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Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And today, our discussion focuses on robotic surgery in organ transplant. Joining me is Dr. Michael Hanaway. He's the Surgical Director of Kidney Transplantation, and he's a Martha Tankersley Endowed Professor at UAB Medicine.

Dr. Hanaway, thank you so much for joining us today. I'd like you to start by giving the primary applications of robotic surgery in organ transplantation today. Tell us a little bit about the success rates that have been observed compared to traditional techniques and a little bit about the evolution of how this came about.

Dr. Michael Hanaway: Well, thank you for giving me the opportunity to speak to everybody today. I think the biggest use of robotics in organ transplantation right now is the use of a robot to perform donor nephrectomies. And so, these are procedures where somebody is going to donate a kidney to a friend or a loved one.

Traditionally, these procedures have been done laparoscopically, I would say over the last 25 years or so. That has become kind of the standard of care in the last 25 years, but is changing now to become, I think, primarily a robotic procedure. I definitely think that within the next five years, robotic procedures to perform donor nephrectomies will be the standard of care in place of laparoscopic techniques.

Melanie Cole, MS: So, have you seen an improved outcome in terms of recovery time and success rates? As you're talking about donor nephrectomies, have you seen a shorter recovery time, better outcomes for the donor? And then, we can also talk about the recipient.

Dr. Michael Hanaway: I think that the numbers that we're talking about for the number of procedures that have been performed are still relatively low. In the United States, this is really the entry point, I think, for robotic surgery and transplantation. So, I don't think that we're talking about a massive experience to date. I think it's difficult to look at those numbers and to look at those numbers of patients and say there's a dramatic difference that's obvious and data that exists to indicate that there is a distinct improvement in outcome for the patients. I think that they're relatively equivalent to the laparoscopic procedure in terms of postoperative pain, in terms of hospitalization time and in terms of recovery time afterwards. I think it would be a little bit premature to say that it's a much better procedure from a postoperative recovery point of view for the donors. But I would say that it is certainly no worse.

Melanie Cole, MS: What about for the recipients? What's going on in robotic surgery for transplantation for kidney transplants?

Dr. Michael Hanaway: I think the robotic procedure to perform the kidney transplants is just over the horizon. I think this is the next step for almost every program. I think most programs are beginning to venture into robotic surgery in the area of transplantation. They're beginning with the donor nephrectomies, because that's a procedure that many institutions have done laparoscopically for a very long time and are very, very good at it.

It's an easy jump to perform that procedure robotically, because it's really just using better tools to do the same operation. So, I think that that's a good entry point for most programs. They can become more comfortable with the robot, they can become more comfortable with the techniques, they can get over the learning curve of learning how to do procedures robotically. But really, the next step, which I think is going to have the broader application in robotics, is going to be the ability to do kidney transplants robotically. And I think that's going to have some distinct benefits for the patients when the procedures are done that way.

But that's a very different operation than the way we do it now, to jump from doing an open procedure to a robotic procedure. So, I think that that's going to take a little bit more time. It's going to require, more patients to get over that learning curve .And I think it's going to be a little bit longer before that becomes the standard of care.

Melanie Cole, MS: Dr. Hanaway, you mentioned the learning curve, and that leads me well into my next question. So speak about that training process for learners for your other physicians and your transplant physicians as far as robotics. Tell us a little bit about what's involved in the learning curve. The training process, I imagine, is arduous. But as you say, would take more patients so that it's going to be something that we're looking at in the horizon. But speak about that just a little bit.

Dr. Michael Hanaway: When you think about the group of surgeons who might be doing these procedures, you've got some more experienced older surgeons who haven't done a lot of robotic procedures, and you've also got a lot of younger people who've trained robotically during their residency and their fellowship training. So, they're a little bit more adept at it to begin with. So, you've got the old dogs trying to learn new tricks, and you've got the younger people who are already pretty accustomed to this. So, you've got two different groups, and I think the learning curve's going to be a little bit different for each one of them.

I think for the older experienced surgeons who haven't done a lot of robotic procedures, it's probably going to take them a little bit more time and a little bit more ramp up before they get over the top of that learning curve. The younger people who have a little bit more experience with a robot are going to be a little more facile at the beginning. So, it may not take them quite as long, but I do think that it may take anywhere from 30 to 60 to even 90 procedures before people have really reached the top of the learning curve. And that's sometimes difficult to get. That's a lot of cases.

Melanie Cole, MS: Are you teaching it?

Dr. Michael Hanaway: We're beginning to teach it, yes. I think we at UAB are now becoming comfortable enough with this that we're beginning to teach our fellows who have a great interest in this, and something that I think they need to learn how to do. These are things that I imagine in five years, as I said, will be the standard of care for this procedure. So, they need to learn how to do this, to be able to be marketable when they try to get a job.

Melanie Cole, MS: Is there anything interesting, Dr. Hanaway, in the robots themselves, that updated technology as they have evolved and they're entering so many realms now of the medical and surgical community? Is there anything interesting you'd like to share? And while you're telling us that, we always talk about the benefits to the patient, but what about to the surgeon themselves?. I mean, there's ergonomics, there's a lot of things involved. Speak a little bit about the robot technology.

Dr. Michael Hanaway: Well, the robot technology has really evolved and changed. I mean, you really think about the evolution of a cell phone. You know, going from the Nokia flip phones in the '90s to what we have today. The first robots came out really for mass use in 2000. So, the technology's been there for quite some time. But it's evolved over time. First robot in 2000, and updated one in 2002. The sort of the mid-level was the da Vinci SI that was FDA approved in 2009. And the current one, which is kind of the workhorse of all the robots, is the da Vinci XI, which is the one that almost everybody uses right now.

The next generation to come out is coming out fairly quickly, and that's what's called the da Vinci DV 5, or the Intuitive DV five. And this has a lot of improvements. This is a lot like going from that Nokia flip phone to the iPhone 15. The number of features that it's got are pretty remarkable.

I think, for us, the biggest thing is that the newest robot has what's called tactile or haptic feedback. So, one of the things that you have with a robot that is limiting is you can't really feel tension. If you were to grab a tissue and pull on it or retract it, you don't really have a feel for how hard you're pulling on it. With the new DV 5 robot, it does have that. So in some ways, I think people think it'll be much safer for the patient because you'll really have that sense of feel that you would with your hands that you don't with the current robots. So, I think that'll be really important for everything moving forward.

In a lot of ways when I think about the question of robotic surgery and transplantation, transplantation has been kind of late to the party here. I think if you look at other areas of surgery like Urology and GI surgery, they've been in this and very active at this for probably 10 to 15 years, especially in Urology. So, they really have a better feel of how the robot fits into their practice and they've been using it very effectively for a long time. Transplant has come a lot later. So, I don't think it's a question necessarily of what can a robot offer in transplantation today, because it's really just at the beginning, but really trying to look over the horizon and figuring out exactly what a robot's going to offer transplantation five to 10 years from now. And really, you got to get started. I think starting with the donor procedures, the donor nephrectomy procedures is a good entry point, but that's really not the endpoint to this. The endpoint to this is being able to do most transplant-related procedures robotically. I definitely think that we'll get there, a little slower than maybe somebody else who started earlier, but we'll definitely get there in time.

When you think about the benefit for the surgeons, I think there's several. But talking to colleagues, I think, what's good for the surgeon is ultimately going to be good for the patient. And I think that the things that are a big improvement with robotic procedures compared to laparoscopic procedures is that the visualization is just markedly, markedly better. Much like going from an old cathode ray tube TV in the '50s or '60s to the current, high definition TVs, it's that much better. And the better you can see and the better you can see at different angles, I think the safer it is for the patient. When you look at laparoscopic procedures, the instruments that you have are fairly rigid. They don't bend, they don't torque, they have no elbows in them. It's kind of like using chopsticks. But really with the robot, the arms and the instruments all hinge kind of like your wrist would, and you can manipulate them much like you would your fingers. So, it's dramatically better in that regard than the laparoscopic procedures that we were doing.

Ultimately, like I said, I think this is safer for the patient. I think it will take a little bit more time and a greater number of patients for us to really demonstrate the data that shows the benefit with robotic procedures. But I do think it will. It took probably 10 to 15 years for that data really to become available, converting from open to laparoscopic procedures. And it may take that long for robotic procedures too.

Melanie Cole, MS: This is fascinating and such an exciting time in your field. Dr. Hanaway, as we wrap up, you mentioned that this is on the horizon. What would you like to see in your opinion happen as far as research in transplantation and robotic surgery? What do you see happening? What would you like to see happening on the horizon?

Dr. Michael Hanaway: Well, I'd really like to see the procedure grow. I really like the use of robotics to improve not just at UAB, but really in all transplant programs. I definitely think there's some huge advantages with robotic surgery that haven't been realized yet, but I think once it's fully incorporated into our armamentarium, I think that you're really going to see things that we couldn't do before.

I think one of the areas of robotic surgery that really has taken off is some GI procedures and some urology procedures because it really allows the ability to see in difficult areas, areas that are really not that easy to see either laparoscopically or through an open technique. And so, it's kind of revolutionized those procedures in a lot of ways. And I do think that there are procedures that we struggle to do open and we struggle to do laparoscopically that will be much easier to do robotically. And I think that we really need to expand everything we do into a robotic platform.

I do think that we'll get to the point in 10 to 15 years where people don't do a lot of open procedures anymore. People don't make a big incision to do a procedure anymore. It's almost all done robotically. I think you're seeing a lot of that in some of the traditional General Surgery areas, Cardiothoracic areas, Urology areas, and I do think you're going to see that in transplant too. It's taken a little bit longer to get started.

Melanie Cole, MS: Thank you so much, Dr. Hanaway, for joining us today and sharing this advanced technology and what's going on in the world of robotic surgery and transplantation. Thank you again. And for more information, you can always visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole. Thanks so much for joining us today.