Hubert John

Peter Wiklund
Editors

Robotic Urology

Third Edition

123
Robotic Urology
Hubert John • Peter Wiklund
Editors

Robotic Urology

Third edition
Editors
Hubert John Peter Wiklund
Department of Urology Department of Urology
Kantonsspital Winterthur Karolinska Institutet
Winterthur Stockholm
Switzerland Sweden

ISBN 978-3-319-65863-6    ISBN 978-3-319-65864-3 (eBook)

https://doi.org/10.1007/978-3-319-65864-3

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For our loved children Flurina, Wim, and Martin
Your fathers Hubert and Peter
Foreword

Surgery has been the mainstay of medical treatment for a large number of
diseases. Approximately 100 years ago, many patients undergoing pelvic or
abdominal surgery died from the intervention due to a lack of medical tech-
nology. It was only in the last four decades that we have achieved the highest
standard of surgical interventions through better delineation of the disease,
better selection of patients, and an enormous improvement in medical tech-
nology. The current third edition of Robotic Urology is a good example of
the rapid developments in surgical technology. Robotic urology is also an
excellent example: improving surgical results with less invasive and still
enabling interventions with the same or even better quality and reduced bur-
den for both the patients and the treating physicians. The origination of urol-
ogy on the other hand has been the invention of the Nitze cystoscope in
1879. Since then urology has always been at the forefront of minimalization
of interventions. It’s no wonder therefore that robot-assisted pelvic and ret-
roperitoneal surgery was initially adopted and further developed in urology.
We have seen, however, that robotic urology does not mean that the robot
takes over the entire work from the surgeon. The current versions are intel-
ligent assistance systems that do whatever the surgeon wants it to do. Despite
the best vision, highest precision and smooth movements of the hands, it is
still the urologic surgeon who will be responsible and instrumental for the
good outcome. A good robotic surgeon must be trained. Part of the training
involves traditional skills such as indication and timing of an intervention as
well as knowledge of the respective anatomy. A robotic surgeon must also
have a deep knowledge of the technology he or she is working with and
develop the power of imagination to use all the capabilities of intelligent
surgical assistance. The current book is a perfect reference manual for both
newcomers and experienced surgeons starting or perfecting robotic
urology.

Tübingen, Germany Arnulf Stenzl

vii
Preface

Hubert John and Peter Wiklund on the Rotspitz, 2517 meters above sea level in the Swiss
Alps deciding to start the 3th edition of “Robotic Urology”

Urology is a technology-driven speciality and has traditionally integrated

new minimally invasive approaches at an early stage. Fifteen years ago in
2002 when both editors began routine robotic urology, it was unexpected
that this master-slave telesurgery system would dramatically change opera-
tive urology in the following decade. The shift developed in pace with the
availability of robotic systems from open to robotic technology on one side
and from conventional laparoscopy to robot-assisted laparoscopy on the
other side.
In 2004 about 8% of radical prostatectomies were performed robotically
in the USA—in 2015 over 85%. At the same time renal and adrenal robotic
surgery developed, especially partial kidney resections. Laparoscopic ure-
teral and reconstructive surgery in the pelvis migrated to robotic procedures
and included ureteral reimplantation, vesicovaginal fistula, sacrocolpopexy,
and many more. Even robotic radical cystectomies with intracorporeal uri-
nary tract reconstruction are embedded in the routine of distinct centers.
Increasingly open procedures were systematically adapted to the robotic
approach with the inevitable benefits of decreased blood loss, fewer compli-
cations, and faster recovery. While some procedures are completely stan-
dardized, others are still under evaluation. In 2016 over 750,000 robotic
procedures were performed with the daVinci® system worldwide, indicating
that a step back from robotics to open or conventional laparoscopy is pres-
ently unthinkable. Challenging laparoscopic interventions have been brought

ix
x Preface

to a broad spectrum of urologists and patients are profiting worldwide. This

third edition, following those in 2007 and 2013, is therefore very timely. The
authors have again invested great effort and personal experience in order to
support other robotic teams around the world. The book highlights the stan-
dards of robotic urology today and shows promising new techniques and
ideas. We are delighted that this edition has come to a fruitful conclusion
within one year of hard work.
Our thanks go to Melissa Morton and André Tournois from Springer
London and Kevin Horton in Winterthur for their great editorial assistance.
We are especially grateful to our families for their support and tolerance of
our high professional workload.
We thank everybody for their motivation as well as for their criticism in
the past—all of you have brought forward the vision of less invasive urology
with equal or better oncological and functional results.
A dream became reality; pioneer work turned to standards!

Winterthur, Switzerland Hubert John

Stockholm, Sweden Peter Wiklund
Contents

Part I General Robotic Aspects

1 New Robotic Platforms���������������������������������������������������������������������� 3

Jens J. Rassweiler, Ali Serdar Goezen, Jan Klein,
and Evangelos Liatsikos
2 Anesthesiological Considerations During Robotic
Urological Surgery �������������������������������������������������������������������������� 39
Alan David Kaye, Elyse M. Cornett, Robert Donner,
Brendon Hart, and John Cefalu
3 Training and Education in Robotic Surgery:
Recommendations of ERUS (EAU Robotic
Urology Section) ������������������������������������������������������������������������������ 49
Alexander Heinze, Paolo Umari, Nicola Fossati,
and Alexandre Mottrie

Part II Kidney

4 Surgical Anatomy of Kidneys and Adrenals �������������������������������� 63

Ibrahim M. Karam, Alexandre Oliver,
and Jacques Hubert
5 Robotic Radical Nephrectomy�������������������������������������������������������� 71
Ronney Abaza
6 Partial Resection of the Kidney for Renal Cancer������������������������ 79
Paolo Umari, Alessandro Volpe,
and Alexandre Mottrie
7 Warm Ischemia During Robotic Partial Nephrectomy���������������� 95
Francesco Porpiglia, Daniele Amparore,
and Riccardo Bertolo
8 Fluorescence in Partial Nephrectomy������������������������������������������ 109
Nina Harke and Jorn H. Witt
9 Robotic Nephroureterectomy�������������������������������������������������������� 117
Mouafak Tourojman and Craig G. Rogers

xi
xii Contents

Part III Adrenal

10 Robot-Assisted Laparoscopic Adrenalectomy���������������������������� 125

Pascal Mouracade and Jihad Kaouk

Part IV Pelvis

11 Surgical Anatomy of Pelvic Lymph Nodes���������������������������������� 141

Martin C. Schumacher
12 Surgical Anatomy of the Bladder ������������������������������������������������ 149
Bastian Amend, Christian Schwentner, Karl-Dietrich Sievert,
and Arnulf Stenzl
13 Surgical Anatomy of the Prostate������������������������������������������������ 163
Arnauld Villers and Jochen Walz
14 Anatomical Aspects of the Neurovascular Bundle
in Prostate Surgery������������������������������������������������������������������������ 177
Prasanna Sooriakumaran, Gerald Y. Tan, Sonal Grover,
Atsushi Takenaka, and Ashutosh K. Tewari

Part V Bladder

15 Female Robot Assisted Radical

Cystectomy - Anterior Exenteration ������������������������������������������ 187
Ahmed A. Hussein, Youssef E. Ahmed, Zishan Hashmi,
and Khurshid A. Guru
16 Male Robot-Assisted Radical Cystectomy ���������������������������������� 195
Wei Shen Tan, Ashwin Sridhar, and John D. Kelly
17 Intracorporeal Urinary Diversion: Ileal Conduit ���������������������� 207
Isabelle S. Keller and Hubert John
18 Intracorporeal Urinary Diversion: Orthotopic Neobladder������ 213
Abolfazl Hosseini, Achilles Ploumidis, Prasanna Sooriakumaran,
Martin N. Jonsson, Christofer Adding, and Peter Wiklund
19 Technique of Extracorporeal Urinary Diversion������������������������ 221
Avinash Chennamsetty and Kevin G. Chan
20 Robot-Assisted Treatment of Bladder Diverticula���������������������� 231
Darko Kroepfl, Michael Musch, Heinrich Loewen,
Anne Vogel, and Inga Kunz
21 Neoadjuvant Chemotherapy in Muscle Invasive
Urothelial Bladder Cancer������������������������������������������������������������ 241
Günter Niegisch and Peter Albers
22 Consensus Views on Perioperative Management
of Robotic-Assisted Radical Cystectomy ������������������������������������ 249
J.W. Collins, A. Hosseini, and N.P. Wiklund
Contents xiii

Part VI Prostate

23 Robot-Assisted Simple Prostatectomy ���������������������������������������� 267

Christian Padevit and Hubert John
24 Trans- and Extraperitoneal Approach for Robotic-Assisted
Radical Prostatectomy������������������������������������������������������������������ 273
Marcus Horstmann, Stephanos Papadoukakis,
and Hubert John
25 Radical Prostatectomy: Anterior Approach�������������������������������� 289
Charles-Henry Rochat
26 Robotic Prostatectomy: The Posterior Approach ���������������������� 297
Randy Fagin
27 Bladder Neck Dissection During Robotic
Radical Prostatectomy������������������������������������������������������������������ 303
Thierry Piechaud and Filippo Annino
28 Techniques of Nerve Sparing in Robot-Assisted
Radical Prostatectomy������������������������������������������������������������������ 313
Travis Rogers, Gabriel Ogaya-Pinies, Hariharan
Palayapalayam Ganapathi, Eduardo Hernandez-Cardona, and
Vipul R. Patel
29 Antegrade Robot-Assisted Radical Prostatectomy:
Factors Impacting Potency Preservation ������������������������������������ 329
Thomas E. Ahlering, Anthony Costello, and Douglas
Skarecky
30 Experimental Techniques of Nerve Regeneration
in the Neurovascular Bundle�������������������������������������������������������� 343
Francesco Porpiglia, Riccardo Bertolo, Beat Förster,
and Hubert John
31 The Apical Dissection�������������������������������������������������������������������� 355
Walter Artibani and Giovanni Cacciamani
32 Posterior Reconstruction of the Rhabdosphincter���������������������� 363
Bernardo Rocco, Angelica A.C. Grasso, Elisa De Lorenzis,
Marco Sandri, and Giampaolo Bianchi
33 The Urethrovesical Anastomosis�������������������������������������������������� 375
Ahmed Ghazi and Jean V. Joseph
34 Anterior Reconstruction After Radical Prostatectomy�������������� 391
Francesco Porpiglia, Riccardo Bertolo, and Cristian Fiori
35 Radical Prostatectomy Through the Posterior
Technique���������������������������������������������������������������������������������������� 401
Antonio Galfano, Silvia Secco, Daniele Panarello,
Dario Di Trapani, Elena Strada, Giovanni Petralia,
and Aldo Massimo Bocciardi
xiv Contents

36 Radical Prostatectomy in Locally Advanced Prostate

Cancer �������������������������������������������������������������������������������������������� 411
Aldo Brassetti and Vito Pansadoro
37 Outcome Measures After Robot-Assisted Radical
Prostatectomy������������������������������������������������������������������������ 421
Kamaljot S. Kaler, Simone L. Vernez, Douglas W. Skarecky,
and Thomas E. Ahlering
38 Urinary Incontinence After Robot-Assisted Laparoscopic
Radical Prostatectomy������������������������������������������������������������������ 439
Kevin G. Chan and Timothy G. Wilson
39 Erectile Dysfunction and Penile Rehabilitation After
Robot-Assisted Radical Prostatectomy���������������������������������������� 455
Emanuele Zaffuto, Giorgio Gandaglia, Nicola Fossati,
Alberto Briganti, and Francesco Montorsi

Part VII Reconstructive Urology

40 Robot-Assisted Pyeloplasty ���������������������������������������������������������� 465

Giuliana Lista, Nicolò Maria Buffi, Davide Maffei,
and Giovanni Lughezzani
41 Robot-Assisted Laparoscopic Ureteral Reimplantation������������ 475
Jens Rassweiler
42 Robot Assisted Laparoscopy for
Genito-Urinary Prolapse �������������������������������������������������������������� 485
Dirk Kusche
43 Robot-Assisted Laparoscopic Repair of Supratrigonal
Vesicovaginal Fistulae with Peritoneal Flap Inlay���������������������� 491
Michael Kurz and Hubert John
44 Robot-Assisted Ventral Inverted YV-Plasty
for Recurrent Bladder Neck Stenosis������������������������������������������ 497
J. Brachlow and H. John

Part VIII Male Genital Tract

45 Robot Assisted Vaso-Vasostomy and Inguinal

Varicocele Repair �������������������������������������������������������������������������� 507
Georges A. de Boccard

Part IX Complications

46 Vesicovaginal Fistula: Epidemiology, Diagnostics and Robotic

Assisted Repair with Peritoneal Flap Inlay �������������������������������� 517
Marco Randazzo, Christian Padevit, and Hubert John
47 Complications of Robotic Instrument Malfunctions������������������ 525
Ziho Lee and Daniel D. Eun
Contents xv

48 Complications of Robotic Oncologic Renal Surgery����������������   533

Andre Luis de Castro Abreu, Tania Gill,
and Giovanni Cacciamani
49 Complications of Robot-Assisted Radical Prostatectomy��������   547
Christian Wagner and Jorn H. Witt
50 Complications After Robotic Bladder Surgery������������������������   559
Stefan Siemer
Erratum to: Robotic Urology��������������������������������������������������������������   E1
Marco Randazzo, Christian Padevit, and Hubert John

Index�������������������������������������������������������������������������������������������������������� 571
 Part I
General Robotic Aspects
 New Robotic Platforms
1
Jens J. Rassweiler, Ali Serdar Goezen, Jan Klein,
and Evangelos Liatsikos

Introduction  istory of Robotic Devices

H
for Laparoscopy
Robotic surgery has been introduced successfully
to facilitate laparoscopic surgery including even It is really fascinating to review the early stages
radical cystectomy and urinary diversion [1, 2]. of robotic surgery in urology (Table 1.2).
However, this was accompanied by monopoly of
Intuitive Surgical [3, 4]. The company owns more
than 1500 patents regarding robotic surgery of ARTEMIS
which some of earlier patents will expire in fol-
lowing years (Table 1.1). This promotes new Buess and Schurr pioneered the first tele-surgical
manufacturers to introduce alternate devices laparoscopic porcine cholecystectomy in 1996
(Table 1.2). Recently, we updated significant using the ARTEMIS-System (Fig. 1.1). They
developments of robotic devices used for uro- started with a bedside version of a robotic arm
logic surgery and endourology [5, 6]. Based on [7]. The final device consisted of a user station
this, we want to focus on technical modifications representing an open console (master) and the
of upcoming devices with special emphasis on instrument station (slave). The surgeon used
future clinical applicability. polarized glasses for 3D–CCD-video-imaging
[8]. In 1996, Frederic Moll, co-founder of
Intuitive visited the Nuclear Research Centre in
Karlsruhe, Germany (A. Melzer, personal com-
munication). Despite various promising experi-
mental trials in abdominal and cardiac surgery,
the device never made it beyond the experimental
state [9]. Subsequently, all existing patents
J.J. Rassweiler (*) • A.S. Goezen expired (Table 1.2).
Department of Urology, SLK-Kliniken Heilbronn,
University of Heidelberg, Heidelberg, Germany
e-mail: [email protected]
ZEUS
J. Klein
Department of Urology, Medical School, University
of Ulm, Ulm, Germany ZEUS (Computer Motion, USA) represented the
first clinically used robot based on patents regis-
E. Liatsikos
Department of Urology, University of Patras, tered in 1999 (Table 1.1). The surgeon sat at an
Patras, Greece open console on a high-backed chair with arm-

© Springer International Publishing AG 2018 3

H. John, P. Wiklund (eds.), Robotic Urology, https://doi.org/10.1007/978-3-319-65864-3_1
 4
Table 1.1 Historical summary of the most relevant patents (modified from Rassweiler et al. 2017)
No Inventors Title Owner Registered Expired Comment
(a) Console-based robot-assisted laparoscopy
US5631973 A Green PS Method for SRI International, since 05.05.1994 05.05.2014 Basis of Da Vinci
telemanipulation with 7.5.2008 assigned by console technology,
telepresence the NIH designed for
battle-field surgery
US 5997471 Gumb L, Schaf A, Apparatus for guiding Nuclear Research 26.08.1997 24.12.2012 Basis of ARTEMIS
Trapp R, Buess G, surgical instruments for Centre Karlsruhe, due to failed Not commercially
Schurr M endoscopic surgery Germany payment of used
maintenance fee
US6436107B1 Wang Y, Uecker DR, Method and apparatus for Computer Motion, 03.03.1999 03.03.2019 Basis of ZEUS
Laby PK, Wilson J, performing minimally since 18.11.2004
Jordan C, Wright J, invasive surgical procedures assigned by Intuitive
Ghodoussi M Surgical
US6312435B1 Wallace DT, Rosa Surgical instrument with Intuitive Surgical 08.10.1999 08.10.2019 Endo-wrist
DJ, Moll FH extended reach for use in technology of Da
minimally invasive surgery Vinci-system
US6459926 B1 Nowlin WC, Repositioning and Intuitive Surgical 17.09.1999 17.09.2019 Basis of Da
Guthart GS, reorientation of master/ Vinci-system
Salisbury K Jr., slave relationship in
Niemeyer G minimally invasive
telesurgery
DE10314828B3 Braun M Surgical instrument Tuebingen Scientific 22.07.2004 22.07.2024 7DOF-instruments
Since 13.3. 2016 for TELELAP
assigned by SOFAR, ALF-X
Italy
US8506555B2 Ruiz Morales, E Robotic surgical system for EURATOM 02.02.2007 02.02.2027 Basis of TELELAP
performing minimally ALF-X manufactured
invasive medical procedures by Sofar
Aquired 2015 by
Transenterix
US20070123855A1 Morley T, Wallace Bipolar cauterizing Intuitive Surgical 09.02.2007 09.02.2027 Improvement for Da
D, Maurer C instrument Vinci S-system
J.J. Rassweiler et al.
 1

US20120265176A1 Braun M Surgical instrument with Tuebingen scientific 18.10.2012 18.10.2032 7DOF-instruments
elastically movable for TELELAP
instrument head ALF-X
US20130204271A1 Brisson G, Mohr Systems and methods for Intuitive Surgical 31.01.2013 31.01.2033 Control system of Da
PW, Nixon TR controlling a robotic Vinci XI
surgical system
US20150150636A1 Hagn, U, Passig G, Minimally invasive German Center for air 09.05.2012 09.05.2032 Basis for EINSTEIN
Lantermann S, instrument for robotic and space (DLR) (Patents from
New Robotic Platforms

Fröhlich F, Seibold surgery MIRO-DLR used by

U Medtronic-Covedien)
US20130165869A1 Blumenkranz SJ, Force sensing for surgical Intuitive Surgical 07.01.2013 07.01.2033 Option for Da Vinci
Larkin DQ instruments XI
US20150005784A2 Seeber M, Karguth Device for supporting and E-sys medical assigned 14.03.2013 14.03.2033 Basis of avatera
A, Trommer C positioning of a surgical 4.12.2013 by system
instrument and/or an Avateramedical
endoscope for use in
minimal-invasive surgery
and a surgical robotic
system
US 9307894 B2 Von Grünberg H, Endoscope comprising a E-sys medical assigned 18.03.2013 18.03.2033 Basis of avatera
Seeber M, system with multiple 3.12.2013 by system
Stolzenburg JU cameras for use in Avateramedical
minimal-invasive surgery Since 11.02.2016
Stolzenburg added to
inventors
US20140249546A1 Shvartsberg A, Apparatus and method for Titan medical 16.05.2014 16.05.2034 Basis of AMADEUS
Charles RA, Mc supporting a robotic arm RSS (development
Caffrey RJ, actually stopped)
Kennedy JJ
US20150157411A1 Choi SH Surgical robot system und Meere Company 5.12.2014 5.12.2034 Basis of REVO I
method for controlling This application claims platform a 4-arm
surgical robot system benefit of Korean system with console
Patent Application No.
10–2013-0152632, filed
on Dec. 9, 2013, in
Korean Intellectual
Property Office
(continued)
5
 6
Table 1.1 (continued)
No Inventors Title Owner Registered Expired Comment
US20150157410A1 Kilroy PE, Egan Hyperdexterous surgical SRI International 9.10.2014 9.10.2034 Basis for Taurus
TD, Shakespear system dexterous robot
Koenig K
(b) Console-based devices for robot-assisted laparo-endoscopic single-port surgery (LESS)
US8545515B2 Prisco GM, Gerby Curved cannula surgical Intuitive Surgical 13.11.2009 13.11.2029 VeSPA-system for
GR, Rogers TW, system robotic LESS
Steger JR
US8347754B1 Veltri JA, Schaible Multi articulating robotic Titan medical 30.06.2009 30.06.2029 Basis of SPORT
UD instrument
US20070299387A1 Williams M, Stack System and method for Synecor 12.05.2007 12.05.2027 Basis of spider
R, Orth G, Smith G, multi-instrument surgical Assigned 5.07.2010 by
Glenn R, Fifer D, access using a single access Transenterix
Athas W, port
US20110230894A1 Simaan N, Xu K, Systems, devices, and The trusties of 07.10.2009 0.7.10.2029 Basis of IREP
Goldman R, Allen P, methods for providing Columbia University in
Fowler D, Ding J insertable robotic sensory the City of New York
and manipulation platforms assigned 10.07.2012 by
for single port surgery NIH
FI2010A000076–77 Scarfogliero U, ARAKNES 1–3 Scuola Superiore 26.04.2010 26.04.2030 Basis of SPRINT-
Piccigallo M, Sant’Anna robot (Italian patent)
Quaglia C, European consortium
Tognarelli P,
Valdastri A,
Menciassi A, Dario
P
US20130304084A1 Beira R, Clavel R, Mechanical manipulator for Ecole Polytechnique 11.10.2011 11.20.2031 Basis of SPRINT-
Bleuler H surgical instruments Federal de Lausanne robot (US patent)
European consortium
(continued)
J.J. Rassweiler et al.
 1

US20130197697A1 Schaible U, Brocilo Force feedback system Titan Medical 25.10.2012 25.0.2032 Optional for further
D, Harmen J Titan Medical
devices
(AMADEUS,
SPORT)
US20150018841A1 Seo KH Surgical robot system and Samsung Electronics 27.03.2014 27.03.2034 Control unit (master)
control method thereof as basis for Kyung
Hee SR1 and single
New Robotic Platforms

port system
US20150366625A1 Tognaccini ME, Medical robotic system Intuitive Surgical 24.06.2015 24.06.2035 SP-system for Da
Gomez DH, Diolaiti providing an auxiliary view Vinci XI for LESS
N, Mustafa T, Mitra including range of motion
P, Liligan PE limitations for articulatable
instruments extending out
of a distal end of an entry
guide
WO2016057989A2 Jay W, Penny MP Electromechanical surgical Transenterix 12.10.2015 12.10.2035 Basis of Surgibot
system
7
 8
Table 1.2 Historical development of surgical robots for laparoscopy. Apart from ARTEMIS all used clinically (modified from Rassweiler et al. 2017)
Degree of freedom
Device and patents Telescope Console Robotic arms Force-feedback (DOF) Milestones
ARTEMIS (Nuclear 3D–CCD-technology 3D monitor with 2 cable actuated No 7 DOF 1996 first robotic device used
Research Centre controlled by camera- polarized glasses 3 robotic arms plus in experimental surgical
Karlsruhe, Germany) arm (joy-stick) joy-sticks with armrest camera-arm (FIPS) models. Designed for
mounted to OR-table abdominal and cardiac
surgery
ZEUS (Computer Motion 2D/3D–CCD- 2D/3D monitor with 2 motorized robotic No 4 DOF First coronary by-pass
aquired by Intuitive technology (voice polarized glasses or arms plus the voice surgery in 1999 including
Surgical) control) helmet and controlled camera arm harvesting of the left internal
microphone (AESOP) mounted to thoracic artery
2 handles (like OR-table 1999 first experimental
chop-sticks) robot-assisted pyeloplasty
2001 transcontinental
robot-assisted
cholecystectomy
(Lindbergh-operation)
2004 use abandoned
(Computer Motion acquired
by Intuitive Surgical)
Da Vinci 2000 (Intuitive 3D–CCD-technology 3D–montor with 2 cable-driven robotic No 7 DOF 1998 first robot-assisted
Surgical) (manipulated by the mirror technology arms plus the camera cholecystectomy
two handles activated Two handles (loops) arm First coronary by-pass
by foot-pedal) with Endowrist- surgery in 1999 including
technology foot-pedals harvesting of the left internal
for focussing, clutch, thoracic artery
camera, monopolar First robot-assisted
cautery laparoscopic radical
prostatectomy in 2000
J.J. Rassweiler et al.
 1

Da Vinci S (Intuitive 3D–CCD-technology 3D–montor with 2 cable-driven longer No 7 DOF Routine clinical use for
Surgical) (manipulated by the mirror technology robotic arms plus the robot-assisted radical
two handles activated Two handles (loops) camera arm, optional prostatectomy
by foot-pedal) with Endowrist- 4th arm for retraction
technology foot-pedals
for focussing, clutch,
camera, mono- and
bipolar cautery
New Robotic Platforms

Da Vinci SI (Intuitive 3D–HD-technology 3D–montor with 2 cable-driven longer No 7 DOF 2009 release of dual-console
Surgical) (manipulated by the mirror technology robotic arms plus the model da Vinci SI surgical
two handles activated Two handles (loops) camera arm, optional system
by foot-pedal) with 4th arm for retraction 2010 first use of VeSPA-
Endowrist-technology system for robotic single-port
Foot-pedals for surgery with only 4
focussing, clutch, DOF-instruments
camera, mono- and 2011 first use of infrared
bipolar cautery, fluorescence imaging using
finger-tip-switch for indocyanine green dye
individual clutching
Da Vinci XI (Intuitive 3D–HD-technology 3D–montor with 4 cable-driven thinner No 7 DOF 2014 used for robotic partial
Surgical) (manipulated by the mirror technology robotic arms with nephrectomy with improved
two handles activated Two handles (loops) additional joint each docking and minimal
by foot-pedal) with applicable as instrument clashing
Endowrist-technology camera-arm (8 mm) 2014 first clinical application
Foot-pedals for Laser crosshairs of SP-system for robotic
focussing, clutch, aligning the patient single-port radical
camera, mono- and cart with designated prostatectomy and partial
bipolar cautery, camera port nephrectomy
finger-tip-switch for In combination with 2016 introduction of
individual clutching Trumpf-medical 7DOF-instruments for the
OR-table no need to VeSPA-system for robotic
undock, when moving single-port surgery
the patients
(continued)
9
 10
Table 1.2 (continued)
Degree of freedom
Device and patents Telescope Console Robotic arms Force-feedback (DOF) Milestones
Da Vinci X (Intuitive 3D–HD-technology 3D–montor with 4 cable-driven thinner No 7 DOF 2ß17 CE-mark for this device
Surgical) (manipulated by the mirror technology robotic arms with mainly designed for hospitals
two handles activated Two handles (loops) additional joint each not focusing on general
by foot-pedal) with applicable as surgery
Endowrist-technology camera-arm (8 mm)
Foot-pedals for
focussing, clutch,
camera, mono- and
bipolar cautery,
finger-tip-switch for
individual clutching
TELELAP ALF-X/ 3D–HD-technology 3D–glasses and 3 cable actuated Yes 7 DOF (provided by 2015 experimental use for
SENHANCE (Sofar, Italy; (eye-tracking system) monotor with robotic arms plus Tuebingen robot-assisted nephrectomy
aquired by Transenterix, eye-tracking system telescope arm arranged scientific, Germany) 2016 first clinical application
US) special handles on 2 carts for robot-assisted
providing haptic hysterectomy based on
feedback CE-mark
2017 TELELAP ALF-X
renamed in SENHANCE
J.J. Rassweiler et al.
1 New Robotic Platforms 11

rests controlling instruments of two robotic arms experimental trials on robot-assisted pyeloplasty
by use of chop-stick-like handles [10]. The and clinical applications with pelvic lymph
robotic arms were mounted at the operating table node dissection [16, 17]. Following some legal
(Fig. 1.2) including the camera-arm AESOP, actions, the two companies announced in 2003,
which was controlled by the Surgeon’s voice that they were merging into one company [18].
[11]. Unfortunately, the instruments provided Consequently all further developments of ZEUS
only 4 degrees of freedom (DOF: jaw, pitch, (i.e. 7-DOF-instrumentation) and AESOP were
insertion, rotation). A 2-D or 3-D-videosystem stopped (Table 1.2).
(with head-mounted screens) was used for
­visualization of the OR-field. The ZEUS-system
was initially developed for cardiovascular sur- Da Vinci Series
gery [10]. However, the most impressive demon-
stration of ZEUS represented the transatlantic  a Vinci 2000
D
laparoscopic cholecystectomy (“Lindbergh- The da Vinci Surgical system (Intuitive Surgical,
procedure”) by Marescaux [12]. Although the Sunnyvale, United States) was based on studies
camera-arm AESOP found widespread applica- of SRI International (Menlo Park, USA), a non-
tion for laparoscopic urologic procedures [11, profit research institute, who developed a robotic
13–15], ZEUS was used rarely in Urology: in system for open surgery that caught interest of
the Defense Advanced Research Project Agency
(DARPA) due to its potential to operate remotely
a on soldiers wounded in the battlefield [19, 20]. In
1994, Frederic Moll became interested in the
SRI-system with the idea to use it for robot-
assisted laparoscopic surgery [21]. Even if some
of the previous patents regarding open tele-pres-
ence surgery date back to 1994 (i.e. 3D–mirror
technology), all principle patents for Da Vinci
2000 were registered in 1999 (Table 1.1).
Like ZEUS, the device was initially designed
for robot-assisted coronary artery surgery start-
ing clinically at the Heart Centre of Leipzig in
Germany after gaining CE-mark in 1999 [22]. At
b this time the tele-presence effect was much more
in the focus: When we visited the Heart Centre
early in the year 2000, the surgeon was sitting at
the console in a room next to the OR and all com-
mands were transmitted via a microphone. In
2000, Binder pioneered the first robot-assisted
radical prostatectomy in Frankfurt followed by
other European groups [23–26], here the console
was placed in the OR. In 2001, Menon et al.
achieved the breakthrough in urologic surgery
establishing a full-working clinical programme
Fig. 1.1 ARTEMIS. (a) First experimentally used device [27]. Subsequently, FDA approved the use of the
for laparoscopic telesurgery (Institute for Nuclear system for prostatic surgery.
Research Karlsruhe, Germany). In vitro-study of bedside
master-slave system using one robotic arm. (b) Finally
Already da Vinci 2000 addressed most ergo-
design of the robot with an open console, two manipula- nomic problems of classical laparoscopy suffi-
tors and 3D–videosystem ciently, such as limited depth perception,
12 J.J. Rassweiler et al.

b c

Fig. 1.2 ZEUS. Surgical device with voice-controlled system. (b) Three armes: voice-controlled camera-arm
camera-arm and two further robotic arms mounted on AESOP and two manipulators attached at the OR-table.
OR-table with laparoscopic instruments providing 4 DOF (c) Open console with off-line view and chop-stick-like
(Computer Motion, United States). (a) Overview of the handles to manipulate the 4-DOF-instruments

eye-hand coordination, and range of motion At the tip of the instruments, a cable driven
by introducing the Endo-wrist™-technology mechanical wrist (Endo-wrist™-technology)
(Fig. 1.3). Da Vinci provided a closed console adds three more DOF (including rotation) and
offering a 3D–CCD-video-system with in-line one motion for tool actuation (i.e. grip).
view. The cable-driven instruments with up to However, initially, the device had some limita-
seven DOF and loop-like handles enabled an tions: There were no bipolar instruments and the
ergonomic working position due to the clutch- range of motion of the robotic arms was reduced
mechanism [1, 28]. These slave manipulators providing only a three-arm-systems (Fig. 1.4).
(i.e. surgical arms) provide three degrees of free- In 2015 Intuitive Surgical abandoned the pro-
dom (i.e. pitch, jaw, insertion). The last elements duction and technical support of the first genera-
are the surgical instruments (i.e. end-effector): tion [6].
1 New Robotic Platforms 13

a b

c d

Fig. 1.3 Da Vinci 2000—first solution of ergonomic CCD-camera with mirror-technology providing in-line-
problems at console. (a) Master-Slave device with closed view on manipulators. (d) Foot-pedals for camera control,
console for surgeon (Intuitive Surgical, United States). (b) clutch, focussing of the lens, and mono-polar coagulation
Armrests and two loop-like handles for manipulation of (initially no bipolar instruments available)
7-DOF-instruments (Endowrist™-technology). (c) 3D–

 a Vinci S
D were registered in 2007, technical support for Da
Da Vinci S introduced clinically in 2006 provided Vinci S will end in December 2017 (Table 1.2).
better range of motion, longer robotic arms and
optional an HD-video-system respectively fourth  a Vinci SI
D
arm together with implementation of bipolar In 2009, the SI-system was launched offering
energy devices (Fig. 1.5). This allowed perform- integrated HD-videotechnology, finger-based
ing further procedures like robotic bladder diver- clutch-mechanism and isocyanine-green fluores-
ticulectomy [29] or even trans-axillary robotic cence (Firefly™-technology) [5, 31, 32]. The Da
thyroid surgery [30]. Although relevant patents Vinci Si dual console allows two surgeons to col-
14 J.J. Rassweiler et al.

a b

c d

Fig. 1.4 Da Vinci 2000—ergonomic problems for assis- arrows = Da Vinci-trocars). (c) Arrangement of two assis-
tant at OR-table. (a) Arrangement of robot cart and con- tants at the bedside, one has to use bipolar forceps. (d)
sole for cardiac surgery. (b) Trocar placement for Endoscopic view during apex dissection of prostate: two
robot-assisted laparoscopic radical prostatectomy (yellow robotic instruments assisted by the bipolar forceps

laborate during surgery representing an ideal and rectal robot-assisted laparoscopic surgery,
training platform (Fig. 1.6). Although proposed and might be also helpful during a partial
already in 2000 by Autschbach [33], it was real- nephrectomy. The robotic arms are finer to
ized clinically with introduction of Da Vinci SI minimize instrument clashing and the OR-table
(Table 1.2). Additionally, SI-system enabled the can be moved while the robotic arms are con-
use of VeSPA-system for robotic single-sport sur- nected. Additionally, the system can provide a
gery, however offering only 4 DOF-instruments feature in combination with a specific OR-table
[5, 34]. (Trumpf-Medical, Germany), which enables to
move the table without the need to undock the
 a Vinci XI
D arms [6]. This is very important for abdominal
In 2014, Intuitive Surgical launched the Da surgery requiring dissection in different quad-
Vinci XI-system (Fig. 1.7) enabling the 8 mm- rants (ie. colon-surgery, Whipple-procedure).
3D-HD-camera to be chosen liberally at all The design of the console is the same as for the
four ports. This feature is important for colonic SI-version (Fig. 1.6), but now it includes
1 New Robotic Platforms 15

a b

c d

Fig. 1.5 Da Vinci S—next step of robotic evolution. (a) range of motion. (c) Better working ergonomics for the
Unchanged basic console design, but with integrated assisting surgeon(s) due to wider range of motion of
bipolar foot pedal, optionally HD-camera and fourth arm- robotic arms. (d) A variety of 7-DOF-instruments with
pedal). (b) New robotic arms (three or four) with wider monopolar and bipolar functions

always the Firefly™-option. The Da Vinci XI Vinci X takes the thinner, more capable arms and
also provides the use of the new robotic SP instruments of the Xi and moves them onto a cart
1098-platform for 7-DOF-robotic single- like the Si model. That means the system sacri-
port-surgery [35]. Intuitive continues introduc- fices some of the versatility of the higher-end
ing technological advancement such as model, like the ability to perform procedures in
­7-DOF-stapling devices or 7-DOF-intruments several parts of the body at once, but that’s the
for their VeSPa-single-port system. trade-off for the lower price. Thus, the main pur-
pose for introduction of this device is to reduce
 a Vinci X
D the costs for those Hospitals, where General
Recently, the company introduced the X-system, Surgery does not play an important role with
which provides almost all features of the XI, respect to robotics, because it seems to be very
except the table-motion without the need to useful for urologic and gynaecologic applica-
undock, only access to two quadrants. The rest of tions. Intuitive Surgical has now received a CE
the features and all instruments can be used. The mark for the da Vinci X, which promotes its use
new da Vinci X is designed to slip in between the in Europe (Table 1.2). Before it can be rolled out
SI and the XI-model, which is still the top of the in the US though, it will need to undergo FDA
line when it comes to surgery robots. The da approval [36].
16 J.J. Rassweiler et al.

a b

c d

Fig. 1.6 Da Vinci SI—optimizing the design for urologic enabling visualization of renal artery. (c) Simulator train-
indications and robotic training. (a) New design of the ing system applicable with the Da Vinci SI-system. (d)
console with clutch-mechanism also by finger tips— VeSPA-system for single-port surgery with crossover pro-
optional as double console. (b) 3D–HD-camera providing gramming of the handles, but only applicable for
fluorescence filter for isocyanine green (Firefly™) 5-DOF-instruments

a b

EndowristTM_
stapler

Fig. 1.7 Da Vinci XI—optimizing the design for inter- movement of OR-table without undocking the robot. The
disciplinary indications. (a) Finer design of robotic arms software works only with a specific OR-table (Trumpf-
to minimize the risk of clashing of instruments with vari- Medical, Germany). (d) Console enables control of the
able use of all four robotic arms (camera, instruments). new robotic SP 1098-platform for 7-DOF-robot-assisted
(b) Use of 7-DOF-endoscopic staplers can be used with single-port-surgery
the device. (c) Optional module of a software enabling
1 New Robotic Platforms 17

c d

Fig. 1.7 (continued)

Alternative Robotic Systems the instruments attached to the robotic arms

(Fig. 1.8). Unique system features include haptic
From 2004 to 2016, there was no active opponent feedback and an eye-tracking system at the con-
for Intuitive Surgical based on the fact, that sole. Tuebingen Scientific (Tübingen, Germany)
Intuitive acquired Computer Motion in 2004 developed the 4-DOF and 7-DOF-instruments
assigning all patents concerning the principle of based on Radius- technology [38]. Haptic feed-
ZEUS. This may also concern future robotic back is realized by force-induced counter-move-
devices featuring a similar design such as an ments of the laparoscopic handle at the console
open console or three robotic arms mounted to according to the application at tip of the instru-
the operating table. Patent protections are critical ment. An eye-tracking system controls the cam-
to Intuitive Surgical’s success: many are sought era movement: e.g. the camera moves to the left,
for defensive purposes to fend off patent trolls. if the surgeon looks to the left of the screen and
Nevertheless, at least in the year 2019 some of the image is zoomed, when the surgeon’s head
the key-patents of Da Vinci 2000 and ZEUS approaches the screen (Table 1.2). First experi-
expire. This should enable other companies to mental trials included also urological indications,
enter the market. such as nephrectomy and prostatectomy [39, 40].
In 2015, Transenterix (Morrisville, USA)
acquired the Surgical Robotics unit of SOFAR
TELELAP ALF-X (SENHANCE) for 99.8 million $ [41] and subsequently a patent
for 7-DOF-instruments from Tuebingen
Supported by the European Commission, the Scientific (Table 1.1). In the following year first
Italian healthcare company SOFAR (Milan, Italy) clinical reports of robot-assisted hysterectomies
started to develop an alternative robotic device using a new robotic platform, TELELAP ALF-
consisting of a remote control station and three X, have been published [42, 43]. TELELAP
robotic arms arranged on three separate carts ALF-X has CE-mark for indications in general
([37]; Fig. 1.8). The respective patents were reg- surgery, gynaecology, urology and thoracic sur-
istered in 2007 (Table 1.1). TELELAP ALF-X gery. First devices have been sold in Italy. On
provides an open console with a 3D–HD-screen their recent website, the robot is named
requiring polarized glasses. Two handles similar SENHANCE [44].
to those of laparoscopic instruments manipulate
18 J.J. Rassweiler et al.

a b

c d

Fig. 1.8 TELELAP ALF X (Transenterix, US). (a) principle (Tuebingen Scientific, Germany). (d)
Robotic arms mounted on 3 individual carts. (b) Console Laparoscopic handles to control instruments with 4–7
with 3D–Monitor requiring polarizing glasses with eye- degrees of freedom
tracking. (c) 7-DOF-instruments based on Radius-

Medtronic of tactile feedback, which was realized via

potentiometers. Control of instruments is pro-
The Medtronic device is based on collaborations vided by Sigma7™-technology (Force
between three institutions. In 2010, the German Dimension, Nyon, Switzerland) using forceps-
Aerospace Centre (DLR, Oberpfaffenhofen, like handles [47].
Germany) published first experimental results of In 2013, Medtronic (Dublin, Ireland) acquired
their master-slave-system MIROSurge including the licence for commercial use from German
the MICA-instruments [45, 46]. Key-patents Aerospace Centre (DLR) and included further
were registered in 2012 and 2013 (Table 1.1). developments in their two R&D-centres in the
The original system used an open console with USA [48]. Since Medtronic completed already
the surgeon sitting in front of an autofocussing the Covidien-merger in 2015, the company is
monitor (Fig. 1.9). The slave part consisted of now able to develop all necessary instruments (ie.
three light weighted arms mounted to the operat- end-effectors). In the meantime, Medtronic is
ing table. These robotic arms were composed of working on various prototypes of this project
seven joints (A1–A7) with serial kinematics, (Table 1.3). The company plans to initiate clini-
comparable to a human arm enabling to manoeu- cal trials in India and Europe according to less
ver MICA-instruments driven by micro-motors regularity restrictions there and seeks to launch
with three joints (A7–A10) providing the option the device in the US in 2019 [49].