Robotic assisted radical prostatectomy accelerates postoperative stress recovery: Final results of a contemporary prospective study assessing pathophysiology of cortisol peri-operative kinetics in prostate cancer surgery

Objective:To investigate the effects of prostate cancer(PCa)surgery on the stress system and to identify potential independent factors associating with stress recovery.Methods:The design of the study was prospective and PCa surgery included robot assisted radical prostatectomy(RARP)or retropubic radical prostatectomy(RRP).Between February 2013 to December 2014,315 consecutive patients were evaluated.The effects of PCa surgery on the stress system were measured by cortisol serum levels before and after surgery on postoperative day(POD)0,1,3,5 and 45.Cortisol variations in the population and subpopulation(RARP vs.RRP)of patients were investigated by statistical methods.Factors associating with stress recovery were assessed by simple linear regression(SLR)and multiple linear regression(MLR)analysis.Results:RARP was performed in 75.9%of cases.In the patient population,there were wide serum cortisol perioperative variations.PCa surgery triggered the stress system which immediately(POD 0)responded by cortisol overproduction which induced the negative feedback mechanism that started on POD 1,continued on POD 3,was still ongoing on POD 5 and completely settled on POD 45(stress recovery).In the subpopulation of patients,significantly lower cortisol serum levels were detected on POD 3e5 in RARP cases inwhomcortisol levels were close to preoperative levels(stress recovery)on POD 5.Independent predictive factors of serum cortisol on POD 5(stress recovery)were preoperative cortisol(p Z 0.02),cortisol levels on POD 3(p<0.0001)and RARP(p Z 0.03)in which the association was negative(stress recovery faster than RRP).Conclusion:Our study shows that PCa surgery immediately(POD 0)triggers the stress system which respond by overproduction of cortisol which induces the negative feedback mechanism that starts on POD 1,is still ongoing on POD 5,but is completely settled on POD 45.Moreover,after surgical trauma,our study gives evidence that the RARP procedure associates with stress recovery faster than RRP.Further confirmatory studies are required.

Robotic assisted andrological surgery

The introduction of the operative microscope for andrological surgery in the 1970s provided enhanced magnification and accuracy, unparalleled to any previous visual loop or magnification techniques. This technology revolutionized techniques for microsurgery in andrology. Today, we may be on the verge of a second such revolution by the incorporation of robotic assisted platforms for microsurgery in andrology. Robotic assisted microsurgery is being utilized to a greater degree in andrology and a number of other microsurgical fields, such as ophthalmology, hand surgery, plastics and reconstructive surgery. The potential advantages of robotic assisted platforms include elimination of tremor, improved stability, surgeon ergonomics, scalability of motion, multi-input visual interphases with up to three simultaneous visual views, enhanced magnification, and the ability to manipulate three surgical instruments and cameras simultaneously. This review paper begins with the historical development of robotic microsurgery. It then provides an in-depth presentation of the technique and outcomes of common robotic microsurgical andrological procedures, such as vasectomy reversal, subinguinal varicocelectomy, targeted spermatic cord denervation （for chronic orchialgia） and robotic assisted microsurgical testicular sperm extraction （microTESE）.

Robotic assisted laparoscopic simple suprapubic prostatectomy--The Smith Institute for Urology experience with an evolving technique

Objective:Despite a multitude of minimally invasive surgical options available for benign prostatic enlargement,open simple prostatectomy(OSP)remains the standard for large prostates(typically greater than 100 g).OSP,however,is associated with significant morbidity.Recently,a few reports touting robotic application to simple prostatectomy have been published.Herein,we reviewed our series of robotic assisted laparoscopic simple suprapubic prostatectomy(RALSSP)and detailed modifications in our technique as our experience increased.Methods:All RALSSP cases performed between January 2013 and January 2014 were reviewed for demographics,pre-operative features,and perioperative outcomes.All parameters were tabulated and mean values were calculated.Student’s t-test was utilized with p<0.05 deemed significant.Details regarding surgical technique were reviewed and highlighted.Results:Fifteen patients underwent RALSSP during this period.Mean age of these men was 68.7 years.Mean body mass index(BMI)was 28.5 kg/m^2.American Society of Anesthesiologists(ASA)score was on average 2.6.Average International Prostate Symptom Score(IPSS)was 16.2 with the majority of men experiencing some adverse clinical sequela of such benign prostatic hyperplasia(BPH).For those patients not in retention,preoperative post-void residual(PVR)was 428 mL.All patients underwent successful RALSSP without need for conversion or need for blood transfusion.Mean estimated blood loss(EBL)was 290 mL.Five patients underwent other concurrent procedures(e.g.,cystolithotomy).Mean length of hospital stay(LOS)was 2.4 days and only five patients required continuous bladder irrigation(CBI)postoperatively.Postoperative PVR improved to a mean of 33 mL and IPSS improved to 4.5(p<0.001).No major complications were identified.Adaptation of low transverse cystotomy,utilization of a robotic tenaculum in the#3 arm with its control by a surgeon on a second console,and the utilization of mucosal advancement have all subjectively aided in performance of RALSSP and perioperative outcomes.Conclusion:RALSSP allows for feasible performance of prostate adenoma enucleation with low risk of blood transfusion,short LOS,and significant improvement in IPSS and PVR;all while maintaining a minimally invasive approach.The use of a robotic tenaculum controlled by the secondary console and the mucosal advancement facilitate excellent outcomes and may play a role in minimizing hematuria and need for CBI.

Robotically assisted removal of pelvic splenosis fifty-six years after splenectomy: A case report

BACKGROUND‘Splenosis’is defined as the autotransplantation of splenic tissue following trauma or surgery,usually in the form of intraperitoneal nodules.The proliferation of imaging techniques has resulted in increased unexpected discoveries of splenosis nodules,and achieving a differential diagnosis can be challenging.Nuclear medicine studies have been playing an increasingly important role in this process,but the clinical significance of asymptomatic nodules remains uncertain.CASE SUMMARY We present a case of pelvic splenosis in a 73-year-old man diagnosed 56 years after a splenectomy during a computed tomography(CT)follow-up for B-cell lymphoma,presenting intense contrast enhancement of an 18 mm nodule in the right recto-vesical space.18F-fluorodeoxyglucose demonstrated weak metabolic activity.Since histological diagnosis was deemed necessary,the nodule was easily removed with robotically assisted laparoscopy,together with another 6 mm left a paracolic lesion.The latter was previously undiagnosed but retrospectively visible on the CT scan.CONCLUSION In a patient requiring differential diagnosis of splenosis nodules from lymphomarecurrence, the robotic approach provided a safe en bloc removal with shorthospitalization. The Da Vinci Xi robot was particularly helpful because its opticscan be introduced from all ports, facilitating visualization and lysis of multipleintra-abdominal adhesions.

Bimanual motor skill learning and robotic assistance for chronic hemiparetic stroke: a randomized controlled trial

Using robotic devices might improve recovery post-stroke, but the optimal way to apply robotic assistance has yet to be determined. The current study aimed to investigate whether training under the robotic active-assisted mode improves bimanual motor skill learning(biMSkL) more than training under the active mode in stroke patients. Twenty-six healthy individuals(HI) and 23 chronic hemiparetic stroke patients with a detectable lesion on MRI or CT scan, who demonstrated motor deficits in the upper limb, were randomly allocated to two parallel groups. The protocol included a two-day training on a new bimanual cooperative task, LIFT-THE-TRAY, under either the active or activeassisted modes(where assistance decreased in a pre-determined stepwise fashion) with the bimanual version of the REAplan? robotic device. The hypothesis was that the active-assisted mode would result in greater biMSkL than the active mode. The biMSkL was quantified by a speed-accuracy trade-off(SAT) before(T1) and immediately after(T2) training on days 1 and 2(T3 and T4). The change in SAT after 2 days of training(T4/T1) indicated that both HI and stroke patients learned and retained the bimanual cooperative task. After 2 days of training, the active-assisted mode did not improve biMSkL more than the active mode(T4/T1) in HI nor stroke patients. Whereas HI generalized the learned bimanual skill to different execution speeds in both the active and active-assisted subgroups, the stroke patients generalized the learned skill only in the active subgroup. Taken together, the active-assisted mode, applied in a pre-determined stepwise decreasing fashion, did not improve biMSkL more than the active mode in HI and stroke subjects. Stroke subjects might benefit more from robotic assistance when applied "as-needed." This study was approved by the local ethical committee(Comité d'éthique médicale, CHU UCL Namur, MontGodinne, Yvoir, Belgium;Internal number: 54/2010, Eudra CT number: NUB B039201317382) on July 14, 2016 and was registered with ClinicalTrials.gov(Identifier: NCT03974750) on June 5, 2019.

Evolution of endoscopic extraperitoneal radical prostatectomy （EERPE）： technique and outcome

Endoscopic extraperitoneal radical prostatectomy （EERPE） is a well-established and standardized technique for treating patients with localized prostate cancer. Nevertheless, the procedure is continuously being refined with the expansion of anatomical knowledge. The development of a nerve-sparing approach and improvements in currently used equipment are expected to yield better results in cosmesis and convalescence without sacrificing the procedure＇s established benefits in terms of potency, continence and oncological management. In this study, the technique and its evolution are presented in detail, along with an analysis of its clinical efficacy. We also consult the literature to compare EERPE to transperitoneal laparoscopic radical prostatectomy, and we also discuss new technical advancements regarding the use of robotic assistance during EERPE.

Stand-Up Assistive Devices Allowing Patients to Perform Voluntary Movements within the Safety Movement Tolerance

This paper proposes a novel standing assistance robot,which realizes voluntary movements of the patient within a safety motion range.In the previous studies,conventional assistive robots did not require patients to use their own physical strength to stand,which led to decreased strength in the elderly.Such general assistive robots helped patients by using a fixed motion reference pathway in spite of their original intention,and as a result,these robots failed to use the physical strength of the patients.Therefore,this study proposes a novel method for assisting the patient to stand up safely while using their physical abilities,by determining the range of movements that can be safely performed from the patient’s physical condition and allowing the patient to move freely within this range.The standing motion is a set of different movements:inclining the trunk forward,lifting the trunk,and extending the trunk.In this study,the range of movements in which the patient can safely stand in each movement is determined in terms of body stability and the muscle output that the patient can generate.Furthermore,this study proposes a robot control method that allows movements based on the patient’s free will if the patient’s posture is within the safety tolerance,and it corrects the movements when the patient’s posture is estimated to fall outside of it.The proposed idea is implemented in our new prototype,and its effectiveness is verified by experimental results with elderly subjects who live in the nursing care house.

Development of Rehabilitation and Assistive Robots in China: Dilemmas and Solutions

China is rapidly becoming an aging society, leading to a significant demand for chronic disease management and personalized healthcare. The development of rehabilitation and assistive robotics in China has gatheredsignificant attention not only in research fields but also in industries. Such robots aim to either guide patientsin completing therapeutic training or assist people with impaired functions in performing their daily activities.In the past decades, we have witnessed the advancement in rehabilitation and assistive robotics, with diversemechanical designs, functionalities, and purposes. However, the construction of dedicated regulations and policiesis relatively lagged compared with the flourishing development in research fields. Moreover, these kinds of robotsare working or collaborating closely with human beings, bringing unprecedented considerations on ethical issues.This paper aims to provide an overview of major dilemmas in the development of rehabilitation and assistiverobotics in China and propose several potential solutions.

Bone Fracture Reduction Surgery-aimed Bone Connection Robotic Hand

Bone connection with robot is an important topic in the research of robot assisted fracture reduction surgery.With the method to achieve bone-robot connection in current robots,requirements on reliability and low trauma can not be satisfied at the same time.In this paper,the design,manufacturing,and experiments of a novel Bone Connection Robotic Hand(BCRH)with variable stiffness capability are carried out through the bionics research on human hand and the principle of particle jamming.BCRH’s variable stiffness characteristic is a special connection between“hard connection”and“soft connection”,which is different from the existing researches.It maximizes the reliability of bone-robot connection while minimizes trauma,meets the axial load requirement in clinical practice,and effectively shortens the operating time to less than 40 s(for mode 1)or 2 min(for mode 2).Meanwhile,a theoretical analysis of bone-robot connection failure based on particle jamming is carried out to provide references for the research in this paper and other related studies.

Robotic gastrectomy for gastric cancer

Robotic gastrectomy(RG)is increasingly performed,particularly in East Asia.With articulated devices,surgeons are able to perform every procedure more comfortably and meticulously,which makes RG ideal from the surgeon’s standpoint.However,it is still unclear whether it is a suitable treatment strategy from the patient’s viewpoint,due to the lack of solid evidence obtained from randomized controlled trials.The feasibility of RG has been demonstrated in many retrospective comparative studies,which showed similar trends,including relatively less estimated blood loss and longer operation time with RG than laparoscopic gastrectomy(LG),equivalent number of harvested lymph nodes and similar length of postoperative hospital stay between RG and LG.However,considering the higher medical expenses associated with RG,its superiority in terms of long-term survival outcomes will need to be confirmed for it to be accepted more widely.

Eye Robotic System for Vitreoretinal Surgery

Micro incision vitrectomy system(MIVS)is considered to be one of the most difficult tasks of eye surgery,due to its requirements of high accuracy and delicate operation under blurred vision environment.Therefore,robot-assisted ophthalmic surgery is a potential and efficient solution.Based on that consideration,a novel master-slave system for vitreoretinal surgery is realized.A 4-DOF remote center of motion(RCM)mechanism with a novel linear stage and end-effector is designed and the master-slave control system is implemented.The forward and inverse kinematics are analyzed for the controller implementation.Then,algorithms with motion scaling are also integrated into the control architecture for the purpose to enhance the surgeon’s operation accuracy.Finally,experiments on an eye model are conducted.The results show that the eye robotic system can fulfill surgeon’s motion following and simulate operation of vitrectomy,demonstrating the feasibility of this system.

Real-time Compliance Control of an Assistive Joint Using QNX Operating System

An assistive robot is a novel service robot, playing an important role in the society. For instance, it can amplify human power not only for the elderly and disabled to recover/rehabilitate their lost/impaired musculoskeletal functions but also for healthy people to perform tasks requiring large forces. Consequently, it is required to consider both accurate position control and human safety, which is the compliance. This paper deals with the robot control compliance problem based on the QNX real-time operating system. Firstly, the mechanical structure of a compliant joint on the assistive robot is designed using Solidworks. Then the parameters of the assistive robot system are identified. The software of robot control includes data acquisition and processing, and control to meet the compliance requirement of the joint control. Finally, a Hogan impedance control experiment is carried out. The experimental results prove the effectiveness of the method proposed.

Design and Control of a Pneumatically Actuated Transtibial Prosthesis

This paper presents the design and control of a pneumatically actuated transtibial prosthesis, which utilizes a pneumatic cylinder-type actuator to power the prosthetic ankle joint to support the user＇s locomotion. The pneumatic actuator has multiple advantages over the traditional electric motor, such as light weight, low cost, and high power-to-weight ratio. The objective of this work is to develop a compact and lightweight transtibial prosthesis, leveraging the multiple advantages provided by this highly competitive actuator. In this paper, the design details of the prosthesis are described, including the determination of performance specifications, the layout of the actuation mechanism, and the calculation of the torque capacity. Through the authors＇ design calculation, the prosthesis is able to provide sufficient range of motion and torque capacity to support the lo- comotion of a 75 Kg individual. The controller design is also described, including the underlying biomechanical analysis and the formulation of the finite-state impedance controller. The testing results of human subject indicate that the prosthesis is able to generate a natural walking gait and sufficient power output for its amputee user.