The doctor’s skills are crucial, not only modern equipment

The doctor's skills are crucial, not only modern equipment

Paweł Wisz, MD, head of the Neo Hospital Robotic Surgery Center in Krakow, talks about the importance of choosing a center that uses robotic methods in the treatment of prostate diseases and the importance of training specialists using these modern tools.

Robotic surgery for the treatment of prostate cancer has virtually become the norm. More and more centersaboutin Poland, currently also public, invests in modern devices, such as the da Vinci robot. How many such systems currently exist?aboutin the works of our country?

Currently, there are over 40 robotic systems in operation in Poland. The benefits of surgical robot support have become widely accepted by both doctors and patients. Currently, over 200 different types of surgical procedures are performed using them around the world, which illustrates the growing role of technology in the field of medicine.

In 2023 55% of prostate cancer procedures were performed with the assistance of a surgical robot. This is significant progress. The availability of robot treatments in Poland has improved significantly, as prostate cancer patients are guaranteed reimbursed robot treatments under the National Health Fund from April 1, 2022. From August 1, 2023, treatments for endometrial cancer and colon cancer are also financed.

This direction of development is a global trend. The number of procedures performed worldwide using robots is growing at a rate of 27% year on year, with a simultaneous decline in open surgeries.

Better accessibility and greater patient awarenessaboutin, regarding modern methods of treatment, makes them look for they omiddleaboutin those offering such methods. What should they pay attention to when choosing a hospital?

It should be emphasized that not only modern equipment is crucial, but above all the skills of the specialist who uses it. The robot is just a tool used by the doctor.

Although specialists using the robot have certificates issued by the manufacturers of these systems (currently, about 100 surgeons in Poland have them), such certification is only a condition allowing them to work with this tool. However, it is not an indicator of achieving an appropriate level of clinical skills.

Is it determined by the number of procedures performed?aboutIn?

Not always, although it is also important. In Poland, there are still few specialists who perform over 150 procedures a year, which is the norm abroad. Moreover, not only the number of treatments is important, but also their quality. Unfortunately, there are no standards in our country that take into account the effectiveness of the procedures performed, which is measured by the patient’s health condition, well-being and functioning.

The effectiveness of the procedure is the result of the experience of the person performing it, so it is important that as the number of robotic systems in hospitals increases, staff training also develops and training centers are established. There are over 20 of them in Europe and they have been operating for many years, but in Poland there is not a single one.

In 2022, the 3,000th procedure was performed in Polandaboutin using a robotic system. How many were there in 2023?

Last year, over 7,000 of these procedures were performed. According to estimates, surgical systems can be used in approximately 30% of the 20 million advanced surgical procedures performed worldwide each year.

What does such a procedure look like using a robotic system?

The procedure involves making six minimal incisions in the patient’s abdominal wall, through which the so-called trocars. Inside there is a camera and minimally sized surgical tools that are attached to the robot’s arms. The surgeon performing the procedure does not stand at the operating table, but sits behind a special console with which he controls the robotic arms.

Of course, it is not the robot that performs the operation, but it remains in the hands of the surgeon and the operating team, and the device used is only a tool supporting work during such complicated procedures as the removal of prostate cancer, i.e. prostatectomy.

What are the benefits of using a robot for the operator and the patient?

Robotic surgery enables very good visualization of the operating field of 2-5 cm, even at 10x magnification. What is important is the size of the surgical tools located on the robot’s arms, which do not exceed 0.80 cm and have a range of motion of 560 degrees. All this means that robotic surgery has a significant advantage over laparoscopic or open surgery.

Using a robotic system, the surgeon can move efficiently in narrow spaces and also precisely pick out the tissues occupied by the tumor millimeter by millimeter, which, combined with his skills and experience, determines the value of the procedure for the patient, including the oncological purity of the procedure, as well as also the quality of life after the procedure. Precise preparation of the sphincter helps avoid urinary incontinence after surgery and preserves the neurovascular bundles to maintain sexual function, which is especially important if prostate cancer is diagnosed in younger men, aged 50 or even 40.

It is also important that patients after robot-assisted prostatectomy experience less pain, have a shorter convalescence, and stay in the hospital for a shorter time.

Is the effectiveness of the robotic method confirmed by scientific research?

There are many such studies, over the last 20 years, over 38,000 scientific papers have been published, for example in a publication summarizing research and treatment effects in patients with locally advanced prostate cancer in 2015-2018, which was published in August 2020 in the prestigious journal European Urology , the advantage of surgery using a robot over other surgical techniques such as laparoscopy and open surgery was confirmed.

The statistical data on postoperative results presented there showed that in a group of 80 patients, only 11 required further treatment (radiotherapy and/or hormone therapy), i.e. in most cases, oncological purity was achieved and all cancer cells were removed.

At the Neo Hospital hospital in Krakow, the “Collar” method is used, among othersaboutra minimizes the risk of leaving cells postoperativelyaboutcancer hands, the so-called positive marginaboutIn…

Research proves that this method is extremely effective. When it was used in the case of cancer limited only to the prostate, there were no cases with a positive margin around the top of the prostate (i.e. oncological purity was achieved, the cancer was removed), and in the control group, i.e. in the case of using another technique, it was 8.9 percent. In the case of locally advanced cancer with infiltration of the seminal vesicles, subsequent studies have confirmed better results of surgery using a robot compared to traditional methods.

It is worth emphasizing that robotic surgery is often the only treatment option for patients who have been disqualified from surgical treatment using other methods. We have such patients at the Hospital on Klinach, they are usually patients after other, previously performed abdominal procedures, who have developed numerous adhesions that make it difficult to reach the surgical field using traditional methods. The robotic system enables the removal of the prostate, during which adhesions after previous procedures are also removed.

You perform about 450 such operations a year. You gained experience as you performed them, and you also participated in training in foreign centers. In what way?aboutb robotic surgery has changed the methods of training doctors?

Robotics has revolutionized the way doctors are trained. The traditional training method is based on the doctor’s contact with a mentor who passes on his knowledge, and the doctor learns from him by performing procedures. Currently, training centers have simulators that allow them to verify the operator’s skills before he or she starts performing operations on patients.

Such training can be compared to that of pilots, who must master the necessary procedures using simulators before they can take over responsibility for hundreds of passengers. During them, mistakes made by the doctor can be detected and corrected. The next stage is training in certified centers with the appropriate amount of experience and a robot with a set of two consoles. A mentor sits at the second console and constantly corrects the trainee’s movements.

The new training system is validated and based on the principle of proficiency-based progression, i.e. progress training based on proficiency. For this purpose, the operation has been divided into stages to which a specific methodology is assigned. Educational outcomes are objectively assessed. Thanks to this, doctors trained in this way are excellent specialists and can effectively help patients.

The new curricula have become the subject of scientific research and have been verified, which is why we now have materials that show the effectiveness of the new approach. One of the latest publications performed a meta-analysis of the results (JAMA Surg. Published online September 15, 2021. doi:10.1001/jamasurg.2021.4414). They show that, compared to traditional training, participants of proficiency based progression (PBP) achieved much better results. This method of training reduced the number of execution errors by as much as 60 percent and shortened the procedure time by 15 percent. However, the number of correctly performed steps in the treatment procedure was 47 percent higher.

As a member of the board of the European Society of Urology – Robotics Section (ERUS), I am responsible for the development and implementation of these new training programs.

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