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The field of urology has embraced minimally invasive surgical procedures in various phases, leaping from endoscopic to laparoscopic and then to robot-assisted laparoscopic surgery. As these surgical techniques are applied to urological cancers, the oncological outcomes need to be compared with more traditional open surgery. Laparoscopic partial nephrectomy as well as laparoscopic prostatectomy, robotic assisted or not, emulate the open surgical technique and have become an alternative to open surgery in many academic centers. The following review is designed to display the evolution, which has occurred in the last decades in the laparoscopic treatment of urologic malignancies as paradigmatic examples of an evolving process.

Open radical retropubic prostatectomy (ORP) remains the conventional standard of surgical management for patients with organ-confined prostate cancer. Despite improvements in our understanding of male pelvic anatomy, refinements in operative technique, and advances in perioperative care, the procedure remains associated with significant perioperative complications, particularly bleeding risk. Laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic prostatectomy (RALP) are reportedly associated with lower rates of blood loss and other indices of perioperative morbidity, although high-quality comparison studies are lacking. This chapter describes the principle immediate and early complications associated with each of the radical prostatectomy approaches and critically appraises the available literature to allow comparison of the techniques. Particular attention is given to a discussion of required standards and desirable classification systems for the reporting of perioperative complications.

It is possible with the da Vinci robot to reproduce exactly the surgical protocol of an open retropubic prostatectomy and to give to the patient all the advantages of mini-invasive surgery.

Extraperitoneal surgery for the prostate has been the gold standard for open surgeons. The technique can be applied by minimally invasive surgeons if the principles of extraperitoneal space formation are followed. We have endeavored to provide the reader with a stepwise team approach to achieve robotic extraperitoneal laparoscopic prostatectomy in a safe and reproducible manner.

A review of the development of robotic urological surgery in the UK centered on the introduction of robotically assisted laparoscopic prostatectomy (RALP) in a UK National Health Service (NHS) Foundation Trust Hospital. The current UK training program will be evaluated in the context of the developments reported in the latest literature. Future considerations for the progression of robotic urology in the UK will also be discussed.

Anatomical Aspects of the Extra- and Retroperitoneal Space.- Essential Instruments in Laparoscopic and Robotic Surgery.- Upper Tract Retroperitoneal Access Techniques.- Laparoscopic Adrenalectomy.- Retroperitoneoscopic Simple and Radical Nephrectomy.- Laparoscopic and Robotic Partial Nephrectomy.- Retroperitoneal Robotic Partial Nephrectomy.- Laparoscopic and Robotic Mid and Distal Ureteral Reconstructive Surgery.- Robot Assisted Laparoscopic Nephroureterectomy.- Laparoscopic Pelvic Lymphadenectomy in Prostate Cancer.- Laparoscopic Simple Prostatectomy.- Extraperitoneal Laparoscopic Radical Prostatectomy.- Robotic- Assisted Extraperitoneal Laparoscopic Prostatectomy.- Laparoendoscopic Single-Site Retroperitoneal Surgery.- On the Horizon

In 2001, the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) was approved for use in urology (www.fda.gov) and the technological improvements have translated to a paradigm shift, especially in the field of urologic oncology. Robotic-assisted laparoscopic prostatectomy (RALP) has quickly become the minimally invasive surgical procedure of choice at most centers of excellence and robotic-assisted laparoscopic radical and partial nephrectomy (RALPN/RALN) and cystectomy (RALC) are also increasing in numbers. The impetus for the robotic approach to surgical management is based on a combined need for minimally invasive treatment with optimal surgical outcomes. Historically, conventional laparoscopy has been at the forefront of minimally invasive surgical technique and the fundamental principles of robotic surgery are founded upon those used in laparoscopic surgery. However, the advanced technology utilized in robotics has required modifications of these techniques to capitalize on the enhanced capabilities of robotic surgery. Whereas laparoscopic surgery is limited by counterintuitive movement, 2D visualization, and a decreased range of motion, robotic surgery offers 3D visualization, seven degrees of freedom, and is a natural reflection of the surgeon’s movement. Robotic surgery therefore offers enhanced capabilities for visualization, surgical dexterity, and exposure to the surgical field but these are ultimately dependent on the proper placement of the ports used for access. This chapter will provide a comprehensive overview of the standard techniques for access and port placement in a number of major robotic urologic procedures focusing on the nuances of prostate, renal, bladder, and female robotic urologic surgery.

The surgical treatment of localized prostate cancer with nerve-sparing radical prostatectomy (RP) has undergone a substantial improvement in outcomes in recent years due to new insights into the anatomy of the prostate and the adjacent tissues. Minimally invasive approaches to RP have served to focus surgeons on these anatomical landmarks, and interest in the precise anatomy of the neurovascular bundle (NVB) has increased since the advent of telerobotic laparoscopic prostatectomy, where the magnification using the da Vinci’s optical system may allow easier recognition and preservation of these nerves. This has served to “raise the bar” with regards to oncological efficacy, urinary incontinence, and erectile dysfunction, the three primary outcomes following RP.

It is never easy for an already experienced surgeon to take on a new procedure and sooner or later thereafter to relive their forgotten (or suppressed!) anxieties from their early experience. In this chapter, two open surgeons reflect on their transition to robotic surgery, one (TA)in the early stages of the development of the procedure and the other (LG) in the more recent times. We will focus on the learning curve as it applies to an experienced open surgeon and provide a frank and honest discussion of the challenges involved, as well as provide tips and tricks in the early and late part of the transition. Although it may be intuitive that it is “easier” for a very experienced open surgeon to transition to the technologic and surgical steps of the robotic-assisted laparoscopic prostatectomy (RARP) than to pure laparoscopy, that does not mean that it is an “easy” technique to learn. We hope that this chapter will enable the transitioning open surgeon, to learn from our experiences and ease his/her “console anxiety.” Some techniques that have been developed by us and others will be discussed for the “refinement” stages of the learning curve.

The task of learning robotic-assisted laparoscopic prostatectomy (RALP) can be quite challenging for both novice and experienced open or laparoscopic surgeons alike. Therefore, prior to the first procedure, adequate training and planning is required as the entire surgical team prepares for the upcoming challenge. The learning curve to achieve basic competency has been estimated to be between 20 and 25 cases.1, 2 However, during the initial stage of the learning curve, the surgeon should screen potential operative candidates cautiously to minimize the technical challenges of the procedure by selecting “ideal candidates” so that the surgical team can ease into the experience. As the experience of the surgeon and robotic team develops, one can begin to entertain the idea of tackling more challenging clinical scenarios, as studies have shown that difficult cases were attempted after performing a median of 50 procedures.3

The robotic-assisted laparoscopic prostatectomy (RALP) has gained rapid acceptance in the urological community due to its documented advantages over standard laparoscopy radical prostatectomy (LRP)1,2 and open prostatectomy.3–5 This advantage has been most appreciated with regards to the learning curve due to enhanced three-dimensional visualization and instruments that allow six degrees of freedom of motion.6 These benefits to the surgeon must, however, translate to improved overall outcomes to justify the increased economic burden placed by the robot.7–9 In this chapter, we will review the current literature for the peri-operative morbidities of RALP. Due to our extensive experience with pure LRP at Montsouris,10,11 the minimally invasive standard to which the RALP must be compared, we will reference the current literature and our own series of both RALP and LRP to make the necessary comparisons for this developing technology.

Debates about a preferred surgical approach are not new for radical prostatectomy nor limited to this surgical procedure. The relative merits of retropubic versus perineal radical prostatectomy have been considered and discussed for over 50 years and each approach still has its proponents. Pure laparoscopic and robotic-assisted laparoscopic prostatectomy (RALP) are now not only feasible but widely practiced, further expanding the options and debate.