Robotics in urology

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By Patrick Gordon, Final Year Monash Medical Student

High-school work experience is a chance for students to escape the boredom of the classroom and dip their toes into the “real world” of the workplace. Whether this is through earning some extra cash at a fast food restaurant or shadowing a professional throughout their day, work-experience gives a glimpse into life after study. For my own work experience, I was fortunate enough to find myself integrated into the research department of the Peter MacCallum Cancer Centre and it was there that I found my passion for Urology.

As part of my time at Peter Mac, I was shadowing one of the Surgical Registrars conducting research in the lab. On one of my days the Registrar was very excited about a case planned for theatre that afternoon. He was buzzing with excitement and was very keen to bring us along into theatre to watch what he described as a “land-mark case”. We headed down and got changed into scrubs for our very first time. In theatre we were met with a crowd of doctors and nurses outside the operating room, all vying for a position to see this case. I remember catching a glimpse of the operating table and being shocked to find no surgeon there. Instead, over the patient appeared to be a robotic octopus of sorts, with a scrub nurse alongside changing the instruments on the end of its spindly arms. Upon further scanning of the room I spied the surgeon, hunched over inside what appeared to be an arcade console. The surgeon was sitting down with his hands on two small controls, both feet working pedals as he looked down the microscope. It looked more like he was playing a game of Daytona than the textbook illustration of a surgeon operating. This moment was my first glimpse into the exciting possible future of surgery, robot-assisted operations.


Figure 1: The Da Vinci surgical system in use. Image source: https://www.davincisurgery.com/da-vinci-systems/about-da-vinci-systems

Figure 1: The Da Vinci surgical system in use. Image source: https://www.davincisurgery.com/da-vinci-systems/about-da-vinci-systems

The procedure I was lucky enough to observe that day was a robot-assisted laparoscopic partial nephrectomy, one of the first few performed in Victoria at that time. Becoming increasingly common nowadays, robotic-assisted surgery combines the benefits of a laparoscopic approach with a 3-dimensional surgical view and greater fine tissue manipulation capability. This enables more precise operating for the surgeon with the decrease in pain and length of stay typical of laparoscopic operations (1). The Da Vinci surgical system comprises three main components:

The Surgeon Console: The “arcade console” I initially saw is actually the console at which the surgeon operates the robot. Its precise controls allow the fine manipulation of the instruments utilising hand movements and feet pedals. The controls automatically correct for any hand tremor present. The surgeon views the operating field through high-definition 3D images with magnification available.


Surgical Console

Surgical Console

The Patient Cart: This is the “Robotic Octopus” I described standing over the patient. The patient cart consists of four long arms which contain the camera and instruments the surgeon uses to operate. The instrument in use is at the end of these arms and can be swapped as needed by the surgical assistant or scrub nurse. The instruments feature wrist joints to enable a greater range of motion not previously possible with laparoscopic instruments.


Patient Cart and the Robotic Octopus

Patient Cart and the Robotic Octopus

The Vision Cart: Enables communication between all the components, as well as acting as a high-definition 3D vision system for other members of the surgical team.

The Da Vinci surgical system is used for a number of urological procedures, particularly in surgery for Prostate (prostatectomy), Kidney (nephrectomy) and Bladder (cystectomy) cancers (2).  In localised renal cell carcinomas the removal of some of the affected kidney, a partial nephrectomy, is a suitable management option (3). This allows as much heathy kidney tissue (nephron-sparing) as possible to remain. Using a robot-assisted laparoscopic approach to this procedure, in contrast to an open or laparoscopic approach, is associated with fewer overall complications, shorter length of stays and less associated pain (4).

The surgery is performed through four small incisions in the abdomen to create access ports for the robotic arms, the camera and their instruments. During the procedure the surgeon can also utilise Firefly fluorescence imaging technology, which allows visualisation of the kidney’s vasculature through the injection of a fluorescent dye. This technology allows the identification of structures not visible to the human eye in real time. Ensuring adequate vascular supply remains for the healthy tissue left in-situ.  After the diseased tissue is excised the surgical arms can be removed and the small incisions sutured close.


Figure 2: Normal anatomy visualisation versus the Firefly fluorescence imaging, enabling visualisation of the underlying vasculature. Image source: https://www.intuitive.com/en-us/products-and-services/da-vinci/vision

Figure 2: Normal anatomy visualisation versus the Firefly fluorescence imaging, enabling visualisation of the underlying vasculature. Image source: https://www.intuitive.com/en-us/products-and-services/da-vinci/vision

While currently associated with longer operative times, this greatly depends on surgeon experience and can be expected to decrease with increased exposure to the Da Vinci system (1). Other drawbacks to robotic partial nephrectomies are the cost associated with the purchase and up-keep of the Da Vinci system, thus it is only available in limited Victorian Hospitals. There is also significant extra training required for surgeons to learn robot-assisted techniques, particularly due to the limited tactile feedback afforded by this system (5).  This can be a challenge for surgeons who are used to the “feel of operating” and thus must be more aware of their instrumentation. 

Whilst not currently available at all hospitals, the Da Vinci Surgical system and robot-assisted procedures are becoming increasingly commonplace as more surgeons undergo the necessary training. This represents an exciting new frontier for surgery, allowing technology to overcome the challenges associated with operating and improve patient outcomes.

View a robot-assisted laparoscopic partial nephrectomy being performed at the Brigham and Women’s Hospital (Boston, Massachusetts) at the following YouTube link: https://www.youtube.com/watch?v=GQm90mWVMJM

To find more information about the role of the Da Vinci system in kidney surgery: https://www.davincisurgery.com/procedures/urology-surgery/kidney-surgery

References:

1.         Wu Z, Li M, Liu B, Cai C, Ye H, Lv C, et al. Robotic versus open partial nephrectomy: a systematic review and meta-analysis. PLoS ONE. 2014;9.

2.         Stifelman MD, Caruso RP, Nieder AM, Taneja SS. Robot-assisted laparoscopic partial nephrectomy. JSLS. 2005;9(1):83-6.

3.         Ljungberg B, Bensalah K, Canfield S, Dabestani S, Hofmann F, Hora M, et al. EAU Guidelines on Renal Cell Carcinoma: 2014 Update. European Urology. 2015;67(5):913-24.

4.         Shen Z, Xie L, Xie W, Hu H, Chen T, Xing C, et al. The comparison of perioperative outcomes of robot-assisted and open partial nephrectomy: a systematic review and meta-analysis. World journal of surgical oncology. 2016;14(1):220.

5.         Aboumarzouk OM, Stein RJ, Eyraud R, Haber G-P, Chlosta PL, Somani BK, et al. Robotic Versus Laparoscopic Partial Nephrectomy: A Systematic Review and Meta-Analysis. European Urology. 2012;62(6):1023-33.