Dr. Mohan Keshavamurthy, Director Urology, Uro-Oncology, Andrology, Transplant & Robotic Surgery at Fortis Hospital, Bannerghatta Road, Bangalore.
Technological advancements play an important role in optimizing clinical and patient outcomes. Urology as a speciality has been at the forefront in adapting applied science into daily clinical practice. Being a pioneer in laser urology and an expert in complex reconstruction of the urinary tract and major uro-oncological procedures, the value and benefits that robot-assisted surgery could provide to my patients was obvious and profound.
After undergoing training from the prestigious STAN Institute, earning a diploma in Robotic Surgery from the University of Lorraine, France and performing more than 300 surgeries in the last two years, I perceive robot-assisted surgery as an effective tool for surgeons primarily who perform operations to manage Urological and Gynaecological cancers.
There is growing enthusiasm among Indian surgeons to adopt robot-assisted surgery, as it has a promising future and robust opportunity in the Indian context. Continuing to invest in opportunities for surgeon training and education, as well as ongoing efforts to raise general awareness of robotic-assisted surgery, will play an important role in encouraging broader adoption and providing greater access to patients. Though robot-assisted surgery is at its nascent stage in India, the advantages it offers to surgeons and patients may lead to sustained growth in its adoption, similar to what we have seen globally. Robot-assisted surgery can revolutionize the field of surgery in India by providing doctors and hospitals with new technology, refining and expanding minimally invasive procedures beyond the traditional 'straight stick' laparoscopic instrument, and can make a significant difference in the lives of individual patients by enhancing clinical outcomes and earlier return to productive life.
The last decade has seen substantial increase in the number of robot-assisted surgeries performed worldwide and in India, especially for uro-oncology. The da Vinci surgical system has provided surgeons with newer capabilities that can be applied to several complex procedures in the field of urologic oncology. For instance, robot-assisted surgeries can make it easier for surgeons to operate in narrow, confined spaces, such as the male pelvis, during radical prostatectomy. In the case of partial nephrectomy for treating kidney cancer, when using traditional methods such as laparoscopy and open surgery, a surgeon may need to sacrifice a greater amount of a normal kidney while the tumor removal is done, Robot-assisted surgery can enable the surgeon to cut only the affected part, thus potentially preserving maximal organ function. Excellent residual kidney function after kidney cancer removal is the single most important factor in ensuring good quality of life postoperatively. This concept of Nephron sparing surgery is especially important in diabetics and hypertensive patients who are diagnosed with kidney cancer.
Quoting an example of a surgery I performed a few years ago, a female patient was diagnosed with an incidental renal tumor on a master health check done before her proposed travel to the United States to support her pregnant daughter's delivery. Apart from a renal tumor, the patient had comorbid conditions such as diabetes and was overweight with a BMI of 34. Because of the central location of the tumor close to the renal hilum, laparoscopy was not possible. Keeping in mind the complexity of the case and the need of the patient to travel, we discussed the option of performing a robot-assisted surgery with the patient. Recognising the potential post-operative and long- term benefits, she chose to undergo a robot-assisted surgery. A partial nephrectomy was performed on the patient, with no blood transfusion and excellent recovery. The patient was discharged 2 days subsequent to the procedure and could travel to the United States from Bengaluru after just three weeks.
Understanding how the technology works and the capabilities it provides surgeons
The da Vinci surgical system enables the surgeon to operate sitting at an ergonomic console unit instead of standing for several hours during surgery. With a 3D high definition visualization of the surgical site, the surgeon can get a clear and unobstructed view of the patient's anatomy. In addition to the console, the machine is comprised of a patient side cart with three or four interactive arms with a high-performance vision system and wristed instrumentation. One arm holds the camera while the other three holds the instruments, which are inserted through small incisions, generally 1-2 centimetres long. This minimally invasive approach results in less scarring and reduced trauma to the body as compared to large incisions necessary for open surgery.
The technology behind the robotic arms also provides additional reach, dexterity, and control that is often beyond the limits of the human hand. The controls minimize the impact of tremors in the surgeon's hands, thereby adding precision and reducing the risk of inadvertent nicks or punctures that can cause bleeding and complications thereof. The instruments also provide a 360 degree of movement to the surgeon enhancing the ability to perform complex surgery with consummate ease. Besides, since the surgeon is working seated at an ergonomically designed workstation, there is absolutely no need to twist and turn in awkward positions to move the instruments and observe the monitor simultaneously. Increased maneuverability along with the ability to directly control a stable visual field (with an increased magnification) is one the most important aspects of robotic-assisted surgery as compared to traditional techniques, such as laparoscopy or open surgery.
Robot-assisted surgery has a bright future in India. As awareness grows and adoption increases, the new capabilities that the technology provides surgeons, and the resulting excellent clinical outcomes, has the potential for a lasting positive impact on uro-oncology and other surgical specialties.