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Robots have been defined as “a reprogrammable, multifunctional manipulator designed to move materials, parts, tools, or specialized devices through various programmed motions for the performance of a variety of tasks” by the Robot Institute of America. Websters’ English dictionary describes robots as “an automatic apparatus or device that performs functions normally ascribed to humans or operates with what appears to be almost human intelligence.” These definitions encompass three levels of functionality—the ability to perform defined maneuvers, the ability to perform such tasks in a preprogrammed order, and the ability to interpret and modify responses to commands, based on experience and learning.

Surgery has evolved from the 19th century through the introduction of ether anesthesia, principles of antisepsis, and the formalization of surgical training. In the late 20th century, the introduction of laparoscopy and robotics has continued to evolve the practice of surgery. The computer revolution has affected all of our lives. Computers affect the surgeon’s interaction with the patient and the mechanics of tissue manipulation. At present time, a multitude of devices are available to assist, to interact, and to perform tasks in concert with the surgeon to complete the operation. The computer revolution compliments, and has added to, the development of robotic technology. This chapter will review the development of robotic surgical systems and instrumentation, the benefits they offer over conventional laparoscopic surgery, and the future of robotic technology.

A paradigm change in the approach to the surgical patient began in 1987 when Mouret performed the first laparoscopic cholecystectomy. Since then, laparoscopic minimally invasive surgery has been utilized to perform a wide variety of procedures that encompass many surgical specialties. However, limitations in the instrumentation prevented the widespread application of laparoscopic techniques for more complex and reconstructive procedures. Intuitive Surgical Inc. (Sunnyvale, CA) and Computer Motion (Santa Barbara, CA) were the initial companies that developed the technology for robot-assisted surgery, attempting to overcome the limitations of traditional laparoscopic techniques. The first robots were utilized merely as laparoscopic assistants; however, with advancing technology, robots became more widely utilized as critical components of minimally invasive procedures. Contemporary robotic systems offer unparalleled magnified three-dimensional (3D) vision and the robotic instruments are more precise and dexterous than the human hand.

Rapid technological developments in the past decades have produced new inventions, such as robots, and incorporated them into our life. Today, robots perform vital functions in homes, outer space, hospitals, and military installations. Surgical robots have come to the forefront of the market in the past few years, and have started to occupy both space and time in operating rooms in numerous medical centers in United States and overseas. In addition, new robotic urologic surgical applications and techniques are being developed and reported everyday. This chapter briefly reviews the use of robotics in surgery, focusing on its specific applications in urology.

The first successful report of a laparoscopic nephrectomy was in 1991, and just one year later Schuessler, Kavoussi, and Clayman (largely the same group responsible for laparoscopic nephrectomy) reported the first laparoscopic radical prostatectomy (LRP). The continued development of LRP moved across the Atlantic Ocean when, in 1999, two groups in Paris reported fairly large series. These groups had persevered and conquered the difficult learning curve of paving the way for the rapid advancement of this technique. Interestingly, LRP remains more vigorous in Europe and only a small number of American centers have embraced this technique. The group at Henry Ford Hospital stalled in their quest to establish a pure laparoscopic program and subsequently transformed into the first large-scale robotic-assisted laparoscopic radical prostatectomy (RLP) program using the da Vinci® robotics system (Intuitive Surgical Inc., Sunnyvale, CA).

Debates about a preferred surgical approach are not new for radical prostatectomy nor limited to this surgical procedure. The relative merits of retropubic versus perineal radical prostatectomy have been considered and discussed for over 50 years and each approach still has its proponents. Pure laparoscopic and robotic-assisted laparoscopic prostatectomy (RALP) are now not only feasible but widely practiced, further expanding the options and debate.

Robotic prostatectomy is hard to learn but easy to do. Good judgment comes from experience and experience comes from bad judgment. Many surgeons have heard this aphorism and understand its truth. It is self-evident that adequate training can and should take the place of the bad judgment that comes from inexperience. What constitutes an adequate training experience will depend on many factors and is likely to vary from institution to institution. In this chapter, we will discuss our philosophy of and experience with training in robotic surgery at the Vattikuti Urology Institute (VUI). This has developed and evolved over the almost 2400 robotic-assisted procedures, including radical prostatectomy, radical cystectomy, radical and partial nephrectomy, performed by our surgical teams.

Robotic surgery is rapidly gaining popularity throughout the United States. Increasing numbers of hospitals are offering robotic procedures for a variety of indications. Surgical patients, especially those considered higher risk, benefit from the minimally invasive nature of robotic surgery.

The advancement of surgery into the digital and computer-assisted era has generated a new amalgamation of known anesthetic challenges. This chapter is designed to provide both surgeons and anesthesiologists with a quick reference, guiding optimal peri-operative care in patients receiving robotic urologic surgery. In addition, information critical to ensuring patient safety when utilizing computer-assisted surgical techniques is discussed.

Advances in robotic-assistedlaparoscopic surgery have exponentially increased since the introduction of the da Vinci® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA). “Robotic” surgery has become more prevalent in many centers of surgical excellence around the world. The radical retropubic prostatectomy for treatment of prostate cancer has become a focal point of experience for robotic-assisted operations in the pelvis. The most common robotic-assisted renal operation has been the dismembered pyeloplasty. Although necessary long-term follow-up of these procedures has not yet been achieved, it is becoming increasingly apparent that robotic technology is changing the standard of care for complex urologic procedures. In this chapter, we describe logistical issues pertaining to patient positioning for these two most commonly performed urologic operations. Emphasis will be placed on patient and staff safety issues, ergonomics, and optimizing surgical exposure.