Under the knife
How robots are revolutionising surgery
In a private room at University College London Hospital (UCLH), 57-year-old Bayram Dolukup is waiting for a surgical procedure in which, over the course of five hours, his bladder will be removed and a new one created from part of his large intestine. Wearing a hospital gown and clutching his smartphone, he is accompanied by his wife and daughter-in-law, who are nervously quiet.
What led Dolukup to this point was a series of urine infections over the past two years that had become harder to treat and increasingly painful. In October, he heard the worst; the discomfort wasn’t the result of cystitis, but cancer. “That’s it,” he thought, “I could see life’s full stop there.”
Until his diagnosis, the Turkishborn driving instructor from Enfield, Middlesex, had been fit, otherwise healthy and eagerly awaiting the arrival of his second grandchild. But the cancer had advanced so deep into his bladder that the only option was a cystectomy, the complete removal of the bladder, prostate and surrounding lymph nodes. “Cancer is a word that you never want to hear,” he says.
Dolukup was lucky in one regard: he is one of hundreds of patients at UCLH whose surgery will be performed by robots.
One of the first to pioneer robotic cystectomy, the hospital’s urology department is home to two da Vinci Xi robots, created by the Californiabased Intuitive Surgical, which last year removed 700 prostates and bladders. Around 50 per cent of the 2,000 people in the UK who require bladder removal each year are now operated on robotically.
Eleven years after the NHS bought its first da Vinci – the Royal Marsden took receipt of one in 2007, to help with tumour removal – there are now 74 such machines on duty around the country, being used to perform prostate, bladder, kidney, womb and tumour removals. And this year, after a decade of trials, robots will take on an even greater role in Britain’s operating theatres.
Open-surgery bladder removal and reconstruction would have involved a seven-inch incision along Dolukup’s stomach, leading to blood loss, the threat of infection and a three-week spell in hospital. But, thanks to the delicate hands and precise scalpel work of a robot controlled by a trained surgeon, he will be up and walking the next day and out of the hospital within a week. Dolukup will also be left in considerably less pain, with a prescription for paracetamol more likely than opioids.
“I’m glad I was chosen for this, because I think the robot will be more accurate than a normal surgeon,” says Dolukup. “I’ve been told I’ll only be left with a keyhole scar.”
A couple of hours later, he is anaesthetised, with the da Vinci robot poised above him. His stomach, orange-tinged from the skin-sterilising iodine, has been bloated with gas to give the surgeons maximum room to manoeuvre inside. Plugged into his stomach are the robot’s thick, grey arms, three of which hold surgical instruments, such as scalpels and scissors, the other a 3D camera.
Professor John Kelly, clinical lead at the UCLH urology department, is sitting in one corner of the theatre in the first stage of the five-hour operation: removing the bladder. In a corner of the operating theatre, away from the patient, the world-renowned surgeon has his eyes pressed to a 3D screen and is controlling the robot’s every move using not only his hands, but also his bare feet.
“People think of a robot coming in and doing surgery,” says Prof Kelly. “The surgeon actually moves the instruments just as you would in open surgery. But you do it through a console that gives you much finer control and precision.”
Prof Kelly is dexterously cutting through the membranes that surround Dolukup’s bladder using the da Vinci’s cauterising scissors, which prevent internal bleeding and give the room a faint odour of burning flesh. Assisting Prof Kelly is a surgeon from Beijing, who is learning how to operate with the robot.
Which, it turns out, isn’t without its complications. The robot is used to perform keyhole surgery, which in itself is difficult to master; surgeons view the inside of a patient using mirrors, so must perform everything backwards. But manoeuvring the robotic arms during an operation adds another dimension, and can also be uncomfortable; surgeons can only work for a couple of hours per day and often develop physical problems, such as tennis elbow. After UCLH purchased its first da Vinci robot in 2008 – at the cost of £1.7million – it was set to work removing cancer patients’ prostates and bladders; it has been in such high demand, Sundays are its only day off. By the time the department bought its second machine last year, the price tag had halved.
With costs tumbling, robotic surgery is expected to become more widespread across almost all disciplines in the NHS. While Intuitive Surgical has long held a monopoly on robot surgeons, thanks to its early start and broad patents, this could change this year as the likes of Cambridge Medical Robotics (CMR), Medtronic, Google and Johnson & Johnson, among others, bring theirs to market; CMR hopes its Versius Surgical Robot System will be online before the end of the year.
As more robots become available to NHS surgeons, their growth will be exponential as the number of medical professionals trained to use them will also proliferate.
The NHS has earmarked
£300 million for robotics in UK hospitals, and launched a public tender for companies that work with the technology at the end of last month. Globally, the market for surgical robotics is expected be worth $6billion (£4.29 billion) by 2020.
Robotic surgery is already giving surgeons the confidence to perform more complex procedures. Traditionally, Dolukup would have left the operating room with an external bag for a bladder. But the dexterity of the robot means he can instead have a “neo-bladder”, created from a portion of his large intestine. While available in manual surgery, neo-bladders aren’t yet common; nationally, only five per cent of patients who are eligible for the reconstruction undergo it. At UCLH’S specialist robot division, this number is 30per cent.
“It’s going to get better and better,” says Prof Kelly. “Today, I don’t tie a suture or use a knife to cut skin. It’s done with lasers and special devices. Looking forward, we’re working with engineers to bring X-ray and MRI images onto the robotic screen. We’re exploring energy devices that can see blood vessels and little probes that can tell us if there’s cancer elsewhere than the bladder.”
Thanks to da Vinci, Dolukup should have a working bladder again within five months of leaving the hospital. Bodily activity, including continence and erectile function, also have a greater chance of returning to normal than with open surgery.
Dolukup’s operation went smoothly, which means in mere weeks he will be back on his feet, playing with his two grandchildren, one of whom was born days before his surgery. In time, he could return to work as a driving instructor.
“I’m not in much pain and don’t have any big scars, so I’m very happy I had the robotic surgery,” he says. “I stopped taking the painkillers before the doctors told me to. I’m feeling fit enough to go out and see friends.” He hopes his next scan will put him in the clear.
Shortly before going under the robot, he stresses what recovery means to him. “Once I was diagnosed with cancer, I gave up a bit,” he says. “I’m looking forward to hearing, after the operation, that I’m totally clear of cancer.”
The surgeon controls the robot’s every move using his hands and bare feet