the vattikuti urology institute ( vui ) at henry ford hospital in detroit , michigan , usa established the first urologic robotic surgery program in the world in 2000 .
it would not have happened without 3 crucial factors : an innovative idea , an experienced surgeon with tremendous foresight , and considerable philanthropic funding . in keeping with the legacy of henry ford and the spirit of innovation , we sought to develop and improve upon techniques of minimally invasive prostate surgery .
mani menon and his colleagues adopted a laparoscopic approach for radical prostatectomy in collaboration with dr .
however , it became apparent that due to the different body habitus of american men compared to europeans , the laparoscopic approach was not as comparable to the retropubic approach as expected .
the advent of a robotic surgical system approved for cardiac surgery offered a potential solution .
menon 's experience informed his foresight in seeking to apply the surgical robot to urologic surgery . with the generous support from the raj and padma vattikuti foundation , a perfect storm gathered to initiate our journey into the robotic era .
the first radical prostatectomy was performed by the perineal approach in 1903 by young , and the first retropubic approach described by millin   in 1947 .
the current concept of retropubic radical nerve - sparing prostatectomy was established by patrick walsh et al .   in 1982 .
novel approaches using laparoscopy were introduced starting in the 1990s , and the robotic approach in prostate surgery was introduced in originally in 2000 and at that time , only a few studies showed feasibility via a case report or series without clinical benefits .
the robotic approach has now been adopted exponentially since its introduction in 2000 , when it was conceived as the vattikuti institute prostatectomy ( vip ) . demonstrating a benefit in terms of perioperative outcomes reflected the initial experience with robotic prostatectomy at the vui .
patients undergoing robot - assisted prostatectomy had shorter operating room times , lower estimated blood loss ( ebl ) , lower complication rates , earlier urethral catheter removals , and a shorter hospital length of stay .
these benefits were attributed to the surgical robot 's 3-dimensional vision , high quality and intuitive controls , and high degree of freedom in instrument movements .
although oncological outcomes and positive surgical margin ( psm ) rates are equivalent between robot - assisted radical prostatectomy ( rarp ) and radical retropubic prostatectomy ( rrp ) , rarp may have a benefit in a long - term cancer - recurrence free survival rate in d'amico - classification high - risk prostate cancer patients . a systematic review by ficarra et al .   revealed that functional outcomes were favorable in rarp over rrp .
most of all , the enhanced visualization and dexterity of the surgical robot have helped to reduce postoperative complication rates , as demonstrated in a series of 3,317 patients by agarwal et al .   in 2011 .
the surgical technique in robotic prostatectomy has evolved in many ways over the last 15 years .
initial surgical technique imitated a laparoscopic approach , which started posteriorly to dissect the seminal vesicles and vasa deferentia , followed by the bladder takedown to approach the bladder neck .
it was not long before this posterior approach was supplanted by what we now think of as the vip technique , wherein the prostate is approached anteriorly , starting with the bladder takedown , followed by the bladder neck , then dissection of the seminal vesicles and vasa deferentia .
this change enabled the robotic approach to be applied on patient populations with higher body mass indices .
furthermore , progressive anatomic studies revealed that the neural tissue was not confined to a " neurovascular bundle , " but rather spread over the wider surface of the prostatic fascia .
we hypothesized that the preserved neural tissue of the anterolateral aspects of the periprostatic fascial layer , which we named the , " veil of aphrodite , " could potentially allow for greater nerve preservation .
we found that a bilateral " veil of aphrodite " technique used in men with localized prostate cancer and normal baseline erectile function resulted in better recovery of postoperative erectile function and a higher percentage of erections firm enough for intercourse at 12 months postoperatively , compared to men undergoing a standard bilateral nerve sparing technique .
although a double - layered urethrovesical anastomosis ( uva)consisting of posterior rhabdosphincteric reconstruction , as well as , lateral and anterior reconstruction was expected to show an early return of urinary control , a randomized control trial in our institution demonstrated no advantages to double - layered uva compared with single - layered uva on early continence recovery or long - term continence rates .
however , double - layered uva did show a significant decrease in cystographic leaks compared to single - layered uva . at the vui in 2007 ,
the urinary diversion for uva has been done with the aid of a percutaneous suprapubic tube ( spt ) instead of the conventional method of utilizing a urethral foley catheter .
the benefits of the spt are less catheter - related discomfort , decreased need for anticholinergic medications for bladder spasm related symptoms , and reduced risk of urethral or meatal strictures , without increasing the risk of bladder neck contractures . the standard technique for the uva was using a double - armed monocryl suture in a running fashion until the food and drug administration ( fda ) approved the polyglyconate - barbed suture for soft tissue approximation in 2010 .
the barbed suture reduced the anastomotic time by 26% without compromising outcomes , compared with the conventional monofilament suture .
most recently the gelpoint ( applied medical , rancho santa margarita , ca , usa ) has been applied for our vip technique along with renal surgery which will be described later , for real time bedside bimanual examination of the specimen , and for regional hypothermia by introducing ice slush , the introcorporeal cooling and extraction ( ice ) technique . by applying the ice technique with the use of the gelpoint , and real time bimanual examination ,
the impact of regional hypothermia by cooling the neurovascular bundle is currently being evaluated as short - term outcomes were unclear .
radical cystectomy ( rc ) has been the gold standard of treatment for patients with muscle invasive bladder cancer , and now minimally invasive techniques have been adopted as the treatment of choice .
robot - assisted radical cystectomy ( rarc ) , as described by menon et al .   in 2003 ,
the robotic approach has noted an early return of bowel function , decreased length of stay and lower estimated blood loss in the short term .
nix et al .   published a prospective randomized controlled trial of rarc in 2010 , with lymph node yield as a primary end point , and concluded that the robotic approach was non - inferior to the open approach .
a multi - institutional cohort database from the international robotic cystectomy consortium ( ircc ) , with approximately 450 lymphadenectomies , revealed that the yield of lymph nodes retrieved between the robotic and open approaches were similar , obtaining an average of eighteen lymph nodes .
davis et al .   reported a series in which the lymph node yield was forty - three , with an efficiency of 93% . on second look lymphadenectomy by the open approach ,
as we know , rc is associated with significant perioperative morbidity and mortality along with changes in the patient 's quality of life .
there have been a few series that have described a reduced rate of complications in patients who underwent rarc vs. open radical cystectomy ( orc ) .
specifically , musch et al .   reported that patient 's who underwent rarc experienced fewer postoperative adverse events of any clavien - dindo grade complication < 90 days and < 60 days after surgery , lower frequency of major complications , decreased estimated blood loss and transfusion requirement compared to the orc arm .
the lower risk of adverse perioperative outcomes with rarc would have potential benefits in the elderly population and has been shown to be a feasible treatment option in this age group ( 80 years old ) with acceptable perioperative morbidity and short - term oncologic control .
described in a single - institution prospective cohort study of 20 patients aged 75 years or older , there were fewer postoperative complications in those who underwent rarc , compared to those who underwent orc .
khan et al .   reported the oncologic control of local disease in patients who underwent rarc after a follow - up period of 8 years were similar to the outcomes of patients who had orc .
several other series and reviews have also demonstrated comparable oncologic outcomes between orc and rarc . however , rarc has the added benefit of offering a minimally invasive approach with smaller surgical incisions , which results in less postoperative pain and shorter hospital course . albeit some of these studies were limited to a single surgeon or institution
, these results should encourage a more robust , randomized controlled trial to ascertain select patients or institutions that can efficiently optimize these potential benefits .
in 2003 , menon et al .   published a pioneering rarc series of 17 cases .
the 5- to 6-cm suprapubic incision , made for cystoprostatectomy specimen removal , was used to create an extracorporeal neobladder or ileal conduit .
the created pouch was internalized , and the neo - vesicouretheral anastomosis was completed with robotic assistance after closure of incision .
. mohamed a. ghoneim 's group in mansoura , egypt , where the majority of urinary diversions were created using the w - pouch technique .
the extracorporeal technique progressed into an intracoporeal technique with robot - assisted suturing dexterity as well as new advances in stapling devices .
multicentric ircc data for 90-day postoperative follow - up has recently been published , comparing intracorporeal and extracorporeal urinary diversions , 167 vs. 768 , respectively .
the operative time and median hospital stay were comparable , as were reoperation rates and complication rates . as expected with less bowel manipulation , gastrointestinal complications were significantly less in the intracorporeal group .
partial nephrectomy ( pn ) is the gold standard treatment for small renal masses ( srms ) .
compared to radical nephrectomy , pn has been shown to confer a survival advantage , similar oncologic outcomes , and minimizes the chance of severe chronic kidney disease in patients with associated renal dysfunction in the future .
laparoscopic partial nephrectomy ( lpn ) is more commonly performed , has comparable oncologic control , less morbidity and shorter postoperative recovery period compared to open partial nephrectomy ( opn ) .
however , lpn is more technically challenging , requires advanced surgical skills to achieve a negative tumor margin and to perform complex renal reconstruction , and has a steeper learning curve .
the advent of the robotic platform transformed the realm of upper tract surgery , and robot - assisted nephrectomies were performed starting in january 2004 . with minimally invasive pn becoming the standard of care for renal tumors < 4 cm in size , we published our initial experience of robot - assisted partial nephrectomy ( rapn ) in 10 patients with mean tumor size of 2 cm . in order to improve minimally invasive surgical skills , we devised novel laboratory models for solid renal tumor ( " pseudotumor " ) and renal vein tumor thrombus ( " pseudothrombus " ) in pigs and cadavers .
techniques of rapn were continuously refined and in 2009 , we illustrated our four - arm technique of rapn using a transperitoneal approach , highlighting the role of the fourth arm for renal hilar dissection , vascular control and during renorrhaphy .
the tile - pro feature of the da vinci robotic system allowed visualization of intraoperative ultrasound and preoperative imaging study as a picture - on - picture image on the console screen to aid tumor margin identification .
development of robotic bulldog clamps and intraoperative ultrasound probes gave further functional autonomy to the console surgeon by reducing his dependence on the variably skilled patient - side assistant .
the first report on the single - surgeon , single - center experience of rapn for renal tumors was published from our institution , comparing t1a with larger tumors .
we found equivalent ebl , total operative time , length of stay , complication rates and change in estimated glomerular filtration rate in the 2 groups .
multi - institutional series later confirmed our results even for more complex tumors and in obese patients .
various techniques for minimally invasive pn , like sliding clip renorrhaphy and early unclamping , appeared in an effort to reduce warm ischemia .
encouraged with the success of uva with barbed suture during vip , we established its safety and feasibility of a two - layered , running closure of the collecting system and renal capsule during renorrhaphy , and significantly lowering warm ischemia time ( wit ) compared to the standard polyglactin suture ( 18.5 minutes vs. 24.7 minutes , respectively p=0.008 ) .
as regional hypothermia would expand the window for duration of permissible ischemia , we successfully experimented with the gelpoint access platform to introduce ice - slush . with a mean cold ischemia time of 19.6 minutes and mean ebl of 296 ml , the technique of intracorporeal cooling was successfully used to achieve reproducible results .
retroperitoneal access to the kidney obviates the need for bowel mobilization , and may reduce bowel related complications , pain management issues , as well as length of hospital stay .
this approach will also confine blood and urine leaks to retroperitoneum , and may maximize the effectiveness of hypothermia techniques in the limited retroperitoneal space .
our recent description of robot - assisted retroperitoneal pn , which permits direct access to renal hilum for posterior and hilar tumors , is an effort in this direction .
a multicentric study by hu et al .   showed retroperitoneal rapn to have an acceptable morbidity and cancer control outcomes over a median follow - up of 2.7 years , proving retroperitoneal rapn to be a reasonable alternative for patients with posterior renal masses or with prior abdominal surgery .
recent trends show a resounding interest in the use of robot - assisted partial nephrectomy ( rapn ) over lpn .
there are reported benefits and for some outcome measures , a superiority of rapn over opn and lpn .
the " trifecta " ( which comprises a wit<25 minutes , negative surgical margins and zero perioperative complications ) has been used as a surrogate for quality of surgery in patients undergoing pn . in a single - surgeon series of 500 patients ,
rapn achieved the " trifecta " in almost 30% of the cases , with better operative outcomes and lower perioperative complications than compared to lpn .
rapn is associated with a decreased length of stay , decreased intraoperative blood loss , and is less affected by the complexity of the renal tumor .
rapn also offers a shorter wit , which is a surrogate for final outcomes and achieves an overall better " trifecta " compared to lpn .
rapn has a shorter learning curve than lpn and addresses some of the technical difficulties associated with the laparoscopic approach .
commonly cited advantages over lpn include a shorter learning curve with a wider range of indications , comparable or better operative , functional and oncologic outcomes , and better perioperative morbidity .
we described the feasibility of robot - asssited extended pyelolithotomy in 13 patients with staghorn calculi with a mean operative time of 158 minutes , mean console time 108 minutes , and ebl 100 ml , achieving stone free status in all but one patient .
described a four - port " baseball diamond " strategy of port placement for patients undergoing nephroureterectomy to allow instrument access to the ipsilateral upper and lower urinary tract in the same operative session , without repositioning the patient and redocking the robot . utilizing the robotic magnification and precision in movement for micro dissection of anatomical planes around the adrenal gland , a four - step technique of robot - assisted right adrenalectomy and synchronous bilateral adrenalectomy were described
the application of robot - assisted surgery continues to expand as technical improvements and surgeon experience continues to develop .
other notable areas where the robotic system are used include : pediatrics , solid organ transplant , endocrine and gastrointestinal surgery .
early experience has found robotic surgery to be a feasible option in renal , pancreatic , thyroid , gastrointestinal transplantation , and in gynecologic surgery .
the first robot - assisted living donor kidney transplantation ( rakt ) was performed in 2000 . since then , numerous reports of good renal graft outcomes , perioperative outcomes and reduced morbidity and mortality have been published .
rakt is particularly useful in obese patients and more appealing to would - be donors given the smaller surgical incisions , decreased postoperative pain , estimated blood loss , and shorter length of hospital stay .
there is also decreased associated morbidity and mortality intra and postoperatively and better cosmesis . in obese patients
, rakt reduces the risk of surgical site infection , which is very important for the transplanted graft and newly immunosuppressed recipient .
mani menon originally modified the rarp as the vui technique via a standard anterior approach in 2001 .
however , recently bocciardi group from italy and rha group from south korea have tried a posterior approach , retzius - sparing prostatectomy ( rsp ) .
although the learning curve on perioperative outcomes , such as operating time and psms , were noted in their data , the rsp has potential benefits on the achievement on continence .
the early experience of the rsp in our institution also showed similar outcomes of early return of urinary continence . with the use of the gelpoint at our institution for immediate bimanual palpation ,
the initial learning curve for psms has reduced , although long - term oncological outcomes still need to be evaluated through a large prospective cohort or randomized controlled trial .
the robotic platform has even adopted into the pediatric population . in children with ureteropelvic junction obstruction , robot - assisted pyeloplasty
is associated with significantly shorter length of stay , which directly correlates with decreased loss of parental wages and hospitalization cost .
the robotic approach enhances the laparoscopic technique , while maintaining the additional advantage of decreased pain , length of stay , rapid recuperation , and better long term cosmesis .
robot - assisted laparoscopic ureteroureterostomy ( raluu ) has been shown to be a viable option in patients with duplicated and single system ureters .
currently , intuitive surgical ( sunnyvale , ca , usa ) is leading the market of robotic surgical systems , and 11 major companies are sharing the rest of the market . according to the report from the wintergreen research company , robotic surgical systems collectively markets at $ 3.4 billion in 2014 are anticipated to reach up to $ 20 billion by 2021 .
new surgical robotic systems will continue to approach the market , but the leaders in robotic surgical system will still be intuitive surgical 's da vinci surgical system . as of december 2015
the da vinci surgical system was approved for a cardiac surgery in 1999 by the fda and applied for prostate cancer in 2000 .
the application of da vinci system has since been extended within the urologic field to include the kidney , bladder , reconstructive urologic surgery , and even to kidney transplantation .
evolution of robotic approach might expand its boundary toward new techniques to replace the established open and laparoscopic surgical techniques , or its indication from localized tumor to the locally advanced disease .
initially , the idea of a robot - assisted surgical system was driven by the navy and designed to enable a surgeon to perform tele - surgery . however , this has not been possible since the master and slave systems are connected through signals travelling close to light speed , and the delay between the movements of a surgeon and the machine increases with longer distance .
minimally invasive surgical techniques have been expanding the boundary of application on urologic surgeries , because of the decreasing rate of perioperative outcomes and similar oncological results . due to intuitive movements with advanced wrist movements , 3-dimensional vision and surgeon 's ergonomics ,
the market growth and the competition of newer surgical systems should translate to improvement of surgical technique and clinical outcomes .
 the first urologic robotic program in the world was built at the vattikuti urology institute , henry ford hospital detroit , michigan , in 2000 under the vision of surgical innovator , dr . 
 mani menon for the radical prostatectomy . 
 the robot - assisted radical prostatectomy continues being modified with techniques to improve perioperative and surgical outcomes . 
 the application of robotic surgical technique has since been expanded to the bladder and upper urinary tract surgery . 
 the evolution of surgical technique and its expansion of application will continue to improve quality , outcome parameters and experience for the patients . 
A PERFECT STORM
RADICAL PROSTATECTOMY
RADICAL CYSTECTOMY
UPPER URINARY TRACT SURGERY
NEWER FRONTIERS IN ROBOTICS SURGERY
THE FUTURE OF ROBOTIC SURGERY
CONCLUSIONS