BERKELEY, CA (UroToday.com) - Since the first robot-assisted laparoscopic radical prostatectomy was performed by Binder and Kramer[1] in May 2000, the central-docking position of the robotic system has been the conventional way to adopt such technology in prostatectomy. However, there is a trend of more and more diversified application of robotic systems in the field of urology. With perfection of skills and progress in technology, there are innovative techniques that may assist the use of robots in urological surgeries. Intra-operative transrectal ultrasound during robotic-assisted laparoscopic (RAL) radical prostatectomy,[2] application of fluorescence agents to allow more precise identification of important structures during RAL surgery of bladder or ureter,[3] and the use of a robotic system in the management of vesical fistula[4] all require manipulations via the rectum or urethra route. Side-docking technique would thus allow an easier access to the perineum, facilitating the use of robots in a wider range of urological surgery.
While more freedom is gained from the side-docking technique, the positioning of the robot may be less straightforward when compared with the conventional central-docking technique. In the conventional central-docking setting, the surgeon could easily determine the midline of the patient, and move the robot in accordingly. However in the case of side-docking technique, the surgeon would need to determine the angle between the robot and the torso. When side-docking technique was described by Einarsson et al. in the gynecological surgery setting, it was reported that the robot was docked at an approximate 45 degree angle to the lower torso.[5] In our series,[6] the robot was docked near the anterior superior iliac spine at an angle nearly parallel to the lower torso. We found this positioning of the robotic system further decreases the chance of robotic arm collision on the docking side, prevents over-stretching of the third working arm, and gives more freedom to the robotic arm on the contralateral side.
In addition to the angle of docking, more fundamentally there is the need to determine the side of docking. The initial experience of side-docking RAL radical prostatectomy reported by Uffort et al. placed the robotic system on the left side of the patient.[7] Einarsson reported a similar practice in gynaecology.[5] While many conditions would likely achieve a similar outcome from either left- or right-sided docking, certain circumstances deserve deliberate consideration on the side of docking. One example is RAL radical cystectomy with total intracorporeal urinary diversion. Though currently this approach may not be the mainstream in bladder cancer management, it has been widely reported to be safe and feasible, and has been gaining interest in the urology community[8] To prepare the bowel segment for intracorporeal reconstruction, an endoscopic tissue stapler, e.g., Endo GIA™, is often used. In order to cater for the alignment of small bowel mesentery, it would be more convenient to insert the stapler from the patient’s left side than from the right side. It implies that the robotic system would better be docked on the right side, so that the assistant can apply the endoscopic stapler from the left side without the need of ports re-arrangement.
The above discussion is not meant to be a caveat of the side-docking technique. On the other hand, attention to these aspects would further optimize your experience with this relatively new and also convenient docking routine. We hope that future research and advances would allow us to further explore the advantages and disadvantages of its use in urological surgeries.
References:
- Binder J, Kramer W. Robotically-assisted laparoscopic radical prostatectomy. BJU Int. 2001 Mar;87(4):408-10.
- Hung AJ, Abreu AL, Shoji S, Goh AC, Berger AK, Desai MM, Aron M, Gill IS, Ukimura O. Robotic transrectal ultrasonography during robot-assisted radical prostatectomy. Eur Urol. 2012 Aug;62(2):341-8.
- Hockenberry M, Smith Z, Mucksavage P. A Novel Use of Near-Infrared Fluorescence Imaging During Robotic Surgery Without Contrast Agents. J Endourol. 2013 Dec 19. (Epub ahead of print)
- Perveen K, Gupta R, Al-Badr A, Hemal AK. Robot-assisted laparoscopic repair of rare post-cesarean section vesicocervical and vesicouterine fistula: a case series of a novel technique. Urology. 2012 Aug;80(2):477-82.
- Einarsson JI, Hibner M, Advincula AP. Side docking: an alternative docking method for gynecologic robotic surgery. Rev Obstet Gynecol. 2011;4(3-4):123-5.
- Chan ES, Yee CH, Lo KL, et al. Side-docking technique for robot-assisted urologic pelvic surgery. Urology. 2013; 82(6): 1300-3.
- Uffort EE, Jensen JC. Side docking the robot for robotic laparoscopic radical prostatectomy. JSLS. 2011 Apr-Jun;15(2):200-2.
- Collins J, Wiklund N. Totally intracorporeal robot assisted radical cystectomy - optimizing total outcomes. BJU Int. 2013 Nov 13. doi: 10.1111/bju.12558. (Epub ahead of print)
Written by:
Samuel Chi-hang Yee and Eddie Shu-yin Chan as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Division of Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
Side-docking technique for robot-assisted urologic pelvic surgery - Abstract
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