Robotic Urology in India
 
Introduction
The story of the operating surgeon relinquishing his hallowed position beside an operating table to a chair positioned a few feet away began in the 1980’s in the USA when NASA, Stanford Research Institute, and the US Department of Defence developed the SRI Telepresence Surgery System, which was intended to aid the wounded in a battle by surgeon’s miles away from the frontline (1). Although it did not accomplish the intended objective, this surgical system eventually led to the development of the present day Da Vinci Robotic System.
Robotic surgery is the latest cutting-edge technological advancement in the surgeon’s armamentarium. Almost like science fiction to the uninitiated, the surgeon sitting at a console controlling a robotic arms assembly has revolutionized the surgical approach to many procedures which were hitherto either very complicated or fraught with prohibitive complications.
Although newer modifications of the Da Vinci robot are on the anvil, the present configuration is likely to remain the mainstay in the Indian scenario for the foreseeable future.
The Da Vinci Surgical System was released in April 1997 and received FDA approval in 2000 for laparoscopic surgeries.(2) Today it is being used in increasing number of specialities including gynaecology, ENT, Cardiac Surgery, General Surgery, Orthopaedics and Urology.
In its present configuration Da Vinci Surgical System can be used in most contemporary operating suites. It has 3 major components
• Robotic Tower: Assembly where instruments are attached and mechanically manipulated within the patient
• Surgeon’s console: Workstation where the surgeon sits and manipulates the instruments
• Ancillary Vision Cart: Supports a flat screen monitor

Advantages
Any technical advancement is a tool for execution of the basic technique of surgery and hence must be examined with the question - Does this further aid, simplify or facilitate our adherence to our time honoured basic surgical steps and their outcomes?
The answer for the robot is probably a resounding “Yes”. It unquestionably offers some distinct advantages. (3)
1. 3D vision and depth perception: One of the biggest hindrances of Laparoscopic surgery has been a 2 dimensional representation of a 3 dimensional operating field. The incorporation of binocular optics in the operating console offers the operating surgeon a 3 dimensional simulation and thereby improves depth perception which is invaluable when operating in the limited confines of areas like the pelvis.
2. Elimination of hand tremors and field magnification: Robotic arms eliminate tremors and help in movement scaling. This increases the precision of the surgical steps and helps define difficult anatomical landmarks.
3. Ergonomically superior and cause less fatigue to the surgeon: Better operating posture and surgeon’s comfort translates into better surgical outcomes.
4. Reduces the learning curve of Laparoscopic surgery: The exposure to robotic surgery offers a chance for surgeons who are not laparoscopically trained to offer a minimally invasive surgery option. (4)
The additional advantages of minimally invasive surgery like lesser post-operative pain, shorter convalescence period, lesser bleeding and more cosmetic incisions unarguably further the case of robotic assisted surgery. (5)
Disadvantages
The biggest and possibly the only uncontested disadvantage of the Robotic Surgery is the incurred cost. The Da Vinci Surgical systems robot costs a considerable $ 2 million with a further $ 100,000 required for annual maintenance. (6, 7)
Undoubtedly the higher costs involved translate into higher cost of Surgery which is principally borne by the patient. In the Indian context this is a very pertinent consideration where a vast majority of the population cannot afford such high costs. Another uniquely piquant condition in India is that even in patients who have medical insurance; the companies refuse to cover surgeries done using the robotic technology.




The Indian Scenario

Major diseases causing maximum number of deaths in India are still TB and infectious diseases like malaria. ( A question that is most frequently and arguably the most aptly asked in this scenario is – Can we afford it?
At present this question is akin to asking - Can India afford to market a Mercedes Benz or an Audi car?
The reply to the question, as written in an essay by Vipul et al is, that the Robot is already there in India and the question is becoming increasingly redundant.


Role of Urology

In July 2006, India witnessed its first Robotic Assisted Surgery at AIIMS. Fittingly, it was pioneered by the Department of Urology and a Robotic radical prostatectomy was completed successfully (5). We have indeed come a long way since then. As PN Dogra et al have analyzed, the results of a series of 190 cases performed at their centre compare very favourably with the western figures. The number of Robots in India has also been steadily increasing and although the precise number is not available, there are about 21 centres, across the country, which are regularly performing Robotic surgeries (10).
In terms of departments, Urology is quite definitely the forerunner in the use of Robotic technology. The number of radical prostatectomies being performed has gone up tremendously as compared to the open era. The improved continence results (some patients at our centre report continence at day 1 or day 2 post catheter removal) and the lesser erectile dysfunctions attributable to better nerve sparing achieved due to the robotic technology, have gone a long way in establishing radical prostatectomy as the flagship surgery of robotics worldwide and in India. The advantages have also been extended to procedures requiring precision and accuracy like partial nephrectomy which has enabled efficient nephron sparing surgery with resultant renal function preservation. Robotic assisted adrenalectomy, pyeloplasty, radical nephrectomy and donor nephrectomy are being performed with increased frequency as the Surgeon is getting more and more acclimatized to the Robot. A further testament to the proficiency of the Indian surgeon with the robot is the increasing number of Robotic Renal Transplant surgeries being performed successfully at some centres.
Other Surgical departments in India are also joining the Robotic revolution in increasing numbers. Gynaecology, ENT, Cardiac Surgery and General Surgery are using the Robot in a wide variety of cases.

The challenges
As Dr Mani Menon, of the Vattikutti Institute said in an interview to Express Healthcare, - “India is ideally suited for robotic surgery as the surgeons are skilled, the patient volume is high and a full spectrum of complex diseases are encountered. In India particularly, multispecialty robotic surgery has a great future.”
Even with this well recognized potential, Robotic surgery is still in its infancy in India.
As mentioned earlier the inherent costs associated with it remain the biggest challenge to be overcome for a more uniform dispersion of this technology throughout the country. The only way to tackle this and to make robotic surgery financially feasibleis for multidisciplinary utilization of the robotic system to its fullest potential. The maintenance cost remains the same whether one case or 6 cases aredone in a day. So it is logical that if more cases were generated out of arobotic system, the cost per case would automatically decrease. Government support is also of paramount importance in making this technology available to more people at a subsidized rate.
With Indians at the forefront of Robotics worldwide, it is not unreasonable to anticipate the development of an indigenous robotic surgical system in the future. The department of biomedical engineering at the IndianInstitute of Technology have made some headway in the goal of developingour very own Indian prototype. (5) Needless to say, such a system will go a long way in making this technology come within reach of a majority of our population.
Another major drawback with the current Indian scenario is the lack ofrobotic surgery fellowships in India. With increasing number of centres attaining competence in performing surgeries, it is expected that a number of them shall make the logical transition of imparting Robotic training also.

Conclusion
India today, is gaining momentum in the process of becoming a very competent Robotic Surgery destination. Our costs still remain lower than most western counterparts while our skills match up to the world’s standards.
Steve Jobs famously said at the inauguration ceremony of the Macintosh – “Everyone here has the sense that right now is one of those moments when we are influencing the future”. Witnessing and actively participating in the rapid growth and spread of Robotic technology in India, one cannot help having the same sense of shaping the future of health delivery in India
 
References
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5. Dogra PN, Current status of Robotic surgery in India. JIMSA July-September 2012 Vol. 25 No. 3; 145
6. www.modernhealthcare.com/article/20140419/magazine/304199985
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9. Vipul Patel, Robotic surgery: India is not ready yet. J Urol. 2007 JulSep;23(3): 244–245.
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