The fourteenth meeting of the EAU Robotic Urology Section in Bruges, Belgium represented an informal 10th anniversary: a return to Belgium where the first meeting of an independent ERUS took place. The scope and scale of the meeting was a clear sign that robotic urology has grown to an important pillar within urology.

“The specialty is around 15 years old, so it’s only natural that there are new stars coming in. At ERUS meetings, we give visibility to all surgeons. We want to be a section that gathers all of those who are interested in robotics, it should not be a club for established big names. When I say that robotic urology is maturing, I also mean that robotic surgery is getting standardised and better because it is becoming more reproducible than it used to be.”

ERUS17 was organised in conjunction with the EAU Young Academic Urologists Meeting, the Junior ERUS-YAU meeting, an extended ERUS-EAUN Robotic Urology Nursing Meeting, courses by the European School of Urology, Hands-on Training and a technical exhibition. Altogether, nearly 1,000 participants descended on Bruges on 24-27 September, making this one of the largest urology meetings in Europe.

On the first day, Prof. Mottrie welcomed the delegates in the Bruges Concert Hall from behind his console in Aalst, pointing out the use of three operating theatres simultaneously, which allow a record-breaking sixteen cases to be squeezed into six sessions.

“With this year’s programme, we’re pushing the boundaries a little bit. In earlier editions of the ERUS meeting, we went for easier indications. Now we have seen quite difficult cases, including preoperated patients, very difficultly located kidney cancers, and a wonderful example of an extended radical prostatectomy, with an extended lymphadenectomy done by prof. Briganti.”

“As we are progressing as a subspecialty, our role is changing. In the beginning our role was instructing robotically naïve surgeons on basic technique. Now the majority of the auditorium is filled with robotic surgeons and we want to teach them how to push their boundaries.”

A sign of the maturation of robotic surgery can be found in the special session for the Surgery in Motion School, which examined a great variety of approaches for surgical procedures. The School in question (surgeryinmotion-school.org) is an online platform that collects videos of the foremost surgeons and sorts them according to organ, procedure and technique. Beyond an online presence, the platform can be used as a resource for ERUS courses and discussions.

A further indication of the maturing of robotic urology is its expansion into new areas of medicine. On the morning of the 26th, Dr. Anne-Françoise Spinoit’s (Ghent, BE) state-of-the-art lecture concerned the ways in which robotic surgical techniques are being applied to paediatric urology. She shared her experiences in a talk that set out some of the particularities associated with treating children with robots designed for adults.

“So far, not many centres are using robotic surgical systems with child patients, perhaps four or five in Europe. There is a lot of improvisation involved, as it’s not easy to use full-size robots designed for adults on much smaller children,” Spinoit explained. “But I think children deserve minimally invasive technology, so that’s why we apply it anyway.”

The difficulties mainly involve the consequences of the child patients’ smaller and more fragile physique. Rather than simply being “smaller adults”, the child’s body (and organs) is still developing. There is a danger of collapsed lungs when too much insufflation pressure is applied, and the non-standard way of placing trocars, unique to every child. The newer Xi system table is not suitable for children due to its size, so urologist have to (re-)acquaint themselves with a three-armed system and much smaller cavities to operate in.

So far, there is not much support from manufacturers to customize systems or approaches for use on children, so paediatric urologist like Dr. Spinoit are blazing the trail. The major paediatric procedures that lend themselves to ‘robotisation’ are pyeloplasty or other procedures that involve a lot of suturing.

“I’m sure that paediatric robotic surgery has the potential to be practiced across Europe, and I certainly hope it will soon. The dynamic is similar to how robotic surgery was a new development some twenty years ago and it took some time to convince people. Nowadays it’s widespread and popular. Paediatric robotic surgery is only a few years behind ‘regular’ robotic surgery.”

Prof. Mottrie was impressed with the talk. “Robotic urology for children is quite a rare indication, but it’s becoming more known and renowned. I feel it’s important for ERUS to push these rare indications into the urological specialty. Paediatric urology is also being practiced by paediatric non-urological surgeons, but I believe that we as EAU must keep these indications in our specialty.”

“We have several working groups within ERUS, one of them being paediatric urology. They have started organising the first hands-on courses in the world on this subspecialty. Dr. Spinoit is doing a great job, and with great success.”

Fitting for the aforementioned motto of ERUS17, the 7th Junior ERUS – Young Academic Urologists meeting asked about this upcoming generation: “Will they be using new robotic systems? Will they be ‘technology freaks’? And will they become super-specialised organ surgeons?”

Dr. Alessandro Larcher (Milan, IT) presented the plans for an ERUS curriculum for robotic partial nephrectomy, based on the successful programme for radical prostatectomy. After weeks of VR, dry and wet lab training, followed by console training and scoring each phase, surgeons can master the procedure before operating on patients. This can compensate for the relatively low volume of the robotic partial nephrectomy, which is on average 60 per centre per year for the 15 most high-volume centres for this procedure.

The 80 delegates present that morning were then treated to an extensive overview of the robotic systems that are currently in development, some just around the corner and others better treated with caution. Dr. Stavros Tyritzis (Athens, GR) pointed out the explosive growth of the sector, going from $3.2 billion in 2014 to a projected $20 billion a mere six years later.

“As surgeons, we are in expectation of several features in future robotic systems,” Tyritzis started, listing tissue recognition/haptic feedback, augmented reality/image guidance, a smaller footprint, affordability and automation. “The new systems need to be as good as the DaVinci systems that we have, or better, and offer new features in order to become widely adopted.” The multitude of (planned) systems that were then presented each had unique selling points, some focusing on affordability, some on a mobile form factor, miniaturisation and almost all trying to offer surgeons a complete, multifunctional package. Human and even animal trials were still far off in most cases, with some robots first being presented in 2014 and still not available.

Beyond surgical systems, technology has a lot to offer the future urologists. Dr. Ruben De Groote (Aalst, BE) presented a selection of recent or upcoming technological breakthroughs, including the 3D-printing of soft tissue models in order to rehearse operations, software tools like Alexa and Watson that simplify organisational duties and help surgeons make informed choices.

The morning session ended with a live surgery demonstration by Dr. Achilles Ploumidis (Athens, GR), who performed a rather unusual partial nephrectomy with the assistance of the Firefly visual guiding system.

Dr. Geert De Naeyer (Aalst, BE), chairman of the YAU Robotic Urology Working Group and Chairman of the Junior ERUS-YAU Meeting at ERUS17 was pleased with how the programme unfolded: “We had a perfect Junior-ERUS meeting, with very interesting topics, and practical advice for young urologists. Particularly the interactive case discussions on the management of complications drew a lot of comments from the audience.”

“This year, the live surgery was streamed through the internet rather than satellite transmission. We were a little apprehensive about this, but it went well and it has potential. Moderation was a little different. Due to the 30 second lag, we used mobile instant messaging platform Whatsapp to get in touch with the surgical team, rather than simply speaking directly. This made interaction a little more complex.”

“Achilles did a great job on a difficult case, clamping two of the three arteries. It looked perfect as he was finishing up and the session ended.”