Review Article
Robotics in urologic oncology Saurabh Jain, Gagan Gautam Department of Urology, Kidney and Urology Institute, Medanta - The Medicity, Gurgaon, Haryana, India Address for Correspondence: Dr. Gagan Gautam, Department of Urology, Kidney and Urology Institute, Medanta - The Medicity, Sector 38, Gurgaon - 122 001, Haryana, India. E-mail: [email protected]
Abstract Robotic surgery was initially developed to overcome problems faced during conventional laparoscopic surgeries and to perform telesurgery at distant locations. It has now established itself as the epitome of minimally invasive surgery (MIS). It is one of the most significant advances in MIS in recent years and is considered by many as a revolutionary technology, capable of influencing the future of surgery. After its introduction to urology, robotic surgery has redefined the management of urological malignancies. It promises to make difficult urological surgeries easier, safer and more acceptable to both the surgeon and the patient. Robotic surgery is slowly, but surely establishing itself in India. In this article, we provide an overview of the advantages, disadvantages, current status, and future applications of robotic surgery for urologic cancers in the context of the Indian scenario. Key words: Robot-assisted partial nephrectomy, robot-assisted radical cystectomy, robot-assisted radical prostatectomy, robotassisted retroperitoneal lymph node dissection, robotic surgery, urologic oncology
Devol in 1961.[2] Twenty two years later, the first surgical robot was developed in Vancouver, Canada in 1983 and 1-year later the first robotic surgery was performed at UBC Hospital, Vancouver.[3] Since then, robotic surgery has undergone a long evolution with the introduction of PROBOT (1992) to assist prostatic surgery at Guy’s and St. Thomas’ Hospital, London, ROBODOC (1992) for assisting orthopaedic surgery;[4] and AESOP and the ZEUS robotic surgical systems (Computer Motion Inc., Santa Barbara, CA) for assisting gynaecological and cardiac surgeries.[5] The original telesurgery based robotic system was initially developed for assisting surgeries at the battlefield and other remote surgical areas. Based on this concept the da Vinci system (Intuitive Surgical Inc., Mountain View, CA) was first introduced in 1999 and was granted Food and Drug administration approval in July 2000 for laparoscopic surgeries.[6] Surgical robots have now evolved to become the epitome of minimally invasive surgery (MIS). Apart from the advantages of robotic surgery, market-driven forces and the patients’ choice for robotic surgery have also played a key role in the expansion of this technology.
ADVANTAGES OF ROBOTIC SURGICAL SYSTEM EVOLUTION OF ROBOTIC SURGERY International Organisation for Standardisation has defined an industrial robot as an automatically controlled, reprogrammable, multipurpose manipulator programmable in three or more axes.[1] Conforming to this definition, the first industrial robot was developed in 1937, and the first robotic patent was granted to George Access this article online Quick Response Code:
Website: www.journalofmas.com
DOI: 10.4103/0972-9941.147687
40
The inception of surgical robots took place to overcome the hurdles of conventional laparoscopic technology and to develop distance monitored telesurgery. In a master-slave system, the surgeon operates while sitting comfortably on a master console thus making it ergonomically optimal and less stressful for the surgeon to operate. Vision is provided by a dual 3-chip camera, which gives a magnified threedimensional (10-12X) vision and provides a better depth perception to the surgeon when compared to conventional laparoscopy. Robotic instruments are equipped with an “endowrist” technology, which puts the fulcrum right next to the tip of the instrument, thereby permitting fine, dexterous movements in multiple planes with a wide range of motion. Further, movements are scaled up to 3:1 and hence that large movements of the master controls are manifested as micromovements of the robotic instruments. All these features of
Journal of Minimal Access Surgery | January-March 2015 | Volume 11 | Issue 1
Jain and Gautam: Robotics in urologic oncology
the surgical robot make it optimal for surgeries, which were once considered difficult or even impossible by conventional laparoscopy. Apart from these advantages, a surgical robot can also be used for telesurgery across the globe. One such example is operation Lindbergh performed on 7 September 2001, where a surgeon in New York performed a transatlantic cholecystectomy on a patient in Strasbourg, France over a dedicated fibre optic line.[7]
LIMITATIONS OF ROBOTIC SURGICAL SYSTEM The main limitations of the surgical robot are its cost, need for specifically trained extra staff and lack of tactile sensations. The estimated cost of the da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, California, USA) is about $1.7 million with additional annual maintenance fees and a disposable supply cost of approximately $1500/case.[8] This heavy cost has made it out of reach for many institutions. Another concern regarding robotic surgery is its learning curve. Although it has been shown that robotic surgery can be learnt faster than conventional laparoscopy, there is a definite learning curve involved in the assimilation and optimal implementation of any robotic procedure. Depending on the variable being studied, it may take anywhere from 8 to 150 cases to reach a plateau on the learning curve.[9] A deficiency of structured training facilities in robotic surgery along with a lack of exposure to this modality during residency training in most institutions in this part of the world also adds to the hurdles in the expansion and safe implementation of robotic surgery in India.
ROBOTIC SURGERY FOR PROSTATE CANCER The MIS benefits of robot-assisted radical prostatectomy (RARP) over conventional retro pubic radical prostatectomy (RRP) are well-documented in the literature. Many of the authors have reported significantly less blood loss during RARP, [10,11] even if it was performed by a non-robotic trained urologic oncologist assisted at the patient side by a trained robotic surgeon.[12] This can be attributed to better visualisation of the dorsal venous complex and the tamponade effect provided by the pneumoperitoneum. Contrary to most other laparoscopic or robotic procedures, there is conflicting evidence in support of RARP with regards to a decrease in postoperative pain.[13,14] This is attributed to the infraumblical midline muscle splitting incision used for RRP, which is generally less painful. With increasing experience, the length of hospital stay after prostatectomy has decreased drastically irrespective of the surgical modality used and mainly depends on the hospital policy. While few centres in the United States have a policy of equivalent stay and early discharge for both RRP and RARP,[15] others have
reported shorter hospital stay after RARP compared with RRP.[16] As with other surgical procedures the mean operative duration during the initial phase of the learning curve is longer but once adequately experienced, the operating time of RARP decreases to 800 patients treated with L-RPLND and found that lymph node dissection based on modified templates removed an average of 16 (5-36) lymph nodes. Compared to the open approach, L-RPLND did not differ in terms of relapse rates, percentage of patients receiving chemotherapy (29% vs. 31%) and rate of salvage surgery (1.2% vs. 1.5%).[42] However, L-RPLND is a technically difficult procedure requiring laparoscopic experience and skills. The surgical robot, equipped with a three-dimensional magnified vision and scaled movements of the instruments with an elimination of hand tremor, offers a great promise to overcome these hurdles. The initial data on robot-assisted RPLND (R-RPLND) is in the form of case reports[43] and small case series.[44] These studies have stated the feasibility of R-RPLND in low stage NSGCT. However, larger studies with long-term data are required to validate these results and establish R-RPLND at the forefront of NSGCT management.
ROBOTIC SURGERY FOR PENILE CANCER Pelvic lymph node dissection is an important part of radical cystectomy. It has vital implications towards staging the disease and planning adjuvant therapy, while having a 42
Conventional radical inguinal lymph node dissection is associated with high local morbidity. Video endoscopic
Journal of Minimal Access Surgery | January-March 2015 | Volume 11 | Issue 1
Jain and Gautam: Robotics in urologic oncology
inguinal lymphadenectomy (VEIL) using traditional laparoscopic instruments has been reported to reduce the surgical morbidity without compromising oncologic outcomes.[45] Robotic-VEIL offers increased magnification, three-dimensional clarity, additional degrees of freedom and more precise and controlled dissection during surgery. Initial case reports have shown the feasibility of performing roboticVEIL, with operating time ranging from 90 to 130 min for one side.[46,47] Sotelo et al. performed bilateral inguinal lymph node dissection in the same sitting and reported a total operative time of 360 min and mean blood loss of 100 ml.[48] These results point towards a promising role of robotic surgery in the management of inguinal lymph nodes, but need further long-term randomised studies for validation.
FUTURE ADVANCES IN ROBOTIC SURGERY Currently, the da Vinci surgical system is an unchallenged leader in the $5 billion surgical robot market. Any new system, which wants to challenge the market stronghold of the da Vinci system has to tap into the drawbacks associated with it; by reducing the cost, shortening the learning curve, and introducing technical advancements like tactile sensation and reduction in the number of ports, etc. Titan Medical Inc., (Toronto, Ontario, Canada) is developing single port orifice robotic technology (SPORT™) robotic surgical system.[49] It’s expected to be commercially available by 2015. It includes a single-port surgeon controlled robotic platform (with threedimensional vision system and interactive instruments) and a surgeon workstation. This system is being developed with an aim to expand robotic surgery into areas that are currently underserviced, such as cholecystectomy, appendectomy and ENT procedures. With the advent of SPORT™ and other such robotic systems under development, the science and art of surgery may be at the cusp of a robotic revolution!
ROBOTIC SURGERY IN INDIA The robotic surgery market is dynamic and rapidly expanding worldwide, and India is not left untouched by it. Due to the increased cost of surgery, there was an initial apprehension about the success of the robotic surgical programs in India. Nelivigi, in his review article, discounted robotic surgery as just another “me too technology,” with no promising future in a developing country like India.[50] However, contrary to previous apprehensions, robotic surgery is now gaining increased acceptance in India as revealed by an annual 44% rise in the number of procedures performed in India in 2013 (in contrast to ~21% rise worldwide). As per the unpublished data sourced from Intuitive Surgical (Intuitive Surgical Inc., Mountain View, CA), 21 da Vinci surgical units
Table 1: Robotic surgery in India Robotic surgery parameters Total units installed (2013) Total surgical procedures performed (2013) Number of procedures performed per unit annually (2013) % annual increase in the number of procedures performed (2012-2013) Specialty performing the maximum number of procedures
Worldwide
India
2976 ~500,000
21 2545
~168
121
~21
~44.7
Gynaecology
Urology
had been installed in India at the time of preparation of this manuscript [Table 1]. Most of these (16/21), are installed in the private sector hospitals. There is an interesting contrast in the spectrum of robotic surgery performed worldwide and in India. While gynaecological surgeries remained the most commonly performed robotic surgeries worldwide, urological procedures dominated in India. As dedicated training facilities are created and a larger number of surgeons are trained in this craft, a further surge in robotic surgery can be expected in India in the very near future.
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Cite this article as: Jain S, Gautam G. Robotics in urologic oncology. J Min Access Surg 2015;11:40-4. Date of submission: 25/08/2014, Date of acceptance: 28/08/2014 Source of Support: Nil, Conflict of Interest: None declared.
Journal of Minimal Access Surgery | January-March 2015 | Volume 11 | Issue 1
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Robotics in urologic oncology Saurabh Jain, Gagan Gautam Department of Urology, Kidney and Urology Institute, Medanta - The Medicity, Gurgaon, Haryana, India Address for Correspondence: Dr. Gagan Gautam, Department of Urology, Kidney and Urology Institute, Medanta - The Medicity, Sector 38, Gurgaon - 122 001, Haryana, India. E-mail: [email protected]
Abstract Robotic surgery was initially developed to overcome problems faced during conventional laparoscopic surgeries and to perform telesurgery at distant locations. It has now established itself as the epitome of minimally invasive surgery (MIS). It is one of the most significant advances in MIS in recent years and is considered by many as a revolutionary technology, capable of influencing the future of surgery. After its introduction to urology, robotic surgery has redefined the management of urological malignancies. It promises to make difficult urological surgeries easier, safer and more acceptable to both the surgeon and the patient. Robotic surgery is slowly, but surely establishing itself in India. In this article, we provide an overview of the advantages, disadvantages, current status, and future applications of robotic surgery for urologic cancers in the context of the Indian scenario. Key words: Robot-assisted partial nephrectomy, robot-assisted radical cystectomy, robot-assisted radical prostatectomy, robotassisted retroperitoneal lymph node dissection, robotic surgery, urologic oncology
Devol in 1961.[2] Twenty two years later, the first surgical robot was developed in Vancouver, Canada in 1983 and 1-year later the first robotic surgery was performed at UBC Hospital, Vancouver.[3] Since then, robotic surgery has undergone a long evolution with the introduction of PROBOT (1992) to assist prostatic surgery at Guy’s and St. Thomas’ Hospital, London, ROBODOC (1992) for assisting orthopaedic surgery;[4] and AESOP and the ZEUS robotic surgical systems (Computer Motion Inc., Santa Barbara, CA) for assisting gynaecological and cardiac surgeries.[5] The original telesurgery based robotic system was initially developed for assisting surgeries at the battlefield and other remote surgical areas. Based on this concept the da Vinci system (Intuitive Surgical Inc., Mountain View, CA) was first introduced in 1999 and was granted Food and Drug administration approval in July 2000 for laparoscopic surgeries.[6] Surgical robots have now evolved to become the epitome of minimally invasive surgery (MIS). Apart from the advantages of robotic surgery, market-driven forces and the patients’ choice for robotic surgery have also played a key role in the expansion of this technology.
ADVANTAGES OF ROBOTIC SURGICAL SYSTEM EVOLUTION OF ROBOTIC SURGERY International Organisation for Standardisation has defined an industrial robot as an automatically controlled, reprogrammable, multipurpose manipulator programmable in three or more axes.[1] Conforming to this definition, the first industrial robot was developed in 1937, and the first robotic patent was granted to George Access this article online Quick Response Code:
Website: www.journalofmas.com
DOI: 10.4103/0972-9941.147687
40
The inception of surgical robots took place to overcome the hurdles of conventional laparoscopic technology and to develop distance monitored telesurgery. In a master-slave system, the surgeon operates while sitting comfortably on a master console thus making it ergonomically optimal and less stressful for the surgeon to operate. Vision is provided by a dual 3-chip camera, which gives a magnified threedimensional (10-12X) vision and provides a better depth perception to the surgeon when compared to conventional laparoscopy. Robotic instruments are equipped with an “endowrist” technology, which puts the fulcrum right next to the tip of the instrument, thereby permitting fine, dexterous movements in multiple planes with a wide range of motion. Further, movements are scaled up to 3:1 and hence that large movements of the master controls are manifested as micromovements of the robotic instruments. All these features of
Journal of Minimal Access Surgery | January-March 2015 | Volume 11 | Issue 1
Jain and Gautam: Robotics in urologic oncology
the surgical robot make it optimal for surgeries, which were once considered difficult or even impossible by conventional laparoscopy. Apart from these advantages, a surgical robot can also be used for telesurgery across the globe. One such example is operation Lindbergh performed on 7 September 2001, where a surgeon in New York performed a transatlantic cholecystectomy on a patient in Strasbourg, France over a dedicated fibre optic line.[7]
LIMITATIONS OF ROBOTIC SURGICAL SYSTEM The main limitations of the surgical robot are its cost, need for specifically trained extra staff and lack of tactile sensations. The estimated cost of the da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, California, USA) is about $1.7 million with additional annual maintenance fees and a disposable supply cost of approximately $1500/case.[8] This heavy cost has made it out of reach for many institutions. Another concern regarding robotic surgery is its learning curve. Although it has been shown that robotic surgery can be learnt faster than conventional laparoscopy, there is a definite learning curve involved in the assimilation and optimal implementation of any robotic procedure. Depending on the variable being studied, it may take anywhere from 8 to 150 cases to reach a plateau on the learning curve.[9] A deficiency of structured training facilities in robotic surgery along with a lack of exposure to this modality during residency training in most institutions in this part of the world also adds to the hurdles in the expansion and safe implementation of robotic surgery in India.
ROBOTIC SURGERY FOR PROSTATE CANCER The MIS benefits of robot-assisted radical prostatectomy (RARP) over conventional retro pubic radical prostatectomy (RRP) are well-documented in the literature. Many of the authors have reported significantly less blood loss during RARP, [10,11] even if it was performed by a non-robotic trained urologic oncologist assisted at the patient side by a trained robotic surgeon.[12] This can be attributed to better visualisation of the dorsal venous complex and the tamponade effect provided by the pneumoperitoneum. Contrary to most other laparoscopic or robotic procedures, there is conflicting evidence in support of RARP with regards to a decrease in postoperative pain.[13,14] This is attributed to the infraumblical midline muscle splitting incision used for RRP, which is generally less painful. With increasing experience, the length of hospital stay after prostatectomy has decreased drastically irrespective of the surgical modality used and mainly depends on the hospital policy. While few centres in the United States have a policy of equivalent stay and early discharge for both RRP and RARP,[15] others have
reported shorter hospital stay after RARP compared with RRP.[16] As with other surgical procedures the mean operative duration during the initial phase of the learning curve is longer but once adequately experienced, the operating time of RARP decreases to 800 patients treated with L-RPLND and found that lymph node dissection based on modified templates removed an average of 16 (5-36) lymph nodes. Compared to the open approach, L-RPLND did not differ in terms of relapse rates, percentage of patients receiving chemotherapy (29% vs. 31%) and rate of salvage surgery (1.2% vs. 1.5%).[42] However, L-RPLND is a technically difficult procedure requiring laparoscopic experience and skills. The surgical robot, equipped with a three-dimensional magnified vision and scaled movements of the instruments with an elimination of hand tremor, offers a great promise to overcome these hurdles. The initial data on robot-assisted RPLND (R-RPLND) is in the form of case reports[43] and small case series.[44] These studies have stated the feasibility of R-RPLND in low stage NSGCT. However, larger studies with long-term data are required to validate these results and establish R-RPLND at the forefront of NSGCT management.
ROBOTIC SURGERY FOR PENILE CANCER Pelvic lymph node dissection is an important part of radical cystectomy. It has vital implications towards staging the disease and planning adjuvant therapy, while having a 42
Conventional radical inguinal lymph node dissection is associated with high local morbidity. Video endoscopic
Journal of Minimal Access Surgery | January-March 2015 | Volume 11 | Issue 1
Jain and Gautam: Robotics in urologic oncology
inguinal lymphadenectomy (VEIL) using traditional laparoscopic instruments has been reported to reduce the surgical morbidity without compromising oncologic outcomes.[45] Robotic-VEIL offers increased magnification, three-dimensional clarity, additional degrees of freedom and more precise and controlled dissection during surgery. Initial case reports have shown the feasibility of performing roboticVEIL, with operating time ranging from 90 to 130 min for one side.[46,47] Sotelo et al. performed bilateral inguinal lymph node dissection in the same sitting and reported a total operative time of 360 min and mean blood loss of 100 ml.[48] These results point towards a promising role of robotic surgery in the management of inguinal lymph nodes, but need further long-term randomised studies for validation.
FUTURE ADVANCES IN ROBOTIC SURGERY Currently, the da Vinci surgical system is an unchallenged leader in the $5 billion surgical robot market. Any new system, which wants to challenge the market stronghold of the da Vinci system has to tap into the drawbacks associated with it; by reducing the cost, shortening the learning curve, and introducing technical advancements like tactile sensation and reduction in the number of ports, etc. Titan Medical Inc., (Toronto, Ontario, Canada) is developing single port orifice robotic technology (SPORT™) robotic surgical system.[49] It’s expected to be commercially available by 2015. It includes a single-port surgeon controlled robotic platform (with threedimensional vision system and interactive instruments) and a surgeon workstation. This system is being developed with an aim to expand robotic surgery into areas that are currently underserviced, such as cholecystectomy, appendectomy and ENT procedures. With the advent of SPORT™ and other such robotic systems under development, the science and art of surgery may be at the cusp of a robotic revolution!
ROBOTIC SURGERY IN INDIA The robotic surgery market is dynamic and rapidly expanding worldwide, and India is not left untouched by it. Due to the increased cost of surgery, there was an initial apprehension about the success of the robotic surgical programs in India. Nelivigi, in his review article, discounted robotic surgery as just another “me too technology,” with no promising future in a developing country like India.[50] However, contrary to previous apprehensions, robotic surgery is now gaining increased acceptance in India as revealed by an annual 44% rise in the number of procedures performed in India in 2013 (in contrast to ~21% rise worldwide). As per the unpublished data sourced from Intuitive Surgical (Intuitive Surgical Inc., Mountain View, CA), 21 da Vinci surgical units
Table 1: Robotic surgery in India Robotic surgery parameters Total units installed (2013) Total surgical procedures performed (2013) Number of procedures performed per unit annually (2013) % annual increase in the number of procedures performed (2012-2013) Specialty performing the maximum number of procedures
Worldwide
India
2976 ~500,000
21 2545
~168
121
~21
~44.7
Gynaecology
Urology
had been installed in India at the time of preparation of this manuscript [Table 1]. Most of these (16/21), are installed in the private sector hospitals. There is an interesting contrast in the spectrum of robotic surgery performed worldwide and in India. While gynaecological surgeries remained the most commonly performed robotic surgeries worldwide, urological procedures dominated in India. As dedicated training facilities are created and a larger number of surgeons are trained in this craft, a further surge in robotic surgery can be expected in India in the very near future.
REFERENCES 1.
2. 3.
4. 5.
6.
7.
8.
9. 10.
11.
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Cite this article as: Jain S, Gautam G. Robotics in urologic oncology. J Min Access Surg 2015;11:40-4. Date of submission: 25/08/2014, Date of acceptance: 28/08/2014 Source of Support: Nil, Conflict of Interest: None declared.
Journal of Minimal Access Surgery | January-March 2015 | Volume 11 | Issue 1
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