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There is a growing need to bring together endourological approaches and sound oncological principles to achieve minimally invasive cancer control in urologic malignancies. Reduced treatment morbidity and quality-of-life issues are becoming more valued by both patients and physicians. In this chapter, we present an overview of the most recent advances in endoscopic, laparoscopic, and energy-based ablation techniques for the treatment of upper-tract transitional-cell carcinoma, renal-cell carcinoma, prostate cancer, adrenal tumors, and germ-cell testicular tumors. The merge between endourology and urologic oncology will undeniably revolutionize our approach to urologic malignancies.

Surgery in the 21st century will use advanced technologies such as surgical robots, three-dimensional medical imaging, computer graphics, computer simulation technology, and others. Three-dimensional medical imaging for surgical operations provides surgeons with advanced vision. A surgical robot provides surgeons with an advanced hand, but it is not a machine to perform the same action of a surgeon using scissors or scalpels. Recently, two new systems were developed in Japan: an advanced vision system called integral videography (IV), which can project a full-color three-dimensional video image in real three-dimensional space, and a novel robotic endoscopic system using two wedge prisms at the tip, which can observe a wide area without moving or bending the endoscope. As an advanced hand, a high-safety navigation robot of the laparoscope and a forceps manipulator with a bending mechanism have also been developed in Japan. The advanced vision and hands available to surgeons are creating new surgical fields in the 21st century: minimally invasive surgery, noninvasive surgery, virtual reality microsurgery, telesurgery, fetal surgery, neuroinformatics surgery, and others.

Robotic urologic surgery is an interesting and new development in the field of urology that has tremendous possibilities for progress in the future. Reports from various centers worldwide of complex urologic procedures in humans performed with robotic assistance have documented their safety, efficacy, efficiency, and feasibility. This review attempts to define the incorporation of robotics into laparoscopic urologic surgery and also reflects on our experience with over 900 cases of robotic surgery. Most of the recent reports pertaining to robotic surgery have been in the domain of localized cancer of the prostate (radical prostatectomy), bladder cancer (radical cystectomy and urinary diversion for muscle-invasive bladder cancer), kidney surgery (nephrectomy, donor nephrectomy, and pyeloplasty), and adrenal surgery. There are also reports in other areas of urology such as male infertility.

Urology has continuously embraced novel technologies, such as shockwave lithotripsy, lasers, and laparoscopy, that reduce patient morbidity yet maintain an excellent standard of care. To potentially increase the clinical applicability of laparoscopy, robots that enhance operative performance have recently been introduced for a variety of laparoscopic procedures, such as laparoscopic radical prostatectomy, pyeloplasty, and nephrectomy. Although the introduction of robotics has generated excitement, its benefits in large series of patients remain largely unknown. In this review, we mainly focus on one of the available robotic systems, the ZEUS system, and describe its features, including its advantages and limitations. We also review the emerging clinical applications of the ZEUS robotic system, including our recent cases of laparoscopic radical prostatectomy assisted by ZEUS, and the future potential of robotics in urology.

Laparoscopic surgery is the most commonly practiced and accepted form of minimally invasive surgery. Laparoscopic surgery in urology has, in many instances, become the standard of care. However, laparoscopy is associated with a steep learning curve because of its complexity and difficulty. This learning curve causes long operative times and potentially increases operative complications. Interestingly, to date there are no formal credentialing guidelines. Telesurgery has become feasible with the advent of recent Internet and robotic technology. This new technology has applicability within urology, as it enables an expert laparoscopic surgeon to mentor an inexperienced surgeon from a remote location. In this article, we review the background to current telesurgical research and describe experiences, with emphasis on the current status of this technology within urology. Telesurgery is feasible and may play a major role within urology. Although the utility of this technology is apparent, especially within minimally invasive approaches, barriers such as technical limitations and legal implications may hinder its progress and eventual acceptance. Urologists standing at the beginning of the twenty-first century should be cognizant of the eventual implementation of this technology.

Urology is increasingly becoming a technology-driven specialty. With advancing technical expertise and a shift towards minimal invasion in urologic procedures, urologists are looking for ways to improve patient care using robotic and telerobotic surgical systems. Percutaneous renal access is a procedure that is ideally suited to telerobotic control, as it is a complicated task that requires precise control of the access needle through accurate initial placement and insertion without deviation. The URobotics laboratory at Johns Hopkins has developed a system for image-guided percutaneous access. An active and radiolucent needle driver, PAKY (percutaneous access to the kidney), was designed and constructed. This was then combined with the remote center of motion (RCM) robot to enable needle orientation. We describe the development of this robotic percutaneous access system from the initial laboratory trials through local clinical applications to a sequence of transatlantic telerobotic trials that have statistically proven the increased accuracy of the robot over the human hand. This has provided strong qualitative and quantitative data to support remote percutaneous renal access and telerobotic surgery in general.

We review our early experience with radiofrequency (RF) ablation of malignant renal tumors. Sixteen malignant renal tumors in 12 patients were treated. These tumors included 15 renal-cell carcinomas (RCCs) and one metastatic tumor of the retroperitoneal leiomyosarcoma. Tumor size ranged from 7 to 35mm (mean, 24mm). No tumor had a cystic component. Thirteen tumors were exophytic, and the other 3 tumors showed parenchymal localization. All procedures were performed with computed tomographic (CT) fluoroscopic guidance in an Interventional CT System Suite in our hospital. On the basis of the size and location of the lesion on CT scans, overlapping ablations were performed by repositioning the needle to ablate the entire tumor. In one patient whose RCC was incidentally discovered during the survey of metastatic lesions of esophageal carcinoma, transcatheter arterial chemoembolization of RCC was performed before the start of radiotherapy and chemotherapy of the esophageal carcinoma. Technical success was defined as the absence of enhancement in any area of tumor on CT or magnetic resonance (MR) images. In 15 of 16 tumors (94%), technical success was achieved. We could not achieve a complete ablation in one RCC of parenchymal localization adjacent to the renal sinus. No patient showed significant renal dysfunction after RF ablation procedures. Complications, including macro- or microhematuria, subcapsular hematoma, and pneumothorax, required only conservative observation, and all were resolved without any treatment. RF ablation for renal malignant tumor is a minimally invasive and effective treatment.

The conviction that the presence of a renal-cell carcinoma does not require the entire organ to be removed allows new therapeutic methods to be envisaged that involve only local tissue ablation, rather than the complete removal of the organ. The trend toward minimally invasive options in the management of renal tumors has prompted interest in energy-based ablation techniques as a possible alternative to radical or partial nephrectomy in selected patients. Cryoablation, radiofrequency interstitial tumor ablation, microwave thermotherapy, and high-intensity focused ultrasound (HIFU) are among such techniques. HIFU has emerged as the least invasive of the possible tumorablation methods. The present review addresses the current literature on experimental and clinical application of HIFU for extracorporeal thermoablation of renal tumors.

We evaluated 85 patients with localized prostate cancer treated with high-intensity focused ultrasound (HIFU) for biochemical disease-free rate, safety, morbidity, and predictors of biochemical outcome. A total of 85 patients underwent HIFU with the use of Sonablate and with at least 12 months of followup. The median age was 70 years (range, 54 to 86 years), and the median preoperative prostate-specific antigen (PSA) level was 10.9 ng/ml (range, 3.39 to 89.6). The median length of follow-up was 20 months (range, 6 to 56). Biochemical failure was defined according to the criteria recommended by the American Society for Therapeutic Radiology and Oncology Consensus Panel. Biochemical failure developed in 27% (23/85) of the patients. The biochemical disease-free survival rates at 3 years for patients with pretreatment PSA less than 10 ng/ml, 10.01 to 20.0 ng/ml, 20.01 to 30.0 ng/ml, and more than 30.0 ng/ml were 97%, 75%, 33%, and 0%, respectively. Final follow-up sextant biopsies showed 91% (77/85) of the patients to be cancer free. Fifteen patients (18%) developed a urethral stricture, 3 patients (4%) underwent transurethral resection of the prostate for prolonged urinary retention or urethral stricture, 2 patients (2%) developed epididymitis, and 1 patient (1%) developed a rectourethral fistula. Twenty-eight percent (18/25) of the patients complained of postoperative erectile dysfunction. Accordint to multivariate analysis, preoperative PSA ( < 0.0001) and Gleason score ( = 0.0466) were significant independent predictors of time to biochemical recurrence. In conclusion, HIFU therapy appears to be a safe and efficacious minimally invasive therapy for patients with localized prostate cancer, especially those with a pretreatment PSA level less than 20 ng/ml.

With the widespread use of imaging modalities, the majority of renal tumors are incidentally detected as small masses. Although these small tumors have been traditionally treated with radical nephrectomy, partial nephrectomy has recently become accepted as a nephron-sparing surgery (NSS). In the stream of minimally invasive therapy (MIT), laparoscopic partial nephrectomy has been established, but some problems, such as bleeding, urine leakage, and A-V shunt, still remain after the operation. Currently, energy ablation therapies with some approaches are evaluated to manage small renal-cell carcinomas. Ablation therapy, combined with MIT and NSS, is a potential new-generation therapy. Among the various ablation therapies, cryosurgery is the most notable for its high local control rates in initial clinical studies. In this review, the principles of cryoablation and the initial clinical results of renal cryoablation are assessed and our clinical experience with renal cryoablation are reported. Renal cryoablation appears to be a safe and effective minimally invasive alternative for the treatment of small renal masses. However, careful selection of patients with lesions that are less than 3 cm in diameter and close monitoring of the iceball are necessary for successful treatment, and long follow-up is also mandatory for final establishment.