Invited Lecture at the British Association of Indian Anaesthetist Annual Meeting 2014

1. The invasion of Robotics in
Theatre
Mr Nikhil Vasdev
Consultant Urological and Robotic Surgeon
Hertfordshire and South Bedfordshire Urological
Cancer Centre
Lister Hospital
Senior Visiting Clinical Lecturer in Uro-oncology
University of Hertfordshire

3. Introduction

4. Medical Robotics

5. Robotic Urology
• The widespread adoption of robotic technology over the
past decade has resulted in significant changes in the way
numerous urological conditions are managed
• Robotic devices continue to evolve and as they become
less expensive and more widely disseminated – it is likely
they will become more frequently utilized in an increasing
number of surgical procedures
• The rapid introduction of robotic procedures in urology
necessitates the need for the development of new training
methods

6. da Vinci® European Installed
1999
2000
2001
2002
2003
Base 1999 – 2012
2004
2005
2006
2007
2008
2009
2010-­‐‑12

7. da Vinci® USA Installed Base 1999 – 2012

8. Surgical Advantages of Robotic Surgery
6 degrees of movement

9. Surgical Advantages of Robotic Surgery
10 X magnification
3 D vision

10. Robotic Prostatectomy and Lymph node dissection

11. Robotic Partial Nephrectomy

12. Nature Reviews Urology 2004
Technology Insight: surgical robots
Expensive toys or the future of urologic
surgery?
‘‘A Robot Saved My Life’’: Is It a Myth?
Premature Robotic Surgery:
Putting Patients and Professionals
at Risk
Robotic Surgery: Hope or Hype?
Presidential Debate SAGES 2011
Will the Future of Health
Care Lead to the End of the
Robotic
Golden Years?

14. • Baseline problems in finding evidence for superiority
o A Randomized clinical trial is not feasible because both expert surgeons
and patients have their bias regarding the optimal technique
o No level 1 evidence
o Different definitions – Positive margins, biochemical recurrence, urinary
incontinence and sexual function
o Limited to single case series, systematic reviews and meta-analysis
o Selection bias in these studies often from high volume, academic centers

16. Aim of robotic prostate
cancer surgery
ORP / LRP
RRP
Trifecta
Pentafecta
Disease control
Disease control
Potency
Potency
Continence
Continence
Negative Margins
Complications

17. Lister Hospital Robotic
Urology Experience
• 3 Consultant Robotic Urological Surgeon (NV, JA, TL)
• 2 Consultant Anaesthetists (GMS, VP)
• Theatre Team
• Only National Robotic Urological Fellowship
programme accredited by RCSEng / BAUS

18. Current Achievements Robotic Urology at the Lister
Hospital (2014)
• 1 of 3 trust offering a full range of robotic urological surgery
o Robotic Prostatectomy
o Robotic Cystectomy +
Intracorporeal Ileal Conduit / Neobladder formation
o Robotic Partial Nephrectomy
o Robotic Pyeloplasty
o Robotic Nephroureterectomy

19. Current Achievements Robotic Urology at the Lister Hospital
• Only centre in the UK performing Intra-operative frozen
section analysis of the prostate during robotic
prostatectomy*
*My Theses for MCh (Urology) – University of Edinburgh / Royal College of Surgeons of
Edinburgh 06/2014

20. Activity and Referral pa[erns
• Increase in Robotic activity by 25% over 12 months
• Increase in 2 week wait cancer referrals by 27% over 12
months
68
73
67
2012/13
2013/14
66
79
73
81
78
69
87
72
76
54
86
79
99
85
75
111
114
98
108
114
111
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar

21. Robotic Urology in the NHS 2020
• Centralization of Cancer Services to 15 – 30 centres in the
England [NHS England – Everyone counts (2014)]
• Potential funding gap of £ 30 billion by 2020/21 [A Call to
Action (2013)]
• Variable cost of Robotic system leasing and maintenance
contracts [Intuitive Surgical (2014)]

23. Our experience

24. Cost

25. Cost

26. Cost

27. Intuitive sales

28. What makes robotic surgery expensive ?
• The initial cost is extremely high, estimated to be about
$1.8 million and the maintenance costs
• After ten uses of a robot, the instruments must be replaced
• Use of the robot comes with a slower learning curve for
doctors.
• When hospitals attempt to balance patient safety with the
high training costs, sometimes poor patient outcomes
occur.
• There are also increased costs to the patient per surgery,
estimated at around $2,500 per procedure compared to
traditional methods

29. Robotic prostatectomy will always be more costly to the NHS because of the fixed
capital and maintenance charges for the robotic system
Our modelling showed that this excess cost can be reduced if capital costs of
equipment are minimised and by maintaining a high case volume for each robotic
system of at least 100–150 procedures per year. This finding was primarily driven by
a difference in positive margin rate

31. How can we improve
robotic theatre efficiency

32. Theatre Robotic
Urology Utilization
Audit
Urology – N Vasdev, S Cashman, S Elands,
S Brooks, D Hanbury, T Lane, G Boustead, J Adshead
Anaesthetics – Gowrie Mohan S, Venkat Prasad
Urology Theatre – J Ocampo, L Jones

33. Urology Robotic Theatre Cycle
Time patient
sent for theatre
Time from
preoperative
area to theatre
Anaesthetic start
time to theatre
Operative time
Time list finishes
Time second
patient sent for
second patient

34. Patient and Methods
• N = 43 Robotic Urological Cases
• August 2013 until February 2014
• 2 Groups of patients
o Group 1 – List on which 1 Robotic Urological Case was
performed (n=18) [40%]
o Group 2 – List on which 2 Robotic Urological Cases were
performed (n=25) [60%]

35. Time from “patient sent” to arrival in theatre
pre-­‐‑operative area
• Mean = 29.8 minutes
• Range = 10 – 95 minutes
20
20
15
15
18
15
65
14
18
15
15
10
10
13
20
19
72
78
90
95
10
30
25
25
20
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

36. Time from Pre-­‐‑operative area to Anaesthetic
Room
• Mean = 65.4 minutes
• Range = 10 – 126 minutes
10
30
15
20
67
95
125
115
95
95
126
73
11
62
78
87
12
28
25
22
10
70
80
100
85
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

37. Comparison of total time in pre-­‐‑operative area
when patient arrives before 8 am or after 8 am
67
95
115
125
95
95
126
73
110
62
78
87
70
80
85
100
28
25
10
22
20
15
30
10
12
140
120
100
80
60
40
20
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Before 8 am
After 8 am

38. Anaesthetic Time
Mean Anaesthetic Time = 61.8 minutes (Range
20 – 110)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
95
11
93
30
65
59
50
29
70
40
67
20
99
74
65
72
75
105
20
23
70
65
72
38
39

39. Operative Time
(Surgery + Time to recovery) for first case
Mean operative time + Time to recovery = 3.6
hours (Range 2.45-4.5)
4.75
3.80
3.15
3.88
4.10
3.95
3.95
4.55
4.45
3.15
4.05
3.85
3.40
4.20
3.10
3.98
3.15
2.45
4.05
4.24
3.90
3.25
2.45
3.15
3.25
5.00
4.50
4.00
3.50
3.00
2.50
2.00
1.50
1.00
0.50
0.00
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

41. Comparison of
Anaesthetic times
120
100
80
60
40
20
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
AM case
PM Case

42. Details of robotic cases completed by 5 pm
One Robotic
Case
78%
Two Robotic
Cases
20%

43. Time of completion of theatre list
(Patient leaves theatre at 5 for recovery)
20%
8%
68%
4%
By five
By six
By six.thirty
By eight

44. Areas of improvement
• When 2 Robotic cases are performed only
20% of cases finish at or before 5 pm
• There is significant variability in the following
areas
o Waiting time from pre-operative area to theatre before 8 am
o Issues with nursing handover and time of sending for theatre
need to be addressed (Swift Ward)
o Theatre turn around time between cases needs to be evaluated

45. How can we improve
robotic surgical outcomes
• Regulation of Training (National guidelines being
prepared - 2015)

46. How can we improve
robotic surgical outcomes
• Simulation
o Simulation and Technology enhanced Learning Initiative (STeLI) project
o SAGES / RAST (Robotic assisted surgical training) programme
• Formal Fellowship training
o 6 robotic fellowships in the UK
o Only one recognized by the RCS/BAUS
• Strict audit of outcomes

47. How can we improve
robotic surgical outcomes
STOP COWBOY ROBOTIC SURGEONS

48. Latest developments
• Robotic image integration surgery (Imris)
medical)

49. Latest Developments
• Haptic Feedback

50. Latest Developments

51. Robotic Surgery-­‐‑
Is the jury out ?

52. Conclusion
• Patients undergoing Robotic Urological Surgery appear to
have
o Lower blood loss
o Reduced surgical morbidity
o Equivalent oncological outcome
• There is likely to be in an increase in robotic surgical
procedures
o Functional and quality of life benefits to patients
o Demand to provide service

53. Conclusion
“The Surgeon, Anaesthetist and
Theatre Team are most important
determinant of robotic surgical
patient outcomes of peri-operative
complications and length of stay”
L Klotz
“The aim now should be to
evaluate the cost of robotic
surgery results in long term gain for
patient”
J Meeks

54. “Efficiency is doing things
right; effectiveness is doing
the right things”