Nicole Broughton

 

Glossary

Benign prostatic hyperplasia, Biopsy, Bronchoscopy, Colorectal, Complication, COVID-19, Endometrial cancer, Gynecologic, Laparoscopy, Minimally invasive surgery, Musculoskeletal, Nosocomial infection, Oropharyngeal cancer, Pedicle screws, Prostatectomy, Quality of life, Robotic laparoscopic radical prostatectomy, Surgical Robotics, Thoracic, Tumor

Abbreviations

Benign prostatic hyperplasia, BPH; Lower urinary tract symptoms, LUTS; Minimally invasive surgery, MIS

 

Introduction

In recent years, the field of surgical robotics has been evolving at a great speed. Robotic surgery is surgery that is carried out using robotic systems controlled by surgeons. Typically, these systems have cameras and mechanical arms that allow surgeons to operate remotely. Surgical robotics can be used in some ‘traditional’ open surgeries. However, surgical robots are most commonly used for minimally invasive surgeries. Minimally invasive surgery (MIS) is a type of surgery in which smaller incisions and techniques, such as laparoscopy, that cause less damage to the body, are used. With MIS, patients are likely to recover more quickly and are less likely to experience scarring, pain, and damage to healthy tissues [1]. Recently, there has been a rise in the development and use of numerous surgical robots within hospitals. The use of surgical robots has even become commonplace for certain procedures and types of surgery in the fields of gynecology, urology, and spinal surgery.

There is a growing body of supporting evidence that suggests that robotic surgery is safe and effective and it offers many advantages. It is likely that we will continue to see the field of surgical robotics grow and witness a significant expansion in the application of this technology across healthcare systems worldwide in the near future. In this post, we will explore some of the exciting robotic systems that are currently available. Some of these are already being used today in National Health Service (NHS) hospitals across the United Kingdom (UK). We will also discuss the potential benefits of robotic surgery and the challenges that still remain.

What are the advantages of using surgical robots?

The current evidence suggests that robotic surgery could have many advantages for patients, surgeons, and healthcare systems. The use of surgical robots facilitates minimal access surgery and higher surgical precision. This leads to numerous benefits for patients including fewer complications with post-operative wounds, better cosmetic results, and less damage to healthy tissue [1]. Patients undergoing MIS are more likely to have a better and faster recovery in comparison to those who undergo more traditional surgeries. Therefore, they typically spend less time in hospital and are less likely to be re-admitted. This is clearly favourable to patients and in addition, also reduces risks of nosocomial infection [2, 3]. A nosocomial infection is an infection that a patient acquires during their hospital stay, which was not present at the time of their admission. Shorter hospital stays also benefit healthcare systems greatly in terms of costs and resource-effectiveness as they increase the availability of hospital beds and reduces the burden on resources [2]. This has been reflected in various studies, including a study that compared radial cystectomy (bladder removal) carrie out either with or without robotic assistance, in cancer patients. The patients that underwent robotic surgery recovered and left hospital sooner than patients who did not, had fewer readmissions, and had an improved quality of life following surgery [3].

In the aftermath of the COVID-19 pandemic, the use of robotic surgery could be helpful for more efficiently managing surgical waiting lists while still maintaining a high quality of care as faster recoveries and shorter hospital stays will free up beds and resources. Also, as robotic surgery creates physical distance between the patient and healthcare staff, the risk of transmitting infectious diseases, including COVID, is reduced [4].

Another advantage of robotic surgery is the flexibility and wide range of surgeries and specialties that robotic surgery can currently, and could in the future, be used to treat. It is already available for use in a wide range of surgeries and this is constantly evolving. A recent report stated that evidence suggests that the use of robotic surgery for the spine, oropharyngeal carcinoma, vitreoretinal surgery, hysterectomy, prostatectomy and endometrial cancer leads to improved outcomes for patients in comparison to non-robotic methods [5]. Robotic surgery also allows surgeons to use minimal access while performing more complex procedures with high accuracy [6].

The use of robotic surgical systems serves to benefit surgeons as well as patients, as it gives surgeons better visualization, precision, navigation capabilities, and control [2]. In addition, robotic surgery could also help to tackle the musculoskeletal issues that surgeons are at a high risk of experiencing when performing MIS. Surgeons performing minimally invasive techniques such as laparoscopies tend to experience musculoskeletal pain and fatigue over time, particularly in the neck, shoulders, and back due to the long hours spent in unnatural and awkward positions and due to the limitations of currently available surgical instruments[7]. The use of surgical robots can reduce physical stress as the surgeon can sit or stand at a console to control robotic arms. Therefore, the use of surgical robots may help to reduce physician burnout and potentially prolong the length of surgical careers. This is supported by a recent review that analyzed the ergonomics of robotic surgery, which found that robotic surgery is ergonomically better for surgeons in comparison to traditional open or laparoscopic surgeries [8].

surgical robotics - robotic surgery
Intuitive: da Vinci surgical systems

Intuitive Surgical, founded in 1995, is dedicated to developing robotics to improve patient outcomes by providing minimally invasive interventions. Since the creation of their da Vinci surgical platform in 2000, it has been used globally to perform MIS for a wide range of procedures including prostatectomies, hysterectomies, cardiac valve repair, and colorectal surgeries [9]. Their surgical systems, which are currently in use in numerous NHS centers across the UK, allow surgeons to operate from a console by controlling its four robotic arms to which surgical tools and a camera can be attached. Intuitive continue to further improve and develop their da Vinci systems, with their da Vinci Xi model being their most advanced system to date [10]. They also have the Ion robotic-assisted platform, which allows surgeons to obtain biopsies of the lung with minimally invasive access and precision [11].

The Royal Marsden currently have two da Vinci surgical robots and routinely use these to treat cancer patients who have various types of tumors, including urological, gynecological, and colorectal tumors [12]. Mr Pardeep Kumar, a consultant urological surgeon at the center said, “our patients lose less blood, experience less pain, recover quicker, and leave hospital sooner” [12].

surgical robotics - robotic surgery
Figure 1 Intuitive’s Da Vinci Xi Patient Cart. Image sourced from Intuitive Surgical.  ©[2023] Intuitive Surgical Operations, Inc.

surgical robotics - robotic surgery
CMR Surgical: Versius robotic surgical system

CMR Surgical is a Cambridge-based robotics company that was founded in 2014. They currently offer the surgical robotic system Versius, which can be used to perform minimally invasive surgery. Versius can be used in a wide range of different surgical specialties including gynecology, thoracic surgery, urology, general surgery, and colorectal surgery [13]. At present, surgeons are able to control up to five robotic arms and the surgeon console is open, allowing for better communication between members of the surgical team [6, 13]. In contrast to the da Vinci models, Versius is smaller, with a more flexible, modular, and portable design. This allows it to be integrated into different types of operating rooms more easily. It also allows the robot to be adapted in terms of the number of robotic arms required and where the ports are placed, according to the type of surgical procedure being performed [13].

A scientific review of the current research on the Versius system found that it is a safe and effective way to perform MIS [6]. These findings have been reflected in real-life cases in which the robot has been used to treat patients. For instance, Guy’s and St Thomas’ Trust were the first to perform a prostatectomy using this system in the UK. The patient, 78-year-old Nasser Jadalizadeh, shared his positive experience with robotic surgery, saying that he had “no pain at all” when returning home with “just slight discomfort for a few days” and had gradually been making a smooth recovery to regain his abilities to do activities he had been able to enjoy prior to surgery [14].

surgical robotics - robotic surgery
Figure 2 An image of the Versius Surgical System by CMR Surgical in an NHS hospital. Image credit: CMR Surgical

surgical robotics - robotic surgery
Procept BioRobotics: AquaBeam robot system

Founded in 2007, Procept BioRobotics develops surgical robots with a focus on urology. Their AquaBeam robotic system allows surgeons to deliver aquablation therapy to patients with benign prostatic hyperplasia (BPH) who are experiencing lower urinary tract symptoms (LUTS) [15]. Benign prostatic hyperplasia is a medical condition in which the prostate, which is a gland located close to the bladder in males, becomes enlarged. The AquaBeam system can remove the excess prostate in order to lessen LUTS associated with BPH which includes symptoms such as problems when urinating. Surgeons achieve this by inserting the robot’s probe which has a camera into the urethra and bladder, this along with ultrasound images and the robot’s software maps the area so the robot’s high velocity waterjet can be used to precisely destroy excess prostate [15]. Numerous studies support the safety and efficacy of aquablation therapy and have found that patients have lower risks of secondary BPH and retrograde ejaculation [16]. A study analysing 5-year outcomes after aquablation compared to traditional surgery (transurethral resection of the prostate) found that those who underwent aquablation had more consistent reduction of symptoms and improved urinary flow in comparison [17].

As of January 2023, aquablation is available in five centers across the NHS, with Guy’s Hospital achieving a world record by performing aquablation on ten patients in a single day, demonstrating the potential of this technology to effectively tackle waiting lists for surgery, especially following the aftermath of the COVID pandemic [18, 19]. A patient treated with aquablation at Guy’s, 69-year-old retired dentist John Wade, had undergone the traditional surgical route prior, but required further treatment [19]. When asked about his experience, he said “My recovery has been very good and my quality of life has improved” and that “This procedure was so much ‘kinder’ to me physically than the one I had had previously” [19].

surgical robotics - robotic surgery
Figure 3  An image of the AquaBeam system used to treat BPH. Image sourced directly from the Procept BioRobotics website [15]

 

surgical robotics - robotic surgery
Globus Medical: ExcelsiusGPS robot system

Globus Medical was founded in 2003 and focuses on developing medical devices that improve the treatment of musculoskeletal disorders. ExcelsiusGPS, their robotic navigation platform, allows surgeons to use a robotic arm along with the platform’s navigation capabilities when performing MIS [20]. Currently, it is available for use in spinal surgery as well as for cranial surgeries, including for carrying out biopsies and deep brain stimulation [21]. One of the most common applications of ExcelsiusGPS has been in spinal alignment surgery. A study assessing the placement of screws using the robotic guidance of this system concluded that it allows for accurate placement [22]. Pedicle screws are implants that are made from either stainless steel or titanium, and that can be secured between vertebral pedicles. Each vertebra has two cylinder-shaped pieces of bone that project from the back part of the vertebral body, helping to protect the spinal cord and nerves and connect the front and back parts of the vertebra. These screws are used in various spinal surgeries to strengthen and support the spine. This robotic system aims to improve efficiency, precision, and safety of these procedures to ensure that surgeons have an improved ability to visualize, plan, and navigate as they operate [20].

ExcelsiusGPS is already in use for spinal surgeries in some NHS centers today. In 2022, Globus Medical partnered with the NHS in order to make this technology available across the UK. Centers that use the platform currently include the Oxford University Hospitals NHS Foundation Trust and The Walton Centre NHS Foundation Trust Liverpool [23]. The first-hand experience of surgeons using ExcelsiusGPS to date has been positive. For instance consultant spinal surgeon and metastatic spinal cord compression surgical lead at the Walton Centre Miss Maggie Lee said, “The system enables us to operate with a higher degree of accuracy in navigation, so we can progress through the stages of the procedure much quicker” and that, “This means patients will be in surgery for a much shorter time and therefore hopefully have a much shorter stay in hospital” [24].

 

surgical robotics - robotic surgery
Figure 4 An image of the ExcelsiusGPS Robotic Platform from Globus Medical. Image sourced from Globus Medical’s website [20].

What are the future considerations and challenges for robotic surgery?

Despite the many potential benefits of robotic surgery, there are still important considerations and challenges facing the field as it evolves and as the use of this technology becomes more common. With an increasing number of surgical robots in development and becoming available, it will be important to determine which of these are the best to use by considering evidence to evaluate their pros and cons (such as which are the most cost effective or versatile).

A major challenge encountered when implementing robotic surgery on a large scale is that the high cost of these systems. A da Vinci robot system costs around £1.55 million. This price does not include the costs of annual servicing and disposable surgical instruments for each procedure [1]. It is possible that with increasing competition within the robotics field, and as newer surgical robots become available,  along with an increase in the applications of robotic surgery, the cost of these robots may decrease. This would make surgical robots easier to access and to facilitate the establishment of less expensive cost schemes, allowing more centers to utilize these technologies [1]. It is important to consider the cost-effectiveness and accessibility of surgical robotics. There could be great benefits especially for patients and healthcare systems in low and middle-income countries, with high costs being a significant barrier to its implementation in these countries [2]. Unlike surgery that is performed traditionally by a surgeon, robotic systems may also require maintenance and troubleshooting if they malfunction.

Adequate and standardized training of healthcare professionals for surgical robotics is essential and formal training schemes supported by evidence will be necessary to facilitate the best, safest, and most consistent outcomes for patients [25]. This may prove to be a considerable issue in lower and middle-income countries as there is more likely to be a lack of trained personnel and/or general surgical training and therefore there could be a higher risk of errors [2].

To conclude, robotic surgery is a fast-evolving sector with a wide variety of surgical robots either available and currently in development. Robotics will likely play a key role in the future of surgery and will gradually become available for even more types of procedures. Despite the challenges facing robotic surgery, there are some potential solutions. For instance, the high costs are likely to decrease with time and increased competition in the market. In addition, as further evidence is gathered, standard training schemes can be implemented in healthcare systems to ensure high quality of care consistently. An increased use of surgical robotics could lead to better health outcomes for patients, an increase in the precision and efficacy of operations, and improved ergonomics for surgeons.

For further information on robotic surgery, please refer to our Robotic Surgery Directory to find a listing of numerous companies specializing in the development of surgical robots and details of their innovations. To learn more, please refer to our useful links section below.

 

About PMM

Personalize My Medicine (PMM) keeps you updated on the latest in medical innovation via our articles, blog posts, and the unique PMM Directories, which list verified companies and details of their medical innovations contributing to personalized medicine including AI medical imaging, biomarkers, cancer diagnostics, cord blood, digital health, gene therapy, pharmacogenomics, regenerative medicine, RNA therapies, and robotic surgery. Our Directories are free to access by all, searchable, and sortable. PMM also offers a personalized research service for both patients and doctors. Please note that PMM´s content and research services are purely informational and PMM does not offer any medical advice.

 

Useful Links

https://www.intuitive.com/en-gb – Intuitive Surgical website

https://www.globusmedical.com – Globus Medical website

https://cmrsurgical.com – CMR Surgical website

https://www.procept-biorobotics.com – Procept BioRobotics website

https://www.surgicalroboticstechnology.com – Surgical Robotics Technology website with the most recent news and updates in surgical robotics

https://www.guysandstthomas.nhs.uk/news/doctors-tackle-prostate-surgery-backlog-new-world-record – Post from Guy’s and St Thomas’ NHS Trust on their record-breaking use of aquablation to treat BPH with a real-life case study

https://www.royalmarsden.nhs.uk/private-care-magazine/robotic-future-surgery-today – Post from the Royal Marsden covering how they utilise the da Vinci robotic system to treat cancer patients

Current clinical trials

https://clinicaltrials.gov/ct2/show/NCT04831580 – A clinical trial assessing open hysterectomy vs robotic (da Vinci system) for cervical cancer which is currently ongoing

https://clinicaltrials.gov/ct2/show/NCT02792322?term=robotic+surgery&recrs=ad&draw=2&rank=7 – An ongoing clinical trial investigating if robotic surgery with the da Vinci surgical system enables improved visualization and removal of malignant or benign tumours of the head and neck

https://clinicaltrials.gov/ct2/show/NCT05535712?term=robotic+surgery&recrs=ad&draw=3&rank=19 – The first clinical trial that is investigating if it is feasible to perform lung anatomic resections via the Da Vinci SP surgical platform

https://clinicaltrials.gov/ct2/show/NCT04801381?term=aquablation&draw=4&rank=2 – An ongoing clinical trial aiming to compare safety and efficacy of Aquablation (Procept BioRobotics) and transurethral laser enucleation as a therapy for BPH with large prostates

https://clinicaltrials.gov/ct2/show/NCT04257279?term=ExcelsiusGPS&draw=2&rank=1 – A clinical trial examining patient outcomes for those who have undergone surgery with the ExcelsiusGPS robotic system – with particular focus on screw placement accuracy

 

References

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[2] A. Mehta, J. Ng, W. Awuah, H. Huang, J. Kalmanovich, A. Agrawal, T. Abdul-Rahman, M. Hasan, V. Sikora and A. Isik, “Embracing robotic surgery in low- and middle-income countries: Potential benefits, challenges, and scope in the future,” Annals of Medicine & Surgery, vol. 84, p. 104803, 2022.
[3] J. Catto, P. Khetrapal and F. Ricciardi, “Effect of Robot-Assisted Radical Cystectomy With Intracorporeal Urinary Diversion vs Open Radical Cystectomy on 90-Day Morbidity and Mortality Among Patients With Bladder Cancer A Randomized Clinical Trial,” Journal of the American Medical Association, vol. 327, no. 21, pp. 2092-2103, 2022.
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[17] P. Gilling, N. Barber, M. Bidair, P. Anderson, M. Sutton, T. Aho, E. Kramolowsky, A. Thomas, R. Kaufman, G. Badlani, M. Plante, M. Desai, L. Doumanian, A. Te and C. Roehrborn, “Five-year outcomes for Aquablation therapy compared to TURP: results from a double-blind, randomized trial in men with LUTS due to BPH,” Canadian Journal of Urology, vol. 29, no. 1, pp. 10960-10968, 2022.
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[19] Guy’s and St Thomas’ NHS Foundation Trust, “Doctors tackle prostate surgery backlog with new world record,” Dec 2022. [Online]. Available: https://www.guysandstthomas.nhs.uk/news/doctors-tackle-prostate-surgery-backlog-new-world-record. [Accessed 24 Feb 2023].
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[22] C. Kanaly, D. Backes, N. Toossi and B. Bucklen, “A Retrospective Analysis of Pedicle Screw Placement Accuracy Using the ExcelsiusGPS Robotic Guidance System: Case Series,” Operative Neurosurgery (Hagerstown), vol. 24, no. 3, pp. 242-247, 2023.
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[24] The Walton Centre NHS Foundation Trust, “The Walton Centre operates on first patients using cutting-edge navigation in complex spinal surgery,” 17 Oct 2022. [Online]. Available: https://www.thewaltoncentre.nhs.uk/news/the-walton-centre-operates-on-first-patients-using-cutting-edge-navigation-in-complex-spinal-surgery/622052. [Accessed 27 Feb 2023].
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