Laparoscopic radical prostatectomy was initially described in 1992 by Schuessler et al.. In the last 2 years, the laparoscopic procedure has been standardized by Guillonneau and Vallancien  and others , and by last year had replaced the open retropubic approach in some centres. However, laparoscopic radical prostatectomy remains a complex operation. Besides perfect knowledge of the topographical anatomy, it demands training in specific laparoscopic skills, like endoscopic suturing and intracorporeal knotting, which require considerable practice to become proficient.
A telerobotic surgical system (the da Vinci Surgical System, InSite Vision Systems, Intuitive Surgical Inc., Mountain View, CA, USA) was developed in 1999 and used immediately by cardiac surgeons. In this field, it has heralded a new era in minimally invasive surgery by enhancing endoscopic vision and anastomotic suturing . The objective of the present report was to determine whether the da Vinci system could be used to facilitate laparoscopic procedures in urology. We chose laparoscopic prostatectomy mainly because this operation requires perfect endoscopic vision and meticulous suturing within a limited space below the symphysis on the pelvic floor.
After a period of technical development and training on cadavers with the da Vinci telemanipulation system, the first clinical applications in urological surgery were undertaken over 6 weeks in 10 patients eligible for laparoscopic radical prostatectomy. All operations were performed by one of the authors. The median (range) age of the patients was 60.5 (57–69) years, the clinical tumour stage T1b, T1c, T2a or T2b, and the median PSA level 6.4 (0.5–22.4) ng/mL. One patient had undergone a previous TURP, and three had received neoadjuvant hormone ablative therapy prescribed elsewhere.
Patients are placed supine with their arms at their sides and legs parted on spreader bars, to provide access for the surgical cart column. A 2.5–3 cm midline laparotomy is made subumbilically and all trocars inserted under digital guidance. Two 8 mm special trocars for the robotically assisted tools are positioned pararectally bilaterally, and two 10 mm standard trocars just medial to the iliac crest. The laparotomy is closed temporarily around the 12 mm camera trocar to prevent gas leakage from the pneumoperitoneum.
The operating urologist then operates the remote console, controlling three robotic arms (Fig. 1). After attaching the 30° 3D-endocamera (InSite Vision System) to the medial arm, the laparoscopic tools are inserted through the 8 mm trocars under direct vision (Fig. 2). These tools are especially designed for robotic use and feature the Endo-Wrist™ articulations, which allow for wrist-like instrument movement. A cautery hook, a short-tip grasper and a bipolar haemostatic grasper are used for dissection and bleeding control, and two needle holders for suturing and knotting.
The entire laparoscopic prostatectomy is carried out by the operating urologist from the remote console. An assistant and an operating room nurse remain at the patient's side and use the two lateral 10 mm ports, which allow access for conventional laparoscopic instruments, e.g. clip applicator, large grasper and a suction device.
The operative technique used is essentially a combined Walsh retrograde and Campbell anterograde procedure. In brief, bilateral pelvic lymphadenectomy and frozen section examination of lymph tissue is followed by; dissection of the urachus to open up Retzius' space; preparation and lateral incision of the endopelvic fascia; dissection of the puboprostatic ligaments and preparation of the prostatic apex; ligation of the venous plexus with 2/0 polyglactin; dissection of the urethra; incision of Denonvilliers' fascia and ascending preparation of the dorsal aspect of the prostate; dissection of the bladder neck; descending dissection of ducts and seminal vesicles; placing the prostate in an organ bag; reconstructing the bladder neck and vesico-urethral anastomosis with eight interrupted 3/0 polydioxanone sutures (Fig. 3); transurethral insertion of a Foley catheter and insertion of a silicone drain; removal of the organ bag through the midline laparotomy; and finally wound closure.
In nine of 10 patients, the planned operative procedure was completed after a median (range) laparoscopy time of 9 (8.75–11) h. Laparoscopy was abandoned in one patient because of difficulties in controlling haemostasis (the first patient) after completing the prostatectomy. This was the only patient to require autologous blood transfusions. All patients recovered rapidly after surgery. The transurethral Foley catheter was removed after a median (range) of 18 (5–23) days. When discharged 1–3 days after catheter removal, all patients but one complained of mild to moderate stress incontinence.
The final pathological examination of the resected specimen showed a median (range) of 7 (4–12) pelvic lymph nodes. In all but one of the 10 patients the lymph nodes were free of tumour (pN0). In one patient (with a preoperative PSA level of 3.3 ng/mL), nodal micrometastases had been missed by frozen-section examination (pN1). Prostate histology showed adenocarcinoma of the prostate, classified as pT2a in two, pT2b in four, pT3a in two and pT3b in two. The resection margins were positive (R1) in three patients (two with pT3a tumour and one with pT3b pN1 tumour).
Advantages and disadvantages
The da Vinci Surgical System has some potential advantages over conventional laparoscopic surgery in urology. This initial experience with robotically assisted laparoscopic radical prostatectomy in 10 patients showed that: (i) Visualization is clearly improved by the InSite Vision System, through three-dimensional vision, 10-fold magnification and infinitely variable positioning of the 30° endoscope by the urological surgeon; (ii) The handling of the laparoscopic tools is greatly facilitated by the Endowrist™ instrument technology, which allows the surgeon to dissect, suture and tie knots endoscopically much as would be possible in open surgery; (iii) The laparoscopic procedure can be undertaken in a relaxed working position at the console, with harmonious control of two surgical instruments and camera position. However, as with conventional laparoscopic surgery, operating with the assistance of the da Vinci Surgical System requires intensive practice. The potential of this novel technique is its surgical accuracy; we expect that the surgery could be faster with increasing routine use, as was seen with other laparoscopic techniques . The disadvantages of the telerobotic technology are presently the limited choice of laparoscopic tools and the considerable cost.