;6.2 The Anesthetic Implications of Pneumoperitoneum and Positioning;95
4.6.2.1;6.2.1 Inflation Gas;95
4.6.2.2;6.2.2 Intra-abdominal Pressure;96
4.6.2.3;6.2.3 Cerebral, Ocular, Facial, and Laryngeal Effects;96
4.6.2.4;6.2.4 Cardiovascular Effects;96
4.6.2.4.1;6.2.4.1 Background;96
4.6.2.4.2;6.2.4.2 Hemodynamic Changes;98
4.6.2.4.3;6.2.4.3 Special Considerations with Cardiac Disease;98
4.6.2.5;6.2.5 Pulmonary Effects;98
4.6.2.5.1;6.2.5.1 Lung Volumes;98
4.6.2.5.2;6.2.5.2 Hypercarbia and Hypoxia;98
4.6.2.5.3;6.2.5.3 Ventilation Strategies;99
4.6.2.6;6.2.6 Lower Limb Circulation;99
4.6.3;6.3 Special Monitoring Issues;99
4.6.3.1;6.3.1 Routine Monitoring;99
4.6.3.2;6.3.2 Peripheral Nerve Stimulation;99
4.6.3.3;6.3.3 Hydrostatic Gradients, Blood Pressure, and CVP;100
4.6.3.4;6.3.4 Pulse Oximetry;100
4.6.3.5;6.3.5 Capnography and Pulmonary Function;101
4.6.3.6;6.3.6 Renal Function;101
4.6.4;6.4 Pre-anesthesia Assessment ;101
4.6.5;6.5 Special Anesthesia Concerns;102
4.6.5.1;6.5.1 Airway Management;102
4.6.5.2;6.5.2 Neuromuscular Blockade;102
4.6.5.3;6.5.3 Anesthetic Maintenance Drugs;102
4.6.5.4;6.5.4 Fluid Management;103
4.6.5.5;6.5.5 Complications;103
4.6.6;6.6 The Specific Conduct of Anesthesia;104
4.6.6.1;6.6.1 Reported Methods;104
4.6.6.2;6.6.2 Local Anesthetics;104
4.6.6.3;6.6.3 Neuraxial Blockade;105
4.6.6.3.1;6.6.3.1 Epidural Supplementation;105
4.6.6.3.2;6.6.3.2 Neuraxial Alone;105
4.6.6.3.3;6.6.3.3 Subarachnoid Supplementation;105
4.6.6.3.4;6.6.3.4 Extended Release Epidural Morphine (EREM);106
4.6.6.4;6.6.4 Pharmacologic Multimodal Analgesia;106
4.6.6.5;6.6.5 Promotility and Antiemesis;107
4.6.6.6;6.6.6 Author's Preferences for Anesthetic Management;107
4.6.6.7;References;108
4.7;7 The Development of a Robotic Urology Program in the UK;112
4.7.1;7.1 History of Robotic Urology in the UK;112
4.7.2;7.2 Establishing a Robotics Program Within an NHS Foundation Trust Hospital;113
4.7.2.1;7.2.1 The Decision to Start a Robotics Program in the UK;113
4.7.2.2;7.2.2 Financing a Robotics Program;113
4.7.2.3;7.2.3 Establishing a Robotics Team;114
4.7.2.4;7.2.4 Training the First Robotics Team;115
4.7.2.5;7.2.5 The First Cases: A Mentor-Guided Approach;116
4.7.3;7.3 Current Practice of RALP Within an NHS Foundation Trust Hospital: Development and Training;117
4.7.3.1;7.3.1 Refining the Operative Technique;117
4.7.3.2;7.3.2 Perioperative Management;118
4.7.3.3;7.3.3 Results and Learning Curves: A Personal Experience;119
4.7.3.4;7.3.4 Training the Next Generation;121
4.7.4;7.4 The Difficulties of Developing a Robotics Program Within the NHS, and the Future. . .;122
4.7.4.1;7.4.1 Funding Robotic Surgery in the NHS;123
4.7.4.2;7.4.2 The Future of Robotic Urology in the UK;123
4.7.5;References;124
4.8;8 Robotic Urologic Surgery: How to Make an Effective Robotic Program;125
4.8.1;8.1 Introduction;125
4.8.2;8.2 Market and Cost Analysis;125
4.8.3;8.3 Cost and Performance of a Urological Robotics Program;126
4.8.4;8.4 Initial Purchasing and Maintenance Costs;128
4.8.5;8.5 Robotic Surgical Procedures Currently Offered;128
4.8.6;8.6 Facility Planning;128
4.8.6.1;8.6.1 Operating Room Requirements;128
4.8.6.2;8.6.2 The Robotics Team;129
4.8.6.3;8.6.3 Necessary Equipment;129
4.8.6.4;8.6.4 Training Programs;129
4.8.7;8.7 Research and Outcomes;130
4.8.8;8.8 Establishing a Plan of Action – Is Robotics Program Sustainable at Your Institution;130
4.8.9;References;130
4.9;9 Witnessing the Transition of Open to Robotic Surgery;132
4.9.1;9.1 Introduction;132
4.9.2;9.2 A History of Robotic Technology;132
4.9.3;9.3 Robotic-Assisted Laparoscopic Radical Prostatectomy;133
4.9.3.1;9.3.1 RAP: The Learning Curve;134
4.9.3.2;9.3.2 RAP: Positive Margins and Oncologic Outcomes;134
4.9.3.3;9.3.3 RAP: Functional Outcomes;135
4.9.3.4;9.3.4 RAP: Conclusions;136
4.9.4;9.4 Robotic-Assisted Laparoscopic Pyeloplasty;136
4.9.5;9.5 Robotic-Assisted Laparoscopic Partial Nephrectomy;137
4.9.6;9.6 Robotic-Assisted Laparoscopic Radical Cystectomy;138
4.9.7;9.7 Expanding Application and the Future of Robotics in Urology;138
4.9.8;9.8 Conclusions;140
4.9.9;References;140
4.10;10 Patient-Side Surgeons: The Unsung Heroes of Robotic Surgery;143
4.10.1;10.1 Introduction;143
4.10.2;10.2 Importance of the Assistant;143
4.10.3;10.3 Requirements of the Assistant;143
4.10.3.1;10.3.1 Patient Positioning, Gaining Access, and Port Placement;144
4.10.3.2;10.3.2 Principles of Docking, Sweet Spot, and Burping;145
4.10.3.3;10.3.3 Being Comfortable;145
4.10.4;10.4 Basic Rules and Principles During the Operation;146
4.10.5;10.5 Urgent and Emergent Scenarios;147
4.10.6;10.6 Troubleshooting;147
4.10.7;10.7 Summary;147
4.10.8;References;149
5;Part II Training and Research;150
5.1;11 Training in Robotic Urologic Surgery;151
5.1.1;11.1 Introduction;151
5.1.2;11.2 Learning Curve for Robotic Surgery;151
5.1.3;11.3 Robotic Training for Residents;152
5.1.4;11.4 Robotic Training in Fellowship;153
5.1.5;11.5 Postgraduate Courses;153
5.1.6;11.6 Postgraduate Mini-Fellowship;154
5.1.7;11.7 Simulators;154
5.1.8;11.8 Conclusion;155
5.1.9;References;155
5.2;12 Animal Laboratory Training: Current Status and How Essential Is It?;157
5.2.1;12.1 Introduction;157
5.2.2;12.2 Inanimate Models;158
5.2.3;12.3 Animate Models;158
5.2.4;12.4 Human Cadavers;160
5.2.5;12.5 Virtual Reality Simulators;161
5.2.6;12.6 Standard Robotic Training Curriculum;161
5.2.7;12.7 Experimental Study;161
5.2.8;12.8 Conclusion;164
5.2.9;References;165
5.3;13 Training of Operating Room Technician and Nurses in Robotic Surgery;167
5.3.1;13.1 Introduction;167
5.3.2;13.2 Role of the Nurse and Technician;167
5.3.3;13.3 The Dedicated Operating Room Team;169
5.3.4;13.4 Robotic Room Preparation;170
5.3.5;13.5 Robotic Assistants;171
5.3.6;13.6 Conclusion;172
5.3.7;References;172
5.4;14 Impact of Virtual Reality Simulators in Training of Robotic Surgery;173
5.4.1;14.1 Overview of Simulation;173
5.4.2;14.2 Reliability and Validation;174
5.4.3;14.3 Overview of Current Virtual Reality Robotic Simulators;174
5.4.4;14.4 Mimic dV-Trainer;174
5.4.5;14.5 Surgical SIM Robotic Surgery Simulator;175
5.4.6;14.6 RoSS System;176
5.4.7;14.7 Incorporation of Virtual Reality Simulation in the Robotic Surgical Curriculum;176
5.4.8;14.8 Future Directions;177
5.4.9;References;178
5.5;15 Training, Credentialing, and Hospital Privileging for Robotic Urological Surgery;179
5.5.1;15.1 Introduction;179
5.5.2;15.2 Measuring the Robotic "Learning Curve" and Its Impact on Patient Care;180
5.5.3;15.3 Current Status of Robotic Urological Surgery Credentialing;181
5.5.4;15.4 Current Status of Robotic Urological Surgery Training;184
5.5.4.1;15.4.1 Residency and Fellowship;184
5.5.4.2;15.4.2 Mini-Residency Training;185
5.5.4.3;15.4.3 Simulators;185
5.5.4.4;15.4.4 Proctoring and Preceptoring;187
5.5.5;15.5 Remote Presence Proctoring;188
5.5.6;15.6 Credentialing and Privileging in Other Surgical Specialities;188
5.5.7;15.7 Conclusions and Current Recommendations;189
5.5.8;References;190
5.6;16 Research in Urologic Oncology in an Era of Minimally Invasive Surgery;192
5.6.1;16.1 Introduction;192
5.6.2;16.2 The Surgeon Scientist;192
5.6.3;16.3 Challenges;192
5.6.4;16.4 Corrective Action;194
5.6.5;16.5 Conclusion;196
5.6.6;References;196
5.7;17 Databases and Data Management for Robotic Surgery;198
5.7.1;17.1 Motivation;198
5.7.2;17.2 Form Design;198
5.7.3;17.3 Selection of Variables;199
5.7.4;17.4 Data Collection Tool Development;199
5.7.5;17.5 Database Considerations;200
5.7.6;17.6 Cloud Computing;201
5.7.7;17.7 Private Clouds;201
5.7.8;17.8 Conclusion;204
5.7.9;References;204
5.8;18 The Role of Scientific Journals in Disseminating New Technology;205
5.8.1;18.1 Introduction;205
5.8.2;18.2 Appraisal of New Technology;205
5.8.3;18.3 Regulating New Technologies;206
5.8.4;18.4 Scientific Journals at the Hub of Disseminating New Technologies;206
5.8.5;18.5 Transurethral Resection of the Prostate;206
5.8.6;18.6 Laparoscopic Radical Nephrectomy;207
5.8.7;18.7 Applying Technology in New and Innovative Ways;208
5.8.8;18.8 Exciting New Technologies Surfacing in Scientific Journals: Augmented Reality Images;209
5.8.9;18.9 Natural Orifice Surgery;209
5.8.10;18.10 Summary;210
5.8.11;References;210
5.9;19 Predicting Robotic Utilization in Urologic Disease: An Epidemiology-Based Model;212
5.9.1;19.1 Introduction;212
5.9.2;19.2 Overview of Epidemiology;212
5.9.3;19.3 Description of the Model;213
5.9.3.1;19.3.1 Variables;214
5.9.3.2;19.3.2 Changes in Population Trends;214
5.9.3.3;19.3.3 Changes in Incidence or Progression;215
5.9.3.4;19.3.4 Changes in Detection;215
5.9.3.5;19.3.5 Therapies That Make Inoperable Patients Operable;216
5.9.3.6;19.3.6 Treatment Trends or Changes in Paradigms;216
5.9.3.7;19.3.7 Price and Popularity;216
5.9.4;19.4 Examples of Its Application;216
5.9.4.1;19.4.1 Prostate Cancer;216
5.9.4.1.1;19.4.1.1 Epidemiology;216
5.9.4.1.2;19.4.1.2 Treatments and Trends;217
5.9.4.1.3;19.4.1.3 Sample Calculation;217
5.9.4.1.4;19.4.1.4 Variables;219
5.9.4.1.5;19.4.1.5 Summary;219
5.9.4.2;19.4.2 Renal Cell Cancer;219
5.9.4.2.1;19.4.2.1 Epidemiology;219
5.9.4.2.2;19.4.2.2 Treatment and Trends;219
5.9.4.2.3;19.4.2.3 Sample Calculation;219
5.9.4.2.4;19.4.2.4 Variables;219
5.9.4.2.5;19.4.2.5 Summary;220
5.9.4.3;19.4.3 Bladder Cancer;220
5.9.4.3.1;19.4.3.1 Epidemiology;220
5.9.4.3.2;19.4.3.2 Treatment and Trends;220
5.9.4.3.3;19.4.3.3 Sample Calculation;221
5.9.4.3.4;19.4.3.4 Variables;221
5.9.4.3.5;19.4.3.5 Summary;221
5.9.4.4;19.4.4 Female Pelvic Dysfunction;221
5.9.4.4.1;19.4.4.1 Epidemiology;221
5.9.4.4.2;19.4.4.2 Treatment and Trends;221
5.9.4.4.3;19.4.4.3 Sample Calculation;222
5.9.4.4.4;19.4.4.4 Variables;222
5.9.4.4.5;19.4.4.5 Summary;222
5.9.5;19.5 Conclusion;222
5.9.6;References;223
6;Part III The Prostate;224
6.1;20 Development of the Vattikuti Institute Prostatectomy: Historical Perspective and Technical Nuances;225
6.1.1;20.1 Introduction;225
6.1.2;20.2 Historical Perspective (See Timeline);225
6.1.3;20.3 Comparison with Open and Laparoscopic Radical Prostatectomy;226
6.1.4;20.4 Outcomes After First 1,100 Cases;227
6.1.5;20.5 Nerve Preservation;227
6.1.6;20.6 Outcomes with the "Veil of Aphrodite" Nerve-Sparing Technique;229
6.1.7;20.7 Progression to the "Super Veil" Nerve-Sparing Technique;229
6.1.8;20.8 Outcomes of the Super Veil Nerve-Sparing Technique;230
6.1.9;20.9 Optimization of Urinary Continence Through Precise Apical Dissection;232
6.1.10;20.10 Anastomosis Using a Barbed Wound Closure Device: the Knotless Anastomosis;232
6.1.11;20.11 Initial Outcomes with Single-Layer Running Urethrovesical Anastomosis;234
6.1.12;20.12 Double-Layer Urethrovesical Anastomosis;236
6.1.13;20.13 Outcomes of the Double-Layer Urethrovesical Anastomosis;236
6.1.14;20.14 Percutaneous Suprapubic Tube (PST) Drainage;237
6.1.15;20.15 Outcomes of Percutaneous Suprapubic Tube (PST) Drainage;238
6.1.16;20.16 Isolated Internal Iliac Node Dissection for Low-Risk Prostate Cancer;238
6.1.17;20.17 Outcomes for Isolated Internal Iliac Node Dissection for Low-Risk Prostate Cancer;239
6.1.18;20.18 Biochemical Recurrence and Oncologic Outcomes;240
6.1.19;20.19 Effect of the Learning Curve;241
6.1.20;20.20 Steps of the Vattikuti Institute Prostatectomy (VIP) Procedure;242
6.1.21;20.21 Basics;242
6.1.22;20.22 Release of Bowel;242
6.1.23;20.23 Bladder Mobilization;242
6.1.24;20.24 Division of the Bladder Neck;244
6.1.25;20.25 Incision of Denonvilliers Fascia and Dissection of Vas Deferens and Seminal Vesicles;244
6.1.26;20.26 Nerve Sparing;244
6.1.27;20.27 Apical Dissection and Division of the Urethra;245
6.1.28;20.28 Bilateral Pelvic Lymphadenectomy;245
6.1.29;20.29 Running Urethrovesical Anastomosis;245
6.1.30;20.30 Postoperative Care;246
6.1.31;20.31 Summary;246
6.1.32;20.32 Conclusion;246
6.1.33;References;246
6.2;21 Transferring Knowledge of Anatomical Dissection from the Laboratory to the Patient: An Australian Perspective;248
6.2.1;21.1 Introduction;248
6.2.2;21.2 Preliminary Anatomical Dissection of the Neurovascular Region of the Prostate;249
6.2.2.1;21.2.1 Background to the Study;249
6.2.2.2;21.2.2 Dissection Protocols;249
6.2.2.3;21.2.3 Discussion of NVB Anatomy;249
6.2.3;21.3 Autonomic Immunohistochemical Staining;251
6.2.3.1;21.3.1 Background to the Study;251
6.2.3.2;21.3.2 Experimental Techniques;251
6.2.3.3;21.3.3 Results;252
6.2.3.4;21.3.4 Parasympathetic Nerve Fiber Distribution;252
6.2.3.5;21.3.5 Discussion of Immunhistochemical Staining;254
6.2.4;21.4 Discussion;255
6.2.5;21.5 Future Directions;256
6.2.6;21.6 Conclusions;257
6.2.7;References;257
6.3;22 Robot-Assisted Radical Prostatectomy: A Prostate Surgeon's Perspective;259
6.3.1;22.1 Introduction;259
6.3.2;22.2 Radical Prostatectomy in Perspective;259
6.3.3;22.3 Summary;263
6.3.4;References;263
6.4;23 Cautery-Free Technique of Robot-Assisted Radical Prostatectomy: Impact on Nerve Preservation and Long-Term Outcome on Recovery of Sexual Function;265
6.4.1;23.1 Introduction;265
6.4.2;23.2 Cavernous Neuroanatomy;265
6.4.3;23.3 Classification of Nerve Injury;267
6.4.4;23.4 Thermal Injury;267
6.4.5;23.5 Inflammatory Damage;268
6.4.6;23.6 Hypothermia;268
6.4.7;23.7 Preoperative Planning;269
6.4.8;23.8 Neurovascular Bundle Dissection;270
6.4.9;23.9 Irrigation;271
6.4.10;23.10 Anatomic Factors Affecting Operative Technique;271
6.4.10.1;23.10.1 High Anterior Release and the Veil of Aphrodite;271
6.4.11;23.11 Controlling the Prostatic Vascular Pedicle;272
6.4.12;23.12 Potency Outcomes with Cautery-Free Technique;272
6.4.13;23.13 Effect of Unilateral Wide Excision on Potency;273
6.4.14;23.14 Conclusion;274
6.4.15;References;274
6.5;24 Current Concepts in Cavernosal Neural Anatomy and Imaging and Their Implications for Nerve-Sparing Radical Prostatectomy;277
6.5.1;24.1 Introduction;277
6.5.2;24.2 Anatomic Basis of Erectogenic Nerve Preservation;277
6.5.2.1;24.2.1 Neurovascular Bundles and Cavernosal Nerves;277
6.5.2.2;24.2.2 Anatomic Variants of Cavernosal Nerves;278
6.5.2.3;24.2.3 Trizonal Hammock Concept;278
6.5.2.4;24.2.4 Fascial Planes Surrounding the Prostate Capsule;279
6.5.3;24.3 Techniques for Optimizing Cavernosal Nerve Preservation;280
6.5.3.1;24.3.1 Techniques for Retropubic Radical Prostatectomy;280
6.5.3.2;24.3.2 Periprostatic Planes of Fascial Dissection;281
6.5.3.3;24.3.3 Trizonal Risk-Stratified Nerve-Sparing Approach;282
6.5.3.4;24.3.4 Alternatives to Electrocautery;283
6.5.3.5;24.3.5 Nerve Reconstruction and Regeneration;285
6.5.4;24.4 Advances in Cavernosal Neural Imaging;285
6.5.5;24.5 Optical Coherence Tomography;286
6.5.6;24.6 Spectroscopy;287
6.5.7;24.7 Fluorescent Imaging;287
6.5.8;24.8 Exogenous Fluoroscopy;288
6.5.9;24.9 Endogenous Autofluorescence;288
6.5.10;24.10 Conclusion;290
6.5.11;References;291
6.6;25 Robot-Assisted Radical Prostatectomy for Large Glands and Median Lobe;294
6.6.1;25.1 Introduction;294
6.6.2;25.2 Embryology of the Prostate;294
6.6.3;25.3 RARP for Median Lobe;294
6.6.3.1;25.3.1 Literature Review;295
6.6.3.2;25.3.2 Surgical Technique;295
6.6.3.3;25.3.3 Management of the Ureteral Orifices;296
6.6.4;25.4 RARP for Large Prostate;297
6.6.4.1;25.4.1 Technical Modifications for Large Prostates;298
6.6.4.2;25.4.2 Management of the Large Bladder Neck;298
6.6.5;References;299
6.7;26 Extraperitoneal Robot-Assisted Radical Prostatectomy: Simulating the Gold Standard;301
6.7.1;26.1 Introduction;301
6.7.1.1;26.1.1 Robot-Assisted Radical Prostatectomy Procedure;301
6.7.1.1.1;26.1.1.1 Access;301
6.7.1.1.2;26.1.1.2 Port Placement;301
6.7.1.1.3;26.1.1.3 Endopelvic Fascia;302
6.7.1.1.4;26.1.1.4 Dorsal Vein Ligation;302
6.7.1.1.5;26.1.1.5 Bladder Neck Dissection;302
6.7.1.1.6;26.1.1.6 Seminal Vesicle Dissection;302
6.7.1.1.7;26.1.1.7 Posterior Prostate Dissection;302
6.7.1.1.8;26.1.1.8 Neurovascular Bundle Dissection;302
6.7.1.1.9;26.1.1.9 Apical Dissection;303
6.7.1.1.10;26.1.1.10 Vesicourethral Anastomosis;303
6.7.1.1.11;26.1.1.11 Specimen Retrieval and Closure;304
6.7.1.1.12;26.1.1.12 Postoperative Care;305
6.7.1.2;26.1.2 Comparing to the Gold Standard;305
6.7.1.3;26.1.3 The False Arguments Against the Extraperitoneal Approach;305
6.7.1.3.1;26.1.3.1 The Anastomosis;305
6.7.1.3.2;26.1.3.2 The Working Space;306
6.7.1.3.3;26.1.3.3 The Extended Node Dissection;307
6.7.2;26.2 Conclusions;308
6.7.3;References;308
6.8;27 The Retrograde Extraperitoneal Approach: Robotic Retrograde Extraperitoneal Laparoscopic Prostatectomy (RRELP);309
6.8.1;27.1 Introduction;309
6.8.2;27.2 Indication and Preoperative Preparation;309
6.8.3;27.3 Operative Setup;310
6.8.4;27.4 Patient Positioning;310
6.8.5;27.5 Instrumentation List;311
6.8.6;27.6 Step-by-Step Technique;312
6.8.7;27.7 Postoperative Management;317
6.8.8;27.8 Data Management;317
6.8.9;27.9 Special Considerations;317
6.8.10;27.10 Steps to Avoiding Complications;318
6.8.11;27.11 Discussion;318
6.8.12;27.12 Conclusion;319
6.8.13;References;320
6.9;28 Technical Modifications for Robotic Prostatectomy;321
6.9.1;28.1 Introduction;321
6.9.2;28.2 Periurethral Suspension Stitch;321
6.9.2.1;28.2.1 Surgical Technique;322
6.9.2.2;28.2.2 Comments;323
6.9.3;28.3 Modified Posterior Reconstruction of the Rhabdosphincter;323
6.9.3.1;28.3.1 Surgical Technique;323
6.9.3.2;28.3.2 Comments;324
6.9.4;28.4 Athermal Seminal Vesicle Dissection;324
6.9.4.1;28.4.1 Surgical Technique;324
6.9.4.2;28.4.2 Comments;325
6.9.5;28.5 Athermal Early Retrograde Release of the Neurovascular Bundles;325
6.9.5.1;28.5.1 Surgical Technique;325
6.9.5.2;28.5.2 Comments;326
6.9.6;28.6 Conclusions;327
6.9.7;References;327
6.10;29 Robotic Radical Prostatectomy: Cancer Control and Implications of Margin Positivity;328
6.10.1;29.1 Introduction;328
6.10.2;29.2 Definitions of Positive Surgical Margins;329
6.10.3;29.3 Positive Surgical Margins with RARP;329
6.10.3.1;29.3.1 Early RARP PSM Outcomes;329
6.10.3.2;29.3.2 Experienced RARP PSM Outcomes;330
6.10.4;29.4 Risk Factors for Positive Surgical Margins;331
6.10.5;29.5 Comparison of PSM Outcomes Among RARP, ORP, and LRP Series ;332
6.10.6;29.6 Location, Number, and Size of Positive Surgical Margins;333
6.10.7;29.7 Impact of PSMs on Oncologic Outcomes;334
6.10.8;29.8 Adjuvant Radiation for Locally Advanced Disease and/or Positive Surgical Margins;336
6.10.9;29.9 Surgical Techniques to Improve Cancer Control;337
6.10.10;29.10 Conclusions;338
6.10.11;References;339
6.11;30 Techniques to Improve Urinary Continence Following Robot-Assisted Radical Prostatectomy;342
6.11.1;30.1 Introduction;342
6.11.2;30.2 Definitions;342
6.11.3;30.3 Background;342
6.11.4;30.4 Mechanism of Urinary Incontinence After Radical Prostatectomy;344
6.11.5;30.5 Factors Influencing Continence After RARP;345
6.11.5.1;30.5.1 Age;345
6.11.5.2;30.5.2 Prostate Size;345
6.11.5.3;30.5.3 Pathology;345
6.11.5.4;30.5.4 Nerve Sparing;345
6.11.5.5;30.5.5 Anastomotic Strictures;346
6.11.5.6;30.5.6 BMI (Body Mass Index);346
6.11.5.7;30.5.7 Effect of Previous Surgery;346
6.11.6;30.6 Evaluation of Incontinence After RARP;346
6.11.6.1;30.6.1 History and Physical Examination;346
6.11.6.2;30.6.2 Further Investigation;347
6.11.7;30.7 Non-operative Strategies to Improve Continence Following RARP;347
6.11.7.1;30.7.1 Smoking Cessation;347
6.11.7.2;30.7.2 Pelvic Floor Muscle Exercise/Therapy (PMFT);347
6.11.7.2.1;30.7.2.1 Pharmacotherapy;348
6.11.8;30.8 Intraoperative Techniques;348
6.11.8.1;30.8.1 Preservation of the Puboprostatic Ligaments;348
6.11.8.2;30.8.2 Suspension of the Dorsal Venous Complex;349
6.11.8.3;30.8.3 Bladder Neck Preservation;349
6.11.8.4;30.8.4 Nerve Sparing;349
6.11.8.5;30.8.5 Hypothermia of the Pelvic Floor;350
6.11.8.6;30.8.6 Apical Dissection;350
6.11.8.7;30.8.7 Preservation of Urethral Length;352
6.11.8.8;30.8.8 Posterior Repair;353
6.11.8.9;30.8.9 Walsh Intussusception Stitch;354
6.11.8.10;30.8.10 Creation of a Watertight Anastomosis;355
6.11.9;30.9 Postoperative Surgical Therapies for Post-prostatectomy Incontinence;355
6.11.9.1;30.9.1 Injection Therapy;355
6.11.9.2;30.9.2 The Male Sling;356
6.11.9.3;30.9.3 Artificial Urinary Sphincter;357
6.11.10;30.10 Conclusion;357
6.11.11;References;357
6.12;31 Penile Rehabilitation After Robotic Radical Prostatectomy: The Best Strategy;362
6.12.1;31.1 Introduction;362
6.12.2;31.2 Rationale for PDE5-I Prophylaxis in the Prevention of Post-RP Erectile Dysfunction;364
6.12.3;31.3 Management of Post-RP Erectile Dysfunction;365
6.12.4;31.4 Phosphodiesterase Type 5 Inhibitors in the Management of Post-prostatectomy ED;366
6.12.5;31.5 Other Treatments in the Management of Post-prostatectomy ED;367
6.12.6;31.6 Conclusions;368
6.12.7;References;368
6.13;32 Laparoscopy or Robotic Radical Prostatectomy: Pros and Cons;372
6.13.1;32.1 Advantages of the Laparoscopic Approach;372
6.13.2;32.2 Disadvantages of the Laparoscopic Approach;372
6.13.3;32.3 Advantages of the Robotic-Assisted Procedure;372
6.13.4;32.4 Disadvantages of the Robotic-Assisted Procedure;373
6.13.5;32.5 Results;373
6.13.5.1;32.5.1 Perioperative Results;373
6.13.5.2;32.5.2 Oncologic Outcomes;374
6.13.5.3;32.5.3 Functional Results;374
6.13.5.3.1;32.5.3.1 Urinary Continence;374
6.13.5.3.2;32.5.3.2 Erectile Function;374
6.13.6;32.6 Conclusions;374
6.13.7;References;375
6.14;33 Complications of Robotic Prostatectomy;377
6.14.1;33.1 Introduction;377
6.14.2;33.2 Technique of Vattikuti Institute Prostatectomy (VIP);377
6.14.2.1;33.2.1 Patient Selection;378
6.14.2.2;33.2.2 Patient Positioning and Port Placement;378
6.14.2.3;33.2.3 Developing of the Extraperitoneal Space;378
6.14.2.4;33.2.4 Lymph Node Dissection;378
6.14.2.5;33.2.5 Bladder Neck Transection and Posterior Dissection;378
6.14.2.6;33.2.6 Nerve Sparing;379
6.14.2.7;33.2.7 Apical Dissection and Urethral Transection;379
6.14.2.8;33.2.8 Urethrovesical Anastomosis;379
6.14.2.9;33.2.9 Suprapubic Catheter Placement;380
6.14.2.10;33.2.10 Specimen Retrieval;380
6.14.2.11;33.2.11 Postoperative Care;380
6.14.3;33.3 Data Collection;381
6.14.4;33.4 Complications;381
6.14.4.1;33.4.1 Anesthesia-Related Complications (<0.1%);381
6.14.4.2;33.4.2 Non-vascular Access-Related Complications (0.1%);382
6.14.4.2.1;33.4.2.1 Subcutaneous Emphysema and Air Embolism (0%);382
6.14.4.2.2;33.4.2.2 Visceral Injury (0.1%);382
6.14.4.3;33.4.3 Vascular Complications (<0.1%);383
6.14.4.3.1;33.4.3.1 Access Related (<0.1%);383
6.14.4.3.2;33.4.3.2 Access Unrelated (<0.1%);383
6.14.4.4;33.4.4 Rectal Injury (0.3%);384
6.14.4.5;33.4.5 Ureteral Injury (<0.1);384
6.14.4.6;33.4.6 Postoperative Anemia and Blood Transfusion (1.9%);384
6.14.4.6.1;33.4.6.1 Management of Acute Postoperative Hemorrhage After Robotic Prostatectomy;385
6.14.4.7;33.4.7 Urinary Ascites (0.7%);385
6.14.4.8;33.4.8 Postoperative Ileus (0.7%);386
6.14.4.9;33.4.9 Bowel Complications (0.2%);387
6.14.4.10;33.4.10 Lymphocele (0.2%);387
6.14.4.11;33.4.11 Urinary Retention (1.5%);387
6.14.4.12;33.4.12 Medical Complications (0.5%);388
6.14.5;33.5 Delayed Complications;388
6.14.5.1;33.5.1 Continence;388
6.14.5.2;33.5.2 Potency;388
6.14.6;33.6 Conclusion;389
6.14.7;References;389
7;Part IV Adrenal, Kidney, and Ureter;391
7.1;34 Robotic Urologic Surgery: Robotic-Assisted Adrenalectomy;392
7.1.1;34.1 Introduction;392
7.1.2;34.2 Planning;392
7.1.3;34.3 Operative Team and Positioning;392
7.1.4;34.4 Trocar Configuration;393
7.1.5;34.5 Left Robotic-Assisted Adrenalectomy;393
7.1.5.1;34.5.1 Exposure of the Adrenal Gland;393
7.1.5.2;34.5.2 Identification of the Adrenal Vein;394
7.1.6;34.6 Removal of the Gland;395
7.1.7;34.7 Right Robotic-Assisted Adrenalectomy;395
7.1.7.1;34.7.1 Exposure of the Adrenal Gland;395
7.1.8;34.8 Post-operative Management;397
7.1.9;34.9 Complications;397
7.1.10;34.10 Conclusion;398
7.1.11;References;398
7.2;35 Robot-Assisted Laparoscopic Radical Nephrectomy and Nephroureterectomy;400
7.2.1;35.1 Robot-Assisted Laparoscopic Radical Nephrectomy;400
7.2.1.1;35.1.1 Indications/Contraindications;400
7.2.1.2;35.1.2 Patient Preparation;400
7.2.2;35.2 Transperitoneal RALN;401
7.2.3;35.3 Retroperitoneal RALN;405
7.2.4;35.4 Patient Positioning, Retroperitoneal Access, and Port Placement;405
7.2.5;35.5 Docking of Robot;405
7.2.6;35.6 Robot-Assisted Nephroureterectomy;406
7.2.6.1;35.6.1 Indication;406
7.2.6.2;35.6.2 Patient Preparation;406
7.2.6.3;35.6.3 Procedure;406
7.2.7;References;409
7.3;36 Robot-Assisted Partial Nephrectomy;410
7.3.1;36.1 Introduction;410
7.3.2;36.2 The Evolution of Renal Surgery;410
7.3.3;36.3 Atlas of Technique;411
7.3.3.1;36.3.1 Patient Selection and Other Considerations;411
7.3.3.2;36.3.2 Patient Positioning and Trocar Placement;412
7.3.3.3;36.3.3 Robot Docking and Instrument Selection;413
7.3.3.4;36.3.4 Initial Dissection;414
7.3.3.5;36.3.5 Preparing for Excision;414
7.3.3.6;36.3.6 Tumor Excision;415
7.3.3.7;36.3.7 Renal Reconstruction;415
7.3.3.8;36.3.8 Extraction and Closure;416
7.3.3.9;36.3.9 Postoperative Care and Management of Perioperative Complications;416
7.3.3.10;36.3.10 Long-Term Follow-Up;416
7.3.4;36.4 Outcomes of Robot-Assisted Partial Nephrectomy;416
7.3.5;36.5 Learning Curve and Technical Refinements;417
7.3.6;36.6 The Case for Robot-Assisted Partial Nephrectomy;419
7.3.7;36.7 Conclusions;419
7.3.8;References;419
7.4;37 Robotic Urologic Surgery: Robot-Assisted Partial Nephrectomy;422
7.4.1;37.1 Introduction;422
7.4.2;37.2 Operative Setup;422
7.4.3;37.3 Patient Positioning;422
7.4.4;37.4 Trocar Configuration;423
7.4.5;37.5 Sutures;424
7.4.5.1;37.5.1 Inner Layer Reconstruction;424
7.4.5.2;37.5.2 Capsular Reconstruction;424
7.4.6;37.6 Step-by-Step Technique;424
7.4.6.1;37.6.1 Step 1: Trocar Placement;424
7.4.6.2;37.6.2 Step 2: Bowel Mobilization and Identification of Anatomic Landmarks;424
7.4.6.3;37.6.3 Step 3: Hilar Dissection;425
7.4.6.4;37.6.4 Step 4: Tumor Identification;426
7.4.6.5;37.6.5 Step 5: Hilar Clamping;427
7.4.6.6;37.6.6 Step 6: Tumor Excision;427
7.4.6.7;37.6.7 Step 7: Inner Layer Renal Reconstruction;428
7.4.6.8;37.6.8 Step 8: Capsular Reconstruction and Clamp Removal;429
7.4.6.9;37.6.9 Step 9: Specimen Retrieval and Closure;430
7.4.7;37.7 Special Considerations;430
7.4.8;37.8 Steps to Avoid Complications;431
7.4.9;37.9 Conclusions;432
7.4.10;References;432
7.5;38 Robotic Donor Nephrectomy: Technique and Outcomes – An European Perspective;433
7.5.1;38.1 Introduction;433
7.5.2;38.2 Preoperative Kidney Evaluation;433
7.5.3;38.3 Patient Positioning and Port Placement;433
7.5.4;38.4 Surgical Steps;434
7.5.5;38.5 Postoperative Care;435
7.5.6;38.6 Results;435
7.5.7;38.7 Conclusion;435
7.5.8;References;435
7.6;39 Robotic Donor Nephrectomy;436
7.6.1;39.1 Introduction;436
7.6.2;39.2 Surgical Anatomy;437
7.6.3;39.3 The Robotic System;437
7.6.4;39.4 Preoperative Evaluation;437
7.6.5;39.5 Surgical Technique;437
7.6.5.1;39.5.1 Patient Positioning;437
7.6.5.2;39.5.2 Port Placement;438
7.6.5.3;39.5.3 Mobilization of the Descending Colon and Identification of the Ureter;438
7.6.5.4;39.5.4 Posterior Dissection of the Kidney;438
7.6.5.5;39.5.5 Anterior Dissection of the Kidney;439
7.6.5.6;39.5.6 Dissection of the Renal Hilum;439
7.6.5.7;39.5.7 Division of the Renal Hilum and Kidney Removal;439
7.6.6;39.6 Postoperative Care;439
7.6.7;39.7 Management of Complications;439
7.6.8;39.8 Conclusion;440
7.6.9;References;440
7.7;40 Robot-Assisted Laparoscopic Pyeloplasty;441
7.7.1;40.1 History and Introduction;441
7.7.2;40.2 Surgical Technique of Robot-Assisted Laparoscopic Pyeloplasty (RALPP);442
7.7.2.1;40.2.1 Pre-operative Assessment;442
7.7.2.2;40.2.2 Indications;442
7.7.2.3;40.2.3 Contraindications;442
7.7.2.4;40.2.4 Pre-operative Preparation;442
7.7.2.5;40.2.5 Position;445
7.7.2.6;40.2.6 Surgical Approach;445
7.7.3;40.3 Excision, Reduction Pyeloplasty, Stenting, and Ureteropyelostomy;446
7.7.4;40.4 Managing Concomitant Surgical Pathologies;454
7.7.5;40.5 Discussion;456
7.7.6;40.6 Conclusion;459
7.7.7;References;459
7.8;41 Robotic Surgery for Urolithiasis;462
7.8.1;41.1 Indications;462
7.8.1.1;41.1.1 Renal Calculi with Ureteropelvic Junction Obstruction;462
7.8.1.2;41.1.2 Large/Staghorn Renal Calculi;463
7.8.1.3;41.1.3 Pediatric Renal Calculi;463
7.8.1.4;41.1.4 Ectopic Kidneys;464
7.8.1.5;41.1.5 Stones in Renal Diverticula;464
7.8.1.6;41.1.6 Calculi with Associated Anomalies;464
7.8.1.7;41.1.7 Non-functioning Segments/Kidneys;464
7.8.2;41.2 Operative Setup;465
7.8.2.1;41.2.1 Retrograde Catheter Placement;465
7.8.2.2;41.2.2 Patient Positioning;465
7.8.2.3;41.2.3 Trocar Configuration;465
7.8.2.4;41.2.4 Instrumentation List;466
7.8.2.5;41.2.5 Step-by-Step Technique: Pyelolithotomy/Pyeloplasty;466
7.8.2.5.1;41.2.5.1 Trans-mesocolic Approach;466
7.8.2.5.2;41.2.5.1 Step #2: Pelvis Exposure, Retraction, and Pyelotomy;466
7.8.2.5.3;41.2.5.1 Step #3: Stone Extraction;467
7.8.2.5.4;41.2.5.1 Step #4: Pyeloplasty/Pyelotomy Closure;467
7.8.2.5.5;41.2.5.1 Step #5: Postoperative Care;468
7.8.2.6;41.2.6 Step-by-Step Technique: Diverticular Stones;468
7.8.2.6.1;41.2.6.0 Step # 1: Kidney Exposure: Colon Mobilization;468
7.8.2.6.2;41.2.6.0 Step #2: Stone Localization and Removal;468
7.8.2.7;41.2.7 Step-by-Step Technique: Partial/Simple Nephrectomy;468
7.8.3;41.3 Specific Situation: Pelvic Kidney;468
7.8.4;41.4 Avoiding Complications;469
7.8.5;41.5 Conclusions;469
7.8.6;References;470
7.9;42 Ureteral Reconstruction Utilizing Robotic-Assisted Techniques;471
7.9.1;42.1 Introduction;471
7.9.2;42.2 Preoperative Assessment;471
7.9.3;42.3 Operative Setup;471
7.9.4;42.4 Robotic Ureterolysis;472
7.9.5;42.5 Ureterocalicostomy;472
7.9.6;42.6 Ureteroureterostomy;473
7.9.7;42.7 Ureteral Reimplantation;474
7.9.8;42.8 Conclusion;475
7.9.9;References;475
7.10;43 Robotic or Laparoscopic Renal Surgery: Pros and Cons;476
7.10.1;43.1 Malignant Disease;476
7.10.1.1;43.1.1 Partial Nephrectomy (PN);476
7.10.1.1.1;43.1.1.1 Introduction;476
7.10.1.1.2;43.1.1.2 Indications and Contraindications;476
7.10.1.1.3;43.1.1.3 Oncological Outcomes;477
7.10.1.1.4;43.1.1.4 Positive Margins;478
7.10.1.1.5;43.1.1.5 Risk of Tumor Spillage or Port-Site Seeding;480
7.10.1.1.6;43.1.1.6 Functional Outcomes;480
7.10.1.1.7;43.1.1.7 Complications in LPN and RAPN;484
7.10.1.1.8;43.1.1.8 Conclusion;484
7.10.1.2;43.1.2 Laparoscopic Nephrectomy (LN);485
7.10.1.2.1;43.1.2.1 Introduction;485
7.10.1.2.2;43.1.2.2 Indications and Contraindications;485
7.10.1.2.3;43.1.2.3 Oncological Outcomes;485
7.10.1.2.4;43.1.2.4 Complications;486
7.10.1.2.5;43.1.2.5 Robot-Assisted Radical Nephrectomy (RAPN);486
7.10.2;43.2 Benign Disease;487
7.10.2.1;43.2.1 Laparoscopic or Robot-Assisted Pyeloplasty;487
7.10.2.1.1;43.2.1.1 Introduction;487
7.10.2.1.2;43.2.1.2 Indications;487
7.10.2.1.3;43.2.1.3 Laparoscopic Pyeloplasty (LP) vs Robot-Assisted Laparoscopic Pyeloplasty (RALP);487
7.10.2.1.4;43.2.1.4 Conclusion;488
7.10.3;References;489
8;Part V Bladder;493
8.1;44 Robot-Assisted Radical Cystectomy in Male: Technique of Spaces;494
8.1.1;44.1 Introduction;494
8.1.2;44.2 Surgical Technique;495
8.1.2.1;44.2.1 Pelvic Anatomy Overview;495
8.1.2.2;44.2.2 Periureteral Space;495
8.1.2.2.1;44.2.2.1 Lateral Pelvic Space;495
8.1.2.2.2;44.2.2.2 Anterior Rectal Space;495
8.1.2.3;44.2.3 Positioning;496
8.1.2.4;44.2.4 Port Placement;496
8.1.2.5;44.2.5 Surgical Steps;497
8.1.2.5.1;44.2.5.1 Development of Periureteral Space;497
8.1.2.5.2;44.2.5.2 Development of Lateral Pelvic Space;497
8.1.2.5.3;44.2.5.3 Development of Anterior Rectal Space;497
8.1.2.5.4;44.2.5.4 Control of Vascular Pedicles and Mobilization of Neurovascular Bundles;497
8.1.2.5.5;44.2.5.5 Anterior Exposure and Apical Dissection;498
8.1.2.5.6;44.2.5.6 Crossing of the Ureter;498
8.1.2.6;44.2.6 Extended Lymph Node Dissection (Release and Roll Technique) ;498
8.1.3;44.3 Postoperative Care;499
8.1.4;44.4 Results;501
8.1.5;44.5 Conclusions;501
8.1.6;References;501
8.2;45 Robotic-Assisted Laparoscopic Anterior Pelvic Exenteration for Bladder Cancer in the Female;502
8.2.1;45.1 Introduction;502
8.2.2;45.2 Methods;502
8.2.2.1;45.2.1 Pre-operative Evaluation;502
8.2.2.2;45.2.2 Patient Selection;503
8.2.2.3;45.2.3 Bowel Preparation;503
8.2.2.4;45.2.4 Intraoperative Considerations;503
8.2.2.5;45.2.5 Steps of the Procedure;503
8.2.2.5.1;45.2.5.1 Positioning and Port Placement;503
8.2.2.6;45.2.6 Procedural Steps;505
8.2.2.7;45.2.7 Postoperative Care;510
8.2.3;45.3 Results;510
8.2.4;45.4 Comment;511
8.2.5;References;512
8.3;46 Robotic-Assisted Laparoscopic Extended Pelvic Lymph Node Dissection for Bladder Cancer;513
8.3.1;46.1 Introduction;513
8.3.2;46.2 Anatomy of Lymphatic Drainage of the Bladder;514
8.3.3;46.3 Incidence of Lymph Node Metastases Identified at Cystectomy;515
8.3.4;46.4 Implications of Bladder Cancer Lymph Node Metastases;515
8.3.5;46.5 Extent of Lymph Node Dissection at Time of Cystectomy;516
8.3.6;46.6 Robotic-Assisted Laparoscopic Radical Cystectomy;517
8.3.7;46.7 Technique for the Robotic-Assisted Laparoscopic Extended Lymph Node Dissection at Wake Forest University;517
8.3.8;46.8 Results at Our Institution and Others with the Robotic-Assisted Laparoscopic Lymph Node Dissection;519
8.3.9;46.9 Complications of Robot-Assisted Lymph Node Dissection for Bladder Cancer;520
8.3.10;46.10 Conclusions;521
8.3.11;References;521
8.4;47 Robot-Assisted Intracorporeal Ileal Conduit;523
8.4.1;47.1 Introduction;523
8.4.2;47.2 Historical Background;523
8.4.3;47.3 Surgical Technique;524
8.4.3.1;47.3.1 Operative Steps;524
8.4.3.2;47.3.2 Postoperative Care;528
8.4.4;47.4 Results;528
8.4.5;47.5 Discussion;528
8.4.6;47.6 Conclusions;529
8.4.7;References;529
8.5;48 Robotic Urinary Diversion: Technique, Current Status, and Outcomes;530
8.5.1;48.1 Introduction;530
8.5.2;48.2 Patient Selection;531
8.5.3;48.3 Preoperative Preparation;531
8.5.4;48.4 Operative Setup;531
8.5.4.1;48.4.1 Patient Position;531
8.5.5;48.5 Equipment;532
8.5.6;48.6 Surgical Steps ;532
8.5.6.1;48.6.1 Trocar Configuration;532
8.5.6.2;48.6.2 Urinary Diversion;532
8.5.6.2.1;48.6.2.1 Orthotopic Neobladder, Intracorporeal Technique;532
8.5.6.2.2;48.6.2.2 Ileal Conduit, Intracorporeal Technique;535
8.5.6.2.3;48.6.2.3 Orthotopic Neobladder, Extracorporeal Technique;536
8.5.6.2.4;48.6.2.4 Ileal Conduit, Extracorporeal Technique;536
8.5.6.2.5;48.6.2.5 Special Consideration;536
8.5.7;48.7 Steps to Avoid Complication;537
8.5.8;48.8 Current Status and Outcomes;537
8.5.9;References;539
8.6;49 Robotic Bladder Surgery Complications: Prevention and Management;541
8.6.1;49.1 Current Literature on Robot-Assisted Bladder Surgery;542
8.6.2;49.2 Complications Inherent to the Robotic Approach;543
8.6.2.1;49.2.1 Equipment Malfunction;543
8.6.2.2;49.2.2 Positioning;543
8.6.2.3;49.2.3 Creation of Pneumoperitoneum, Port Placement, and Insertion of Trocars;544
8.6.2.4;49.2.4 Cardiopulmonary Complications;546
8.6.2.5;49.2.5 Unidentified Bowel Injury;547
8.6.2.6;49.2.6 Electrosurgical Etiology;547
8.6.2.7;49.2.7 Mechanical Etiology;548
8.6.3;49.3 Complications Inherent to Bladder Surgery;548
8.6.3.1;49.3.1 Vascular Injury;548
8.6.3.2;49.3.2 Incisional Hernia;549
8.6.3.3;49.3.3 Postoperative Ileus;550
8.6.3.4;49.3.4 Lymphocele and Lymph Leak;551
8.6.3.5;49.3.5 Wound Infection;551
8.6.3.6;49.3.6 Deep Venous Thrombosis;552
8.6.4;49.4 Complications of Urinary Diversion and Urine Leak from the Bladder;552
8.6.5;49.5 Summary;553
8.6.6;References;553
9;Part VI Pediatric Urology;556
9.1;50 Robotic Surgery for Ureteral Anomalies in Children;557
9.1.1;50.1 Introduction;557
9.1.1.1;50.1.1 Operating Room Setup;557
9.1.1.2;50.1.2 Patient Positioning;557
9.1.1.3;50.1.3 Trocar Configuration;557
9.1.1.4;50.1.4 Instrumentation List;559
9.1.2;50.2 Step-by-Step Technique;559
9.1.3;50.3 Ureteral Reimplantation – Intravesical;561
9.1.4;50.4 Uretero-ureterostomy – High;563
9.1.5;50.5 Uretero-ureterostomy – Low;564
9.1.6;50.6 Special Considerations;565
9.1.7;50.7 Steps to Avoid Complications;565
9.1.8;References;566
9.2;51 Robotic Surgery of the Kidney in Children;567
9.2.1;51.1 Introduction;567
9.2.2;51.2 Extirpative Surgery;567
9.2.2.1;51.2.1 Nephrectomy, Heminephrectomy, and Nephroureterectomy;567
9.2.2.1.1;51.2.1.1 Indications;567
9.2.2.1.2;51.2.1.2 Operative Setup;568
9.2.2.1.3;51.2.1.3 Step-by-Step Technique (Nephrectomy);570
9.2.2.1.4;51.2.1.4 Step-by-Step Technique (Partial Nephrectomy);571
9.2.2.1.5;51.2.1.5 Step-by-Step Technique (Nephroureterectomy);572
9.2.2.1.6;51.2.1.6 Results of Heminephrectomy;572
9.2.2.1.7;51.2.1.7 Steps to Avoid Complications;572
9.2.3;51.3 Reconstructive Surgery;572
9.2.3.1;51.3.1 Pyeloplasty;572
9.2.3.1.1;51.3.1.1 Indications;573
9.2.3.1.2;51.3.1.2 Operative Setup;573
9.2.3.1.3;51.3.1.3 Step-by-Step Technique;573
9.2.3.1.4;51.3.1.4 Results;575
9.2.3.2;51.3.2 Transposition of Lower Pole Crossing Vessel (''Vascular Hitch'');575
9.2.3.2.1;51.3.2.1 Indications;575
9.2.3.2.2;51.3.2.2 Step-by-Step Technique;575
9.2.3.2.3;51.3.2.3 Results;576
9.2.3.3;51.3.3 Ureterocalicostomy;576
9.2.3.3.1;51.3.3.1 Indications;576
9.2.3.3.2;51.3.3.2 Operative Setup;576
9.2.3.3.3;51.3.3.3 Step-by-Step Technique;576
9.2.3.3.4;51.3.3.4 Results;577
9.2.3.4;51.3.4 Robotic Pyelolithotomy;577
9.2.3.4.1;51.3.4.1 Indications;577
9.2.3.4.2;51.3.4.2 Operative Setup;577
9.2.3.4.3;51.3.4.3 Step-by-Step Technique;578
9.2.3.4.4;51.3.4.4 Results;578
9.2.3.5;References;578
9.3;52 Robotic Bladder Surgery in Children;580
9.3.1;52.1 General Technique of Robotic Bladder Surgery in Children;580
9.3.2;52.2 Robotic Surgery for Vesicoureteral Reflux (Ureteral Reimplantation);580
9.3.2.1;52.2.1 Vesicoscopic Approach (Transvesical Approach);581
9.3.2.1.1;52.2.1.1 Technique;581
9.3.2.1.2;52.2.1.2 Clinical Results;581
9.3.2.2;52.2.2 Extravesical Approach;582
9.3.2.2.1;52.2.2.1 Technique;582
9.3.2.2.2;52.2.2.2 Clinical Results;582
9.3.3;52.3 Robotic Surgery for Neuropathic Bladder;583
9.3.3.1;52.3.1 Robotic Appendicovesicostomy;583
9.3.3.1.1;52.3.1.1 Technique;583
9.3.3.2;52.3.2 Robotic Bladder Augmentation (Ileocystoplasty);584
9.3.3.2.1;52.3.2.1 Technique;584
9.3.3.2.2;52.3.2.2 Clinical Results;585
9.3.4;52.4 Robotic Surgery for Urachal Anomalies;585
9.3.4.1;52.4.1 Technique;585
9.3.4.2;52.4.2 Clinical Results;586
9.3.5;52.5 Conclusion;586
9.3.6;References;586
10;Part VII Female Urology and Infertility;588
10.1;53 Robotic Surgery in Urogynecology;589
10.1.1;53.1 Introduction;589
10.1.2;53.2 Hysterectomy;589
10.1.3;53.3 Myomectomy;590
10.1.4;53.4 Tubal Reanastomosis;590
10.1.5;53.5 Sacrocolpopexy;590
10.1.5.1;53.5.1 Introduction;590
10.1.5.2;53.5.2 Preoperative Evaluation;590
10.1.5.3;53.5.3 Patient Preparation and Positioning;591
10.1.5.4;53.5.4 Postoperative Course;592
10.1.5.5;53.5.5 Results;592
10.1.6;53.6 Potential Pitfalls;593
10.1.7;53.7 Conclusion;593
10.1.8;53.8 Future Directions;593
10.1.9;References;593
10.2;54 Robotic Repair of Vesico-vaginal Fistula;595
10.2.1;54.1 Introduction;595
10.2.2;54.2 Operative Setup;595
10.2.3;54.3 Patient Positioning;595
10.2.4;54.4 Trocar Configuration;596
10.2.5;54.5 Instrumentation List;596
10.2.6;54.6 Step-by-Step Technique;596
10.2.6.1;54.6.1 Vaginoscopy, Urethro-cystoscopy, and Bilateral Ureteric Double J Stenting or Catheterization;596
10.2.6.2;54.6.2 Adhesiolysis;596
10.2.6.3;54.6.3 Robotic Dissection of VVF;596
10.2.6.4;54.6.4 Repair of the Fistula;597
10.2.6.5;54.6.5 Interposition of the Tissue Between Two Suture Lines;598
10.2.7;54.7 Special Considerations;599
10.2.8;54.8 Step to Avoid Complications;599
10.2.9;References;600
10.3;55 Robotic Surgery in Male Infertility (Robotic-Assisted Microsurgery);601
10.3.1;55.1 Introduction;601
10.3.2;55.2 Installation in the Operating Room;601
10.3.3;55.3 Patients Position;601
10.3.4;55.4 Trocars Placement;601
10.3.5;55.5 Instrumentation List;602
10.3.6;55.6 Technique;603
10.3.7;55.7 Important Points;606
10.3.8;55.8 How to Avoid Complications;607
10.3.9;References;607
11;Part VIII Patient's Perspective;608
11.1;56 Treater to Target: Experiences of a Prostate Cancer Participant;609
11.1.1;56.1 Diagnosis;610
11.1.2;56.2 Life After Radical Prostatectomy;611
11.1.3;56.3 Postradiation;613
11.1.4;56.4 Search for Clinical Trial;613
11.1.5;56.5 The Rest of the Story;614
11.1.6;References;615
11.2;57 My Prostate Cancer;617
11.2.1;57.1 Introduction;617
11.2.2;57.2 Diagnosis and Treatment Plan;617
11.2.3;57.3 Recovery from the Biopsies;618
11.2.4;57.4 Detroit;618
11.2.5;57.5 Radical Robotic Prostatectomy + Bilateral Pelvic Lymphadenectomies;618
11.2.6;57.6 Postop Days 1–6;619
11.2.7;57.7 One-Week Follow-up;620
11.2.8;57.8 The First 3 Months;620
11.2.9;57.9 Three Months;622
11.2.10;57.10 Six Months;622
11.2.11;57.11 Nine Months;623
11.2.12;57.12 One Year;623
11.2.13;57.13 Eighteen Months;623
11.2.14;57.14 Two Years;623
11.2.15;57.15 Three Years;623
11.2.16;57.16 Afterthought;623
12;Part IX Future Perspectives;624
12.1;58 Telementoring and Telesurgery in Urology;625
12.1.1;58.1 Introduction;625
12.1.2;58.2 Components of a Telemedicine Link;626
12.1.3;58.3 Early Telemedicine;627
12.1.4;58.4 Telementoring;628
12.1.4.1;58.4.1 Telesurgical Telementoring;628
12.1.5;58.5 Telesurgery;629
12.1.5.1;58.5.1 Telesurgery Using Master–Slave Devices;629
12.1.6;58.6 Benefits;631
12.1.7;58.7 Problems;631
12.1.8;58.8 The Future;631
12.1.9;58.9 Conclusions;632
12.1.10;References;633
12.2;59 Robotic Systems: Past, Present, and Future;635
12.2.1;59.1 Introduction;635
12.2.2;59.2 History;635
12.2.3;59.3 Classification of Medical Robots;636
12.2.4;59.4 Evolution of Medical Robots;637
12.2.5;59.5 Robots in Current Clinical Use;638
12.2.6;59.6 Future Directions;638
12.2.6.1;59.6.1 Remote Manipulation Robots;639
12.2.6.2;59.6.2 Direct Image-Guided Robots;640
12.2.6.3;59.6.3 MRI-Compatible Robots;641
12.2.6.4;59.6.4 Image-Augmented Remote Manipulation Robots;643
12.2.7;59.7 Conclusion;643
12.2.8;References;643
13;Index;646