By Rajesh Laungani, MD & Nikhil L. Shah DO, MPH
From ATLANTA Medicine, 2014, Vol. 85, No. 2
Historically, urology has embraced and even pioneered the use of innovative technology, especially with respect to integrating minimally invasive means for both diagnosis and treatment of disease.
This trend began with endoscopy – the use of a patients natural openings, in our case the urethra, to access the bladder, ureters and kidney with the intent to be both diagnostic and therapeutic. Then came the advent of laparoscopic and minimally invasive techniques for treatment of urologic cancer, namely kidney cancer and prostate cancer. Advocates of laparoscopy cite improvements in convalescence, such as decreased time to recovery, reduced hospital stay and decreased postoperative pain. In the prostate cancer patient, minimally invasive approaches also offer patients significant decreases in blood loss compared to open surgery.
The origins of robotic-assisted surgery date back more than a decade ago to around 2000 or 2001. Initially created for cardiac surgery, robotic-assisted surgery found its home in the male pelvis, as it has gained the most ground in the hands of urologists. It is currently used for the treatment of localized prostate cancer, kidney cancer and bladder cancer as well as a multitude of urological reconstructive procedures, including Ureteropelvic Junction (UPJ) obstruction as well as Sacrocolpopexy for treatment of vaginal prolapse.
More than ever, technology continues to influence our lives on a day-to-day and even minute-to-minute basis. Medical technology may not be changing as quickly as the newest smartphone, but its influence, particularly in the surgical arena, is evident. The goal of any surgeon continues to be to provide the best possible care for his/her own patient while minimizing morbidity and mortality and maximizing outcomes. Yet, the definition of outcomes has changed dramatically in the new healthcare environment, as patient safety and providing quality care must also encompass equal parts efficiency and cost savings.
What minimally invasive and robotic surgery has allowed the urologist to do is to perform an equivalent, if not superior, operation on the patient for his/her particular disease with a recovery period and morbidity far decreased compared to more traditional techniques.
For example, for a patient with localized prostate cancer, standard of care five or ten years ago would have the patient undergo an open radical prostatectomy. This would typically involve a large incision extending from just below the navel to just above the pubic bone. There was usually 500-800 cc of blood loss, catheterization for two weeks and five to seven days in the hospital.
Robotic surgery allows the same patient, with the same disease spectrum, four to five keyhole-sized incisions, 50-75 cc’s blood loss, catheterization for five days and an overnight stay in the hospital.
Smaller incisions lead to less pain, quicker recovery, a shorter hospital stay and less risk of infection. Decreased blood loss results in a transfusion rate of <1 percent. A shorter catheter duration and hospital stay result in a quicker return to work, friends and family. The same trends and benefits extend to patients for treatment of kidney cancer; robotic-assisted radical/partial nephrectomy; and robotic-assisted radical cystectomy for bladder cancer.
What drives the technology continues to be human hands, and what leads to superior outcomes continues to be greater experience in regards to case volume. Surgeons with high case volume and greater experience have been shown to have a significantly decreased complication rate along with superior overall outcomes as compared to those surgeons with a lesser volume.
It’s important to understand, both from a primary care perspective as well as a patient perspective, that just because a hospital has a robotic surgical system does not mean they have the urologists skilled enough to perform robotic surgery at a level that will significantly decrease complications as well as provide your patients with excellent outcomes.
The authors have a combined robotic surgical case experience of more than 5,000 cases dating back to 2002. They were both part of the pioneering robotics team at the Vattikuti Urology Institute – Henry Ford Health System in Detroit. It was there that robotic surgical techniques were established for robotic prostatectomy (2000), robotic-assisted nephrectomy (2003) and partial nephrectomy (2003) as well as robotic-assisted radical cystectomy (2004). They were both mentored by Dr. Mani Menon, who many consider the “godfather of robotic-assisted urologic surgery.â€
The inherent advantages of the robotic surgical system lies in what the technology can provide.
1) 10x magnification with 3-D visualization, which allows for more precise dissection and tissue manipulation with identification of nervous tissue and blood vessels that are imperative to preserve for maintenance of urinary control and sexual function after radical prostatectomy.
2) 180-degree range of motion with stereotactic stabilization, which allows the human wrist to manipulate instruments in a way that would not be possible with traditional surgery with complete steadiness.
3) Instruments that are approximately the width and length of the human pinky nail, allowing for small incisions, less pain and decreased infection risk post operatively.
The technological advantages inherent to the robotic surgical system along with a skilled, fellowship-trained urologist have resulted in better patient outcomes. It has become evident that robotic surgery continues to gain ground, although slowly, but it will surely establish itself as the standard of care for many urologic surgical procedures.
