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Future Applications Of Robotics: Urologic Surgery

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Robotic surgery has been effectively utilized to address the extensiveness of extirpative and reconstructive procedures in the field of urology. The introduction of fluorescence image guided surgery could stimulate enhanced intraoperative identification of anatomic structures. Essentially providing surgeons with a heightened interpretation of the operative field and potentially improving surgical results. The introduction of NIRF, using ICG, to the robotic platform has been tested in a number of surgical specialties. The most widespread application being robotic partial nephrectomy (RPN). During RPN, NIRF is used to asses post arterial clamping renal perfusion, and to guide tumour resection by delineating differential ICG fluorescence between normal parenchyma and renal cell carcinoma.

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Krane et al. carried out the first comparative study in the field RPN. The authors compared the outcomes in 47 consecutive patients where NIRF imaging was utilized, with the outcomes of previous 47 consecutive patients who had undertaken standard RPN. In terms of patient characteristics the groups were similar. It was found that the use of ICG resulted in a decrease in ischemia time. The authors suggest that this could reflect increased speed in the delineation and in surgeon confidence, when NIRF is used. Borofsky et al. labelled a 3-centre study using NIFR during RPN to aid in performing zero ischemia RPN. Successful zero ischemia RPN with super-selective arterial clamping in 79. 4% of 34 patients was performed. This proves the safety and practicality of utilizing NIFR for RPN. The authors suggested that NIRF would be a better alternative to other suitable methods such as intraoperative Doppler ultrasonography, which is more skill demanding and operator-dependent. The findings from this study were consistent with that of a more recent study carried out by Harke et a. A single surgeon matched pair analysis was successfully presented, to assess the outcomes of NIRF assisted selective clamping RPN, in 21 patients. NIRF with ICG has been utilised in several other ways in urology. One area of interest is the management of adrenal masses.

Potentially there are advantages over laparoscopy. Adrenal-sparing surgery has been found to be an effective and benign alternative to other methods like total adrenalectomy for adrenal lesions, as it could potentially decrease the risk of adrenal insufficiency. The introduction of robotic techniques could be beneficial for this process, considering the compound vascularity and small size of the adrenal gland. There has only been one study carried out to investigate the use NIRF for robotic adrenal surgery. A successful ICG-NIRF guided robotic adrenalectomy procedure was carried out by Manny et al. on three consecutive patients with solitary adrenal masses. The authors suggested that the utilisation of NIRF with ICG could facilitate adrenal sparing surgery. While robotic urologic surgery technology is gradually becoming popular, one major hurdle for its potential future perspectives is its associated costs. In all the studies carried out on NIRF for robotic urologic surgery, none of them particularly provided a formal cost analysis to investigate the issue of cost. The added cost of the NIRF technology may be questionable. Whether this cost can be justified would depend on the surgeon and possible outcome of the procedure without using NIRF.

Angell et al. carried out an estimation of an approximate cost at their establishment, of approximately $100, 000 to add NIRF to the system and $100 for each ICG vial. Manny et al projected a further cost accompanying ICG administration of $28-$80 per case. The authors calculated this by taking into consideration a cost per vial of approximately $80 and storing the re-formed dye for up to 6 hours, which allowed one single vial to be used for several cases. Overall the ICG-NIRF system has been tried for numerous applications in the field robotic urologic surgery. A large percentage of the reported investigations carried out have been feasibility studies of limited size. As of now RPN is the application which has been studied the most. Information gathered from these studies suggest that the appropriate use of NIRF with ICG in urologic robotic surgery could potentially be of aid to help guide surgeons intraoperatively and to improve surgical outcomes in the near future.

29 April 2020

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