By Dr. Neal Patel, M.D.
The evolution from open surgeries to minimally invasive procedures is in large part due to the development of robotics. Robotic technology allows surgeons to provide more precise, efficient outcomes for their patients than the traditional approaches used in open surgeries.
From the first robotic-assisted procedure in 1985 (neurosurgical biopsy) to the invention of the da Vinci Surgery System for general laparoscopic surgery in 2000, the advancement of robotic surgery has continued to skyrocket due to the rising patient and doctor demand. Smaller incisions, lower risk of bleeding and shorter recovery time are just a few examples of why this successful, new surgical style is quickly spreading into all facets of medicine.
Growth of Robotic Surgery in Medicine
From urology to cardiothoracic surgery, the prevalence of robots in the operating room has spilled over into all branches of medicine across the country. Surgeons are now able to perform prostate, bladder and kidney removal, appendectomies, cardiac valve repairs, knee replacements, and even complex spinal surgeries using minimally invasive robotics. Patients demand it, and surgical residents demand training in it. Originally exclusive to cardiothoracic surgery, the use of robotic-assisted techniques now accounts for over 50 percent of gynecological and urologic procedures.
Leading the Way in Urology
Urology has always been at the forefront of new technology. Certain fields of medicine haven’t been able to adequately demonstrate all the benefits of robotic surgery yet. However, urologists are able to clearly demonstrate the advantages in several different procedures, particularly oncological cases, for which robotics have become the standard approach.
Robotic Prostatectomy: A robotic prostatectomy, or robotic-assisted radical prostatectomy, has demonstrated incredible success in nerve sparing, or erectile function preserving, with a reduction in blood loss and scaring. Formerly performed using open or laparoscopic techniques, the standard approach for all prostatectomies is now robotics.
Robotic Cystectomy with Intracorporeal Diversions: Although a lengthy and complex procedure, a robotic cystectomy with intracorporeal diversions allows for fewer patient complications and inconveniences than the extracorporeal diversions. After the bladder is removed, various intracorporal diversions, such as neobladders and ileal conduits, are implemented using robotics to ensure the successful flow of urine. Patients with this procedure have shown less blood loss, lowered transfusion rate, decreased hospital stay, and reduced pain compared to traditional open surgery.
Robotic Partial Nephrectomy: Performing a robotic partial and/or total nephrectomy has shown significantly shorter operating times, blood loss and length of hospital stays compared to the traditional, open access. Some high specialized and trained roboticists can also offer retroperitoneal robotic access since the kidneys are located in the retroperitoneal space behind the abdominal cavity, this approach offers a safer, more direct route. Open nephrectomies involving partial rib dissections are no longer required now that robotic and laparoscopic techniques are the standard method.
Do the Pros Outweigh the Cons?
Most surgeons, urologists specifically, would agree that the advantages of robotic surgery surpass the downsides dramatically. Robotics allows surgeons to work in very small spaces with a high degree of freedom of motion. Facilities that are equipped with the latest technology and are able to provide patients with cutting-edge robotic procedures tend to be more in favor of them. Those who do not have access to innovative equipment like the da Vinci Surgical Systems may have a more skeptical view on the progression of these surgeries.
In general, minimally invasive robotic procedures could have longer operating times and higher costs than open surgeries depending on the experience of the surgeon and the institution. There can also be a smaller, more limited visual field to view the structures using this approach, as opposed to the open view of a traditional technique. However, the benefits demonstrated using robotic-assisted techniques exceed these drawbacks both quantifiable and qualitatively.
Robotic methods allow procedures to be more minimally invasive than ever before. Most of these procedures have demonstrated superior perioperative and postoperative outcomes compared to the previous open versions, such as smaller incisions, less blood loss, fewer complications, shorter recovery time, and shorter length of hospital stay.
Where Do Future Opportunities Lie?
The recent advancements in robotic systems have already transformed the operating room, but this innovational field still holds great potential for growth. Surgeons who were trained using traditional open or laparoscopic methods find the lack of haptic feedback in robotics quite limiting. During manual minimally invasive surgery, surgeons could feel the connection between the instrument and the patient.
However, most current robotic systems only provide slight kinesthetic, or force feedback, which is only one aspect of haptic feedback. More research is needed involving surgeons, engineers, and neuroscientists before robotic systems will contain effective tactile, or cutaneous feedback. Tremendous strides have already been taken to improve force feedback, and as the development of haptic feedback continues to grow in the future, robotic surgery will revolutionize medicine.
Robotics also offers tremendous potential in telesurgery. Originally created for astronauts and military use, remote procedures started becoming available to regular patients in 2001. Since then, however, little advancements have been made with regard to latency time and haptic feedback. Telesurgery provides high-quality care to patients in rural areas and those with limited means of travel. More research and clinical trials are needed before it can be used for complex urological procedures like partial nephrectomy, prostatectomy or cystectomy. Once the technology allows for cross-country or even cross-continent remote procedures, the possibilities are endless.
The prevalence of robotic assistance in urology has not only increased in recent years but has become the standard approach for most urologic oncology procedures. The patient demand for robotic surgery across all fields continues to rise at an accelerated rate. As patients continue to demand it, and training programs continue to emphasize it, robotics will likely become the dominant method of all surgery in the future leaving us to scarily wonder if there will still be anyone trained in the open ways.
Dr. Neal Patel is the Chief Technology Officer at Advanced Urology, a leading center for urologic care in the Greater Atlanta area. Before joining Advanced Urology, Dr. Neal Patel completed his residency in Urologic Surgery at Rutgers Robert Wood Johnson Medical School in New Jersey and joined the USC Institute of Urology as a Felix and Mildred Yip Fellow in Advanced Robotics and Laparoscopy.
While Dr. Patel enjoys all aspects of urologic surgery, he specializes in advanced robotic techniques and has co-authored a number of publications, patents and textbook chapters, as well as presented research at many national conferences.