EAU Guidelines on Robotic and Single-site Surgery in Urology

doi:10.1016/j.eururo.2013.05.034

European Urology

Volume 64, Issue 2, August 2013, Pages 277-291

https://doi.org/10.1016/j.eururo.2013.05.034 Get rights and content

Abstract

Context

This is a short version of the European Association of Urology (EAU) guidelines on robotic and single-site surgery in urology, as created in 2013 by the EAU Guidelines Office Panel on Urological Technologies.

Objective

To evaluate current evidence regarding robotic and single-site surgery in urology and to provide clinical recommendations.

Evidence acquisition

A comprehensive online systematic search of the literature according to Cochrane recommendations was performed in July 2012, identifying data from 1990 to 2012 regarding robotic and single-site surgery in urology.

Evidence synthesis

There is a lack of high-quality data on both robotic and single-site surgery for most upper and lower urinary tract operations. Mature evidence including midterm follow-up data exists only for robot-assisted radical prostatectomy. In the absence of high-quality data, the guidelines panel's recommendations were based mostly on the review of low-level evidence and expert opinions.

Conclusions

Robot-assisted urologic surgery is an emerging and safe technology for most urologic operations. Further documentation including long-term oncologic and functional outcomes is deemed necessary before definite conclusions can be drawn regarding the superiority or not of robotic assistance compared with the conventional laparoscopic and open approaches. Laparoendoscopic single-site surgery is a novel laparoscopic technique providing a potentially superior cosmetic outcome over conventional laparoscopy. Nevertheless, further advantages offered by this technology are still under discussion and not yet proven. Due to the technically demanding character of the single-site approach, only experienced laparoscopic surgeons should attempt this technique in clinical settings.

Patient summary

This work represents the shortened version of the 2013 European Association of Urology guidelines on robotic and single-site surgery. The authors systematically evaluated published evidence in these fields and concluded that robotic assisted surgery is possible and safe for most urologic operations. Whilst laparoendoscopic single-site surgery is performed using the fewest incisions, the balance between risk and benefit is currently unclear. The evidence to support the conclusions in this guideline was generally poor, but best for robotic assisted radical prostatectomy. As such, these recommendations were based upon expert opinion, and further high-quality research is needed in this field.

Introduction

This paper summarises the European Association of Urology (EAU) guidelines on robotic and single-site surgery in urology published in 2013 [1]. It supplements the other EAU guidelines and focuses on level of evidence (LE) evaluation of the current literature as well as on clinical recommendations established by the EAU Guidelines Office Panel on Urological Technologies regarding robotic and single-site surgery in urology.

Section snippets

Literature search

An extensive online systematic review of the literature was conducted in July 2012 identifying data regarding robotic and single-site surgery in urology. Searches were carried out in the Cochrane Library Database of Systematic Reviews, the Cochrane Library of Controlled Clinical Trials, Medline, and Embase on the Dialog-Datastar platform. Retrieved papers were assigned a LE. Panel recommendations were graded (grade of recommendation [GR]) following the system currently used by the EAU

Robot-assisted radical nephrectomy

Robot-assisted radical nephrectomy (RRN) was introduced in 2000 [2], but the limited benefit offered with the approach has slowed its widespread adoption. The main limitations of the approach are the increased technical effort associated with robot docking time and the considerably higher cost per procedure, without significant improvement in clinical outcomes compared with standard laparoscopic surgery or nonrobotic laparoendoscopic single-site surgery (LESS).

RRN performed either by a

Terminology and technical principles

LESS is the general term for all surgical procedures performed by one single skin incision for the introduction of camera and instruments, with or without an additional maximum port of 5 mm [119]. The advantages offered by this approach are still in discussion and not yet proven. The superior cosmetic outcome offered by LESS seems to be the main advantage and the primary reason for using this technology [120], [121].

The first report on LESS in urology for human patients was in 2007 by Raman et

References (158)

D.W. Klingler et al.
Feasibility of robotic radical nephrectomy—initial results of single-institution pilot study
Urology
(2005)
M.T. Gettman et al.
Robotic-assisted laparoscopic partial nephrectomy: technique and initial clinical experience with da Vinci robotic system
Urology
(2004)
B.M. Benway et al.
Robotic partial nephrectomy with sliding-clip renorrhaphy: technique and outcomes
Eur Urol
(2009)
I.S. Gill et al.
Zero ischemia” partial nephrectomy: novel laparoscopic and robotic technique
Eur Urol
(2011)
G.P. Haber et al.
Robotic versus laparoscopic partial nephrectomy: single surgeon matched cohort study of 150 patients
Urology
(2010)
J.A. Long et al.
Robotic versus laparoscopic partial nephrectomy for complex tumors: comparison of perioperative outcomes
Eur Urol
(2012)
O.M. Aboumarzouk et al.
Robotic versus laparoscopic partial nephrectomy: a systematic review and meta-analysis
Eur Urol
(2012)
M.N. Patel et al.
Robotic partial nephrectomy for renal tumors larger than 4 cm
Eur Urol
(2010)
J.H. Kaouk et al.
Robot-assisted laparoscopic partial nephrectomy: step-by-step contemporary technique and surgical outcomes at a single high-volume institution
Eur Urol
(2012)
A.J. Wang et al.
Robotic partial nephrectomy versus laparoscopic partial nephrectomy for renal cell carcinoma: single-surgeon analysis of >100 consecutive procedures
Urology
(2009)

J.S. Ellison et al.

A matched comparison of perioperative outcomes of a single laparoscopic surgeon versus a multisurgeon robot-assisted cohort for partial nephrectomy

J Urol

(2012)

P.M. Pierorazio et al.

Robotic-assisted versus traditional laparoscopic partial nephrectomy: comparison of outcomes and evaluation of learning curve

Urology

(2011)

S. Sukumar et al.

National trends and disparities in the use of minimally invasive adult pyeloplasty

J Urol

(2012)

V.G. Bird et al.

Comparison of robot-assisted versus conventional laparoscopic transperitoneal pyeloplasty for patients with ureteropelvic junction obstruction: a single-center study

Urology

(2011)

L.H.P. Braga et al.

Systematic review and meta-analysis of robotic-assisted versus conventional laparoscopic pyeloplasty for patients with ureteropelvic junction obstruction: effect on operative time, length of hospital stay, postoperative complications, and success rate

Eur Urol

(2009)

F. Porpiglia et al.

Randomised controlled trial comparing laparoscopic and robot-assisted radical prostatectomy

Eur Urol

(2013)

A.D. Asimakopoulos et al.

Randomized comparison between laparoscopic and robot-assisted nerve-sparing radical prostatectomy

J Sex Med

(2011)

J.K. Parsons et al.

Outcomes of retropubic, laparoscopic, and robotic-assisted prostatectomy

Urology

(2008)

V. Ficarra et al.

Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies

Eur Urol

(2009)

G. Novara et al.

Systematic review and meta-analysis of studies reporting oncologic outcome after robot-assisted radical prostatectomy

Eur Urol

(2012)

A. Tewari et al.

Positive surgical margin and perioperative complication rates of primary surgical treatments for prostate cancer: a systematic review and meta-analysis comparing retropubic, laparoscopic, and robotic prostatectomy

Eur Urol

(2012)

D.A. Barocas et al.

Robotic assisted laparoscopic prostatectomy versus radical retropubic prostatectomy for clinically localized prostate cancer: comparison of short-term biochemical recurrence-free survival

J Urol

(2010)

G.B. Di Pierro et al.

A prospective trial comparing consecutive series of open retropubic and robot-assisted laparoscopic radical prostatectomy in a centre with a limited caseload

Eur Urol

(2011)

S.B. Williams et al.

Radical retropubic prostatectomy and robotic-assisted laparoscopic prostatectomy: likelihood of positive surgical margin(s)

Urology

(2010)

M.A. White et al.

Comparative analysis of surgical margins between radical retropubic prostatectomy and RALP: are patients sacrificed during initiation of robotics program?

Urology

(2009)

T.A. Laurila et al.

Robotic-assisted laparoscopic and radical retropubic prostatectomy generate similar positive margin rates in low and intermediate risk patients

Urol Oncol

(2009)

V. Ficarra et al.

Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy

Eur Urol

(2012)

A.A. Hakimi et al.

Direct comparison of surgical and functional outcomes of robotic-assisted versus pure laparoscopic radical prostatectomy: single-surgeon experience

Urology

(2009)

V. Ficarra et al.

Systematic review and meta-analysis of studies reporting potency rates after robot-assisted radical prostatectomy

Eur Urol

(2012)

A. Heidenreich et al.

Anatomical extent of pelvic lymphadenectomy in patients undergoing radical prostatectomy

Eur Urol

(2007)

P. Bader et al.

Is a limited lymph node dissection an adequate staging procedure for prostate cancer?

J Urol

(2002)

A. Feicke et al.

Robotic-assisted laparoscopic extended pelvic lymph node dissection for prostate cancer: surgical technique and experience with the first 99 cases

Eur Urol

(2009)

D.S. Yee et al.

Extended pelvic lymph node dissection in robotic-assisted radical prostatectomy: surgical technique and initial experience

Urology

(2010)

D.S. Elliott et al.

Long-term results of robotic assisted laparoscopic sacrocolpopexy for the treatment of high grade vaginal vault prolapse

J Urol

(2006)

B.J. Challacombe et al.

The role of laparoscopic and robotic cystectomy in the management of muscle-invasive bladder cancer with special emphasis on cancer control and complications

Eur Urol

(2011)

H.Y. Yu et al.

Comparative analysis of outcomes and costs following open radical cystectomy versus robot-assisted laparoscopic radical cystectomy: results from the US Nationwide Inpatient Sample

Eur Urol

(2012)

R.S. Pruthi et al.

Robotic assisted laparoscopic radical cystoprostatectomy: operative and pathological outcomes

J Urol

(2007)

K.A. Guru et al.

Robot-assisted radical cystectomy and pelvic lymph node dissection: initial experience at Roswell Park Cancer Institute

Urology

(2007)

D.G. Murphy et al.

Robotic-assisted laparoscopic radical cystectomy with extracorporeal urinary diversion: initial experience

Eur Urol

(2008)

K.A. Richards et al.

Robot assisted laparoscopic pelvic lymphadenectomy at the time of radical cystectomy rivals that of open surgery: single institution report

Urology

(2010)

N.J. Hellenthal et al.

Surgical margin status after robot assisted radical cystectomy: results from the International Robotic Cystectomy Consortium

J Urol

(2010)

G. Novara et al.

Soft tissue surgical margin status is a powerful predictor of outcomes after radical cystectomy: a multicenter study of more than 4,400 patients

J Urol

(2010)

J. Nix et al.

Prospective randomized controlled trial of robotic versus open radical cystectomy for bladder cancer: perioperative and pathologic results

Eur Urol

(2010)

M.N. Jonsson et al.

Robot-assisted radical cystectomy with intracorporeal urinary diversion in patients with transitional cell carcinoma of the bladder

Eur Urol

(2011)

Merseburger AS, Herrmann TRW, Liatsikos EN, et al. EAU guidelines on robotic and single-site surgery in urology....

M. Boger et al.

Comparison of robot-assisted nephrectomy with laparoscopic and hand-assisted laparoscopic nephrectomy

JSLS

(2010)

A.K. Hemal et al.

A prospective comparison of laparoscopic and robotic radical nephrectomy for T1-2N0M0 renal cell carcinoma

World J Urol

(2009)

T. Nazemi et al.

Radical nephrectomy performed by open, laparoscopy with or without hand-assistance or robotic methods by the same surgeon produces comparable perioperative results

Int Braz J Urol

(2006)

C. Rogers et al.

Robotic nephrectomy for the treatment of benign and malignant disease

BJU Int

(2008)

C.G. Rogers et al.

Maximizing console surgeon independence during robot-assisted renal surgery by using the Fourth Arm and TilePro

J Endourol

(2009)

Cited by (120)

Single-port robot-assisted retroperitoneal surgery: A feasible approach
2022, Actas Urologicas Espanolas
La cirugía mediante una única incisión ha sido un concepto perseguido en el campo de la mínima invasión para el tratamiento de diferentes afecciones. Este concepto, sumado a un abordaje retroperitoneal, puede suponer una disminución de la agresión al paciente a diferentes niveles. Describimos los primeros casos de cirugía retroperitoneal asistida por robot mediante puerto único de nuestro entorno.
Presentamos 2 casos de pacientes con masas suprarrenales derechas con un tamaño superior a 4 cm. El primer caso se trataba de una mujer de 55 años con diagnóstico incidental de angiomiolipoma, y el segundo, de un varón de 62 años con adenoma suprarrenal no funcionante. Ambos casos se operaron a través de una única incisión subcostal de 4 cm mediante el sistema Da Vinci Xi®, anulando el brazo 4 sin realizar reasignaciones de lateralidad en consola.
Los tiempos de consola para las cirugías fueron de 75 y 150 min, con tiempos de acceso y acoplamiento robótico inferiores a 30 min. El sangrado fue inferior a 100 cc en ambas cirugías, sin necesidad de realizar incisiones accesorias o dejar tubo de drenaje. Las piezas quirúrgicas fueron extraídas por la misma incisión sin necesidad de ampliación. En ningún caso fue necesaria analgesia intravenosa postoperatoria (EVA 0) y la estancia fue inferior a 24 h en ambos pacientes, sin reportarse ninguna complicación.
La cirugía retroperitoneal asistida por robot mediante puerto único es un abordaje factible a través del sistema Da Vinci Xi®.
The concept of surgery through a single incision has been pursued in the field of minimal invasion for the treatment of different pathologies. This, added to a retroperitoneal approach, implies less aggression for the patient at different levels. We describe the first cases of single-port robot-assisted retroperitoneal surgery (SP-RARS) in our country using the Da Vinci Xi® system.
We present 2 cases of patients with right adrenal masses larger than 4 cm. The first case was a 55-year-old woman with an incidental diagnosis of angiomyolipoma, and the second case was a 62-year-old man with a non-functioning adrenal adenoma. Both cases were operated through a single 4 cm subcostal incision using the Da Vinci Xi® system, annulling arm 4 without reallocating laterality on the surgeon's console.
Console times for surgeries were 75 and 150 min, with access and docking times below 30 min. Bleeding was less than 100 cc in both surgeries with no need of accesory trocars, make new incisions or leave a drainage tube. The surgical specimens were removed through the same initial incision without the need for enlargement. Postoperative intravenous analgesia was not necessary in any case (VAS 0) and hospital stay was less than 24 h in both patients, without reporting any complications.
SP-RARS is a feasible approach using the Da Vinci Xi® system.
Pure Single-site Robot-assisted Radical Prostatectomy Using Single-port Versus Multiport Robotic Radical Prostatectomy: A Single-institution Comparative Study
2021, European Urology Focus
Pure single-site robot-assisted extraperitoneal prostatectomy (EPP) using a single-port (SP) robotic platform has been shown to be feasible and safe in previous descriptive studies.
To compare the perioperative outcomes of patients undergoing SP-EPP versus conventional multiport (MP) transperitoneal robot-assisted radical prostatectomy (RARP).
From January 2019 to January 2020, data of 100 consecutive patients who underwent SP-EPP performed by the same surgeon and 110 consecutive patients who underwent MP-RARP by three surgeons from the same institution were prospectively collected.
All SP-EPPs were performed in a pure single-site fashion without Trendelenburg.
Demographic characteristics as well as intra- and postoperative data of patients in both groups were analyzed. Quantitative data were described in terms of median and quartiles.
After SP-EPP, the rate of patients discharged the same day was nine times higher than that after MP-RARP (p < 0.001), and the median length of postoperative hospital stay was significantly shorter: 4.3 h (interquartile range [IQR] 3.3–17.4) versus 26.1 h (IQR 21.5–44.8). The rate of opioid use in the hospital and after discharge in the SP group was at least half that in the MP group (respectively, 32% vs 64%, p < 0.001, and 35% vs 87%, p < 0.001). The overall positive surgical margin rate as well as continence rate at 12 mo (85% vs 88%, p = 0.97) and the prostate-specific antigen relapse-free survival (p = 0.09) were statistically comparable between the SP and MP groups.
Pure single-site SP-EPP was associated with a shorter length of stay as well as a decreased need for postoperative pain medication and narcotic administration in comparison with conventional transperitoneal multiport prostatectomy, with comparable postoperative complications and readmission rate.
Surgical treatment of localized prostate cancer using a single-port robotic platform allows for a shorter hospital stay, less pain, and less opioid use than conventional robotic surgery without more morbidity.
Pure single-site single-port extraperitoneal prostatectomy was associated with a shorter length of stay as well as a decreased need for postoperative pain medication and narcotic administration in comparison with conventional transperitoneal multiport prostatectomy, with comparable postoperative complication and readmission rate.
Outpatient Extraperitoneal Single-Port Robotic Radical Prostatectomy
2020, Urology
To assess the safety and feasibility of extraperitoneal single-port robotic assisted laparoscopic radical prostatectomy using the da Vinci SP robotic platform for same-day surgery.
Extraperitoneal single-port robotic prostatectomy (ESRP) using the da Vinci SP platform was performed on 60 patients with clinically localized prostate cancer and no prior definitive therapy. An enhanced recovery protocol was used in the perioperative period and minimal to no opiates were used in these patients. Preoperative, perioperative, and postoperative data were collected in a prospectively maintained institutional review board approved database and evaluated in a retrospective fashion.
Mean operative time was 198 minutes and mean estimated blood loss was 179 mL. No patients required blood transfusion and there were no intraoperative complications. Pain at discharge was 0-1 in 37% of patients. Forty-five patients (75%) were discharged home the day of surgery, including patients with all surgical start times. When excluding patients that were planned for an overnight stay preoperatively or patients whose surgery finished after 6 PM, 88% of patients were discharged home the day of surgery and 96% were discharged within 24 hours of surgery. Median length of stay was 4.2 hours. Fourty-eight percent of patients required 0-1 pads at 30 days postoperatively in patients with 30 day follow data (n = 58) and 76% of patients reported requiring 0-1 pads per day by 90 days postoperatively (n = 37).
ESRP using the da Vinci SP platform can be performed safely and reproducibly as a same-day outpatient surgery with minimal to no opiate use, excellent pain control, and acceptable short term functional and oncological outcomes.
Single-Port Robotic Urological Surgery Using Purpose-Built Single-Port Surgical System: Single-Institutional Experience With the First 100 Cases
2020, Urology
To present a comprehensive report regarding our experience with single-port robotic surgery in our first 100 consecutive patients. We describe the diversity of procedures that can be performed with this platform as well as the challenges and complications we had with the application of this novel technology.
Between September 2018 and August 2019, data on 100 patients who underwent single-port robotic surgery were consecutively collected. Preoperative, intraoperative and early postoperative outcomes after various urologic procedures were recorded and analyzed.
During the study period, 100 patients (age [range] 35-84 years; 88 [88%] Male) underwent various single-port robotic surgeries for different indications (Retroperitoneal [n = 14], Pelvic surgeries [n = 86]). Transperitoneal (n = 37), extraperitoneal (n = 53) and transvesical (n = 10) approaches have been used to access the target organs. Of these procedures, 73 (73%) were for different oncological indications: Radical prostatectomy (n = 60), Partial nephrectomy (n = 6), Retroperitoneal lymph node dissection (n = 1) and Radical cystectomy with intracorporeal diversion (n = 6). Surgery was successfully completed in all but 1 patient, in whom the surgery was converted to open surgery due to dense adhesions and failure to progress. Grades II-III postoperative complications were detected in (n = 9) patients.
The purpose-built single-port robotic platform can be safely incorporated into the minimally invasive armamentarium. A wide range of pelvic and retroperitoneal urological procedures can be done with different approaches using this platform. Randomized trials with adequate sample size and postoperative follow up period is advisable for further evaluation of the outcomes and to determine the added value of this emerging technology.
Initial Experience with da Vinci Single-port Robot-assisted Radical Prostatectomies
2020, European Urology
Citation Excerpt :
Systematic reviews of retrospective evidence have suggested that the robotic approach is associated with superior potency [4], continence [5], and complication [6] rates than the open technique with similar oncologic outcomes [7]. Nevertheless, the next stage of surgical evolution from multiport RARP to single-port RARP (spRARP) has been elusive [8,9]. Limited case-series of laparoscopic single-port (SP) radical prostatectomies [10,11] and non-purpose-built robotic platforms adapted for an SP [12,13] have been described, but the technique has failed to gain traction among robotic surgeons due to increased technical difficulty.
Single-port robotic surgery is being adopted for various surgical procedures. There have been interest in and clinical use of single-port robot-assisted radical prostatectomy (spRARP), but little reported data on feasibility and early outcomes.
To describe our institution's initial experience with spRARP utilizing the da Vinci single-port (SP) robotic system.
A retrospective review of the initial experience of three high-volume robotic prostate surgeons performing an spRARP utilizing the da Vinci SP robotic system was carried out.
An spRARP using the da Vinci SP robotic system was performed following the traditional retropubic or Retzius-sparing approach.
Patient demographics, operative time, blood loss, postoperative hospital stay, complications, and catheter duration were obtained and analyzed.
In a cohort of 49 patients undergoing spRARP, median age was 62 yr and prostate-specific antigen 6.4. Of the patients, 35 (71%) had cT1c disease on presentation, 92% had Gleason grade group ≥2 disease, and 85% were pT2 on final pathology. Median operative time was 161 min. Median blood loss was 200 ml. Seven Retzius-sparing cases were performed. Four Clavien 2 complications occurred (complication rate 8.1%). Median hospital stay was 1 d and median catheter duration 7 d. Operative time was <200 min for all three surgeons by their third case.
The da Vinci SP system spRARP is safe and feasible, with acceptable operative time and blood loss. Further research is needed to establish noninferiority to the da Vinci Xi and Si systems, and impact of spRARP on patient-assessed cosmesis and pain.
Robotic prostatectomy using a purpose-built da Vinci single-port robotic system is safe and feasible, and warrants further study to determine whether it can improve patient outcomes.
Robotic kidney transplantation
2024, Nature Reviews Urology

View all citing articles on Scopus

View full text

GuidelinesEAU Guidelines on Robotic and Single-site Surgery in Urology

Abstract

Context

Objective

Evidence acquisition

Evidence synthesis

Conclusions

Patient summary

Introduction

Section snippets

Literature search

Robot-assisted radical nephrectomy

Terminology and technical principles

Urology

Urology

Eur Urol

Eur Urol

Urology

Eur Urol

Eur Urol

Eur Urol

Eur Urol

Urology

J Urol

Urology

J Urol

Urology

Eur Urol

Eur Urol

J Sex Med

Urology

Eur Urol

Eur Urol

Eur Urol

J Urol

Eur Urol

Urology

Urology

Urol Oncol

Eur Urol

Urology

Eur Urol

Eur Urol

J Urol

Eur Urol

Urology

J Urol

Eur Urol

Eur Urol

J Urol

Urology

Eur Urol

Urology

J Urol

J Urol

Eur Urol

Eur Urol

Comparison of robot-assisted nephrectomy with laparoscopic and hand-assisted laparoscopic nephrectomy

JSLS

A prospective comparison of laparoscopic and robotic radical nephrectomy for T1-2N0M0 renal cell carcinoma

World J Urol

Radical nephrectomy performed by open, laparoscopy with or without hand-assistance or robotic methods by the same surgeon produces comparable perioperative results

Int Braz J Urol

Robotic nephrectomy for the treatment of benign and malignant disease

BJU Int

Maximizing console surgeon independence during robot-assisted renal surgery by using the Fourth Arm and TilePro

J Endourol

Guidelines
EAU Guidelines on Robotic and Single-site Surgery in Urology