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Single-port robotic surgery shows promise for urologic cancers and beyond
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The most effective and preferred treatment for many cancers remains surgery, and surgical techniques continue to evolve with the rest of the cancer care arsenal.
Jihad Kaouk, MD, FACS, director of the Center of Advanced Laparoscopic and Robotic Surgery at Cleveland Clinic Glickman Urological and Kidney Institute, has been at the forefront of surgical innovation for more than a decade, as he and his team at Cleveland Clinic pilot ways to turn complex surgeries into less invasive procedures with faster recovery times.
Kaouk is also the institute vice chair for surgical innovations and holder of the Zegarac-Pollock Endowed Chair in laparoscopic and robotic surgery. It’s the result of his role in pioneering new surgical procedures, including the first robotic single-port surgery through the belly button in 2008 and the first complete transvaginal kidney removal in 2009.
Kaouk — who has performed more than 1,700 robotically assisted surgeries — spoke with HemOnc Today about the latest technology in the field, which he helped develop: the da Vinci SP Single Port Robotic Surgical System (Intuitive Surgical), and how it can be applied in cancers previously considered ill-suited for robotic assistance.
Question: Are urologic procedures more well-suited for robotic surgery?
Answer: Robotic surgery cannot be performed across all specialties. The robot is a machine — a tool; it’s not performing the surgery. The tool performs as good as the surgeon using it.
Urologic surgeons across the country have had more experience with robotic surgery than other subspecialties. This level of experience has been reflected in the outcomes. There is a learning curve that must be navigated before you can achieve optimal results with a robotic system.
Q: In the hands of an experience d surgeon with the proper training, what are the benefits of robotic surgery to the patient?
A: There is significant evidence in published reports about the impact of robotically assisted surgery. For example, pelvic area surgeries for prostate and bladder cancer used to be bloody affairs. The use of robotically assisted surgery has shown a significant decrease in the degree of blood loss during these surgeries. Less blood loss means patients are less susceptible to hemodynamic instability and life-threatening situations.
In terms of oncological outcomes, the metrics we use to evaluate a successful surgery — such as complete removal of the cancer and recurrence-free follow-up — are equal between traditional open and robotically assisted surgeries. However, we have seen differences related to the minimally invasive nature of robotic surgery, namely quicker recovery times, less postsurgical pain and significantly less blood loss.
Q: What are the benefits to the surgeon?
A: With robotics, the surgeon can sit comfortably and has a clear 3-D image, which provides the perception of depth. Robotic surgery allows for magnified views; it allows surgeons to work in narrower areas through a small incision, with very powerful lighting. All the camera feedback is displayed on large flat screens, so everyone in the room can see what’s going on. In traditional open surgery, the angular view is narrow, many times the lighting is suboptimal and only the surgeon and perhaps an assistant can see the field of work.
Another benefit to patients is the ability to perform a partial nephrectomy. This surgery requires that the blood supply to the kidney be shut down for a period — so, basically, a surgeon is working against time. This has made the surgery very demanding over the past 20 years, and it’s the reason why only a small portion of patients who could benefit from this procedure had it performed successfully. The use of robotic surgery in these cases has resulted in a major shift in care that allows a far greater portion of eligible patients to be operated on with positive outcomes.
Q: How much and what type of training is required to use a system like the SP Robot?
A: Every technology requires training and a learning curve. If you compare the training of performing a complex open surgery with that of a complex robotically assisted procedure, published studies have shown that robotically assisted surgery is more effective even when used by a surgeon who does not perform a high volume of procedures. Robotic surgery help closes this gap between high-volume and medium-volume surgeons.
Q: What makes the single-port SP Robot system novel?
A: The single-port SP Robot performs the surgery through a single cut, instead of the five or six cuts required by a multiarm robotic system. With one single entry point, we can go through narrower areas and use approaches that were not feasible with the multiarm robot.
For example, we can do certain gastric procedures as effectively using an outpatient approach. Patients with gastric cancer receive one incision, less than 2 inches long just below the belly button, and we enter with the single-port robot extra-peritoneally. By not touching the bowel, we can do the surgery effectively and send the patient home within a few hours.
The surgery decreases the amount of postsurgical pain, and most patients will be sent home without a need for narcotic pain control. Meanwhile, it frees up a hospital bed that can be used by another patient in need.
Q: Can the SP Robot system be used for other complicated cancer surgeries with improved outcomes?
A: We are applying single-port SP Robot at Cleveland Clinic for prostate cancer, kidney cancer and bladder cancer, in addition to some other reconstructive procedures, including kidney blockage of the ureter.
Beyond urology, the single-port robot has potential applications in ear, nose and throat surgery, where the single port can be inserted through the mouth and surgery can be done on the base of the tongue, the tonsils, and so on, all without incisions into the neck.
Colorectal surgeons are already using the single-port robot, inserting it through the anus and performing surgeries without the need for traditional open surgery incisions.
Not only are incisions being minimized, we are limiting the surgical space to directly where the pathology lies, thereby minimizing the collateral damage, speeding recovery time and improving patient outcomes.
Q: You presented your experience with the SP Robot system at th is year’s American Urological Association Annual Meeting. What type of feedback did you receive?
A: The response was overwhelmingly positive. There was a lot of interest in the technology, but perhaps just as much curiosity. There are providers who are convinced that this is the next, best offering for our patients and there are those who are not yet sold on the idea and want to know more about the single-arm robotic system.
Q: Will you be tracking the safety and effectiveness of the SP Robot system?
A: Absolutely — we will keep a very magnified view on these. We are also reaching out to other institutions that use the SP Robot system to share information and expertise in a multi-institutional database. – by Drew Amorosi
For more information:
Jihad H. Kaouk , MD, FACS, can be reached at Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195; email: kaoukj@ccf.org.
Reference:
Kaouk J. Single port robotic surgery: A new era of robotic surgery. Presented at: American Urological Association Annual Meeting; May 3-6, 2019; Chicago.
Disclosures: Kaouk reports consultant/advisory board roles with Endocare and Intuitive Surgical.