What’s the near future of robotic surgery

Robot assisted surgery was introduced 35 years ago, and 20 years have passed since the robotic technology entered the world of urology, ¹ with the first robotically-assisted radical prostatectomy (RALP). Since then, the robotic surgery has rapidly and incrementally spread worldwide in several fields of surgery, with urology and gynecology being the leading specialties. Several attempts to evaluate its superiority—or at least its effectiveness—were carried out through decades, with outcomes often disappointing or misleading, as interpreted by the robotic side. This is the case of a recent systematic review published in the Annals of Medicine, that failed to depict a clear advantage of robotics over other surgical approaches in abdominopelvic surgery. ¹ The review included the highest evidence we currently recognize, namely randomized controlled trials (RCTs) comparing robotics to laparoscopy and/or open surgery.

But is this an adequate way to address surgical success?

Despite being considered the gold standard of evidence-based medicine, RCTs in surgery suffer from several limitations—difficulty of blinding the intervention and data collection, differences in centers’ practice (anesthesia, protocols). ² The learning curve effect makes outcomes variables for each technique and for each surgeon. The same surgeon may have different outcomes at different points of the learning curve and, no matter how standardized a surgical technique could be, the result may be no longer similar for all surgeons. ²

As a proof of frailty of conventional evidences in the field of surgery, the robotic technology rapidly spread even if lacking evidence-based certainties; in urology, 2008 was the year in which robotic surgery overtook laparoscopy and open surgery for the management of prostate cancer.^3,4 And nowadays, is it feasible and acceptable offering patients an open radical prostatectomy for RCT purposes, where the robotic platform is available?

No longer waiting for scientific evidences, surgeons will address a novel issue in the very next future, the drawback of the sudden diffusion of the Da Vinci: the pattern of expertise of younger surgeons, who grew up shaped on robotics during the last decade.

The robotic learning curve is facilitated by simulators, making skills’ achievement recordable and quantified; the training relies on structured programs with international credit, and more opportunities have to come with advances in connections and complementary platforms (i.e. Proximie).

As a result, residents and young surgeons master robotic techniques in an easier and faster way than previous open surgeon did. Given the robotic availability and training in western countries, robotic surgeons under 40s are able to manage by themselves several conditions and diseases, up to embrace challenging robotic cases too.

However, open surgery still encompasses a small, but non-negligible, amount of surgical indications and open surgical skills are still crucial and life-saving in case of conversion.

Are skills acquired with the robotic technology automatically transferrable to open surgery? Are young robotic surgeons able to face an emergency open access and manage a major complication? Or may the lack of open expertise make the robotic surgeon unconfident and unsure of him- or herself? The issue is still unsolved—and often unaddressed too. Senior open surgeons still inhabit urological units and, perhaps, the presence of an interdepartmental open surgeon (and rotation) may be the next solution.

But beyond the role of robotics as a routinely surgical practice, we should ask ourselves when and how the technology will reach the whole surgical community, including low-income and developing countries. Novel robots promise to meet the challenge: but will they stand up with the safety and experience of the Da Vinci platform? More surgical trials are requested to clarify the issue: up to now, the Senhance system is the one mostly supported by clinical studies. ⁵ Moreover, it should be remarked that there is lack of studies evaluating the cost-effectiveness of new robots; whether these platforms might be less expensive than the Da Vinci one is still unclear. ⁵

The next future is going to face these unsolved concerns. Meanwhile, robotic surgery keeps moving—and leading—disease management, surgical training and technological implementation in urology.