Expert robotic surgeon discusses da Vinci 5, advances in urologic surgery

Ronney Abaza, MD, FACS

In this interview, Ronney Abaza, MD, FACS, discusses the current state of robotic technology in urology, gives an overview of the da Vinci 5 robot, and shares his research interests. Abaza is a robotic urologic surgeon at Central Ohio Urology Group in Columbus, Ohio.

At this year's LUGPA Annual Meeting, you shared a discussion titled “What's new in robotic surgery.” Could you recap the key points from that talk?

It's actually a very exciting time to be a robotic surgeon, because obviously robotic surgery is one of those fields that's very technology driven. So, there's constantly new innovations that are coming out from industry to both augment the actual robot that we use during surgery, but then all of these other ancillary devices that have been developed to go along with robotic surgery. Those are also constantly in flux with new things coming out. Then, most recently, the most exciting thing that's about to hit the pipeline are new robots. For about 2 decades, the only robot on the market was the Intuitive da Vinci. And the Da Vinci has also continued to evolve and get better and better with time. But there was really just 1 company out there that was making robots that we could use for surgery, especially here in the US, with very few exceptions. Now, we're about to see a lot of different robots hitting the market.

For example, a couple years ago, the Senhance robot became FDA approved, but really didn't make many inroads here in the US simply because it's a larger robot. It has multiple different patientside carts, so basically 1 robot for each arm that you have to drive in and dock. They're pretty big and take up a lot of room in the OR. So the Senhance robot really hasn't been adopted very much in the US. But most recently, CMR, which is a British company, was FDA approved just last month in October, and so that's about to hit the market here in the US. We'll see what that does in terms of adoption and use. It's a different model, because the robotic arms are actually mounted to the table, and they're not on a cart that you have to drive up to the patient. The CMR robot has actually been used pretty extensively already in Europe, with thousands of procedures that have been done on it. So, it's a pretty well-vetted system that we know can be used on a routine basis for all the surgeries that we do. It will have a better chance of breaking into the market here in the US and giving Intuitive Surgical some competition. The third company that is pretty close to FDA approval here is Medtronic's robot, the Hugo robot. Medtronic, of course, is a huge company that does billions of dollars of business already in health care here in the US. So, whereas CMR is going to come into the market as a standalone robotic company, Medtronic is going to come to the market with their robot already having established relationships and tons and tons of business that they're doing with hospitals around the country. I think they're going to have an easier time getting their robots into the hospitals here in the US, and again, creating some competition on the market. And competition, of course, is always good because it gives options for surgeons in hospitals, but then it also pushes these companies to continue to innovate and really do a better job of providing the technology that we need to help our patients. It gives them some motivation, in other words, to give us better products.

We're really excited as robotic surgeons, because this will be the first time in a couple decades that there'll be competition for robots, and that's only going to make things better. It's going to make the robots better and drive these companies to give us better tools, and also incentivize other companies to, again, create those ancillary products that work along with the robots for robotic surgery, to give us a better chance of doing a great job for our patients. It's an exciting time, again, because of all these innovations and new technologies that are coming out. The robots are getting smarter; they're getting better, especially when it comes to some of these other topics that you're going to ask me about, there's some exciting developments happening, just like we see in other technology driven fields. Obviously, anything having to do with computers and technology, even cell phones and other technology is growing and developing, evolving by leaps and bounds. Everything technology-based evolves exponentially, not linearly. The cell phone that we use today compared to the one a year ago, is exponentially better than the one that was 5 years before that. Technology is developing so quickly that we really expect to see some amazing developments with robotic surgery.

I want to dive into Intuitive's newest iteration of their robotic system, the da Vinci 5. Could you share your experience with that platform?

The da Vinci 5 is called the 5 because it's the fifth generation of the da Vinci robot. I've been around long enough, I'm old enough, that I was there with the first-generation robot. In fact, when I practiced at Ohio State here in Columbus, when I first came to Columbus in 2008 the robot that I used was actually the first robot that was used in human patients, that was produced by [Intuitive]. I think it was serial number 3, because there were a couple of robots that were not used in patients, but in labs. And so I used the very first da Vinci robot that, was purchased and installed at Ohio State before I was there, obviously. But it was the same robot. It was generation 1. And then I was there for generation 2, which was the S, and then the Si, and then,the Xi came out as well as the X, which is kind of a cheaper version of the Xi. And then the SP came out; I've used the SP as well. And then now we're on to the da Vinci five. Each robot that Intuitive has produced has had incremental benefits to it, not huge leaps and bounds compared to the previous version. Probably the biggest jumps in robotic technology with the Intuitive robots was between the original robot, that we called the standard and the S. That was a huge jump forward. S to Si, not a big difference. Si to Xi was also a big change, a big improvement in the architecture.

The Xi to the 5, I think, is not going to be a huge shift. I think it's going to be more of an incremental shift, like it was from S to Si. What was the difference between S and Si? It was really mostly incremental, small improvements, little things that made the robot better and a lot more computing power. And it looks like the 5 is probably going to be very similar to that. It's got a lot more computing power, and it's got just incremental benefits in terms of the vision. It's got haptic feedback for the first time, which is force feedback on the robotic instruments. Still yet to be determined whether or not that's really going to make any difference, especially for experienced surgeons, bu engineering wise, it's a big step forward, and certainly might be helpful for new surgeons. The da Vinci 5 also, again, has a lot more computing power, so as we look on the horizon at things like AI and how that might be incorporated into surgery, the da Vinci 5 is going to be more nimble with those potential applications, which might even be third-party applications, other companies that develop these technologies that can be ancillary to the robot and incorporated into the robot. The da Vinci five is able to record a lot more background information and collect more information on surgeon use of the robot, which may be useful for education, but again, remains to be seen. So there are some things about the 5 that are really interesting, and we may or may not end up really capitalizing on those. And then again, there are a bunch of incremental benefits that are not a huge jump forward, but just little things that make it a better robot. The patientside cart, the actual arms of the robot, and the architecture and the instruments, are identical to Xi. They haven't really changed what the robot itself looks like. The console is very different, but the patientside cart, the actual working instruments that we use in the patient, are identical. That's why I'm saying I don't think it's really a huge step forward. It's just a bunch of little things and some things that may or may not end up making a big difference, but remain to be seen.

Is there any work in the space that you're currently involved with that you wanted to highlight?

I specialize in robotic surgery, so that's really all I do. And the research that I do is all in robotic surgery, and it's all clinical research. It's all based around trying to improve the quality of the operations that we do, and little tweaks in the operations to make them better, or new applications of the robot to new conditions. That's really all the research that I'm doing, rather than lab research, and then obviously incorporating some of the disease state research - research around prostate cancer, kidney cancer. We're constantly doing that as well, in terms of all of the different cancer-related items that go around the surgery, so not just the actual surgery that we do for these cancers, but everything before and after that we do to improve the cancer care for these patients. All of that is part of my research interests and what I focus on.

One of the big research interests that I have surrounds clinical pathways after robotic surgery, the idea that we're doing these robotic surgeries, rather than the old-fashioned open surgery for 2 reasons. One, because they're minimally invasive, and it's better for the patient, easier to recover from. But then number 2, that the instruments are better, the vision is better. We think we can do a better job than we could do through open surgery. That's debatable. The open surgeons would say no, but I think the robotic surgeons are pretty convinced that we can do a better job with robotic surgery than we would be able to do open, but the first topic that I was saying that the minimally invasive nature of the surgery, if we're doing these surgeries minimally invasively, so that the patients can benefit and recover faster, then we should be able to see that benefit on the backside. And so if we can combine the idea of enhanced surgical pathways for patients after surgery with the fact that it's a minimally invasive operation, then we can really take most advantage from the fact that we haven't done a big open surgery, and the pain and the narcotics and all that stuff. That's 1 of my big interests, and how can we most capitalize on the minimally invasive nature of robotic surgery and see that benefit and how well the patients do post operatively. And so a lot of my work is around trying to drive outpatient surgery pathways for outpatient robotic surgery so that patients can have their prostatectomy, nephrectomy, partial nephrectomy, all of these different robotic procedures, and go home the same day, not have to stay in a hospital, not be in a strange environment with the IV beeping all night and the nurse coming and checking the urine output all night, and waking them up and having to eat hospital food and all these different things. Patients would much prefer to be at home if they can be at home. And so the idea is, well, if we're doing this surgery minimally invasively, and there really shouldn't be much pain, then why do we need to keep them in the hospital? Let's see if we can get them home like they do with gallbladder, hernia, these other operations. And so I've gotten to the point now where more than 99% of my patients go home the same day, whether it's kidney surgery, prostate surgery, whatever the operation that I'm doing, the patients are able to go home the same day. It's something like 99.3%, so it's very rare that a patient has to stay in the hospital overnight after a robotic surgery, as long as they're getting a good-quality operation and we do all the patient education, prepare them for it, then patients are really happy to go home and not have to stay in a hospital. And then the other enabling part of this is that it allows us to now be able to offer robotic surgery in a surgery center where I have patients who are coming to see me for prostate cancer, for example, or a kidney tumor, for example, and I can say to them confidently, "You're never going to have to set foot in the hospital. You're going to come into the surgery center about an hour, hour and a half before your surgery, we're going to do your operation for 2 hours, and then we're going to keep you in the recovery room for an hour or 2, and then you're going to get to go home and you'll never have to step foot in the hospital, and in 5 or 6 hours door to door, your kidney tumor is gone, your prostate cancer is gone." We've now done this for over 700 patients. Nobody's had to be transferred to a hospital or admitted overnight. Our surgery center actually doesn't have overnight beds, so the patients come in knowing that they're going to go home the same day. Again, the idea of just streamlining these robotic surgeries, taking advantage of the fact that they're minimally invasive, this is one of my research interests, and one of the things that that I focus on.

And then the last thing that I'll mention that I'm really excited about, and have been for several years now, is the concept of doing robotic surgery at ultra-low pressures. So rather than filling up the belly with gas and stretching these people's bellies out for an hour or 2 at 12 or 15 mm of mercury, for years now, I've been doing robotic surgery at the lowest pressure possible. And for the vast majority of these surgeries, you don't need to have a pressure of 12, 15, or even 10. So all of my pelvic surgery, whether it's prostate or bladder, I do all of these surgeries at a pneumo pressure routinely of 6 mm of mercury. On the skinnier guys, we turn the pneumo down to 5. Most recently, and I think a lot of people are going to be shocked by this, but most recently we had patients skinny enough where we turn the pneumo device off, meaning that we're doing their prostatectomy at a pneumo pressure of 0. Now, some people will think that's crazy. They'll say, "Well, how can you do that?" Remember that the robotic arms are fixed in space, so when you turn off the pneumo, it's not like the belly collapses. The belly wall will still be held up by those robotic instruments going through the belly wall, but instead of it being filled because of the gas, the arms are what are holding the belly wall up and on a skinny enough patient, we can do the entire operation with 0 gas pressure in that patient's abdomen. Now, some people are going to say, "Well, doesn't it bleed a lot like open surgery used to bleed?" Honestly, in my experience, I've not seen that. I've done these prostatectomies at a pneumo pressure of 0, and they don't seem to bleed like the original open surgery that we did, where we used to have transfusions and whatever. So it kind of might blow some people's mind that you would do a prostatectomy at 0, but the benefit to the patient is that with no gas circulating through their abdomen, no gas going in and out circulating the entire time, that's going to dry out their belly less, and again, they're not going to be stretched out at all. It's actually closest to physiologic pressure. I like to remind my colleagues in surgery, who are skeptical of using low pressure, I always ask them the question, "What is the physiologic pressure in your belly right now?" It's 0. It's atmospheric pressure. There's no additional pressure inside your abdomen compared to the outside atmosphere, in the normal steady state that all of us are used to and living in. So whenever we fill the belly with gas, even 5 or 6 mm of mercury, that's an abnormal situation for that patient for 2 hours. So now we have turned the pressure down to the minimum that we can do the operation, and sometimes we can do it at 0, and that's again, closest to the normal physiologic pressure. When we did the randomized study of pneumo of 15 vs pneumo of 6 for prostatectomy, we published this in The Journal of Urology1 a couple years ago, so people can go back and read that. In that randomized trial, we have level 1 evidence showing that patients have less pain and faster return of bowel function when you work at low pressure. So I encourage my colleagues to try it if they haven't tried it. But again, the idea here is that I specialize in robotic surgery. I do so much of it that I like to try new things, figure out what things work and then share that with my colleagues and encourage them to give it a try.

REFERENCE

1. Abaza R, Ferroni MC. Randomized trial of ultralow vs standard pneumoperitoneum during robotic prostatectomy. J Urol. 2022;208(3):626-632. doi:10.1097/JU.0000000000002729