Dr Rajesh Taneja, Senior Consultant, Urology, Andrology and Robotic Surgery, Apollo Hospitals, New Delhi, in conversation with Shahid Akhter, ENN, shares his da Vinci thoughts on Urology
What are the latest advancements in Urology?
Urology is one of the fastest evolving branches of clinical medicine. In last two decades, the advent of lasers, induction of Robotic system of surgery, miniaturization of âuro endoscopesâ and improvements in laparoscopic equipment have caused a paradigm shift in the way the surgical procedures were carried out earlier.
How does the robotic surgery impact and influence urologic conditions like kidney disorders or cancers of the kidney, bladder and prostate?
Robotic surgery has changed the way the surgery of cancers of urinary tract are dealt with today. Cancer of prostate which is localized to the confines of the organ, needs to be treated by surgical removal of entire prostate along with its coverings. The reconstruction of the urinary tract involves stitching of the bladder neck with the exit pipe called urethra in the deep confines of the pelvis. This was very difficult during open surgery or even laparoscopic surgery. The presence of âendo wristâ instruments have ensured that the reconstruction remains as close to the original. It is a great improvement when compared to the earlier procedures.
The ability of the surgeon to save the nerves responsible for sexual function during this procedure has also been improved with better and earlier return of male sexual function in the patients. Better vision and precise cutting apparently result in better cancer control also. The recovery from operation is quick as most patients are walking and taking light meals by the next morning.
Regarding the cancers of the kidney, if a small cancer is detected it can be safely removed from the body using Robotic surgery while saving the kidney behind. This can be done effectively because of the better vision and maneuverability of the robotic camera along with quick and precise stitching technique used for repair of the defect in the kidney caused by removal of tumor. This is technically termed as âNephron sparing surgeryâ. The drainage system of the kidney called âpelvi-calyceal systemâ needs to be meticulously closed in order to avoid the leakage of urine in the post operative period. If the tumor is located in certain critical locations of the kidney, it may not be possible to perform Nephron sparing surgery by any modality including Robotic surgery.
Robotic system has been used with advantage to treat the cancers of the urinary bladder, testes and penis. For muscle invasive cancers of urinary bladder,Robotic assisted Radical Cystectomy with totally intracorporeal reconstruction of urinary diversion or âNeaobladderâ using intestinal segementsÂ is possible with currently established technique. Robotic surgery for cancers of testes and urinary bladder is useful to remove the lymph nodes which have got involved by the disease process. Â pleaThe advantage of Robotic surgery can be delivered to the patients in more useful manner when the disease is detected at an early stage. Therefore, public education and cancer screening programs have a long way to go if the benefits of robotic surgery are to be fully utilized. The idea of these screening programs is to detect cancer before it announces itself by way of symptoms. Usually, if the symptoms have already appeared, the disease has transgressed the boundaries of the organ of origin, making it incurable.
Please throw some light on the advantages and disadvantages of robotic surgery.
The advantages of Robotic surgery are: Better3D vision as the camera has a twin objective lens installed at the inside end and the vision is captured digitally and transmitted to the consol as a high definition 3D picture. This gives the feeling that the surgeon is actually sitting within the huge cavity of abdomen and can precisely handle the structures which need to be treated and avoid disturbing the other normal structures. This results in quicker recovery of the patient as this in effect is a âlocalâprocedure done within the abdomen.
The other major advantage of robotic surgery is the use of âendo wristâ instruments. The human wrist is almost 6 cm wide where as these instruments have a wrist which is less than 6 mm in width. The endo wrist has multiple dimensions of movements as compared to the limited dimensions of human wrist. This turns into several advantages as stitching in otherwise inaccessible areas becomes precise and quick. Various reconstructive procedures like repairing birth defects like PUJ (Pelviureteric junction) obstruction, megaureter ,vesico ureteric reflux (VUR) become more precise with good out comes while inflicting minimum pain to the patient. How do you see the advent of da Vinci in India and the scenario today? In India we have almost 27 installations of this Robotic system and I am sure more are in the pipeline.
What is the minimum volume (of surgeries) required to make robotic surgeries viable in any Indian hospital ?
This is a difficult subject as there are various models of investment.
However if there is a multispecialty use, then it becomes easier for the institute to break even.
Any Surgeon who has been performing these operations as open procedures with an exposure to laparoscopic techniques should be able to take up robotic surgery. It only improves the skills and the capability of the operating surgeon.
What is the minimum experience required before a surgeon can consider himself adequately trained for robotic procedures?
Training involves a vet lab training after familiarization of the equipment and then assisting almost 20 cases as first assistant. After this a surgeon could be mentored into a matured robotic surgeon by trained mentors.
âRobotic surgery has changedÂ the way the surgery of cancers ofÂ urinary tract are dealt with today”Â
As you have been conducting the most advanced roboticÂ surgeries in urology, how do you compare the outcomes when compared to conventional minimally invasive laparoscopic surgery?
The outcomes are really better as the stitching is superior. As the surgeon is more comfortable performing these procedures, he is less tired and makes fewer mistakes. The stitches can be placed as âcorrectlyâ rather than ânearly correctlyâ
Do you think robotic surgeries will become a norm in future?
Yes, I am quite sure of this. There are already other specialties looking at the use of Robotic system for treatment of surgical diseases. Gynecology, transplant, gastro intestinal surgery, bariatric surgery and other surgical specialties have literature documenting these recent successful attempts on the same lines.
Your most memorable case that you think and thank da Vinci, which would not have been possible otherwise?
Recently a man was diagnosed to have a kidney tumor and he was told by many doctors that the kidney needs to be removed along with the tumor. However, after carefully evaluating his CT scan films, I decided to take up the challenge of saving the healthy part of the kidney while completely removing the tumor ( Nephron sparing surgery). With the help of Robotic Technology, it took almost three hours of surgical procedure to achieve the desired goal. The greater challenge was to take the decision of doing a âpartial nephrectomyâ for a relatively large cancerous tumor of the kidney than actually doing it. The patient and the family are a grateful lot.