泌尿器科領域におけるロボット支援手術の現状と課題

There has been a dramatic change in the management of the urologic diseases replacing open surgery by minimally invasive surgeries. Robotic-assisted surgery provides a precise, highly magnified 3-D view and less venous oozing associated with pneumoperitoneum, which has led to a better anatomical understanding of fine structures. It also offers finger-controlled movement and the Endowrist technology that allows for a greater degree of freedom of laparoscopic instruments. Great progress has been made in urologic surgery such as radical prostatectomy or partial nephrectomy during the past several years.

Robot-assisted radical prostatectomy （RARP）
Laparoscopic procedure was first introduced to radical prostatectomy in 1997. Although laparoscopic radical prostatectomy had a steep learning curve, it was less invasive and enabled more precise observation of architecture. The da Vinci surgical system was developed in 1999. Afterward, robot-assisted radical prostatectomy was initially reported in 2001. Since the operative procedure was established by Menon et al. the next year, RALP has been widely expanded. RARP has been reported to have less blood loss and complication rate, better functional outcome, and equivalent oncological outcome compared to open or laparoscopic radical prostatectomies. The appearance of RARP allowed for precise recognition of the structures related to radical prostatectomy. Further discussion on appropriate case selection and operative methods is necessary. In addition, studies involving intraoperative visualization of nerves or cancer sites should also be desired.

Robot-assisted partial nephrectomy （RAPN）
Nephron-sparing surgery has become the standard of care for surgical extirpation of small renal masses. Robot-assisted laparoscopic surgery offers peculiar features, such as 7 degrees of motion, 3-dimensional visualization, improved dexterity, and elimination of physiologic tremors. These characteristics potentially allow RAPN to provide decreased intraoperative estimated blood loss (EBL) and shortened warm ischemia time (WIT) and operative time compared with the laparoscopic approach. Some previous studies showed that RAPN offers better outcomes to laparoscopic partial nephrectomy.

Problems solved in the future
Validation of cost-efficiency has not yet been elucidated. The future of medicine may lie in translational approaches individualizing the treatment by further improvement of imaging technology. Further physiological or intraoperative imaging study should also be encouraged. To establish reliable training system is also expected.