Introduction of Laparoscopy and Robotics in Urology

Minimally invasive surgery, laparoscopic or robotic, is the preferred approach for many urological procedures. The da Vinci Surgical System was first introduced in 1999, offering innovative technology including 3D vision, EndoWrist instrumentation, ergonomic superiority, and surgical precision; features that, theoretically, surmounted the difficulties preventing the widespread adoption of laparoscopy.¹

These features may specifically help in performing surgeries in fixed narrow cavities such as the pelvis, and, therefore, robot-assisted radical prostatectomy was the index case suited for robotic surgery due to the technical difficulties described in the laparoscopic approach. This technology combined the minimally invasive advantages of laparoscopic radical prostatectomy with improved surgeon ergonomics and greater technical ease of suture reconstruction of the vesicourethral anastomosis, and has now become the preferred minimally invasive approach when available.² Surprisingly, a difference of only 3 years separates the first laparoscopic radical prostatectomy, reported by Schuessler et al in 1997, from the first robot-assisted radical prostatectomy, performed by Binder and Kramer in 2000. Since then, simultaneously with the development of robotic surgery, laparoscopic surgery has also undergone considerable development over the years. In fact, the 2 techniques have had a parallel development influencing each other with the technological improvements introduced in one or the other.³

Laparoscopy or Robotics: Which Is Better?

Despite all the technological advantages of robotic surgery, no clear superiority has been demonstrated compared to other approaches in different urological procedures. Several reviews comparing robotic, laparoscopic, and open radical prostatectomy have not shown significant differences in oncologic, urinary, and sexual-function outcomes. Therefore, no surgical approach can be recommended over another. More relevant, the outcomes after radical prostatectomy have been shown to be more related to the surgeon experience and hospital volume. We must not forget that robotic surgery also has important limitations, including its high costs, the absence of haptic feedback, and its limited availability in many countries.

Another important disadvantage of concern of laparoscopy is the learning curve. As mentioned before, radical prostatectomy remains a complex laparoscopic procedure with a steep learning curve. The introduction of the robotic platform and all its features came to simplify the learning of this complex procedure, causing rapid adoption of the robotic technique worldwide. However, laparoscopic surgery is still routinely performed at many centers in Europe, Asia, and Latin America.

Laparoscopic radical and partial nephrectomy is still considered the gold standard treatment for localized renal cancer. The robotic platform has failed to demonstrate any specific advantage over laparoscopy for these procedures and has not been found to be cost-effective. However, the laparoscopic approach is both mentally and physically challenging due to the stress of performing a complex laparoscopic procedure with intracorporeal suturing within a restricted time frame to avoid prolonged warm ischemia, while ensuring the quality of the nephrorrhaphy. The robotic approach enables improved dexterity for tumor excision and easier intracorporeal suturing. However, once again, there is no clear evidence of superiority of one technique over another. Even though the learning curve of robotic partial nephrectomy has been suggested to be lower than the laparoscopic approach, it remains a much more expensive option, which limits its widespread application, particularly in developing countries.

Although robotic assistance may help in reducing the learning curve of a procedure, this advantage needs to be viewed in terms of health care economics and patient finances in developing countries. The learning curve of laparoscopy may also be shortened if laparoscopic training is structured and properly incorporated in residency and fellowship programs similar to robotic training programs. Important improvements in the field of laparoscopy, such as 4K ultrahigh definition, 3D vision, advanced sealing devices, laparoscopic robotized wristed instruments, ergonomic platforms with chest supports, armrests, and camera holders, may prove to be more cost-effective with similar results compared to the robotic technology.

Robotic Surgery Remains Technology Not Uniformly Available

Nowadays there are more than 6,500 da Vinci Systems installed in over 67 countries and more than 55,000 surgeons trained to use this system,⁴ about 4,139 in the United States, 1,199 in Europe, 1,050 in Asia, and 342 in the rest of the world.⁵ In Latin America, a total of 88 da Vinci systems are registered, Brazil having the greatest number of systems with 37, followed by Mexico with 10. Many resource-limited countries do not have a robotic platform. This clearly reflects the lack of systems that low-income countries have and is a very strong reason why laparoscopic surgery cannot be discarded.

Robotic Surgery Is Not Exempt From Technical Flaws

Several studies have reported technical problems of the robotic platforms. A recent study demonstrated that the incidence of malfunction of the console was very low, with only 0.4% to 3.5%, being only 1% of critical malfunction. Various technical issues have been reported, including software and hardware malfunctions, robotic arm joints, optical and power systems, and connector flaws. The most common failure component was the robotic arm and joint systems with 71.4% of all malfunctions. In this scenario, having laparoscopic training makes surgeons confident if they must convert the procedure and still perform a minimally invasive procedure instead of convert to an open procedure.⁶

We personally believe that laparoscopy is an important discipline that cannot just disappear. In an era when robotic surgery is not globally available and free from flaws, alternative options must be available so we can still offer the benefits of a minimally invasive procedure, and laparoscopy is still the answer.

Returning to the initial question, our answer is: No. Currently, laparoscopy remains the preferred approach for many urologists, especially in the resource-limited settings of developing countries. Even though robot-assisted surgery has been found to be feasible in many urological procedures, it is important to note that feasibility by itself should not be translated into superiority.

Since its inception in 2002, the Residents and Fellows Committee has represented the voice of trainee members of the AUA. The Committee’s mission is to address the educational and professional needs of urology residents and fellows, and promote engagement between residents and fellows and the AUA. The Committee welcomes your input and feedback! To contact the Committee, or to inquire about ways to get more involved, please email rescommittee@AUAnet.org.