Personalizing surgical care: Algorithm helps determine optimal approach for robotic surgery

In this interview, Ketan K. Badani, MD, highlights an algorithm that can help determine the optimal approach between single-port and multiport robotic surgery, introducing a new era of personalized care in the surgical treatment of kidney cancer.¹ Badani is a professor of urology at the Icahn School of Medicine at Mount Sinai as well as the Vice Chairman of urology and robotic operations and the director of the comprehensive Kidney Cancer Center at Mount Sinai Health Center in New York, New York.

This transcription has been edited for clarity.

Ketan K. Badani, MD

Could you describe the rationale for developing this algorithm?

I think the algorithm represents 20 years of robotics that's finally evolving to personalize care for patients. What I mean by that is, we started doing robotic surgery back in the year 2000 when the FDA approved it. We started with prostatectomy for prostate cancer, and then went into kidney. But we had 1 system, 1 platform, and 1 approach. We call that transperitoneal or transabdominal. That's how we did all of our kidney surgery: with this robot, in this way, for everyone. It didn't matter the individual characteristics of the patient; that's how we did it. Kidney tumors can come in different sizes, different locations, all kinds of things go on, but we always approached it the same way. I always say, we had 1 hammer, and every nail fit it.

But we are finally at a place now where we have options. Now we have multiport DaVinci surgery, we have a single-port DaVinci platform, and we have different ways of using them with different approaches. So, now instead of saying, "Okay, well, everyone that has this problem, here's my hammer. Here's the 1 way I can do it to take care of you, surgically speaking." Now, we can do it different ways. We can do it single-port, we can do a retroperitoneal, we can do it multi-port, we can do it transperitoneal, or we can go from the low anterior. We can individualize the access and the way we do the operation based on the patient's characteristics, and that hasn't happened in a very long time.

Could you expand on how this tool might fit into the shared decision-making process?

Shared decision-making with surgery has always been, are we going to do it or are we not going to do it? And if you are going to do it, here are the risks and benefits and potential outcomes. But now we have a different element with robotic surgery that we haven't had. It's not just are we going to or are we not going to. It's then, what's the best approach to do it? The 2 platforms—the multiport system and the single-port system—are both robotic systems, but they work very differently. The multiport system is now what I call the traditional robotic system. It sounds funny, but that's what it is. It is through multiple small holes, and you have different arms, and they work independently of each other. That's how the majority of robotic surgery is done. In single-port, everything goes through 1 access point and works through there. You have a smaller working field, but you do everything through that 1 incision. Now, it’s really good for some people, but single-port is not perfect for everyone. Again, [we had] 20 years of not having this option. Now we have this option, so we start thinking for the first time, "well, which one should I use? For whom? For what? Who is going to benefit most from this vs that? That's where this concept of the algorithms comes from, which is, we're in the office and I'm with the fellows and I'm with the physician assistants, and we start asking ourselves these questions. “How do you want to do it? Mr. X or Mrs. Y is here. This one would benefit from this, this one benefit from that.” And I said, well, why don't we figure out a way to put that on paper? [This is so] we have something to follow and so that other people might be able to learn these initial lessons from it and then grow from it and add to it.

What are some considerations for personalizing surgical approaches for patients?

The concept of personalized care or individualized medicine is to treat someone based on their biology. Of course, this started with medications and with other therapies that aren't surgically based. One patient's cancer compared with another patient's cancer, even if they're the same type of cancer, may be different biologically. This drug works better for this person, and this drug works better for this person. For surgery, we haven't really thought about it that way. I can do a laparoscopic this, or I can do a robotic that, or I could do an open this. But it's the same approach each way for all patients. The concept of personalizing surgery is to say, we can get to your problem—your prostate cancer, your kidney cancer—in different ways. Which way is the best way for you? It might be different than the best way for the next person.

I'll give you an example. For kidney cancer, a patient that has a tumor on the backside of their kidney, posteriorly, still 90% of the time in the United States, you go through the abdomen, but then you have to move organs out of the way. You got to move the ball, you got to move the liver, you got to flip the kidney over to the backside to get to it. It can be done, and it's been done. I've done it that way for many years, because that's how we have to do it. Then we learned how to do it retroperitoneal. So, we can go in from the back and get directly to the posterior side of the kidney and not have to do all that manipulation. Now, not only can we get there from the back, we could stay retroperitoneal with a single-port and we can do it from below, near where the bikini line is. We can make a small incision there, so you don't have to have a big ugly looking thing in the middle of your abdomen anymore. These are all options. Different approaches, different ways.

Another thing is patients that have had major abdominal surgery in the past. That's a challenge to go back into that area to get to the kidney and deal with the scarring of the adhesions. A good way to avoid that is to stay in the back, stay in the retroperitoneal, don't even enter the abdomen. That hasn't been a common thing being done. Even though we've been doing it for a long time, it hasn't been widely adopted. With single-port, because it's so good at working in small spaces, more and more people are doing retroperitoneal single-port surgery because it's lends itself to that. We can stay out of the abdomens of patients that have had prior abdominal surgery, adhesions, scarring, and just leave it alone and never look at it.

Is there any future work planned with this algorithm?

One thing to keep in mind is that the algorithms that we published are just a starting point. An algorithm, especially a surgical algorithm, is a living breathing organism. When you're first doing something, there may be reasons why you don't want to do it a certain way and certain things that might seem too challenging to do a new way. But as you get more experience, it changes. It does evolve with time. The initial concept of these algorithms is, if you're going to start doing single-port robotic surgery, here are the basic things to think about when deciding who the right patients are for that vs for multiport. Of course, it's not to say this is how it should be done. It's a thought process, and it'll evolve. And probably what I put out there earlier, may have changed today, now that I've done a lot more of it. So, it grows, but the thought process behind personalizing care, like we do for drugs, for medicines, for cancer therapy, for gene therapy, it's all personalized. We take your information, we create something that helps you as an individual. For surgery, now it's similar. We have your problem, with your tumor, and your kidney, in this location, with this past surgical history in the abdomen, etc. We pick the right surgery, the right platform, and the right approach for that patient, so it is personalized approaches for robotic surgery.

Is there anything else that you wanted to add?

We are just scratching the surface of robotic technology. I have looked at 26, maybe more, new robotic platforms that are emerging across the globe. In the next few years, there's going to be a whole bunch of robots with all kinds of different pluses and minuses and capabilities. All of a sudden, this little algorithm concept of mine with 2 things is going to have 20 different things on it. It's going to get very challenging and complicated to say, which one, for which patient? But that's actually what benefits patients in the end: more options, more available things you can do, and picking the right one for that person. This is just the beginning of the concept of personalizing surgery. We're going to have a ton more robots that are going to show their faces soon. We're going to have to figure out where they fit and where it benefits patients the most.

Reference

1. New algorithm guides decision-making for single-port and multiport robotic nephrectomy. News release. Mount Sinai. Accessed August 1, 2024. https://reports.mountsinai.org/article/uro2024-new-algorithm-guides-decision-making-for-single-port-and-multiport