Robotics: Does Size Matter? Dima Raskolnikov, M.D. PGY-1, Department of Urology

DISCLOSURES No financial conflicts

OUTLINE Why interested? Pros/cons Recent literature Conclusions Simulation Trends Pros/cons Recent literature Conclusions Not inspired by a specific case, but rather a few opportunities and developments at UW recently

OUTLINE Why interested? Pros/cons Recent literature Conclusions Simulation Trends Pros/cons Recent literature Conclusions First of these was a robotic simulator that was housed at UW recently for 1 month, just before SCH rotation

BACKGROUND: Simulation at UW All gen surg, uro, gyn residents explicitly asked to participate https://www.youtube.com/watch?v=utb-8YCvCHY 1 month period w/ robot simulator, available 24/7 Dozens of guided activities with wet + dry lab (unit at SCH as well?) da Vinci simulator at UW “WISH” Examples: Ring Walk Peg Board

BACKGROUND: Simulation at UW 1 month period 43 named surgeons 4,528 minutes of activity 1,464 exercises Real time feedback Practical significance? Successful experience 43 individuals made accounts + Me: night float. Benefits: constant feedback, could track progress

IT WORKS: We Think Lendvay et al. JACS 2013 RCT at UW/SCH 51 residents + faculty GS, uro, gyn validated training curriculum  achieved performance benchmarks  randomize to VR warm up vs. read a book  robotic surgery tasks Outcomes: validated measures of performance (task time, tool path length, economy of motion, technical & cognitive errors) Lendvay et al. JACS 2013

Stat. significant improvements: task time, path length. Cognitive errors, EOM, peg touch all trend towards significance. Lendvay et al. JACS 2013

OUTLINE Why interested? Pros/cons Recent literature Conclusions Simulation Trends Pros/cons Recent literature Conclusions 2) Becoming more popular, especially in urology. We’ve done a handful of robotic cases during this rotation, led me to wonder  emerging standard? Delicate structures, high degree dexterity, small operative workspaces

IT’S THE FUTURE 220 studies 2393 procedures 1840 patients Borne out in studies of cases Reviewed literature for all case reports robotic surgery in children 2001-2012 11 year period: 220 studies, reporting 2393 procedures in 1840 patients Cundy et al. J Ped Surg 2013

IT’S THE FUTURE Cundy et al. J Ped Surg 2013 Robotic GU cases in particular are becoming more common Principles likely apply to other fields in pediatric surgery Cundy et al. J Ped Surg 2013

With increased surgeon volume comes increased competition and marketing some a bit laughable, others with surprisingly specific claims

OUTLINE Why interested? Pros/cons Recent literature Conclusions Simulation Trends Pros/cons Recent literature Conclusions Given volume, would expect level 1 evidence depicting pros/cons Doesn’t exist; instead collection of level 3 and 4 with mostly retrospective reviews + expert opinion

EXPERT OPINION Cundy et al. J Ped Surg 2014 Same group as previous study (Cundy). Surveyed 48 pediatric surgeons w/ first hand experience performing robotic surgery What do they think? Cundy et al. J Ped Surg 2014

IT’S THE FUTURE Cundy et al. J Ped Surg 2014 Hand held bedside instruments Flexible snake robots: Natural Orifice Translumenal Endoscopic Surgery (NOTES) = essentially robotic surgery at the end of an endoscope, and SILS = single incision lap surgery Single site, more conventional Theoretical Guidance to subsurface anatomy (e.g., tumor margins) Least enthusiastic Cundy et al. J Ped Surg 2014

OUTLINE Why interested? Pros/cons Recent literature Conclusions Simulation Trends Pros/cons Recent literature Conclusions Amidst all of this excitement and publicity, what does the most recent data look like?

COMPLICATIONS Dangle et al. J Ped Surg 2015 Previous studies of complication rates mostly single center w/ small numbers Multi-center database study Dangle et al. J Ped Surg 2015

COMPLICATIONS Multi-center retrospective review 2007-2011 858 patients 880 procedures Clavien Grade IIIa, IIIb complications Dangle et al. J Ped Surg 2015

COMPLICATIONS Dangle et al. J Ped Surg 2015

COMPLICATIONS Multi-center retrospective review 2007-2011 858 patients 880 procedures Clavien Grade IIIa, IIIb complications IIIa, IIIb: 41 patients (4.8%) IVa: 1 patient (0.1%) Conclusions: technically feasible, safe Comparable 90 day rates to lap, open surgery IVa:intra-op vascular injury 2/2 instrument change, 500cc blood loss + emergent conversion to open Overall rates similar to those published in laparoscopic, open literature Dangle et al. J Ped Surg 2015

COST & OUTCOMES Pepper et al. Obes Surg 2016 Previous study: complication rates are similar But are the clinical results actually any better? Data fairly disappointing. No level 1 data, but rather retrospective studies w/ narrow indications. Here: establish safety efficacy, but also investigate costs, operative time, etc. Pepper et al. Obes Surg 2016

COST & OUTCOMES Single-center retrospective review 2013-2014 Outcomes 28 patients w/ sleeve gastrectomy 14 lap, 14 robotic Outcomes Length of stay Operative time Cost Complications Comparative study, though retrospective Pepper et al. Obes Surg 2016

COST & OUTCOMES Single-center retrospective review 2013-2014 Outcomes 28 patients w/ sleeve gastrectomy 14 lap, 14 robotic Outcomes Length of stay Robotic 69.6 vs. lap 75.9 (p=0.0094) Operative time Robotic 132 min vs. lap 100 min (p=0.0002) Cost Robotic $56k vs. lap $49k (p=0.037) Complications No difference Conclusion: Safe and effective Shorter LOS Expensive Reality vs. Hype? Modality with more favorable outcome underlined Pepper et al. Obes Surg 2016

COST & OUTCOMES Murthy et al. Eur Urol 2015 Similar study design Retrospective comparative study w/ narrow indication (augmentation ileocystoplasty) Murthy et al. Eur Urol 2015

COST & OUTCOMES 2008-2014 Outcomes 17 patients robotic 13 patients open Outcomes Operative time Pain medication use LOS Complications Same as before; more favorable modality underlined New possibility: more favorable pain control regimen  shorter stays? Murthy et al. Eur Urol 2015

COST & OUTCOMES 2008-2014 Outcomes 17 patients robotic 13 patients open Outcomes Operative time Robotic 623 min vs. open 287 (p<0.01) Complications No difference Pain medication use No difference, but no epidurals in robotic LOS Robotic 6 days vs. open 8 (p=0.01) Conclusion: Safe and effective No epidurals Same as before; more favorable modality underlined New possibility: more favorable pain control regimen  shorter stays? Murthy et al. Eur Urol 2015

OUTLINE Why interested? Pros/cons Recent literature Conclusions Simulation Trends Pros/cons Recent literature Conclusions

CONCLUSIONS Does size matter? Benefits Limitations Depends who you ask Improves dexterity in small workspaces Promising initial data, but no well-powered studies Exciting future directions Flexible snakes, microbots, image-guidance/augmented reality, remote Resident training Limitations Cost Operative time Rapidly expanding technology with limited data Is there a role for robotics in pediatric surgery? Unique situation where we have expensive technology, now finding ways to justify

THANK YOU Questions/Comments Begs the question of whether we have truly made a giant leap Questions/Comments