The Evolution of Microsurgery in Urology
Since the 1970s, there have been significant developments in urologic microsurgery. Silber introduced the operative microscope for urological procedures. Belker reported improved outcomes for vasovasostomy due to increased optical magnification with the microscope. The use of the microscope did bring with it the need for a stable platform for the surgeon to either stand or sit at the patient bedside while operating under the microscope. This led to the development of unique chairs, supportive armrests and other devices to help support and stabilize the surgeon's arms at the bedside. This was a new skill set compared to operating with simple optical loupes.
Abbou et al. first reported the use of robotic assisted laparoscopic radical prostatectomy in 2000 to help alleviate some of the surgeon fatigue and technical limitation issues of laparoscopy. As robotic assisted laparoscopic procedures became more widespread, the potential for using this platform for robotic assisted microsurgery was also explored in animal studies.[10,11] These studies were then followed by early human trials.[12–14] Further exploration of the use of this platform in larger studies are ongoing.
The da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA) is currently the only commercially available FDA approved system for urological procedures. As of October 2013, more than 2,500 systems have been installed in over 2,000 hospitals worldwide. The latest version of the system features a high-resolution 3-D view (with up-to 10–15× magnification) and three robotic instrument arms. These instruments are capable of six degrees of freedom, thus mimicking the surgeon's hand, wrist and finger movements with 180° articulation and 540° rotation. It allows the surgeon to rotate an instrument to a greater degree than the human hand and provides some new maneuvering capability in microsurgery. The robotic instrument arms also eliminate physiologic tremors and provide motion scaling. The surgeon console provides a comfortable, ergonomic interphase to minimize surgeon fatigue. Having an extra third robotic instrument arm also allows the surgeon to control one additional instrument and be less reliant on the surgical bedside assistant. This extra arm can also hold adjunctive imaging or sensing tools such as a Doppler ultrasound probe and provide additional real-time inputs to aid the surgeon.
The surgeon console is also supported by specialized imaging software called TilePro (Intuitive Surgical Inc., Sunnyvale, CA, USA). This allows the surgeon to have up to three simultaneous real-time visual inputs in the console. These additional simultaneous image inputs could be a real-time Doppler ultrasound image to identify vascular structures and/or a real-time view from an optical phase-contrast microscope to evaluate seminal fluid or testicular tissue for any sperm. This multi-view ability provides the surgeon with an aircraft cockpit like experience with multi-simultaneous imaging/sensing data. Well experienced micro-surgeons (Goldstein M: an expert microsurgeon and flight surgeon) have previously commented on the similarity of the hand-eye coordination among performing microsurgery and flying high-performance aircraft between 50 and 500 feet at 500 knots. It would only seem intuitive, that robotic assisted microsurgery would only further bridge these similarities.
Transl Androl Urol. 2014;3(1):102-112. © 2014 AME Publishing Company