• Professor Dasgupta

Health

Q&A: Prokar Dasgupta

Prokar Dasgupta, consultant urologist at The London Clinic, talks robotic surgery, innovation

Interview: Viel Richardson
Image: Joseph Fox

What is robotic surgery?
Robotic surgery is a form of keyhole surgery where a surgeon sits at a computer console and carries out the procedure by controlling little robotic instruments—much smaller than their hand-held counterparts—through a series of robotic arms.

When did you become aware of this type of surgery?
I am often credited as the pioneering urologist in this field in the UK, but the credit should really go to a man called Mr John Wickham. He is the godfather of robotic surgery. He did this kind of procedure in the late 1980s, long before anyone else, with a robot called the Probot, which was used on patients’ prostate glands to help them urinate better.

The prostate sits just under the bladder and as men get older it can become bigger and block the passage of urine. One of the ways of treating it is to cut out the centre of the gland, like the core of an apple. John Wickham designed a robot, along with Imperial College, that could do this. That was the first robotic procedure. What Mr Wickham was doing at the time was revolutionary stuff. We have come to realise he was a man perhaps 20 years ahead of his time.

What drew you to the field?
I was already reasonably experienced at open and keyhole surgery when I heard of another pioneer called Louis R Kavoussi. He had started doing keyhole surgery using a robotic camera holder. With keyhole surgery, you need a camera to see what you are doing. Kavoussi stopped using a human assistant to hold the camera and used a robotic arm called Aesop, which he could control with his voice, a foot pedal or a hand pedal.

I applied for a scholarship to go and see him work. I was really inspired by Kavoussi’s work: this was really pioneering stuff in the mid-90s. I felt that robotic technology and the science it was enabling—such as genetic research—had the potential to revolutionise patient care. It was incredibly exciting.

How did you go about breaking into such a new field?
With difficulty. I went to have a look at the DaVinci robotic system—which is still the only commercially available robotic operating system—and watched a prostate cancer procedure. The system gave the surgeon 3D HD, magnified vision, the instruments had tiny ‘wrists’ called ‘endo wrists’ which could mirror the movements of the surgeon and sometimes move beyond them, for example, rotating further or twisting to a more acute angle. You could also scale the instrument to move a lesser distance than the controlling hand, making it highly precise. Any human tremors, which you can find even in the most experienced surgeons, were eliminated.

When I came back I persuaded the Guy’s and St Thomas’ Charity to spend around £1.1 million on a machine, which is a serious amount of grant money. It was not simply to buy the system, but also to allow us time to evaluate it, because there was no real data at the time on whether this was any better than traditional ways of doing open or keyhole surgery. 

Prof. Dasgupta

How did you get to grips with the machine?
I did simulations in the lab, such as practice sutures on inanimate objects and operated on cadavers to gain experience operating on humans. It was about getting used to the machine. A huge amount of thought about safety protocols went into the programme before we operated on patients. Patient safety is paramount, of course, but we were also very aware that the hospital had taken a giant leap of faith. We did not want to let them down. The trial of the machine began in 2002—the first operations on patients were in June 2004.

It must have been an exciting time.
It was. There was so much going on. In collaboration with Kavoussi, I did the first randomised trial in the world with a robot designed for inserting needles to take out kidney stones. It was a tele-robotic trial where a robot in Guy’s Hospital was controlled from Johns Hopkins in Baltimore, and a robot in Johns Hopkins was controlled from Guy’s. The trial was called Startrak, and it showed that surgery using the robots was more accurate than the human hand.

Which areas have benefitted from robotic technology?
The field of urology has been the biggest beneficiary. Cancer is very common in the prostate gland and we have been able to treat it using robotics. It’s also been successful in dealing with kidney tumours and bladder cancer.

Urology as a field is very forward thinking—all the pioneers in the field of robotics I have mentioned have been urologists—but the best outcomes have been when robotics were used by multidisciplinary teams, where you have for example ENT (ear, nose and throat) surgeons and thoracic surgeons (who operate on the chest) working together. Robotics is a very collaborative field, so that’s not surprising.

Do you still use conventional surgery?
I don’t do any traditional surgery for prostate cancer, bladder or kidneys, but I do for other procedures. If a technical problem arises you have to be able to switch seamlessly to traditional methods. The patient’s safety is paramount, so I have to ensure my skills remain honed.

What have been the biggest changes in robotics during the time you have been operating?
Technical upgrades to the DaVinci system. The instruments have become longer, finer and there is greater variety. The console the surgeon uses to control the robot has become more ergonomic and the internal imaging has improved, so there is better guidance during the surgery. We have traditionally made four to five holes for robotic surgery, but now there are ways to do it through one.

What is driving development in the field?
The prime drivers are the surgeons. They are still the core of the procedure. If I had the choice of an inexperienced robotic surgeon and an experienced open surgeon, I would go to the experienced guy. It is not just the tool, it is the skill of the operator that matters. Surgeons give constant feedback about how the machine works and what they would like the tools to do to scientists who develop the technology.

Where do you see the field in five years’ time?
I think there will be other players in the field of robotics, driving innovation and making things better for patients, which is exactly what we want. At King’s College London, we have a centre for robotics research. We are working very closely to develop ‘soft robots’, inspired by the arms of an octopus.

At present, robotic arms are straight with a wrist at the end—imagine having an arm that can go around corners, that is able to feel and see the tumour and then deal with it. It is a very exciting prospect, which is why the European Union has funded it—to the tune of nearly eight million euros.