Robotic Surgery at Cleveland Clinic London

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Dr. Scott Steele: Hi again, everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the chair of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. This is our first foray across the pond, if you will. And we're very, very excited to have Professor Prasanna Sooriakumaran, globally known by his initials as PS, who's the lead for urology at Cleveland Clinic London. PS, thanks for joining us on Butts and Guts, and welcome.

Prof Prasanna (PS) Sooriakumaran: Thank you so much for having me. I appreciate the invitation.

Dr. Scott Steele: Well, fantastic. And we're super excited today to talk a little bit about robotic surgery, and specifically robotic surgery at Cleveland Clinic London. Before we jump into that, with all of our guests, we would like to know a little bit more about yourself, where you're from, where'd you train, and how did it come to the point that you're at, in this case, Cleveland Clinic London.

Prof Prasanna (PS) Sooriakumaran: I'm originally Sri Lankan. I grew up in the UK. I did my PhD in prostate cancer here as well as all my urology training. And then, went to New York, to Cornell, to do a prostate cancer fellowship in robotic surgery. And then, to the Karolinska institute to do a second prostate cancer fellowship in robotic surgery. And then, I went to Oxford as an academic prostate cancer robotic surgeon, to the University of Oxford there. And then, I moved to London when my mom got sick to be close to home. And having worked in the States when Cleveland Clinic were looking for urologists to help set up their unit in London, I was approached. I've been fortunate enough to be involved in Cleveland Clinic London from quite an early stage. And we've now been open for almost a year, which is great. And we've got a big and expanding, and very successful urology service, which is great.

Dr. Scott Steele: Well, we're super excited to have you and welcome the team. And so, before we dip into it a little bit more, let's take the 10,000-foot view - talk about robotic surgery. What does that mean? Is the robot actually doing the surgery? I mean, we have a lot of patients that listen to this. What does that exactly involve?

Prof Prasanna (PS) Sooriakumaran: Yeah, I wish the robot was doing the surgery, then I could be on the golf course. But sadly, that isn't the case. It's a master slate platform. So, it's far more liked to play the PlayStation®, or the Wii®, or whatever your games console of choice is. You are still controlling the thing that happens on the screen. So, the robot mimics the movements you make with your hands, just as if you move a joystick to the right, your little character on a PlayStation® moves to the right. The same thing happens with robot instruments. The surgeon sits at the console with his head inside the console. Inside that he's got two lenses, so he has got three-dimensional vision. So, it's much better than just watching a movie on TV. It's like watching a 3D movie without the glasses. So, you've got much better vision. And then, the surgeon has these controllers, which are joysticks in hyperspace. And as he moves his hand or one hand one way, the instrument in that hand moves in that same motion.

The advantage of robotics, as well as the better vision, is that you get magnification. So, you get a much greater immersive depth of what you are seeing. As well as that, the robot can filter the tremor. All surgeons, regardless of whether they drink coffee or whatever, will have micro tremors, and the robot will filter that out, so you get a much smoother motion. And the robot also has something called seven degrees of freedom, which means, unlike the human hand, it can move round and round and round, rather than like traditional laparoscopic surgery, which is like operating with chopsticks, where you can only move in one or two different planes. So, here you have much better dexterity, you have much better vision, and the robot mimics everything that you do outside of the body but inside the body.

For surgeries like prostate cancer, gynecological surgery, other pelvic surgery where you've got pelvic bones in the way, you can't see very clearly - when you've got the robot, you've got much better dexterity, your robotic hands can move very easily, and you've got much better vision. For operations, like urological procedures which are in the pelvis, gynecological procedures, colorectal procedures, it allows the surgeon to see better and move their hands better, which of course translates into better outcomes for patients.

Dr. Scott Steele: You mentioned a little bit about the different types of surgeries that are performed robotically, whether it be gynecological, in my case colorectal, even some head and neck surgeries, and pretty much you name it these days, there's different types of robots for different surgical procedures. Can you talk a little bit about how the actual operation is If you're doing a prostatectomy, for example how is the prostatectomy done robotically differ from a prostate that is done via traditional open approach?

Prof Prasanna (PS) Sooriakumaran: With the traditional open approach, you need to get access to the pelvis and where the prostate is. And the prostate lies deep within the pelvis, just underneath the bladder. So, you need to make a big cut on the patient's abdomen, and then you need to get the bowels out the way, you need to get down in the pelvis and try and dig out the prostate, as I say, a walnut shaped organ that is quite deep in the pelvis. So, there's quite a lot of movement of the hands underneath the pelvic bones without a lot of dexterity, a lot of stuff not being seen that clearly, no magnification. And that operation therefore results in quite a lot of blood loss, a long length of hospital stays. And because the prostate has nerves next to it that are important for erections, and it has the continence apparatus, which is important for maintaining urinary function stopping and men leaking all the time. When you take a prostate out, without the position of the robot, the risk of urinary leakage and of erectile problems is much greater.

With the robot, you put these little, small incisions in the belly and put the robotic instruments through those incisions using laparoscopic keyhole trocar ports, if you will. And then, you've got much better magnification times 10, better dexterity, and you can go underneath the pelvic bones and see the prostate very clearly with much better magnification. So, you can actually spare the nerves, which are important for erections. And you can spare the continence apparatus that is important to maintain the dryness of the man afterwards. So, as well as being able to do a good cancer operation, you get less blood loss, quicker recovery because the scars are much shorter, much smaller, so the patients tend to go home the next day. There are people in Cleveland that are doing the operation and the patients are going home the same day even. So, it is a huge improvement.

Dr. Scott Steele: Truth or myth: robotic surgery, or robotic-assisted surgery, lowers the risk of certain complications. Truth or myth?

Prof Prasanna (PS) Sooriakumaran: I think the real key that patients and others should understand is the robot is just a tool. Like any tool, it depends on who's using the tool. You can give me a golf driver that's the state of the art, best thing that's out there, graphite shaft, whatever, and I'll still hit the ball to the right and 150 to 200 yards. You give Tiger Woods a wooden driver and he'll hit the ball straight and 300 yards. So, the tool itself is only a tool. You can still use a robot and have horrible complications if you don't know how to manage it. What you want is the best tool in the best surgeon's hands. If you have an experienced robotic surgeon, the risk of complications is much less than an inexperienced robotic surgeon, and much less than an experienced open surgeon. But an inexperienced robotic surgeon will have worse complications than an experienced open surgeon. So, it is just a tool, which, if you're well-trained in it, will have much lower complication rates.

Dr. Scott Steele: So, how do physicians and patients if I'm a patient listening to this, I'm like, gosh, robotic surgery sounds cool to me. I wish I could have it, if it's less complications, you go home. How do I work with my physician to figure out if I'm one of those patients that are in the minority that maybe can't undergo it, or if I'm in the majority that I can undergo it? How would you suggest they go about that?

Prof Prasanna (PS) Sooriakumaran: Yeah. I mean, as I say, it's only about one in 200 patients. In my unit, for example, we do about 800 robotic surgeries for the prostate per year, and we do about three or four open surgeries per year. So, it's actually even lower than that, when you get more expert at using the robot. But overall, it's probably about one in 200 patients that aren't. It's very simple, because basically the only contraindication is if you've had multiple scars and you can't get access or if you have significant cardiorespiratory disease will mean that you can't go head down when you're having the surgery because of the impact that has on your heart and your lungs. So, if you've got lots of medical problems, like heart disease or lung disease, something called chronic obstructive pulmonary disease, or if you have an eye condition called glaucoma, but actually if it's only acute glaucoma, then you also may not be able to have robotic surgery. Generally speaking, I would say you can assume that you can have robotic surgery unless the robot surgeon, when you see them, says otherwise.

Dr. Scott Steele: Yeah. I think it's important to understand that there are those exceptions and they do maybe differ a little bit slightly across disciplines, but very, very pointed there. Is robotic surgery at Cleveland Clinic London different than other locations in the area?

Prof Prasanna (PS) Sooriakumaran: I think it's not necessarily different, but what we have is we have the latest state-of-the-art robot, the da Vinci® Xi, which is the latest robot that you have in Europe. And we have very experienced robotic surgeons, which, as I said, is very important. And because we have very experienced surgeons, we also offer quite innovative techniques within the surgery. So, doing the robotic surgery for prostate cancer, for example, is done across the UK and certainly across London. But certain technical modifications, for example, something I do is called retzius-sparing prostatectomy, which only half a dozen surgeons or so in the UK perform. It's a more complex operation, which again improves outcomes for patients, especially with their continence recovery and not leaking urine after the operation. So, there are certain technical innovations that are generally confined to very high-volume providers and very expert surgeons, which because we have those surgeons at Cleveland Clinic London and we have an ethos of innovation and research, we are well-placed to deliver those sorts of optimal innovative treatments.

Dr. Scott Steele: We know that there are complications that can occur with any surgery, and we mentioned some of the advantages of robotic surgery. But are there any disadvantages to robotic surgery?

Prof Prasanna (PS) Sooriakumaran: I would say the disadvantages are if you're one of those few people that have contraindications, which I say is fairly few - it depends also on what kind of surgery you're having. For prostate, there really aren't any disadvantages to robotic surgery over open or traditional laparoscopic surgery. But for other surgeries, it's not as well proven for robotics. So, there are surgeries where the robot is quite cumbersome and you can do it just as easily, and quicker, and just as effectively open, and it'll be much cheaper and quicker.

For example, if you are going to have an appendicectomy, for example, there's no need to dock the robot that takes 20 minutes when you can just have it done by keyhole surgery traditionally, because it's a fairly straightforward operation. Same is true perhaps for a gall bladder operation or for pyeloplasties, where we open up the ureteropelvic junction of the kidney. So, there are more straightforward operations, generally benign operations, for which the robot offers no advantage and comes at a significant cost. So, I would not recommend robotic surgery for every operation, but for the more complex operations, especially those in confined spaces, especially those that are generally cancer operations, the robot tends to be now the tool of choice across different specialisms.

As you said earlier, Dr. Steele, it's not one robot anymore. There are multiple robotic manufacturers now in the market which have tailored robots with different indications. So, the robots used for orthopedics are totally different to the robots we use in urology. And again, there are newer robots coming out that are hitting different sweet spots for different specialties, different access points, for example, head and neck, where you've got smaller confined spaces. Going through the mouth, for example, base of tongue tumors, you don't perhaps need a da Vinci® robot, but perhaps a Versius® robot, which is made by Cambridge (Medical Robotics), would perhaps do that job without such a large footprint. So, there are newer robots coming out that are for more specific indications as well.

Dr. Scott Steele: Is there anything different that a patient can expect when recovering from robotic surgery versus laparoscopic surgery? Obviously, open is a larger incision, there may be some pain control issues, but what can that patient expect?

Prof Prasanna (PS) Sooriakumaran: Yeah, so I think what they can generally expect is a quicker operation. Generally, the robotic approach, because you've got much more dexterity than a laparoscopic procedure, gives you a quicker operative time, less blood loss on average, and therefore the patients tend to go home quicker. But you're doing the same operation, whether you do it open, laparoscopically, or robotic, so you're not going to get vastly different oncological outcomes. There's lots of papers out there looking at comparing open surgery, laparoscopic surgery, with robotic surgery for different specialties and talking about cancer outcomes. But actually, you're doing the same operation. So, those things won't change.

What really changes is the side effect profile, and the recovery, and getting back to work quickly, and not needing a blood transfusion, and pain levels, because of course if you have a large scar or you have a laparoscopic instrument, which cause more traction on the scars by going up and down more often, that will cause more pain. So, it's the patient-focused outcomes in terms of recovery that robotic surgery really helps with. And so, things, as I say, like radical prostatectomy, surgery for prostate cancer, the open approach, typically patient in hospital for seven to 14 days. Typically, now they go home within 24 to 48 hours, and they can go back to work the following day if they're doing a sedentary job, and they can go back to pretty much normal activities within a week. So, those are the sorts of things where robotic surgery has really flourished in terms of patient-centered outcomes. It's not going to make your cancer operation more of a cancer operation. It's going to do the same thing for that.

Dr. Scott Steele: As we stand here now, are there any advancements on the horizon for robotic surgery?

Prof Prasanna (PS) Sooriakumaran: Yeah. One of the downsides of robotics, traditional robotics I'll call it now because it's been around for a while, is that you don't have any tactile feedback. So, you can't, for example, feel the tissue, which is one of the big advances of open surgery or even laparoscopic surgery, where you can push against a tissue, and you get a sense of how hard or soft that tissue is. So, that helps you in your dissections as a surgeon. With robotics, you've got none of that. But one of the things that I was involved in coining was a term called reverse brow, which basically means that you can't feel, but you can see so much better. So, you develop these visual cues to help you compensate.

But of course, what would be helpful for junior robotic surgeons or novice robotic surgeons would be to have that tactile feedback. And so, there are companies now trying to develop tactile feedback into robotics to help with that. There are also developments, such as making the instruments, of course, smaller, and now going through a single port rather than having lots of different holes in the belly, being able to all through one hole. So single port robotics, tactile feedback, better vision, better platforms are emerging all the time. So yeah, there are significant innovations in robotic surgery.

Dr. Scott Steele: Now it's time for our quick hitters, when we get to know you a little bit better. If I was to open up any one of your particular music playing instruments, what would be on your playlist?

Prof Prasanna (PS) Sooriakumaran: I don't know if I feel comfortable sharing this, but I'm a bit of a pop guy, and I tend to listen to 80's pop. So, things like Michael Jackson or even nineties pop, like Spice Girls, and even boy band pop like Westlife, and East 17, and the Backstreet Boys, and a lot of newer pop, with bands like Little Mix and things. So, unfortunately, I'm not really very sophisticated. I can't say I listen to Mozart, Handel, and classical stuff. I tend to listen to the top 40 of the charts when I'm happy.

Dr. Scott Steele: Nothing wrong with that. What's your favorite meal?

Prof Prasanna (PS) Sooriakumaran: My favorite meal actually is this drunken curry, so a goat curry.

Dr. Scott Steele: Fantastic. And what's your favorite sport to play and or to watch?

Prof Prasanna (PS) Sooriakumaran: My favorite sport to play is golf. It used to be cricket, which is probably a sport you don't even know what it is in the States. It's a sport, a bit like baseball, which is played throughout much of the Indian subcontinent, Australia, New Zealand, England, but a bit like baseball. And that's my favorite sport to watch and was my favorite sport to play when I was a bit younger and fitter.

Dr. Scott Steele: Here we go for the wickets. And finally, if you could have a place to travel, where would that be?

Prof Prasanna (PS) Sooriakumaran: It would probably be somewhere which has got a bit of culture, but also got a beach and nice weather. So, somewhere like Bali, I think.

Dr. Scott Steele: Fantastic. And so, what's a final take home message for our listeners regarding robotic surgery and especially as it pertains to Cleveland Clinic London?

Prof Prasanna (PS) Sooriakumaran: I think, as it pertains to Cleveland Clinic London, we have the latest robot, and we have the best trained, and skilled, and experienced robotic surgeons. And I would say to you, the final message I'd say about robotic surgery is that it is just a tool. So, it is not all about the robot, it is about who is wielding that robot. If you have a condition that is amenable to robotic surgery that you need to pick not only the facility that has the latest robotics, but the facility that also has the most experienced surgeons at using that robotics.

Dr. Scott Steele: Great advice. And so, for our listeners who would like to learn more about booking an appointment at Cleveland Clinic London, you can call the London Contact Center. And remember, you got to use a plus here. So that's +442034237500. That's +442034237500. To learn more about procedures at Cleveland Clinic's main campus, here in beautiful Cleveland, Ohio, please call 866-320-4573. That's 866-320-4573. Professor PS, thanks so much for joining us here at Butts & Guts.

Prof Prasanna (PS) Sooriakumaran: Thank you so much for having me. It was a real pleasure, and I'm really looking forward to coming and visiting beautiful Cleveland one day.

Dr. Scott Steele: Fantastic.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.