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Robotic Renal Surgery
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Robotic Renal Surgery
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Almost all the development of Robotic surgery has been in pelvic cancer, either for removal of prostates (radical prostatectomy) or bladders (radical cystectomy). There has been almost no development in renal surgery apart from that of my unit at St George's hospital in London.
I was one of the early adopters of the Robotic approach to Partial Nephrectomy in the UK . The popularity of the robotic approach has increased considerably as the enhanced dexterity and maneuverability of the "wristed" instruments have made the excision of the tumour and subsequent reconstruction (all done under considerable time pressure whilst the blood vessels are clamped) easier than pure laparoscopy.
I have been one of the pioneers in robotic renal surgery in the UK and interestingly feel that the place of robotics is more suited to Partial Nephrectomy than Total Nephrectomy.The capability of the fine dissection afforded by the robot is not as important in total nephrectomy as it is an operation where only "removal" of a whole organ takes place , with no reconstruction needed. Hence the pure laparoscopic approach is perfectly adequate and the greater expense of robotics, with no specific gain for the patient (in this particular operation) probably doesn't justify the routine use of robotics in nephrectomy.
Therefore as the advantages are not as profound when comparing to Partial Nephrectomy and Pyeloplasty and hence I tend to decide whether to do the nephrectomy robotically versus laparoscopically on an individual and clinical basis.
In this operation the kidney, whole ureter and a cuff of bladder (into where the ureter inserts into the bladder) is removed. I have also started routinely using a robotic approach for this method. Due to anatomical considerations most laparoscopic surgeons remove the kidney with laparoscopy but remove the lower ureter with open surgery. This is where robotic surgery has the advantage as it is very feasible to perform the dissection of the lower ureter and bladder using the familiar approach that one is used to with pelvic surgeries like prostatectomy/cystectomy.
This is reconstructive operation where the obstructed upper ureter is excised and opened up to facilitate free drainage of urine from the kidney. This is a benign condition where there is a narrowing in the upper ureter where it meets the kidney. Robotic surgery has proved to be ideal for this procedure as the surgery requires complex suturing, a maneuver which is made considerably easier and more precise with the articulation and magnification of the instruments.