Robotic Platforms in Urology: Indian Scenario

Introduction

India has been proactive in utilizing and accepting advanced technologies whenever the opportunity or the platform is feasible. Likewise, with the advent of robotic surgery, it is of no surprise that we are willingly accepting it. The high resolution three-dimensional magnified vision, multi-degree range of movements, tremor dampening, miniaturization of instruments, etc., all work seamlessly to provide better dexterity and precision in the hands of operating surgeon to enable safe and efficient surgery, all on top of already proven advantages of laparoscopic surgery.¹

Robotic surgery was first commercially approved by FDA for clinical use in 2000 with da Vinci robotic systems (Intuitive Surgical, Sunnyvale, USA), which has been dominating the market for almost 20 years.² Since many of the patents of Intuitive Surgical expire, we are entering a new era where other competitors are making a mark in the robotic surgical market.

At present, multiple centers in India are equipped with facilities for robotic surgeries. All Major and some tier two cities have not one but multiple robotic platforms, almost around 117 installations. As of the time of writing, there are 90 da Vinci, 26 Versius and 1 Hugo RAS robotic systems installed in various parts of India. Nevertheless, increasing patient demand for this highend modality has added the zeal for extension of the service to smaller cities and hospitals which is evident by the exponential rate of instillation of robots in these areas. This shows the enthusiasm and even competition prevailing amongst the hospitals to provide world class surgical care. Majority of the robotic surgeries are utilized in Urology, Gynaecology, Gastrointestinal, Thoracic and Head and Neck departments.

The perks of any advanced technology come with its baggage of additional cost, both capital and recurring.³ The cutting-edge technology in terms of healthcare in India has not reached to its maximum potential because of its exorbitant expenditure. Thus, there is a need to look at this parameter against the fragile healthcare system of ours. Robotic system requires larger operating rooms, technicians and nurses who are trained and maintenance costs which can exceed unreasonably.⁴ In addition to that, the insurance coverage for common people has not fully extended beyond the basic surgical technology, which could be a stumbling block for accessing this newer modality of treatment.

Our objective was to review different platforms of robots available in urological practice in India with their advantages and disadvantages in current application scenario.

Methods

A non-systematic literature search was done in Pubmed/ MEDLINE with the following keywords: “India”, “robotic surgical system”, “da Vinci system”, “robotic urology”. Supplementary search was done via Google Scholar using the same keywords. The respective company’s websites for the robotic system were also looked into for compatible information.

Discussion

Different robotic systems available in India

1. da Vinci

Intuitive Surgical Inc. has been a predominant robotic system for the past 21 years⁵ and was one of the firsts to be installed in India as well. Until now, there are four different generations actively functioning and works as a telemanipulator system.⁶ Almost all the generations of da Vinci are available in India, except da Vinci SP. The da Vinci Si, X and Xi (Figure 1) features four robotic arms mounted on a single patient cart, a separate closed surgeon console accommodating finger loop controllers inclusive of Endowrist technology. The instruments are 8 mm in diameter, giving seven degrees of freedom.² Presently, the Si system is in the process of phasing out and is succeeded by the newer Xi system which was released in 2014. Akin to the previous generations of the da Vinci system, Xi has additional features of dual console, slender robotic arms, articulating instruments, 8 mm port hopping camera, facilitating multi quadrant procedures.⁷

The latest advancement is the da Vinci Single-Port (SP) system, which was approved by FDA in May 2018. Its use has been reported in various urological procedures like renal surgery,⁸ radical perineal, as well as transperitoneal prostatectomy^9,10 and cystectomy.¹¹ This is currently unavailable in India.

2. Versius

The Versius surgical system (Cambridge Medical Robotics Ltd., Cambridge, UK) obtained its CE mark in 2019.¹² Few centers are known to have this system in India. The distinctive feature of this system is its five light weight portable carts, individually mounted with robotic arm (Figure 2)⁵ Similarly, the console has open design requiring 3D polarized glasses for vision and additional advantage of haptic feedback to operating surgeon.² The full control of the system is provided by handheld joystick, thus eliminating the necessity of foot pedal controls.¹³ This system provides slender instruments of 5 mm diameter, is wristed and allows seven degrees of freedom. It has been studied in multiple clinical settings and about 66 global instillations has been made until now. The first clinical series was reported in India for its use in gynaecologic and upper gastrointestinal surgeries² and feasibility was assessed in 30 robotic radical hysterectomies.¹⁴

3. Hugo RAS

Hugo™ RAS system by Medtronic (Figure 3) is another open console system having 3D glasses. The system has independent pods. Each pod has six hinges with seven degrees of freedom. The surgeon console is on wheels along with every system component and arms. The advantage of this system is its design which allows upgradation such that newer system purchase is omitted, thereby optimizing the cost.¹⁵

4.Mantra

The Mantra surgical robotic system is the only robotic system developed by an Indian company, SS Innovations, and is regarded economical (Figure 4). Its use is in experimental phase until now. It provides broad spectrum surgical applications, including cardiac surgery. Features include patient side arm carts, surgeon command center (Figure 5, 6) and vision cart. Each of the side arm carts has individual motorized cart with robotic arm with integrated tool interface and instrument actuator. Actuators for each joint has motors, harmonic drives, electro-mechanical brakes and sensors. The system consists of open console system, surgeon command center with dual monitors (3D HD monitor and 2D touch display monitor for system control and patient related data display). It is equipped with visible active hand as well as foot pedal control and head tracking system. The endoscopic camera has Chip on tip technology with motorized articulation control (four way), and allows 75 degrees field of view. The convenience of this articulating endoscope is its capability to allow wider range of vision which is crucial in visualizing ports without shifting the camera as well as to view anatomical structures without changing the endoscopes. Over thirty 9 mm SSI MUDRATM endosurgical instruments are available for multi-specialty procedures including NADI (Automated Anastomotic Connector) for coronary bypass surgery, multi-fire clip appliers and cardiac endo-stabilizer.

Conclusion

The current robotic systems market in India is on a steep rise with definite advantages in terms of reduced hospital stay, decreased blood loss, lower conversion rates and earlier return to work which circumlocutorily reduces health care cost drivers. In addition, with the rise in the number of cases being performed along with increasing patient load and multispecialty utilization of the robotic system, the cost-effectiveness can be considerably revised. Further development and addition of virtual and augmented reality, artificial intelligence in data analytics, deep learning and machine learning algorithms will substantially contribute to making surgeries simpler, safer and accessible.

Conflict of Interest

The authors confirm no conflict of interest or funding for writing this article.