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Plenary 6: Ever-increasing applications for robotic surgery in urology

Robotic urology is a rapidly evolving field with many studies underway and results coming in the next few years, but some careful conclusions were already drawn by the speakers at EAU21 on Sunday. Plenary Session 6, chaired by Profs. Mottrie (BE), Albersen (BE) and O’Brien (GB), examined if the surgical robot is starting to take over reconstructive surgery, traditionally the field for open or laparoscopic techniques, and all signs are pointing to a shift to robotic-assisted surgery.

Speaking after the session, Prof. Mottrie shared his personal view on the various potential applications for the surgical robot:

“We had a very good session that was a good overview of everything that was possible. I think the session has actually proven that the robot will not take over, rather that it has already taken over reconstructive urology. There are still some grey areas like paediatric urology, where we need to prove that the cost vs benefit is worthwhile. So far we have only very small, monocentric studies.”

This was in reference to Dr. Spinoit’s (BE) presentation on the suitability of robotic surgery for very young patients (or vice-versa). “Big tech for small bellies?” she asked. “There are definitely indications for robotics in child patients,” Dr. Spinoit explained. “Specifically for children, indications are pyeloplasty, nephron-ureterectomy, partial nephrectomy, embryologic remnants, ureteric reimplantation and bladder augmentation, specifically continent diversion.”

When looking at pyeloplasty in children in particular, Dr. Spinoit explained that the smaller incisions of a robotic procedure are better tolerated by the patient. In the discussion that followed her presentation, Dr. Spinoit expressed her hope to present a cost analysis in the coming years as cases increase and potential patients are recruited.

Plenary Session 6 covered an extremely wide range of topics, showing the breadth of the adoption of robotic surgery throughout urology. For example, AUA President-Elect Prof. Raju Thomas (US) gave a demonstration of the robotic management of uretero-pelvic junction obstruction in conjunction with calculi management, with beautiful results. Profs. Breda (ES) and Rassweiler (DE) demonstrated the robotic techniques for kidney transplantation and iatrogenic ureteral injuries, respectively, showing great results and evolving techniques.

At the end of the session, Prof. O’Brien raised a point that was later also praised by his co-chairs. Many of the presentations mentioned improved training as a factor that drove the adoption of the robot for such a wide range of indications. O’Brien praised the new methodology in robotic training as pioneered by ERUS: “In-lab training to proficiency level is a crucial development. We should be taking learning out of the operating theatre and into the lab.”


Future of robotic surgery and training

As departing chairman of the EAU’s Robotic Urology Section Prof. Mottrie is, understandably, extremely enthusiastic about the potential of robotic surgery and advanced surgical technology in general:

“This session proves that everything is becoming robotised. We started with prostate, prostatectomy, then kidney, and bladder, but now everything that we do with our bare hands is going more and more towards robotics. There are new robotic systems coming to market, microsurgery and so on. This will very probably soon include urethral reconstruction and whatever else. As the expenses come down, also due to increased competition, there are very few drawbacks left.”

“In the coming decade there will be more dramatic changes in how we operate and think. Artificial Intelligence, deep learning, smart surgery, fluorescent tech, augmented reality, you name it. It’s incredible how quickly these developments are coming upon us.”

While robotic training is becoming increasingly standardised thanks to ERUS, its curriculum and the work of training centres like ORSI, how much of current robotic training is based on a single robotic system, and how useful will it be as the market becomes more diverse?

Prof. Mottrie: “As it currently stands, we only have one system. Our current training protocols are, let’s say, a ‘monorobot training.’ But we will in the coming years come to a new era where we will have robot-agnostic training. When you buy a car, sure, there are differences between brands but the driver’s license is the same. You might need the company to tell you what each button and switch does, but in terms of surgical technique and approach, it’s all basically the same. It’s work in progress on our part.”

Prof. Rassweiler added that the field may not be diversifying as quickly as initially thought. “Many new robotic systems are still in their first generation and are not yet living up to their potential. Nevertheless, the future is clearly in proficiency-based training. Of course, ERUS was the first to implement it, in a way. With new devices, they can use it as a training principle.”