Challenges of robotic surgery.

Abstract

To the Editor: I read with interest the article by Chin and colleagues1 that summarizes their initial Canadian experience with robotic prostatectomy in 30 cases. The authors should be commended for their determination and perseverance despite limitations in resources and the early sporadic patient scheduling. Results presented indisputably demonstrate the feasibility of robotic prostatectomy in the Canadian health care system. However, as pointed out by the authors, these early results reflect the learning curve of a robotic novice team, which compares fairly with other centres. Results beyond this initial phase are anxiously awaited. Thus far in Canada there are 2 da Vinci surgical systems in London, Ont., and 1 in Montreal, Que., at the Sacre Coeur Hospital. Last year, we established a joint venture between McGill University Health Centre and Sacre Coeur Hospital and developed the first robotic prostatectomy program in the province of Quebec. The initial start was hindered by many of the inherent difficulties of our health care system as described by Chin and colleagues. Our initial results will be presented at the Quebec Urological Association meeting in November 2007. The development of a robotic prostatectomy program presents many challenges. In order to ensure success, there needs to be commitment from the institution and the department; a dedicated, motivated surgical team including trained surgeon, assistant, nurses, and anesthesiologist; frequent patient scheduling; and measurements of outcomes. The best training, in my mind, is fellowship training at a high-volume centre of excellence. Robotic surgery as we know it today is expensive and offers few but not many advantages over conventional approaches. The current robotic system is bulky and not versatile enough. This is only the beginning. Computer-assisted surgery is undoubtedly going to evolve similarly to other fields in our information age. Training, rehearsing, integration of real-time and computed imaging, grafting of ancillary systems such a confocal microscopy, and lasers will all become possible on the next generation robots. It is unlikely that we will continue to operate with our limited human capacities, the same way we did for the last century, while machines can “see,” “feel” and “discriminate” multiple times better than our eyes and fingertips as well as remain tirelessly reproducible and extremely precise. This will lead us from organ surgery, to tissue surgery and eventually to molecular surgery. Robotic prostatectomy represents one of the initial steps of this global momentum change in surgery. We need to embark wisely and embrace this technology, contribute to its development and remain critical, otherwise we will lag behind. In Canada, I think we still have the opportunity to conduct a prospective randomized study comparing open and robotic or laparosocpic prostatectomy.