Dr. Palese on robotic surgery in urology: “We should embrace it”

Michael A. Palese, MD

Over the last 2 decades, robotic advancements in surgery have changed the field of urology, giving patients and surgeons more efficient and less invasive options for treatment. Even so, many patients are still taking conservative routes because they question the safety of this treatment method.

Michael A. Palese, MD, weighs in on the stigmas associated with robotic surgery in a recent interview. He emphasizes the success of robotic surgery over time and the importance of transparency with patients in regard to their treatment concerns. Dr. Palese is the Chairman of the Department of Urology at Mount Sinai Downtown & Beth Israel Medical Center as well as a Professor of Urology at the Icahn School of Medicine at Mount Sinai in New York City.

What are some of the stigmas and/or misconceptions regarding robotic surgery? What drives them?

Robotic surgery has developed leaps and bounds over the last 20 years, especially in urology. This was a very hot topic when robotic surgery started being used in urology almost two decades ago, particularly when no one even thought that this was a feasible technology for use in surgery let alone Urology. In particular, robotic surgery was used for prostate cancer surgery and then slowly evolved for use in many other areas in urology, including kidney cancer, bladder cancer and reconstructive surgery. Today most major urologic surgical procedures are being done robotically.

I trained in an era where open surgery was the standard of care and laparoscopic surgery was in its infancy in urology.After residency, I pursued a fellowship in laparoscopic surgery and early robotic surgery, which was where the transition between open and minimally invasive surgery began. So, I'm probably one of the last generations of surgeons who had an excellent open training, laparoscopic training, and was introduced to robotic surgery right at the outset of its use in Urology in early 2001. I find myself very fortunate that I can use any (3) of these surgical skill sets if ever needed. Even to this day, there are times when open surgical approaches or laparoscopic approaches are warranted but in general, most of our procedures are now done robotically. For most of these procedures, the standard of care is to do them robotically. Certainly, prostate cancer surgery and most kidney surgeries, including the partial nephrectomy, nephrectomy, and reconstructive surgeries, are being done robotically. Reasons for pursuing these surgeries with open or laparoscopy are becoming fewer and fewer. A large tumor that you need to make a large incision on might be a reason to do something open or even laparoscopic.

Again, a lot of it is experience, the comfort level of the surgeon, and what we're trying to accomplish. Going back to your original question—the stigma—there's always going to be a stigma of new technologies and new ways of doing things. I think as the surgeons and as the staff get more and more comfortable with these technologies, that's where the stigma starts to go away. And, in fact, if enough surgeons do it, then it becomes "standard of care." And so, the standard of care, like I said in 2021, does call for the robotic approach with many procedures.

What percent of surgery today is performed robotically versus open?

A lot of what we do in urology has become minimally invasive, and when I say minimally invasive, it's an inclusive & collective term for any endoscopic or percutaneous surgery or “keyhole approach” surgery like robotic & laparoscopic surgery. Procedures done for enlarged prostates are now done in the office, sometimes through an endoscopic approach, so these procedures that were done previously with bigger incisions or open incisions really don't need to be done that way anymore. And so, when we talk about robotic surgery, it is really meant for certain procedures that normally would have to either use a large open incision to get into the abdomen or the retroperitoneum. Presumably, some of these things you could do laparoscopically.

The advantage with robotic surgery is that when have to do any kind of sewing or reconstruction, the robot becomes very helpful. If there's a lot of dissection, a lot of times the robot is certainly much more helpful than even the laparoscopic approach. But, when patients ask me what's the difference between laparoscopy and robotic surgery, I say it's like driving a stick shift car versus an automatic car. It's not that you can't get from point A to point B in the stick shift, but certainly much more comfortable with an automatic car.

Again, as we as we get further along in the evolution of the robotic approach, we've now got even newer robotic technology with several new generations being used. Most recently a single port or SP technology was introduced allowing surgeries to be performed through a single 3cm incision. This really makes a big difference cosmetically for patients, also potentially improves recovery time and potentially improves pain control. And so, as we as we continue to move forward with this technology, we also develop newer techniques and move the field forward. Ultimately we are imparting these surgical benefits on patients with quicker recoveries and return to normal lives.

How do stigmas surrounding robotic surgery affect treatment?

When patients hear, "We're going to do robotic surgery," their initial thought is that the robot is doing the surgery.People have this idea that, like something from “The Jetsons,” there's a robot actually doing the surgery. That's not true. The surgeon is very much in control and actively performing the surgery.There is however, technology being developed that may change this one day, where the robots will do some automated processes of a surgery.We have self driving cars why not self operating surgical robots.

Stigmas of robotic surgery may affect some patient’s decision to undergo surgery but as people get comfortable in general with these technologies being in the their lives so will their acceptance of robotic surgery.

What is the urologist’s role in destigmatizing robotic surgery?

Like everything else, I think it's important as a surgeon to speak to your patient in such a way that they understand what's going on. Give them as much information as they need, whether that's directing them to literature or speaking to them directly about what their fears are or what they're expecting during the surgery. One of the things that you don't want is a patient showing up misinformed or uninformed about what's going on. And so, I think it's important to make sure that you give as much information as possible to the patients. You can explain an entire operation and the patient won’t necessarily have retained anything that you said. I always speak to my patients before surgery to address any last-minute questions answered or anything that they may have a concern with. They need to be comfortable going into the surgery just as you as a surgeon who needs to be confident you can do the procedure. Many times, I also tell my patients that it's like getting on an airplane. At a certain point, you have to trust the pilot to do what they're doing and make it from point A to point B. It's the same with a surgeon.

Is there anything else you feel our audience should know about this topic?

I think that we should welcome this technology that has revolutionized the way that we do surgery. Not just in urology, but in all surgical disciplines such as cardiac surgery, thoracic surgery, ENT, general surgery, OBGYN, etc. All these fields are actively doing procedures using robotic technology.It’s time to fully embrace not stigmatize.