The evolution of robotic surgery in urology began with minimally invasive surgery (MIS)/laparoscopic advances in the early 1990s across several subspecialties—but mainly general surgery. My chance encounter with my future career choice goes back to college days in the late 1980s when I was running errands with my father, who practiced many years in Atlanta as an internist/endocrinologist. We ran into one of his general surgeon colleagues in the parking lot who stopped to say hello, but then wanted to show us something exciting he had just acquired. We gathered around the trunk of his car as he showed us a large metal case full of laparoscopic instruments he had bought and described his plans to train and learn laparoscopic cholecystectomy. From a distance, I wondered if the 3 of us standing around a large open car trunk looked like we were doing “business” in a scene from The Sopranos. It was difficult to just look at the box of instruments and imagine the possibilities. As the surgeon described, with these small incisions, small instruments, and working on a camera, patients could have major surgery but fast recoveries—seemed simple enough.

Fast forward a few years to medical school rotations in 1993 and laparoscopic cholecystectomy was a real thing, but learning curves were going on throughout departments, and in training this was considered a “chief resident case.” Fast forward again to general surgery internship in 1994, and now laparoscopic cholecystectomy was already a junior resident case, while pioneers in MIS were moving on to hernias and colon resections. Meanwhile in urology, MIS was a bit on the slow side of development—mainly due to the lack of a common/straightforward case like laparoscopic cholecystectomy to practice. It was a big leap in skills to just go right to laparoscopic nephrectomy or prostatectomy. Some highly skilled pioneers learned such difficult cases,¹ but while general surgery residents were performing laparoscopic cholecystectomy in high volumes, urology residents were just holding the camera for long laparoscopic nephrectomies.

Three representative publications from the late 1990s stand out as examples of the challenges but opportunities ahead. Inderbir Gill published a concept paper in 1998 on using laparoscopy to isolate small renal masses, and rather than resect and get into complex reconstruction steps, just use an ablation method such as cryoablation.² These were much simpler cases and demonstrated that technology advances could likely simplify challenging learning curves. Looking back, I love the fact that his paper only had 11 patients but has been cited over 200 times—a great ratio! Meanwhile there were some bumps in the road, as the small fraternity of laparoscopic pioneers tackled laparoscopic prostatectomy. They famously reported that it was feasible, but that the reconstruction was difficult and the outcomes showed no benefit.³ However, as a lesson to future surgeons, papers describing a procedure as having “no benefit” should be interpreted carefully to discern whether the lack of benefit is solvable or not. Indeed, a group of French surgeons then came along and basically demonstrated that if you really practice the anastomosis and reconstructive skills required, you can reduce the operative times significantly and come up with an experience that mimics what we are more familiar with—reasonable surgery times, equivalent cancer control, less bleeding, and faster recovery.⁴

Bringing our narrative to the 2000 to 2002 era, there were 2 big problems that emerged: (1) instrumentation/vision limitations, and (2) a lack of training opportunities. In this era, laparoscopic was a real thing in urology. However, we were still operating with nonarticulating instruments with vessel sealing technologies limited to monopolar and bipolar. As demonstrated in Figure 1, the monopolar scissor could dissect well but could not handle larger vessels. In addition, the entire metal collar of the instrument was hot, and many surgeons described complications where bowel would get too close to the instrument and suffer a thermal injury. These complications really limited training opportunities until advances like the LigaSure would allow the safer sealing of larger vessels with protection of surrounding structures. Surgeons still had to learn how to operate on 2D cameras, and learning curves were long. There were actual narratives ongoing at the time that if urology did not fix the training and roll out MIS in the field, general surgery experts in MIS would start migrating into our turf. More than a handful of surgeons such as myself, Matt Gettman (Minnesota), and Jim Porter (Washington) all improvised various training rotations in Europe to navigate the difficult learning curves. There were only a few fellowships with high volume MIS training, and they could only train 1 to 2 a year each.

Figure 1. Early laparoscopic instrumentation advances. A, The simple laparoscopic scissors were useful, but the entire metal tip and collar were included in the monopolar current and adjacent organ injury could occur. B, The LigaSure instrument allowed for the sealing of larger vessels and the surrounding metal was not part of the current, which improved the safety profile of the procedures.

And then “The Robot”…

There were some precursors to modern robots. One was called Aesop, which was a single-arm robot that held a laparoscopic camera and could move with manual control or voice-activated commands. This certainly took a lot of the camera shake out of the operation from asking a medical student or junior resident to hold it in an uncomfortable position for several hours. Later, that company built a full-scale robot called Zeus that added a 3D open frame console and multiple arms. Da Vinci launched at that time and by comparison looked like a massive footprint to have in the operating room compared to Zeus. The companies spent a lot of time in litigation against each other before merging and marketing the original da Vinci platform. Of note, there was another fun narrative that was commonly described at meetings: the robot as a learning tool but not the end product. Many laparoscopic experts thought the robot would be good for beginners but that over time, they would gravitate back to laparoscopy.

Figure 2. At Intuitive Surgical headquarters, they display their chronology of robotic platform arms from the various systems. Over the course of robotic platform and instrument upgrades, surgeons have access to longer instruments, articulating tips, and a library of different possibilities for cutting, grasping, sealing, and dissecting.

Most current surgeons and residents know the benefits of robotics well at this point and can understand how laparoscopy is less utilized. Overall, the robotic platform solves multiple needs that came out of the preceding laparoscopic era, including (1) 3D vision, (2) better surgeon ergonomics, (3) better/safer instrumentation with articulation (Figure 2), (4) faster operating room times, (5) reduced learning curve, and (6) a more successful roll out of technology into routine practice. With this platform, many pioneers in robotics could tackle a large range of urologic procedures and optimize what the laparoscopic pioneers dreamed of 10 years before—effective surgery with faster recovery.