Robotic surgical approach in limited access anatomical areas

Abstract

The implementation of robotic surgery in the urological practice was extremely fast due to the advantages offered by this technology, advantages that outweigh the difficulties of the surgical techniques. Some of the challenges of the urological surgeries are the result of the limited access areas. Moreover, the surgery of the male pelvis (which is very narrow) is very difficult because the surgical gestures that are of great importance for the functional outcomes of the patient (urinary incontinence, erectile dysfunction) are performed in a limited access area. Also, the surgery of the retroperitoneum implies access in a narrow space in order to perform plastic or reconstructive interventions that involve the great abdominal blood vessels. Our aim was to evaluate the robotic surgical approach when performing urologic surgeries in limited access areas like the pelvis (radical prostatectomy, radical cystectomy) and the retroperitoneum (partial nephrectomy, radical nephrectomy, pyeloplasty). From a technical point of view, we evaluated the positioning of the trocars, the alignment between the trocars for the camera and for the instruments, the positioning of the trocar for the assistant surgeon, the conflicts between the robotic arms or between the robotic arms and the assistant surgeon’s instruments. The technical aspects were reported to the perioperative and postoperative parameters in order to evaluate the way in which the technical difficulties influence the surgical technique. For the retroperitoneal approach, we used 5 trocars with a particular type of positioning, developed at the Robotic Surgery Center in Cluj-Napoca. The final aspect of the positioning of the robotic trocars is triangular shaped, which offers a generous movement space for them, but also for the assistant surgeon. There were no conflicts between the robotic arms and none of surgeries required conversion. The hospital stay varied depending on the complexity of the procedure. The robotic surgery has well-known technical advantages, but it also shows improvement for the access in limited areas, like the male pelvis and the retroperitoneum. Using the robotic approach and a well studied trocar positioning, the surgeon is able to perform very complex maneuvers without difficulties due to the limited access and without altering the perioperative and postoperative outcomes.