The Da Vinci Xi robot in urology: how it works and when it is used

Short answer. The Da Vinci is a robot-assisted surgery system: it does not operate on its own, but reproduces in real time the movements of the surgeon, who controls it from a console inside the operating theatre. In urology it is used mainly for the surgical treatment of prostate, kidney and bladder cancer.

At San Carlo di Nancy Hospital in Rome, the robotic operations of the Unit of Robotic and Minimally Invasive Urology, directed by Dr. Alessandro Calarco, are performed with the Da Vinci Xi system, privately, under agreement with insurers or through the Italian National Health Service (SSN).

How it works

• The surgeon's console: the surgeon sits at the console and sees the operating field in three dimensions, in high definition and magnified.
• The robotic arms: they are positioned next to the patient and hold the camera and the instruments, inserted through a few small incisions in the abdomen.
• The articulated instruments: their tips bend like a wrist; the system filters tremor and can scale down hand movements.
• The team at the operating table: an assistant surgeon and the nursing and anaesthesia team stay beside the patient throughout the operation.

The robot does not operate on its own

Every movement of the instruments is controlled by the surgeon. The robot makes no decisions and performs no movements autonomously: it is a tool that improves vision and precision of movement in areas that are hard to reach, such as the depth of the pelvis.

Prostate cancer: robot-assisted radical prostatectomy

This is the removal of the prostate and seminal vesicles for localised prostate cancer. Randomised studies comparing the robot with open surgery have shown similar results for cancer control, continence and erections, with less blood loss and a shorter hospital stay with the robot. The EAU guidelines consider both techniques valid. Further reading: Robotic surgery.

Kidney cancer: robot-assisted partial nephrectomy

For small kidney tumours, when technically possible, the guidelines recommend removing only the tumour and preserving the rest of the kidney (partial nephrectomy), to protect kidney function. The robot-assisted technique is one of the ways it is performed. When the tumour is more extensive, removal of the whole kidney (radical nephrectomy) may be indicated, which can also be performed with a minimally invasive approach.

Bladder cancer: robot-assisted radical cystectomy

In cancer that invades the muscle wall of the bladder, removal of the bladder (radical cystectomy) may be needed, with the creation of a new outlet for urine: a neobladder made from a segment of bowel, or a conduit that carries urine outside the body (for example the Bricker ileal conduit). In randomised studies robotic cystectomy has shown oncological results comparable to open surgery; with the reconstruction performed entirely inside the abdomen, one study reported more days spent at home in the three months after surgery.

Other operations

The robot is also used for non-cancer operations, such as correcting a narrowing between kidney and ureter (pyeloplasty) and, in selected cases, surgery for a very large enlarged prostate. The choice of approach always depends on the condition and the patient.

Advantages and limits

Compared with open surgery, the robotic approach generally allows smaller incisions, less blood loss and a shorter hospital stay. It does not automatically mean a better result on the cancer: for the prostate and bladder, studies show similar oncological results. The experience of the team matters a great deal.

The operation requires general anaesthesia, insufflation of carbon dioxide into the abdomen and, for pelvic surgery, a head-down position: for this reason some heart or lung conditions and previous abdominal operations can make it less suitable. The urologist and anaesthetist assess this.

Possible risks

The risks are those of the operation performed (prostatectomy, nephrectomy, cystectomy) and of abdominal surgery in general: bleeding, infection, venous thrombosis, complications of anaesthesia, injury to nearby organs and, rarely, the need to convert to open surgery. Specific risks and alternatives are discussed during the consultation and set out in the informed consent.

Dr. Calarco and robotic surgery

Dr. Alessandro Calarco has been a specialist in Urology since 2013 (Università Cattolica del Sacro Cuore, Rome), holds a PhD in Urological Oncology (2018) and has been a Fellow of the European Board of Urology (FEBU) since 2012. He has personally performed more than 3,000 complex surgical procedures. He directs the Unit of Robotic and Minimally Invasive Urology at San Carlo di Nancy Hospital, where he focuses in particular on the robotic treatment of prostate, kidney and bladder cancer. For an assessment: +39 366 6856844.

Sources

• EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer; EAU Guidelines on Renal Cell Carcinoma; EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer (current editions).
• Yaxley JW, et al. Lancet. 2016 (robotic vs open prostatectomy, randomised study).
• Coughlin GD, et al. Lancet Oncology. 2018 (same study, 24-month results).
• Parekh DJ, et al. Lancet. 2018 (RAZOR study: robotic vs open cystectomy).
• Catto JWF, et al. JAMA. 2022 (iROC study: robotic cystectomy with intracorporeal reconstruction vs open).

For information only: this content does not replace a medical consultation. Any test or treatment is decided only after a visit.