Robotic Cancer Surgery

Overview

The word "robotic" makes many families picture a machine operating on its own. That is not what happens. In robotic-assisted surgery, the surgeon sits at a console in the operating room, looks into a three-dimensional, magnified view of the inside of the body, and moves the instruments with hand controls. The robot copies those movements through thin arms passed into the body through small cuts. It does nothing the surgeon does not direct.

It is a form of minimally invasive surgery, the same family as laparoscopy (keyhole surgery with long, straight instruments and a camera). The difference is in the instruments. Robotic instruments have small wrists that bend and turn more than a human hand can inside a narrow space, and the system filters out any tremor. This helps most in tight, deep areas such as the pelvis, where the prostate, rectum and womb sit.

A robot is a tool, and a tool does not decide the result. The surgeon's skill, the stage of the cancer and the hospital team matter more. We arrange the quotes, travel and stay, and the surgical team decides whether robotic, keyhole or open surgery is right for you.

Who needs it

Robotic surgery is used for many operations where the cancer can be removed through small cuts. Common examples include:

• Prostate cancer: removal of the whole prostate (radical prostatectomy). This is the operation most often done robotically.
• Kidney cancer: removal of the tumour while keeping the rest of the kidney (partial nephrectomy), or removal of the whole kidney.
• Bladder cancer: removal of the bladder (cystectomy) in some centres.
• Colorectal cancer: operations on the bowel, especially the rectum, which lies deep in the pelvis.
• Gynaecological cancers: hysterectomy (removal of the womb) for womb cancer, and some ovarian and cervical operations.
• Lung cancer: removal of a lobe of the lung (lobectomy) or a smaller segment.
• Head and neck cancer: TORS (transoral robotic surgery), where tumours of the tonsil or the base of the tongue are removed through the open mouth, with no cut in the neck for the tumour itself.

Robotic surgery is not right for everyone. Very large tumours, cancer that has grown into nearby organs, a lot of scar tissue from earlier operations or certain heart and lung problems may make open surgery safer. Lying tilted head down for a long time during pelvic surgery is also hard for some patients.

It is not always the better choice either. In early cervical cancer, a large international trial published in 2018 found the cancer came back more often after minimally invasive radical hysterectomy (robotic or laparoscopic) than after open surgery, and many cancer guidelines now advise open surgery for that operation. Your surgeon should be able to tell you what the evidence shows for your cancer.

For a quote, hospitals usually ask for the biopsy report, recent scans with the images (CT, MRI or PET-CT), blood tests, and details of any earlier surgery or treatment. For prostate cancer, add your PSA results (a blood test) and the MRI of the prostate. You can name your preferred country on the quote form, or ask hospitals in several countries to quote for both robotic and standard keyhole surgery.

How it is done

Before the operation

You first meet the surgeon, who reviews your scans and may order more tests, such as a CT, a heart tracing (ECG), breathing tests or an anaesthetic check. Many cases go to the hospital's tumour board, a meeting where surgeons, oncologists, radiologists and pathologists agree a plan together. Bowel surgery often needs a bowel preparation the day before.

In the operating room

You have a general anaesthetic, so you are asleep throughout. The surgeon makes several small cuts, usually under 2 centimetres each. For operations in the abdomen or pelvis, the abdomen is filled with carbon dioxide gas to create working space. The robotic arms are docked to small tubes placed through the cuts. The surgeon then moves to the console, while an assistant stays at the bedside. One cut is usually made a little larger at the end to remove the tissue.

Robotic operations often take longer than open ones, and the setting up adds time. If bleeding or other problems make it unsafe to continue, the team may change to open surgery. This is called conversion. It is a safety decision, and you should ask about it before you agree to the operation.

Benefits and limits, stated fairly

Compared with open surgery, the likely benefits are smaller wounds, less blood loss, less pain, fewer days in hospital and an earlier return to walking. Compared with skilled laparoscopic surgery, the difference is often smaller, and for many operations long term cancer results are similar.

The limits are real. Robotic surgery costs more, partly because the system and its instruments are expensive. Most systems give the surgeon little or no sense of touch, so they rely on what they see. Not every hospital has a robot, and those that do may not use it for every operation.

Recovery and how long you stay

The hospital stay depends on the operation. After robotic prostate or kidney surgery, many patients go home after one to three days. Bowel surgery usually means four to six days, and TORS can mean several days because swallowing needs to be checked first. You are encouraged to walk on the first day, which helps prevent blood clots and chest infections.

After prostate surgery you go home with a urinary catheter (a tube that drains the bladder), usually for 7 to 10 days. Some leaking of urine is common at first and usually improves over weeks to months. Pelvic floor exercises help, and the team will show you how to do them.

Plan for about two to three weeks in the country in total. That allows a few days for tests and consultation, the hospital stay, and then time in nearby accommodation until the stitches are checked, any catheter is removed and the pathology report is back. The pathology report shows whether the edges of the removed tissue are clear of cancer, which affects whether you need further treatment.

Flying soon after abdominal or pelvic surgery raises the risk of blood clots in the legs. Many surgeons ask patients to wait about 10 days to two weeks, longer after lung surgery or if there were complications. On a long flight, walk the aisle, drink water and wear compression stockings if advised. Your coordinator books the return only once the surgeon gives a date.

Questions to ask your doctor

• Why do you recommend robotic surgery for me, rather than keyhole or open surgery?
• How many robotic operations of this exact type do you perform each year?
• How often do you need to convert to open surgery, and what would make you do that?
• How long will the operation take, and how long will I stay in hospital?
• What are the most common complications, and how are they treated here?
• For prostate surgery, what should I expect for urine control and erections, and when?
• When will the pathology report be ready, and will I need radiation or drug treatment after?
• When can I fly, and can my follow up checks be done in my home country?

A surgeon who answers the second question plainly, with a number for the operation you need, gives you something useful to compare between hospitals. Ask the same question to every team, and write the answers down beside each quote.