EDUCATION > Courses and Products > E-Learning > Urologic Robotic Surgery

Urologic Robotic Surgery Course

After completing this module, the learner should be able to:

  • Describe the surgical steps involved with the safe performance of robotic laparoendoscopic single incision surgery and robotic assisted microsurgery.
  • State the indications and contraindications for the robotic LESS approach to urologic surgical procedures.
  • Identify errors that can occur with the system during robotic surgery conditions.
  • Describe the steps involved with safe operation of the daVinci Surgical System (Intuitive Surgery Inc, Sunnyvale, CA).
  • Describe complications that can occur during urologic robotic LESS and microsurgery and describe methods to avoid and manage the complications.

Authors

Sijo Parekattil, MD
Director of Robotic Surgery and Urolgy
Winter Haven Hospital and University of Florida
Winter Haven, FL
Disclosures: Nothing to disclose

Jihad Kaouk, MD
Department of Urology
Cleveland Clinic
Cleveland, OH
Disclosures: Endocare: Meeting Participant or Lecturer; Intuitive Surgical: Consultant or Advisor; Covidien: Consultant or Advisor

UROLOGIC ROBOTIC SURGERY COURSE

Robotic Laparoendoscopic Single Incision Surgery and Robotic Assisted Microsurgery

Contents:

  1. Abstract

Robotic Laparoendoscopic Single Site Surgery (R-LESS)

  1. Indications and Contra-indications
  2. Pre-Operative Work Up
  3. Patient Pre-Operative Preparation
  4. Instrumentation
  5. Surgical Steps
  6. Post-Operative Care
  7. Management of Intra-Operative Complications
  8. Management of Post-Operative Complications
  9. Summary of the Major Published Series in Robotic Single Incision Surgery

Robotic Assisted Microsurgery (RAM)

  1. Indications and Contra-indications
  2. Pre-Operative Work Up
  3. Patient Pre-Operative Preparation and Patient Positioning
  4. Instrumentation
  5. Surgical Steps for RAM Procedures
  6. Tips to Avoid Complications
  7. Post-Operative Care
  8. Management of Intra-Operative Complications
  9. Management of Post-Operative Complications
  10. Summary of the Major Human Published Series of Robotic Assisted Microsurgery
  11. References

Abstract

As the use of robotic assisted surgery gains more momentum for pelvic and abdominal surgery, new avenues for the use of robotic assistance are being explored for procedures that would otherwise be considered technically challenging. This is where the benefits of robotic assisted surgery in terms of magnification, motion scaling and tremor elimination in an ergonomic surgeon platform may play a role. This section will focus on the use of robotic assistance in Laparoendoscopic Single Incision Surgery (R-LESS) and robotic assisted microsurgery (RAM). Technical aspects in terms of instrumentation, robotic setup and preparation will be covered. A brief review of published literature will also be presented.

[return to top]

Robotic Laparoendoscopic Single Site Surgery (R-LESS)

Indications and Contra-indications

Robotic assisted single site surgery (R-LESS) may be a treatment option for certain urologic conditions. It offers the patient the advantage of a single incision approach and may offer the surgeon advantages in terms of improved laparoscopic instrument dexterity and maneuverability since the single incision laparoscopic approach may be technically demanding. However, the robotic platform's (da Vinci S or Si system, Intuitive Surgical, Sunnyvale, CA) use for such applications is still early and in its current form has some limitations. The robotic arms do clash at certain positions when the instrument ports are brought within a five-centimeter radius. Figure 1 below illustrates the robotic positioning for lower pelvic surgery.


Robotic positioning for pelvic Robotic assisted single site surgery (R-LESS)

Figure 1. Robotic positioning for pelvic Robotic assisted single site surgery (R-LESS)

As can be seen from Figure 1, as the surgeon moves the instrument tips, the robotic arms may clash externally thus limiting the range of motion of the instruments within the pelvis (see figure 2).


Figure 2. External collision of the robotic arms during RoLESS surgery in the pelvis

Figure 2. External collision of the robotic arms during R-LESS surgery in the pelvis

Due to this issue, a skilled surgical assistant is required at the bedside to make macro-adjustments to the robotic arms during the procedure to minimize collisions. A few key steps are performed to minimize collision:

  1. Robotic arms are positioned at two different levels,
  2. Separation between the robotic ports is maximized (to get at least 2-3 cm): by using the quad port (Olympus, Inc.), Gelport (Applied Medical Inc.) or a single incision, multi-fascial port approach,
  3. Use of the angled camera lens (30 degree down or up lens) to move the camera above or below the plane of the robotic instrument arms
  4. Can utilize one 5mm robotic instrument in one arm and one regular robotic instrument in the other arm: the curved angulation of the 5mm instrument will allow for enhanced separation of the instruments

Given these restrictions, cases that are ideal for R-LESS are procedures where the surgical field is small. Cases where extensive adhesions from prior surgery are expected and wide ranges of motions are required are probably not well suited for this approach given our current robotic platform. R-LESS has been successfully performed for pelvic surgery (radical prostatectomy, sacro-colpopexy and abdominal neurolysis of the spermatic cord)1,2 and renal surgery (nephrectomy, partial nephrectomy and pyeloplasty).1-4 For renal surgery, the location of the single incision site is at or just above the umbilicus and the robot is brought in from the lateral side of the patient. For pelvic surgery, the single incision site is at or just below the umbilicus and the robot is brought in caudally between the patient's legs (Trendelenberg position).

[return to top]

Pre-Operative Work Up

Pre-operative workup for patients is identical to that of the multi-port laparoscopic or robotic approaches. As previously mentioned, patients with extensive adhesions from prior surgery or procedures requiring a wide range of motions are required are probably not well suited for this approach.

[return to top]

Patient Pre-Operative Preparation

For most renal cases, a mild mechanical bowel prep may be utilized. For prostatectomy patients, mild mechanical bowel prep in addition to Fleet's enema may be utilized. For abdominal neurolysis patients (with chronic or phantom groin pain), no bowel prep is usually needed. Patients are instructed to avoid any type of blood thinner (aspirin, Motrin™, vitamin E, etc.) for 1 week prior to surgery.

[return to top]

Instrumentation

Non-disposable:

  1. daVinci Si or S robotic platform with HD magnification (the older daVinci platform is not ideally suitable for R-LESS applications. Angled 30 degree up or down camera lens is used
  2. Weck clip applier for assistant (Teleflex Medical Inc.)
  3. Laparoscopic needle driver for assistant to deliver sutures as needed

Disposable:

  1. Robotic instruments: Bipolar grasper, Micro Bipolar forceps, Curved Monopolar scissors, Prograsp grasper, hook cautery
  2. Suction-irrigator laparoscopic probe for assistant
  3. Hand-held cautery for assistant

Optional:

  1. Micro Doppler probe for the robot (Vascular Technology Inc., Nashua, NH) for arterial and vein identification during the neurolysis procedure

[return to top]

Surgical Steps

Robotic Assisted Single Site Abdominal Microsurgical Neurolysis (RASMN) for Chronic or Phantom Groin or Testicular Pain

Figure 3. Robotic assisted single site abdominal microsurgical neurolysis: Doppler probe being used to identify the left side gonadal vessels

Figure 3. Robotic assisted single site abdominal microsurgical neurolysis: Doppler probe being used to identify the left side gonadal vessels

  • Patient is positioned in Trendelenberg position on a split-leg table. Once patient is prepped and draped, the robotic platform is not brought in caudally between the patient's legs till the camera lens reaches the port site (at or just below the umbilicus)
  • Foley catheter is placed to drain the bladder. Oro-gastric tube is placed to decompress the stomach.
  • Initially a 2-3 cm midline incision is made just below the umbilicus. Incision is carried down to the level of the fascia
  • The fascia is then incised (3-4cm opening). The fascial incision may be made slightly longer than the skin incision. The peritoneum is then incised.
  • The single port device is placed (Quad port or GelPort). Alternatively, a single incision, multi fascial port placement approach can be used if a specific single port device is not available.
  • The robotic instruments and camera are now docked. The 30-degree up camera lens is first placed just into the abdomen to maintain a view of the robotic port tips. The robotic ports are carefully advanced under visual guidance above the plane of the camera. The robotic arms are stretched apart as much as the fascia will allow, to gain the maximal separation possible.
  • Once the robotic instruments have been delivered to the internal inguinal ring on the side of the neurolysis to be performed, then the camera is gently advanced
  • The peritoneum is opened over the internal inguinal ring. The gonadal vessels leading to the internal ring are identified using the robotic micro Doppler probe (VTI, Inc.). The peri-vascular tissue (that contains the genito-femoral nerve fibers) is carefully dissected off the vessels and cauterized at multiple levels and then transected.
  • The vas deferens leading to the internal ring is next identified and the micro Doppler probe is used to identify the deferential artery. The vas deferens is carefully stripped from its sheath and preserved along with the deferential artery. The vasal sheath and the peri-vasal tissues are then cauterized at multiple levels and then transected (contain fibers from the inferior hypogastric nerve plexus).
  • The neurolysis is complete at this point. The instruments are carefully removed under vision. The camera is removed and the single site port device is removed. The fascia is closed using interrupted 0-polyglactin sutures. The subcutaneous tissue is closed using interrupted 3-0 poliglecaprone 25 (Monocryl-Ethicon Inc, Somerville, NJ) sutures. The skin is closed with a subcuticular running 4-0 poliglecaprone 25 and skin glue.

[return to top]

Post-Operative Care

The RASMN procedures are all outpatient procedures. These patients are all sent home with a jock support and fluff dressings to provide compression of the scrotum to minimize swelling and possible hematoma formation. The fluff dressings are removed the next morning and the patient is allowed to shower at that point. The patient is instructed not so swim or tub bath for 2 weeks post-op till the incision has healed. Patients are requested to be on bedrest for 1 week and not to perform any heavy lifting for 4 weeks postop.

[return to top]

Management of Intra-Operative Complications

Gonadal artery injury is one possible intra-operative complication. Use of intra-op Doppler monitoring of the arteries can minimize this risk and also help identify an injury if it occurs. If an injury occurs, the procedure is completed and then the artery is re-anastomosed using 8-0 prolene or 8-0 nylon interrupted sutures. Patency is confirmed using intra-op micro Doppler monitoring.

Bowel injury is a possible risk for any intra-abdominal procedure. Care must be taken during port and instrument entry under vision to ensure that no inadvertent bowel injury occurs. If a bowel injury occurs, the best management route is to consult general surgery intra-op to assess if the injury can be repaired using laparoscopic/robotic technique or requires open conversion. For small serosal injuries, these can be repaired using imbricating suture techniques using 2-0 polyglactin or nylon sutures. For full thickness bowel injuries, open conversion and bowel resection with re-anastomosis may be required.

[return to top]

Management of Post-Operative Complications

Wound infection and scrotal hematoma formation are the two most common post-operative complications after RASMN. Wound infections if superficial are treated with oral antibiotics. If there is evidence of a wound abscess, then incision and drainage of the wound is warranted. Hematomas may usually be treated conservatively with bedrest. However, if the patient develops a very large painful hematoma in the groin, incision and drainage will provide the patient with immediate relief.

[return to top]

Summary of the Major Published Series in Robotic Single Incision Surgery

Group

Date

Brief description of results

Kaouk et al.,
Cleveland Clinic Foundation 3

2009

2 patients undergoing robotic single port partial nephrectomy

Kaouk et al.,
Cleveland Clinic Foundation 4

2009

3 patients: Radical prostatectomy, dismembered pyeloplasty and radical nephrectomy

Stein et al.,
Cleveland Clinic Foundation 1

2010

11 cases – kidney and pelvic procedures

White et al.,
Cleveland Clinic Foundation 2

2010

13 cases – seven kidney procedures and six pelvic procedures

[return to top]

Robotic Assisted Microsurgery (RAM)

Indications and Contra-indications

Robotic assisted microsurgery (RAM) may be utilized for most microsurgical procedures as a substitute for the operating microscope. The RAM platform offers 10-15 times magnification, compared to 10-25 times magnification with the regular microscopic platform. Thus, the microsurgeon should probably limit the use of robotic assistance to procedures where 20-25 times magnification is not essential. Currently, the RAM platform has been utilized for vasovasostomy, vasoepididymostomy, sub-inguinal varicocelectomy, denervation of the spermatic cord for chronic orchialgia, testicular sperm extraction, vascular anastomosis and nerve grafting procedures.

[return to top]

Pre-Operative Work Up

Most RAM procedures are outpatient procedures. Patients are usually operated on under general anesthesia and with muscle blockade to prevent any inadvertent patient movement during fine microsurgical maneuvers. Standard preoperative anesthesia guidelines are utilized for patient preparation: chest x-ray if previous smoker or age greater than 50, EKG if age greater than 50 or any previous cardiac history, serum electrolytes if patient is greater than 50 years age or has any other medical co-morbidities. For most younger, healthier patients, no preoperative testing is required.

[return to top]

Patient Pre-Operative Preparation and Patient Positioning

Patients are instructed to avoid any type of blood thinner (aspirin, Motrin™, vitamin E, etc.) for 1 week prior to surgery. They are asked not to shave the area before surgery and are instructed to shower with an antibacterial wash the night before and morning of surgery. Figure 4 illustrates patient positioning for robotic male infertility procedures. The patient is placed in the supine position. The table is placed level (there is no Trendelenberg). The robot is brought in from the right side of the patient after skin incisions are made and the operative tissues exposed. The arms of the patient may be placed alongside (gently wrapped in the draw sheets) or apart on arm boards with adequate padding to prevent any nerve compression injuries. Sequential compression devices are placed on the lower extremities to reduce the risk of deep venous thrombus formation. A urethral catheter is generally not utilized, however, if the procedure lasts more than 2 hours, the patient is usually straight catheterized at the end of the procedure to drain the bladder (before recovering the patient from anesthesia).

Figure 4. Robot Positioning relative to the patient

Figure 4. Robot Positioning relative to the patient

The robot is positioned after skin incisions are made and operative tissues are exposed. The robot is used to perform the microsurgical components of the procedure. Since this is an open case, the trocars are loaded only to allow the instruments to function and to stabilize their movements outside the patient's body. Figures 5 illustrates the trocar placement, robotic arm placement and positioning of the assistant. It is important to advance the instruments at least 4-5cm beyond the tip of the trocar when positioning the robotic arms to optimize range of motion. The 4th robotic arm may be placed lateral to the left robotic arm to minimize instrument clashes. The zero degree camera lens is used for all cases. The camera is placed at least 3-4cm away from the operative field to avoid thermal heat damage from the tip of the camera.

Figure 5. Robotic trocar placement and assistant position

[return to top]

Instrumentation

Non-disposable:

  1. daVinci Si or S robotic platform with HD magnification (the older daVinci platform is not ideally suitable for microsurgical applications – no digital magnification and too much heat dispersion from the camera tip to the tissues. Digital magnification in the S and Si systems allows the placement of the camera at least 3-4 cm away from the operative field to avoid thermal damage). Zero degree camera lens is used.

Disposable:

  1. Micro Doppler probe for the robot (Vascular Technology Inc., Nashua, NH). May use regular hand held micro Doppler probes, but not as easily manipulated with robotic arms.
  2. Robotic instruments: Black diamond micro forceps x 2, Micro Bipolar forceps, Curved Monopolar scissors, Potts Scissors
  3. Weck sponge sticks
  4. Irrigation via 10cc syringe w/ 18 Guage angiocatheter – by assistant
  5. 15 blade scalpel

Optional:

  1. Fine tip hand-held cautery for assistant

[return to top]

Surgical Steps for RAM Procedures

Robotic Assisted Microsurgical Vasovasostomy

Figure 6. Robotic assisted microsurgical vasovasostomy

  • The proximal (testicular side) and distal (beyond vasectomy site) vas deferens around the previous vasectomy site is palpated through the scrotal skin. The distal vas just above the vasectomy site is fixed with a towel clip through the scrotal skin.
  • A 1-2 cm vertical incision is made with a 15 blade scalpel inferiorly from the towel clip over the vas
  • The distal and proximal vas ends are dissected free using fine cautery (handheld ophthalmologic fine cautery) and sharp dissection.
  • The proximal vas is carefully transected with a 15 blade scalpel and the fluid effluxing from the lumen is collected on a glass slide and examined under phase contrast microscopy to assess for the presence of any sperm. If there is sperm found or the efflux is copious and clear or milky, then a vasovasostomy is performed on this side. If the efflux has no sperm and is thick and pasty – then a vasoepididymostomy is performed
  • The distal end of the vas is also transected and the two clean ends of the vas are now approximated to each other to allow a tension free anastomosis. Small hemostats are placed on the adventitia next to each end of the vas to avoid any direct manipulation of the vas. The same procedure is performed on the contralateral scrotal side. The robot is now positioned to perform the microsurgical vasovasostomy as described in the patient and trocar positioning sections above.
  • The left side vasovasostomy is performed first. The black diamond micro-forceps are loaded on the right and left surgical robot arms. The zero degree camera lens is loaded onto the robot camera arm. The micro Potts scissors are loaded onto the 4th robot arm. The two vas ends are placed over a 1/4" Penrose drain. The assistant now irrigates the field with saline using a 10cc syringe with an 18 Gauge angiocatheter tip. Weck sponge sticks are used to dry the field. Each of the lumen of the vas is dilated with the black diamond forceps.
  • The assistant now passes the 9-0 nylon suture in its inner packaging to the surgical field to allow the robot console surgeon to grasp the suture (using the black diamond right hand grasper) and cut it at about 2 inches length using the micro Potts scissors (left hand 4th arm)
  • The 9-0 nylon suture is used to approximate the posterior muscularis layer of the two ends of the vas. The surgeon uses the black diamond forceps in both left and right arms as needle drivers. The fourth arm is used by toggling the surgeons left arm to use the micro Potts scissors whenever suture needs to be cut.
  • Two or three double armed 10-0 nylon sutures are now placed to re-anastomose the posterior mucosal lumen of the vas. The sutures are placed inside out to ensure good mucosal approximation. All sutures are placed before they are tied.
  • Three double armed 10-0 nylon sutures are used to close the anterior mucosal lumen of the vas
  • Five to six 9-0 nylon sutures are used to approximate the muscularis layer of the vasa
  • The bridging scar tissue between the vasal ends is excised using fine cautery by the surgical assistant
  • The adventitia is approximated using a 6-0 polypropylene suture to relieve any tension in the anastomosis and to wrap the repair site
  • The Penrose drain is gently removed from under the repair. The vas is then replaced in the scrotal cavity
  • The same procedure is now performed on the contralateral right side by repositioning the robot away from the patient to the right scrotum. The camera lens is changed to 30 degrees down to allow a better angle of visualization of the anastomosis. The robotic vasovasostomy is performed on the right side as previously described.
  • The dartos layer is closed using a running 3-0 chromic suture for both scrotal skin incisions. The skin is closed using a 4-0 chromic running suture. Bacitracin ointment is applied to the incision and fluff dressings with an athletic support are applied. An ice-pack is carefully applied to the scrotum in the recovery room

Robotic Assisted Microsurgical Varicocelectomy

Figure 7. Robotic assisted microsurgical varicocelectomy

  • A 2-3cm subinguinal incision is made over the location of the external inguinal ring
  • The spermatic cord is carefully dissected and then raised through the skin incision. A ½" inch Penrose drain is placed under the cord to keep it elevated. A sterile tongue blade is placed through the Penrose drain under the cord to further elevate and spread the cord. The robot is positioned from the patient's right side as described in the beginning of this section. The black diamond micro forceps are used in the right robotic arm, the micro bipolar forceps in the left arm and the curved monopolar scissors in the 4th arm. For either side, a zero degree camera lens is utilized. The cremasteric sheath of the spermatic cord in now incised to separate the cord structures
  • Real-time intra-operative Doppler ultrasound is utilized to localize the testicular artery and ensure that no injury occurs to this vessel
  • Enlarged veins are carefully dissected and then ligated using 3-0 silk suture ties. Doppler ultrasound verification of each vessel before it is ligated is performed to ensure that no arteries are ligated. The Potts scissors in the 4th arm is used to cut the vessels after being tied
  • The tongue blade is removed from within the Penrose. The Penrose is now carefully removed and the spermatic cord is released. The testicle is gently pulled down to retract the spermatic cord completely into the incision
  • The skin incision is closed at the subcutaneous layer using a 3-0 monocryl suture. The skin is closed using a running subcuticular 4-0 monocryl suture and skin glue.

Robotic Assisted Microsurgical Denervation of the Spermatic Cord

Figure 8. Robotic assisted microsurgical denervation of the spermatic cord

  • A 2-3cm subinguinal incision is made over the location of the external inguinal ring
  • The spermatic cord is carefully dissected and then raised through the skin incision. A ½" inch Penrose drain is placed under the cord to keep it elevated.
  • Posterior cauterization of the fascia above the lateral edge of the pubic symphysis is performed to ligate branches of the Ilioinguinal and Genitofemoral nerve bundles
  • A sterile tongue blade is placed through the Penrose drain under the cord to further elevate and spread the cord. The robot is positioned from the patient's right side as described in the beginning of this section. The black diamond micro forceps are used in the right robotic arm, the micro bipolar forceps in the left arm and the curved monopolar scissors in the 4th arm. For either side, a zero degree camera lens is utilized, The cremasteric sheath of the spermatic cord in now incised and cauterized to reveal the cord structures
  • Real-time intra-operative Doppler ultrasound is utilized to localize the testicular arteries and ensure that no injury occurs to these vessels
  • The vas deferens is identified and the deferential artery is preserved if present by Doppler exam. The arteries are preserved by using red vessel loops. The vasal sheath is now carefully cauterized and ligated while preserving the vas deferens itself with a yellow vessel loop
  • The arteries, veins and lymphatics are preserved as a bundle using a red vessel loop and the loose remaining peri-arterial tissues are cauterized and ligated
  • The remaining posterior Cremasteric muscle fibers are cauterized and ligated
  • The tongue blade is removed from within the Penrose. The Penrose is now carefully removed and the spermatic cord is released. The testicle is gently pulled down to retract the spermatic cord completely into the incision
  • The skin incision is closed at the subcutaneous layer using a 3-0 monocryl suture. The skin is closed using a running subcuticular 4-0 poliglecaprone 25 (Monocryl-Ethicon Inc, Somerville, NJ) suture and skin glue

[return to top]

Tips to Avoid Complications

  • Ensure that the robot camera is at least 3-4cm away from the operative field to avoid any thermal injury to the patient
  • Have the surgical assistant pass the sutures to the surgical field with the sutures still in the original inner packing. This allows the surgeon to remove the suture from the pack under magnified vision and reduces that risk of misplacing fine suture and needles.

[return to top]

Post-Operative Care

The RAM procedures are usually all outpatient procedures. These patients are all sent home with a jock support and fluff dressings to provide compression of the scrotum to minimize swelling and possible hematoma formation. The fluff dressings are removed the next morning and the patient is allowed to shower at that point. The patient is instructed not so swim or tub bath for 2 weeks post-op till the incisions are healed. Patients are requested to be on bedrest for 1 week and not to perform any heavy lifting for 4 weeks postop.

[return to top]

Management of Intra-Operative Complications

Testicular artery injury is one possible intra-operative complication. Use of intra-op Doppler monitoring of the arteries can minimize this risk and also help identify an injury if it occurs. If an injury occurs, the procedure is completed and then the artery is re-anastomosed using 8-0 prolene or 8-0 nylon interrupted sutures. Patency is confirmed using intra-op micro Doppler monitoring.

[return to top]

Management of Post-Operative Complications

Wound infection and scrotal hematoma formation are the two most common post-operative complications. Wound infections if superficial are treated with oral antibiotics. If there is evidence of a wound abscess, then incision and drainage of the wound is warranted.

Scrotal hematoma is usually managed conservatively. Bedrest, jock support and ice packs to the groin and scrotum are quite effective, but it may take weeks for the hematoma to resolve completely. If the patient rapidly develops a large hematoma postop and is having intractable pain, incision and drainage is an option for immediate pain relief for the patient.

[return to top]

Summary of the Major Human Published Series of Robotic Assisted Microsurgery

Group

Date

Brief description of results

Fleming,
Vattikutti Urology Institute 5

2004

2 human vasovasostomy cases performed with excellent patency

Parekattil et al.,
University of Florida 6

2010

20 human robotic vasovasostomy cases performed with 100% patency

Parekattil et al.,
University of Florida 7

2010

69 human cases (vasovasostomy, varicocelectomy and denervation cases) performed with good outcomes

[return to top]


References

  1. Stein, R. J., White, W. M., Goel, R. K. et al.: Robotic laparoendoscopic single-site surgery using GelPort as the access platform. Eur Urol, 57: 132, 2010.
  2. White, M. A., Haber, G. P., Kaouk, J. H.: Robotic single-site surgery. Curr Opin Urol, 20: 86, 2010.
  3. Kaouk, J. H., Goel, R. K.: Single-port laparoscopic and robotic partial nephrectomy. Eur Urol, 55: 1163, 2009.
  4. Kaouk, J. H., Goel, R. K., Haber, G. P. et al.: Robotic single-port transumbilical surgery in humans: initial report. BJU Int, 103: 366, 2009.
  5. Fleming, C.: Robot-assisted vasovasostomy. Urol Clin North Am, 31: 769, 2004.
  6. Parekattil, S. J., Atalah, H. N., Cohen, M. S.: Video technique for human robot-assisted microsurgical vasovasostomy. J Endourol, 24: 511, 2010.
  7. Parekattil, S. J., Cohen, M. S.: Robotic surgery in male infertility and chronic orchialgia. Curr Opin Urol, 20: 75, 2010.

[return to top]





Status
Module 6 LESS and Microsurgery Posttest Available 1.50 credits/hours

ADVERTISEMENT

ADVERTISEMENT
Donate
Contact
Press/Media
Sections
Term of Use
Site Map


ADVERTISEMENT