Robot-Assisted Surgery in Urology: The Show Must Go On

Initially, robot-assisted surgery (RAS) was developed by the USA forces as a tele-surgery tool in order to perform procedures in war zones without endangering the surgeon [...]

Concerning kidney surgery, RAS provides no advantages with respect to laparoscopy when radical nephrectomy should be performed. Conversely, for partial nephrectomy that is the gold standard treatment of T1 renal tumor, RAS has significant advantages with respect to laparoscopy. Recently Leow et al. performed a systematic review of the literature and meta-analysis and they found robotic partial nephrectomy decreased complications, conversions to open, positive surgical margin and ischemia time [7]. During partial nephrectomy it can be necessary to induce a renal ischemia and the length of ischemia time is a key point for possible postoperative renal damage. Nevertheless, many different laparoscopic techniques of partial nephrectomy are reported in the literature and it has now been demonstrated that in some cases renal ischemia could be carried out only on demand [8]. Conversely, in robotic partial nephrectomy the ischemia time is always applied. However, postoperative renal damage may be due to the quantity of preserved healthy parenchyma. Although there are no trials evaluating the possible relation between the type of suture, remaining healthy tissue, and postoperative renal function, we feel that RAS can perform a more accurate suture of resection bed with respect to laparoscopy and this could reduce the damage of preserved healthy tissue.
Similarly, we believe that the accuracy of the robotic suture can improve the functional outcome of the pyeloplasty with respect to laparoscopy. Robot-assisted pyeloplasty has shown excellent results with a success rate ranging from 94 to 100%. However, Autorino et al. performed a recent systematic revision of the literature and meta-analysis comparing clinical outcomes of 277 robotic pyeloplasties with 196 laparoscopic ones. The authors found no significant differences between the two procedures except shorter operative time for the robotic technique [9].
Concerning adrenal surgery, the laparoscopic approach is the standard procedure. Nevertheless, many trials showed exciting results when the adrenalectomy was performed using the robotic technique. We feel that RAS is very useful to perform both radical and partial adrenalectomy thanks to the magnification of the operative field and a more accurate dissection. These advantages allow more careful detection of the adrenal vascular pedicles, as well as identification of the cleavage plane between the tumor and healthy tissue [10]. A recent meta-analysis comparing the traditional and robotic or laparoscopic adrenalectomy, showed a reduction of blood loss and length of hospitalization with RAS [11].
In conclusion, because of the increasing diffusion of RAS and the continuous technological innovations in the urological field, indications for the applications of RAS will be further extended. Recently, many studies reported the safety and feasibility of robotic treatment of metastasis, paraganglioma, colovesical fistula, retroperitoneal lymph nodes as well as robotic renal transplantation [12][13][14][15][16]. Mostly in the field of uro-oncology, the future perspective will be to reach an earlier diagnosis of urological tumors due to the development of new and more accurate biomolecular markers [17][18][19][20][21]. Therefore, an early diagnosis helps to treat a greater number of localized masses by less destructive surgery such as RAS and likewise oncologically safe.

Conflicts of Interest:
The authors declare no conflict of interest.