Urology. What a robot can do and why it will never replace the surgeon?

The Da Vinci robot has been working in the Clinic of General, Oncological and Functional Urology since 2022. Are such devices often used in Polish medicine, or is it unique?

Robotics in global medicine has over 20 years of history. In Poland the first such devices appeared in 2010-2012. Then nothing happened for a long time. However, currently we have an abundance of robots. This is due to the fact that some treatments using them are finally reimbursed by the health insurance.

What treatments is the Da Vinci robot most often used for?

It is most often used in urology, much less often in gynecology or surgery. In urology, we primarily use a robot to perform radical prostatectomy, i.e. removal of the prostate due to cancer – in my specialty this is the only robotic procedure refinanced by the National Health Fund. Due to certain provisions of the grant agreement concluded by our clinic, we could additionally test the robot in other indications. The first one is the removal of complicated kidney tumors. In my opinion, this is a very important indication that asks for health insurance coverage. We are fighting to save every nephron, so accurate removal of the tumor instead of the entire kidney is extremely important. The second indication for the use of the robot is surgery to remove the bladder due to cancer. The main benefit in this case is minimal invasiveness.

You mentioned that the robot is most often used to remove the prostate due to cancer. How many such procedures are performed in the clinic?

Currently we have six people who operate the Da Vinci robot. The device works every morning, and on some days also in the afternoon. We perform at least one such treatment a day, about 18-20 a month. Ultimately, we want to perform over 200 surgeries of this type this year. The queue of patients is not dramatically long – you have to wait from a month and a half to two. I emphasize that this is a standard procedure. We have stopped performing radical prostatectomy laparoscopically or using the classic method in our clinic.

And what does it look like across the country? Is the robotic prostate removal a standard only in large cities or also in smaller sites?

Today, we have almost 50 different types of robots in Poland. There is at least one in every province. Of course, there are also small centers where the prostate is removed laparoscopically or by open surgery. It is worth noting, however, that in some cases open surgery is recommended, e.g. when laparoscopic pneumothorax cannot be created and the patient does not tolerate high pressures in the abdominal cavity. After the conventional procedure a 6 cm long scar is left on the lower abdomen, which is not particularly unsightly. It should be emphasized that in terms of oncological effectiveness, removal of the prostate using the robotic and conventional methods provides comparable results.

So, why is the prostate removal surgery performed using a robot better than using laparoscopy or a scalpel?

Robotic surgeries are less traumatic and we have less blood loss. Their advantage is also a shorter hospital stay. Most patients leave the next day after the surgery. Robotic procedures also provide significantly better functional results. This means that after the operation the patient has no problems with urinary incontinence and it is also possible to maintain his potency (if nerve-sparing surgery can be performed). These are very important benefits, especially if we take into account the fact that the average age of patients diagnosed with prostate cancer has significantly decreased. A 50-year-old man with prostate cancer still wants to have urinary continence, preserved potency and an active sex life. These are the benefits for the patient. However, it is worth adding that the operating surgeon also benefits. During procedures using a robot, the surgeon operates in a sitting position, which means that the doctor is less tired than he or she would be while performing laparoscopy, for example. Performing three robotic radical prostatectomies in a day is not a problem. In contrast, performing three laparoscopic procedures is a serious burden on the spine. Moreover, you can learn how to use the robot quite quickly. This learning curve is definitely shorter than for laparoscopy. This year the clinic got richer with a second Da Vinci console. Therefore, we can conduct operations on a master-apprentice basis. One person shows how the procedure is performed, and the other person joins in the operation at specific moments. Then the roles are reversed. However, there is always a mentor who will take over the „controls”, if necessary, just like a pilot in an airplane.

You said that the average age of developing prostate cancer is much younger now. Does this mean that men get the disease more often?

No. The number of prostate cancers in the population is still the same. However, we can detect them earlier and faster. Early diagnosis means that we increasingly use active observation instead of radical surgical treatment. This applies to those changes that are not yet advanced enough to require surgical treatment and are unlikely to progress in the near future.

To what do we owe this early recognition? Is it better patient awareness or, perhaps, more sensitive tests?

The screening has not changed, we still have rectal examination and prostate-specific antigen testing. Men, however, are more aware indeed. Not only that preventive tests need to be performed, but also that their results need to be shown to a urologist. If I were to talk about a breakthrough, it has happened in further diagnostics. If we suspect prostate cancer, we must perform a prostate biopsy. 10-15 years ago it was a biopsy under the guidance of transrectal ultrasonography. Today, thanks to advances in magnetic resonance imaging, we take a look at the prostate gland in most patients before performing a biopsy. The MRI result tells us whether we have a low, medium or high probability of prostate cancer. This translates into a much lower percentage of missed or unneeded biopsies. There is also a fusion biopsy, which is a combination of an ultrasound-guided biopsy with a superimposed magnetic resonance image. Such a biopsy is ultra-sensitive and ultra-accurate, but unfortunately it is not covered by the National Health Fund.

You tested and used the Avicenna robot in your clinic, for the first time in Poland, to treat kidney stones in adults. Is Avicenna similar to Da Vinci?

It is a completely different robot. It is used to treat nephrolithiasis. We now perform the so-called “flexible ureterorenoscopy” in such patients. Thanks to this treatment we can reach into the furthest corners of the kidney, find the smallest stones, crush them with a laser, and then pull them out. From the operator’s perspective, this requires some forced positioning of the body, especially the hands, and making small, precise movements. Therefore, it may happen that the hand will twitch. There is no such risk when we perform the same procedure using the Avicenna robot. It is worth realizing that we colloquially talk about “stones” but in fact they are “pebbles” with a diameter of 1-1.5 cm. The renal pelvis has a lumen of approx. 2 cm, and the calyx just a few millimeters. The operation therefore requires exceptional accuracy and precision, and this is where the Avicenna robot is most useful. Interestingly, another type of robot has also been invented – it is called Nautilus. It is actually a robotic X-ray machine that helps target kidney stones, among other things. The device moves around the patient and precisely visualizes what is happening inside.

Is robotic treatment of nephrolithiasis a difficult procedure? Why has it only recently been used in adults?

It is not a complicated procedure. However, the robot is expensive and therefore has not been used before in adults, but only in children – where even greater precision is needed. It can be said that this is a very interesting piece of equipment but, considering our limited budget, it is not the first need. That is also why we only tested Avicenna and we do not have it in our clinic anymore.

Innovative treatments using modern equipment are not the only thing that distinguishes the Department of General, Oncological and Functional Urology of the Medical University of Warsaw. What else do you specialize in?

In neurourology. We are pioneers in this field and have been setting trends in procedures in Poland, and sometimes in the world, for over 20 years. Neurourology, as the name suggests, is a combination of urology and neurology. The urinary bladder and urethra are controlled by the nervous system and thanks to this we urinate consciously – only when we want to. Neurological diseases and injuries to the nervous system disturb this process. But there are effective treatments. 25 years ago we were the first in the world to administer botulinum toxin into the bladder in a patient with the overactive bladder syndrome. Today we are the largest center in Poland that deals with implanting neuromodulators. This is a completely new chapter because, after 20 years of efforts, urinary system neuromodulators are finally covered by the health insurance in Poland. The first such procedure took place over 10 years ago (we obtained funds from a grant). Today it is a standard procedure – it happens that we implant several neuromodulators a week.

What is a neuromodulator?

This device looks similar to a pacemaker. Thanks to it, a patient who had to use the toilet 30 times a day now uses it only 10 times or less often during the day. We perform the procedure under local anesthesia – and here again we are pioneers in Poland. The first stage involves inserting an electrode into the area of the nerves of the bladder. After 20 minutes the patient leaves the operating table and has an external stimulator programmed. Then the patient goes home for 4-5 weeks. If the external stimulator works properly, we arrange for the insertion of an internal one. We currently have a new generation of internal stimulators – the so-called “system X” the lifetime of which is up to 15 years. It is worth emphasizing that implantation is a “smart” treatment. Thanks to the test stimulation period we know for whom the device works, so the permanent stimulator is given to those patients who need it and respond to it correctly.

In one of your interviews you said that “robots are a natural development in medicine and wondering whether we should use them makes no sense”. Does this mean a diminishment of the surgeon’s role?

Robots are not autonomous entities that could operate by themselves. There must always be an operator at the helm of the device. To illustrate what robots are in medicine, you can use a simple comparison. A doctor with a scalpel is like a worker with a shovel. A doctor with a robot is a worker with an ultra-smart and highly accurate excavator. The future that may come is a partially autonomous robot, something like a digital machine tool.

If robotics is the inevitable future, do the Department of General, Oncological and Functional Urology have classes where students can learn how to use a robot?

The robot is a very useful teaching tool. We have many displays in the clinic on which students can follow the course of robotic surgeries. They also may ask the operator questions during the procedure. In addition, the robot’s consoles are equipped with simulators, so willing students can take an accelerated robotics course on them, experiencing a feeling as if they were playing a computer game.

Interviewed by Iwona Kołakowska
Fot. Michał Teperek
Communication and Promotion Office