Robotics in GU oncology: Current status, future directions

Leonardo da Vinci is credited with having drawn the world’s first robot in 1495. This device was a complex suit of armor with flexible joints controlled by a series of pulleys and is the same basic concept used by the current iteration of Intuitive Surgical’s da Vinci robotic surgical system.

Urology, as a field, has been at the forefront of the utilization of this technology since its inception. Robot-assisted laparoscopic prostatectomy is almost synonymous with robotic technology. Nearly every hospital system with a robotic platform has at least one high-volume genitourinary oncologist recording the most time on the console.

The most familiar robots used in genitourinary oncologic surgery are known as online robotic systems. These devices were designed to replicate, in real time, a surgeon’s hand movements. Interestingly, the first non-microscopic surgical robots were designed for use by the U.S. Department of Defense.¹ The concept was a mobile armored operative suite that could be manned by surgeons at the rear of the battle. This setup would keep them out of harm’s way, with the hope of minimizing casualties and protecting surgeons. Although we now associate robotics with safe, sterile operative suites, this could not have come to fruition without the U.S. military.

Thanks to urologic pioneers and an ongoing push for a minimally invasive approach in an ever-growing breadth of surgical applications, the future looks bright for robotics in genitourinary oncology.

Shift in practice patterns

Mani Menon, MD, is an American surgeon whose pioneering work laid the foundation for modern robotic cancer surgery. In 1997, Dr. Menon was recruited to become chairman of urology at Henry Ford Hospital. This transition of power led to Henry Ford Hospital’s urology department receiving a $20 million donation from the Vattikuti Foundation, effectively establishing the Vattikuti Urology Institute.

This financial backing freed Dr. Menon to explore minimally invasive techniques and establish robotic prostatectomy. He has performed nearly 4,000 robotic prostatectomies and is considered a world authority on the use of robotic surgery for prostate cancer.²

Current technology

Intuitive was founded in 1995. World-renowned experts in telerobotic technology, human-machine interfaces, and minimally invasive surgical techniques laid the groundwork for surgical robots. Intuitive launched the first da Vinci surgical system in 1999; it became the first robot-assisted surgical system for laparoscopic surgery cleared by the FDA in 2000.

As of 2018, there was an installed base of 4,986 units worldwide-close to 3,000 in the United States. Per the company website, more than six million minimally invasive surgeries have been completed using da Vinci technology as of 2018. Additionally, more than 18,000 scientific articles on Intuitive surgical products and procedures have been published.¹

The da Vinci Si System was launched in 2009 and is the first model to offer dual-surgeon console capability, thus supporting training and collaboration during minimally invasive surgery. Additionally, this model also incorporated high-definition 3D vision.

In 2014, the da Vinci Xi System had broader capabilities than earlier generations. These included the ability to perform multiquadrant surgeries or procedures where instruments must be able to reach up and down across the abdomen or chest. The Xi was the first system to have an overhead instrument arm configuration, allowing anatomic access from virtually any position. It also incorporated the ability to attach the endoscope to any arm, as well as the greatest range of motion with a longer instrument shaft designed to give surgeons greater operative reach.

Announced in 2017, the da Vinci X is the newest Intuitive product on the scene. It is advertised as a cost-conscious option with arm architecture similar to that of the Xi, with the goal of placing even more units into hospitals where price had previously precluded purchase.

The da Vinci SP is a new member of the family, designed for the narrowest access surgery. With the SP, a single arm delivers three multijointed instruments and a fully wristed 3-D high-definition camera for visibility and control in narrow surgical spaces. At present, the potential benefits of laparoendoscopic single-port surgery include improved cosmesis, reductions in wound infection rates, quicker recovery, and reduced postoperative hernia. However, these benefits cannot be fully evaluated until the size of single-site trocar incisions and tools is optimally miniaturized.

General limitations for robotic surgical platforms include high start-up costs and setup times involved with individual surgeries. The da Vinci system uses proprietary software that cannot be modified by physicians, thereby limiting the freedom to adjust the operation system. Furthermore, a $2 million cost places it beyond the reach of many institutions. For example, the Si version costs on average slightly under $2 million, in addition to several hundred thousand dollars of annual maintenance fees.

Another large drawback is the lack of haptic feedback, requiring the use of visual cues compared with more traditional attention and texture techniques. This can be dangerous and has also led to a reported steep learning curve for robotic surgery.

One of the greatest strengths of robotic technologies is increased manual dexterity along with tremor-filtering functions. Additional benefits include the ergonomic control stations and the ability to perform complex surgery in a solo fashion by using more than two arms at once.

Developments and competitors

As laparoscopy and robotic surgery continue to gain popularity, a continued push to develop laparoendoscopic single-port surgery has followed. Engineers and medical technology companies continue to develop products with the ultimate goal of natural orifice transluminal endoscopic surgery-a transvaginal cystectomy/neobladder with no abdominal incisions. Although Intuitive continues to dominate the field, there are several competing systems worth noting.

The Senhance Surgical System (TransEnterix) currently used in some gynecologic procedures has multiple manipulator arms controlled from a remote station. One main feature of this platform is that it provides actual tactile haptic feedback so surgeons can feel the tension they are applying at the distal end of their endoscopic instruments. Interestingly, the Senhance system also employs eye-tracking software that allows the surgeon to naturally focus on tissue of interest without having to redirect the endoscopic camera.

Competing in the single-port surgical space is the Flex Robotic System (Medrobotics Corp.). This is not currently approved for urologic procedures but is used in oral and head and neck surgery. Flex allows surgeons the freedom to manipulate around target anatomy by defining a nonlinear path to surgical sites. The operator is able to perform this technique by advancing a flexible outer sheath through which the inner channel instruments are deployed.

Although not currently FDA approved, SPORT (Single-Port Orifice Robotic Technology, Titan Medical Inc.) features a design with a collapsible system that can be inserted through a 25-mm incision. In preclinical testing, it has been used to successfully complete a nephrectomy in animal models.

Anecdotally, one cannot discuss future robotic technologies without mentioning Verb Surgical (Verb J&J/Alphabet), a company founded in partnership with Google. Although little information is available, the prototype has been reported to combine robotics and data-driven machine learning to reduce surgical costs and expand the use to a larger array of surgeons. The company’s stated goal is to “democratize surgery,” an attempt to not just create a new surgical platform but also truly develop a new category of digital surgery.

As exciting as these newer platforms may sound, it will be some time before we see competitors in the commercial market. Regardless, the prevalence of robotic platforms will increase in smaller communities and other countries. Contemporary literature has demonstrated that the use of partial nephrectomy has increased and open radical nephrectomy has decreased since the adoption of the robot.³ This trend will continue not only in kidney cancer but also in other subspecialties.

Future directions

In tertiary referral centers, we will continue to see more and more difficult procedures performed robotically as experience continues to grow. In addition to the now standardized oncologic surgeries, we will see more complex reconstructions and vascular surgeries performed by a robot. In October 2019, a team from the Glickman Urological & Kidney Institute in Cleveland successfully performed the world’s first robotic single-port kidney transplantation.⁴ Small case series are beginning to come out presenting radical nephrectomy with inferior vena cava thrombectomy up to a level IV thrombus.⁵

Robotic surgical platforms, as evidenced by the adoption of the da Vinci, have had a rapid and far-reaching impact on the performance of minimally invasive surgical procedures in urologic surgery as well as in other disciplines. Further developments in robotics will continue to enhance this performance and promise to improve outcomes in a wide swath of surgical fields. Urologic surgery has been a leader in robotic surgery development, and this technological revolution in the operating room continues to redefine urology and all of surgery.

All data seem to expect this trend to continue accelerating. It is projected that the global market for surgical robots will experience a compound annual growth rate of 10.4%, from $3.9 billion in 2018 to $6.5 billion by 2023.⁶ 

References

1. Yoo AC, Gilbert GR, Broderick TJ. Military Robotic Combat Casualty Extraction and Care. Surgical Robotics. Springer; 2011.

2. Menon M, Tewari A. Robotic radical prostatectomy and the Vattikuti Urology Institute technique: an interim analysis of results and technical points. Urology 2003; 61(4 suppl 1):15-20.

3. Leslie S, Goh A, Gill I. Partial nephrectomy-contemporary indications, techniques and outcomes. Nat Rev Urol 2013; 10:275-83.

4. Cleveland Clinic first in the world to perform robotic single-port kidney transplant. Accessed 2/6/20. Cleveland Clinic website. (https://cle.clinic/3bs5QU3). 

5. Wang B, Huang Q, Liu K, et al. Robot-assisted level III-IV inferior vena cava thrombectomy: initial series with step-by-step procedures and 1-yr outcomes. Eur Urol May 15, 2019.

6. Surgical Robots Market by Product & Service (Instruments & Accessories, Systems, Service), Application (Urological Surgery, Gynecological Surgery, Orthopedic Surgery), End User (Hospitals, Ambulatory Surgery Centers) - Global Forecasts to 2025. Markets and Markets. Accessed 2/6/20. https://bit.ly/33SaOGR.