Pioneering robotic surgery for better patient outcomes

In the UK, there are about 40,000 men diagnosed with prostate cancer per year. As a solid tumour, current treatments include surgical procedures that remove the prostate in an operation called radical prostatectomy.

Keyhole surgery is the ideal mode of operation for patients as the less invasive option which is proven to reduce pain, blood loss and hospital stay when compared to open surgery. But many surgeons struggle with keyhole surgery due to the procedure’s intricacy.

Researchers at King’s College London, most notably Professor Prokar Dasgupta, have been pioneering robotic surgery technology since the beginning of the century. Throughout the last 20 years, King’s has been a leader in the remarkable burst of innovation that has enabled robotic surgery to become the most effective and common method for prostate cancer surgery in the UK.

The journey into robotic (prostate cancer) surgery began with telerobotics – a field that studies the distanced control of semi-autonomous robots. With John Hopkins Hospital, King’s College London co-conducted the first randomised, controlled trial for robotic surgery, testing the ability of a robotic arm to remove kidney stones from models. The results showed that the robot was more accurate than the human hand.

With momentum developing from this proof-of-concept, the King’s urology team took advantage of the new technology by setting up the new da Vinci Surgical System in their department. This surgical robot consists of wrist-like robotic instruments controlled at a console with a 3D camera at 10x magnification that provides 540-degree motion and tremor cancelling technology. Introduced in 2001, they are now found in around 80 NHS hospitals and are involved in 90% of radical prostatectomies in the UK.

Though its potential was immediately apparent, the first iterations had some issues. Surgeons, including those at King’s, noticed impairments in accuracy due to a lack of ‘touch’ feeling from the controls.

To address this, academics in the urology and engineering departments developed a flexible robotic surgical arm with ‘haptic technology’ which applies forces, vibrations, and motions to create a feeling of touch for the surgeon. This was followed with a multitude of technological innovations including: image guidance systems that layers MRI photos of the patient’s tumour on the console screen to show its position during operations; creating an exact 3D printed replica of a patient’s prostate with their MRI scans for planning operations; and collaborating with Ericsson to use 5G for real-time connectivity with robotic surgery devices in different locations.

The first randomised controlled trial in bladder cancer (CORAL trial) found that, within 90 days, patients had shorter hospital stays and less blood loss with robotic surgery without increasing complications. These findings were published in European Urology.

Because of this expertise, Guy’s and St. Thomas’ Hospitals now conduct approximately 1300 robotic surgeries each year – the most robotic operations in the UK, the majority being prostate but also bladder, kidney, and other specialty operations like chest surgery.

King’s College London has a long history of sharing its robotic surgery expertise, as seen by Professor Dasgupta travelling nationwide to train urology surgeons in robotic surgery. The Urology Foundation (TUF) has selected King’s as one of five Centres of Robotic Training in the UK, which has trained thirty-one urologists, directly or via cascaded training, between 2016 and 2019.

Based on the success of Professor Dasgupta’s work, the Vattikuti Foundation (VF) donated £600,000 to establish the Institute of Robotic Surgery, becoming the first of its kind in 2014. Many of the Institute’s trainees have since become robotic surgeons, and the Institute has published more than 700 articles on related topics to develop and evaluate potential new technologies for application to robotic surgery.

King’s College London have also used their expertise to develop the first international curriculum on robotic surgery with guidelines on safe training and best practice. These have been adopted by the British Association of Urological Surgeons (BAUS) and validated by the European Association of Urology Robotic Urology Section (ERUS).

Unsurprisingly, this expertise has also informed government policy. A systematic review co-authored with Harvard and the Henry Ford Institute showed that, despite high costs from initial set-up and maintenance, the da Vinci machines are cost-effective if they are used for at least 150 operations per year. This has been incorporated into NICE guidelines, and official recommendations from the Canadian Agency for Drugs and Technologies in Health.

The improvements on patient outcome from robotics, and its impact on medical guidelines shows the importance of robotic surgery now and in the future. The pioneering research being conducted at King's College London will undoubtedly continue to improve patient’s lives.