What are the next steps with robotic surgery?
[There are] things that we should move forward on in terms of technological improvements. The first is that we can see well with integrated imaging. We can even do immunofluorescence to look at blood flow. The next logical step is the ability to tag cancer cells. This will allow us to see the cancer cells in real time so when we are removing the tumor, we know exactly where the cancer is, as well as where the normal kidney is, leaving no question or doubt. That would be the next hurdle to overcome. The foundation is in place, but we need to work out the biological markers.
Additionally, there is a learning curve involved with robotic surgery, especially with complex kidney surgery. There are centers that do a lot of robotic surgery, and particularly complicated kidney operations, but in general, across the country, there is a learning curve involved with it. We need to figure out a way to transfer that type of experience to a much more general population of urologists who are taking care of these patients.
How do you determine which patients will receive a robotic surgery?
How you determine who gets robotic surgery is in the hands of the physician that is treating that patient. Doing an open partial nephrectomy, a laparoscopic partial nephrectomy, or a robotic partial nephrectomy are all good options. These are all good things to do.
As you mature your experience with robotics, you start getting some of the advantages that come with it, but unless you’re comfortable doing that, you’re going to offer what you’re most comfortable with. Most kidney operations done in the United States are not done using robotics. However, most places that have active robotic centers are doing the majority of those operations with robotic surgery.
In my program, I would say that 99 percent of patients would get a robotic operation. There are some medical contraindications, but not often. [However, robotic operations are] not what’s happening across the country yet.
Are more doctors taking on this learning curve?
The adoption of robotic surgery for kidney cancer has gone up quite a bit. This is where we’re seeing the most growth. There is no question that urologists, in general, are applying this technology to kidney surgery. Most urologists have experience with robotic prostatectomy and then you can transfer that robotic skill to the kidney.
Just like in anything else, even open surgery, to do a complicated kidney operation, it is important to be comfortable doing that. There is an amount of experience, confidence and maturity needed to do a robotic surgery.
If you’re just learning robotic kidney surgery, you should tackle the more straightforward tumors first and build up that learning curve before you start taking on the more challenging ones.
Ultimately, you want to do it safely. The whole point is to be safe and robotic surgery is a safer operation. I believe that and we have data to support it, but it doesn’t happen on the first day.