Urologic Robotics: An Example of Overrated Hype or Potential for Surgical Change?

Abstract

It is undeniable that urology has become one of the fastest evolving surgical specialities in the last two decades. With the recent advent of robotic systems such as the da Vinci^™ Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA), the Automated Endoscopic System for Optimal Positioning (AESOP^®) (Intuitive Surgical, Inc., Sunnyvale, CA), the HERMES Control Centre and the PAKY-RCM robot, robotic laparoscopic techniques have been revolutionised in a way that is minimally invasive, accurately duplicative and tireless. But in a world where patients demand the best care and Medical Councils rightly placing an unwavering emphasis on autonomy and awareness of moral issues surrounding the materialisation of novel surgical technologies, is robotic surgery feasible in this current economic climate or are robots indeed the future of urology as a surgical speciality and for surgery in general? This article aims to evaluate the current roles of robot-assisted surgery, its rewards and drawbacks, and to present the popular and innovative perspectives balancing the views of the sceptic and the aficionado.

Introduction

The term “robot” is derived from the Czech word robota which literally means compulsory labour. In surgery, robots are defined as reprogrammable, computer-controlled machines equipped with sensors and actuators able to move and position tools to carry out a multitude of surgical tasks [1,2]. The very first implementation of urologic robotic surgery took place in 1988 when the PROBOT was designed in an astute joint initiative by Guy’s Hospital and Imperial College London and utilised a robotic frame in concert with a rotating cutting loop to undertake transurethral resections of the prostate (TURP) [3]. Since then, following many painstaking years of technical honing on animals and cadavers, clinical trials and modifications, patients have put their trust in the hands, or arms rather, of robots performing life-saving surgeries.

The current and most advanced application of robots in surgery – the da Vinci Surgical System – operates as a ‘master-slave system’, whereby the surgeon has control of the robotic arms from an independent console. Thus, the term “robot” used in this context is somewhat of a misnomer as it disregards its ability for automation; much more suitable terms would be ‘computer-assisted surgery’ or ‘robot-assisted surgery’ [4]. The task and purpose, however, of a surgical robot can be evaluated aptly using the following analogy. Isaac Asimov, the famous biochemist and science fiction author, summarised the role of robots within our society in his “Three Rules of Robotics” [5]. Firstly, a robot may not injure a human being or, through inaction, allow a human being to come to harm. Secondly, a robot must obey orders given to it by human beings, except where such orders would conflict with the First Law. Lastly, a robot must protect its own existence as long as such existence does not conflict with the First or Second Law. These three rules encompass all the criteria a robot must possess pertaining to surgery and attitudes towards patients [1].

Clinical uses of robot-assisted surgery

Urology is one such specialty which has been quick to recognise the benefits of robotic technology. Radical prostatectomies are the commonest procedures performed with the aid of surgical robots – namely the da Vinci Surgical System (Fig. 1). Its implementation has yielded truly astonishing results; over 300 robotic radical prostatectomies were undertaken by Menon’s group, with an average operating time of 120-160 minutes and an average blood loss of 150 ml compared to times of 232 minutes and blood loss of 370 ml conducted in 240 laparoscopic procedures [6]. In comparison to open radical prostatectomies, robot-assisted methods offered a shorter hospital stay and improved continence and potency [7].

The first robotic radical cystectomy and Hautmann neobladder was conducted in 2003, with an operative time of 8.5 h and a blood loss of 200 ml [8]. In comparison to open radical cystectomies, there is decreased blood loss and postoperative pain, reduced hospital stay and improved intraoperative vision [9]. This, however, is offset by longer operative times, greater procedural complexity and unverified long-term prospective oncological outcomes.

In urology, a number of other procedures are performed using robot-assisted surgery, such as live-donor nephrectomies, simple and radical nephrectomies, sural nerve grafting, ureteric reimplantation, adrenalectomies, colposuspension and even renal transplantation [10]. However, its use is not just limited to urology. Minimally invasive direct coronary artery bypass (MIDCAB) surgery and mitral valve replacement and repairs, gynaecological applications such as hysterectomies and myomectomies and treatment for fibroids, endometriosis and ovarian tumours, and certain neurosurgical and orthopaedic procedures have all been achieved using robot-assisted surgery, all with varying success.

Why go robotic?

Over the last two decades there has been a welcome trend towards laparoscopic techniques and minimally invasive surgery (MIS) and its advantages have been well documented. In MIS, instead of the trauma associated with a large incision, surgical instruments are introduced via small incisions, whilst long manipulators are used to execute the surgery under visual guidance. As a result, there is a faster recovery time and thus shorter post-surgical hospital stay, less pain and more aesthetically pleasing results. However, as with most things in Medicine, MIS possesses its own drawbacks, which include the loss of 3-dimensional vision, the fulcrum effect and poor natural tactile feedback. The fulcrum effect is a phenomenon whereby the instrument tip moves in the opposite direction to the surgeon’s hand [11]. In an experienced laparoscopist’s hand, this may not be a hindrance; however, the latest in robot-assisted surgery offers arms with six degrees of freedom mimicking the intricacies of the human hand [12]. There is a popular view that laparoscopic surgery is the “transitional” phase between its open and robotic equivalents [1]. Furthermore, it is anticipated that the introduction of robotic surgery will overcome the disadvantages presented by laparoscopic techniques and will pave the way for a more technologically advanced future.

The implementation of surgical robotic systems also comes at a cost – and a substantial one. The da Vinci master-slave system costs in excess of US$1.2 million, and has an annual maintenance fee of approximately $100,000 after the first year [13]. This has become an even more important issue in recent times, with the emergence of the economic downturn. In the long term though, these costs will be counterbalanced by lower hospitalisation rates, decreased theatre times, less complications and fewer blood transfusions [13]. Another concern, however, is the paradoxical effect of purchasing these surgical systems; instead of bridging the gap between countries that are at the very frontier of surgery and those that are currently at the developmental stage, it will only amplify the chasm to the determent of such countries and of Medicine as a whole. If, therefore, robotic surgery is to be deemed a success, it must be a more favourable option than its open and laparoscopic equivalents [2].

Maximising the potential of surgical robotic technology will take time, requiring input from surgeons, medical engineers and healthcare officials alike [1], whilst communicating in concert with the person that matters the most – The Patient. That patients view this relatively embryonic technology with scepticism is a matter of debate. To place one’s trust in a machine whilst it freely undertakes potentially dangerous and sometimes life-threatening procedures may be unreasonable. But behind every robot is a skilled and experienced master – The Surgeon. Thus, with evolving times, come contemporary attitudes. Patients, regardless of their qualms about this emerging technology, are demanding the latest applications of the very frontiers of science and are willing to submit themselves in that cause.

The promise of robot-assisted surgery is best capitalised by the synergy of man and machine. To prove this point, retinal surgery exceptionally epitomises this notion. The human hand is not designed to undertake such intricate surgery due to fatigability and thus developing an intention tremor. Instead, computer-guided lasers can be positioned to within 25 ?m of the retinal vessels and the surgeon’s tremors can be filtered, altogether making this implementation of robotic technology ten times more accurate than the unaided human hand [14]. It is clear that there is one single rationale for robot-assisted surgery; robotic systems are produced to iron out the shortcomings of humans. Therefore, the ultimate goal for surgery would involve both the intuition and expertise of a surgeon in concert with the dexterity and accuracy of a robot.

The future

In spite of the surfacing of robot-assisted surgery of late, fully automated robots independently performing surgical operations still seems a matter of science fiction. Richard Satava, Professor of Surgery at University of Washington School of Medicine has been an outspoken supporter of emerging robotic technology and has put forward the argument comparing the human brain and the world’s fastest supercomputers [15]. He estimates that – if the current trends continue – the next three decades will yield a computer so powerful in terms of computational power that it may match, and even, surpass the human brain. Therefore, will we see “intelligent” robots in our lifetime? And if so, will these robots be programmable to conduct radical prostatectomies, for example? Of course, such ideas would be met with great cynicism by the masses, but it is not beyond the realms of possibility. The implementation of purely robotic surgery would require extensive algorithm development [1] and a complete renewal of the biomedical, ethical and moral issues involved in such medical technologies [15].

One of the most radically novel and exciting applications of robotic surgery is telerobotics. Pioneered by the Baltimore group in 1998 [16] and then first clinically implemented by Professor Jacques Marescaux’s team in 2001 during a transatlantic laparoscopic cholecystectomy [17], telerobotics is defined as the operation of a robot performing surgery at a distance. With the aid of high speed ISDN lines, the surgeon and the robotic console were situated in New York City, whilst the patient and computer-assisted robot were in Strasbourg, France. The major advantages of this type of technology include a solution to surgical manpower shortages in deprived or remote regions, improving outcomes for seldom performed or particularly demanding procedures, and possibly – with the use of mobile telerobot transporting vehicles – providing a roaming surgical service in third world countries [18]. However, in order for telerobotics to be incorporated into common urologic practice, many technical, ethical and legal issues will have to be overcome, not least the matter of interfering with the traditional doctor-patient relationship.

Nonetheless, we must be reminded of the infancy of robot-assisted surgery. Any sceptics of this notion would argue that its emergence would be to the detriment of the surgical fraternity. There is a lot to prove, but advocates of this technology can gain solace in the fact that in over 25 years since the first robot-assisted surgery, great advances have been made, especially in urology. Whether robotic technology will grace urology – and surgery in general – with the same fervour that it had been introduced, is still yet to be seen. Future directions are promising, though, and involve the next generation upgrade of the da Vinci robot, which will offer faster set-up, greater manipulation and interactive video displays [11]. A surgical system that comprises haptic technology allowing tactile feedback is still awaited; this could possibly revolutionise opinions whereby returning the intimacy which is fundamental in conventional open surgery.

Conclusion

If robotic technology as a surgical entity is to have a future, several changes must be made. Long-term evidence based prospective clinical trials comparing clinical outcome and patient satisfaction of robot-assisted and open surgery should be the utmost priority. Education of the target population is also necessary to modify beliefs and to resolve any reservations which may arise. The truly fascinating results yielded by the latest surgical technology may not be evident in the immediate future but with time and patience, the results could transform the way surgery is perceived. Furthermore, the real desire to implement these tools should stem from the intimate wish to further scientific boundaries and enhance patient care by providing a means of treatment which is more superior to any other. Urology is just one example of many where the surfacing of robotic surgery has the potential to refashion the specialty.

Urologic surgery is a field with an extraordinary mixture of the ancient and the contemporary; some surgical instruments used in urologic surgery continue to be unchanged for hundreds of years [11], yet it remains at the very forefront of employing the latest robotic technologies available. With the application of the da Vinci robot in some surgical specialties, it seems we have only scratched the surface. Medicine has the propensity to evolve quickly, and so we await the future with great anticipation. The British science fiction author, inventor and futurist Arthur C. Clark once said – “Any sufficiently advanced technology is indistinguishable from magic”. If robotic surgery can be given a chance to establish itself and then be honed and perfected, it may herald a new era of technology in surgery and ultimately, enhance surgical care.

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