Your work has been at the forefront of robotic surgery. How have advances in robotics changed outcomes for patients undergoing kidney operations over the past decade?
Robotic surgery has been increasingly applied to kidney tumors for more than 20 years. During this period, surgical techniques changed in parallel with developments in the surgical robotic systems used.
Examples may include:
- Thinner, more ergonomic robotic arms with smaller instruments are used with better technique, resulting in precise dissection with selective vascular clamping and zero ischemia.
- Better 3D vision thanks to high-quality lenses, and the ability to use Industrial Green (ICG) with fluoroscopic imaging to determine perfusion of the mass and kidney.
- Ability to use endoscopic ultrasound to specifically locate internal masses.
- Ability to use virtual reality (VR) images as a guide during robotic surgery.
- In addition to multi-port surgical robotic technology, we now also have single-port systems that have their own advantages.
- In summary, these recently developed and still under-developed techniques have increased the quality and efficiency of the robotic surgical technology used, resulting in better localization of the kidney tumor, better tumor resection with clear surgical margins, less injury to normal kidney tissue, and reduced ischemia of the normal kidney, ultimately leading to better surgical and oncological outcomes.
How do robotic techniques compare to conventional surgery in terms of recovery, kidney preservation, and long-term outcomes?
Traditional open surgery is rarely applied nowadays due to the increasing use of robotic surgery due to the advantages of being minimally invasive, reducing complications, and reducing bleeding and the need for blood transfusions. These factors also lead to less pain, and therefore less painkillers, faster recovery, shorter hospital stays, and better cosmetic results.
Cost seems to be a disadvantage. However, when these advantages are taken into account, the total cost is much lower than expected. In addition, we now have many robotic systems available from different countries, each with similarities and advantages over each other, with commercially cheaper models due to competition.
Thanks to the technological advantages of surgical robotic systems, we can better preserve normal kidney tissue and better remove kidney tumor with less damage, less ischemia, and better oncological outcomes (eg, with selective clamping, using laparoscopic ultrasound and smaller, ergonomic robotic instruments with better 3D vision) in the long term.
Partial nephrectomy has become a major strategy for preserving kidney function in patients with kidney tumors. How has robotic surgery improved the accuracy of nephron preservation procedures?
Because the robotic systems we have been using over the past 20 years have improved dramatically and will certainly be better in the future, this gives the surgeon the opportunity to better see, identify and remove the kidney tumor with clear surgical margins, leading to better oncological, surgical and functional outcomes. Nowadays, kidney tumors of smaller size are recognized as a result of the development of radiography and regular screening programs, which leads to the removal of the tumor instead of the kidney.
What role do you think multidisciplinary collaboration between nephrologists, urologists, oncologists and surgeons plays in improving outcomes for patients?
Managing kidney tumors is a team effort between urologists, nephrologists, oncologists, pathologists, radiologists, nuclear medicine doctors, and even geneticists. Therefore, with this multidisciplinary approach, we can provide better diagnosis, treatment, follow-up and preventive measures. Collaboration with the nephrologist is important, as a kidney that has been surgically injured (i.e. due to robotic partial resection of the tumor) will require postoperative follow-up by the nephrologist after surgical recovery, and patients with a single kidney who have undergone renal tumor resection are especially important. Because the age of patients with kidney tumors is generally over 50 years, a significant portion of this population suffers from hypertension, cardiovascular disease, and diabetes, all of which have a negative impact on kidney function.
Artificial intelligence is rapidly entering surgical practice. Where do you see AI having the greatest impact in robotic kidney surgery over the next five to 10 years?
As in all fields, artificial intelligence is increasingly being used and applied in urology. I believe that AI can play an important role in surgical planning by evaluating patient data from preoperative imaging with patient characteristics, combined with surgeon experience, which may suggest the type of robotic surgical approach required, i.e. transperitoneal versus retroperitoneal; Type of robotic surgical system used, i.e. multi-port versus single-port; and the type of robotic tools used, i.e. using endoscopic ultrasound, ICG, or virtual reality tumor navigation, to achieve better outcomes.
Do you think remote robotic surgery could ultimately improve access to specialized kidney procedures globally?
Testing and use of telesurgery and remote surgery is increasing, with particular success in the last 2-3 years due to the increasing availability of 5G technology, which allows negligible transmission delays (less than 0.035 seconds) that the human eye cannot detect. Remote surgeries have also been successfully performed across continents at a distance of more than 12,000 kilometers between the surgeon and the patient. Therefore, I believe that this will be the future of robotic surgery, not only in urology, but in almost all robotic surgical specialties. Using this technology, an experienced robotic surgeon can help a colleague on the other side of the world who is less experienced to successfully and safely complete the kidney tumor removal procedure, with both patient and surgeon ultimately benefiting. However, governments need to establish global guidelines through collaboration with medical specialties to use this technology safely and efficiently, taking into account medical, legal and ethical precautions.
In your experience, what are the most important factors when balancing the fight against tumors and maintaining kidney function?
In surgical oncology, our goal is to completely remove the malignant tumor and preserve as much healthy tissue as possible while causing the least amount of harm to patients. Through robotic surgery, we can achieve all of these goals. We can perform a minimally invasive robotic approach using 8mm robotic instruments resulting in less injury to the patient and using magnified 3D vision with ICG application; Using endoscopic ultrasound to determine the boundaries and location of the tumor in the kidney; And applying selective clamping and VR navigation technology to the tumor, through which we can completely remove the tumor and preserve normal kidney tissue with less injury. In addition, we can send this removed tumor for intraoperative pathological evaluation to ensure that it has been completely removed.
In short, we currently have all the techniques we need to achieve our goal of completely removing the kidney tumor while preserving maximum residual kidney function, and I love using these techniques.
What advice would you give to young doctors interested in pursuing robotic surgery and innovation in kidney care?
The future generation will definitely be better than us, and we will give our full support to their training. I think they will help us a lot in using AI technology, for example, to improve our daily surgical practices using a robot. This will be an intergenerational collaboration that will lead to better outcomes for patients. I would suggest that young urologists interested in robotic surgery collaborate with experienced robotic urologists, as well as engineers and biomedical engineers, who will accelerate their adaptation to the surgical techniques that we currently apply in robotic kidney surgery and also help them create new ideas for the future, especially in the use of artificial intelligence.
