The role of robotics in functional urology (Part 1)

(1) Department of Urology, Jagiellonian University Medical College, Krakow, Poland
(2) Department of Urology, Royal Hallamshire Hospital, Sheffield, UK

While robotic minimally invasive surgery offers many potential advantages, it requires a high level of technical expertise, especially in the complex and challenging scenarios often encountered in functional urology. Therefore, surgeons must ensure they are adequately trained not only in surgical principles but also in the assessment, management, and follow-up of patients with functional urology conditions. 

Robotic assistance has been utilised in functional urology for procedures such as augmentation cystoplasty, neobladder reconstruction, simple prostatectomy, colposuspension, sacrocolpopexy, and artificial urinary sphincter implantation. However, most studies to date are retrospective, and carefully designed prospective studies are needed to better evaluate the safety, efficacy, and cost-effectiveness of robotic surgery compared to laparoscopic and open approaches.

Functional urology encompasses a broad range of treatments, from conservative (non-pharmacological) and pharmacological approaches to endoscopic and open surgery. Treatment decisions rely on thorough patient evaluation, which includes a detailed medical history and non-invasive urodynamic assessments such as bladder diaries, flow rates, and post-void residual estimation. In some cases, invasive urodynamic studies and radiological imaging may also be required. This careful functional assessment provides the foundation for planning any surgical intervention. 

Historically, surgery for functional urological conditions has relied on open approaches. Unlike in urological oncology, where laparoscopic techniques have been widely adopted, the uptake in functional urology has been limited. This trend can be attributed to several factors:

1. Surgical approaches to the lower urinary tract often favour the perineal route, which provides optimal access for conditions such as urethral disease, pelvic trauma, urinary incontinence, fistula repairs, mesh complications, and vaginal prolapse.
    
2. In cases where transabdominal access is preferred, there is no commonly practiced index procedure that could facilitate foundational skill development for functional urologists (as seen with laparoscopic nephrectomy in uro-oncology or laparoscopic cholecystectomy in general surgery).
    
3. Advances in pharmacological and minimally invasive treatments have reduced the need for surgical intervention in many functional urology cases.
    
4. Abdominal reconstructive surgery in functional urology is often complex, typically performed in patients with a history of previous surgery or iatrogenic injury (e.g., post-hysterectomy, radical oncological surgery, or radiation therapy), making surgeons hesitant to pursue experimental approaches.

Robotic surgical platforms have allowed surgeons to operate with enhanced visualisation and improved access to anatomical structures, while also increasing their dexterity, minimising tremors, and providing ergonomic benefits for lengthy and complex procedures. These advantages have collectively contributed to the refinement of surgical techniques. 

A key consideration in adopting robotic technology is the understanding that it is merely a surgical tool; the surgeon must be thoroughly trained in the foundational principles of the procedures being performed. Another critical factor is the well-recognised learning curve associated with developing robotic skills, which requires careful consideration in training and practice.

Recently, there has been increasing interest in applying robotic techniques to functional urology, driven by the potential for improved outcomes and procedural advancements.

Augmentation cystoplasty
With the advent of botulinum toxin and electrical nerve stimulation, augmentation cystoplasty has become much less commonly performed for both idiopathic and neuropathic patients. The first robotic augmentation cystoplasty was reported in 2008 in a paediatric case, and subsequent reports have primarily been individual case studies. The only series published to date in adults included 19 patients with conditions like low bladder compliance, refractory detrusor overactivity, and bladder pain syndrome. In this series, all parts of the procedure were performed robotically except for bowel division and anastomosis, which were done extracorporeally. No major complications were reported, and long-term functional outcomes were excellent. While a few other small retrospective series have been published, the robotic augmentation cystoplasty technique appears feasible. Nevertheless, further prospective comparative studies are essential to determine the long-term outcomes and efficacy of this approach.

Neobladder
Robotic intracorporeal neobladder has been explored in the context of reconstruction following robotic radical cystectomy. The first description of this technique was in 2003, using the Hautmann technique for reconstruction. The initial procedure had an operative time of 8.5 hours, with minimal blood loss, and the functional outcome was reported as excellent. Since then, several groups have reported on their techniques and modifications aimed at simplifying the procedure and reducing operative time. A large series from two expert centres in the US and Sweden included 132 patients who received intracorporeal neobladder. At a mean follow-up of 25 months, 84% of the 73 patients who had a minimum follow-up of 6 months achieved urinary continence (no or one daily pad). 

The procedure is considered technically demanding and time-consuming, which has led many surgeons to adopt a hybrid approach. In this approach, the bladder is removed, the robot is undocked, and the neobladder is constructed extracorporeally. The robot is then re-docked to perform the urethrovesical anastomosis.

There is some evidence suggesting that the intracorporeal approach may offer benefits such as reduced fluid loss, less blood loss, and faster return to bowel function. However, this assessment must take into account operative time and long-term outcomes. Surgeons are also aware of the long-term morbidity associated with neobladder formation, highlighting that it is by no means a "fit-and-forget" procedure.

Simple prostatectomy
The treatment landscape for benign prostatic obstruction has evolved significantly over the past two decades. While open simple (Millin’s) prostatectomy was once considered the gold standard for glands larger than 80cc, the development of laser enucleation techniques has provided less invasive alternatives. The first robotic simple prostatectomy was described in 2008, and although many case series have been reported, no randomised studies exist. 

Available case series suggest that robotic prostatectomy may have longer operating times, but similar complication rates (i.e., Clavien–Dindo Grade >II) and functional outcomes compared to open simple prostatectomy. Reported benefits include reduced blood loss, lower rates of transfusion, shorter length of stay, less need for irrigation, shorter catheterisation times, and smaller incisions. However, only a few studies have focused on prostates with a mean volume greater than 150cc. There is a clear need for randomised studies comparing robotic simple prostatectomy to laser enucleation in larger glands.

To be continued in part 2...