“Robotic surgical oncology will not become available until US monopoly is broken up”
Professor Cemil Uygur about the future of oncological surgery
At the end of May, Cemil Uygur, an oncourology doctor with more than 20 years of experience, member of the American (AUA) and European (EAU) urological associations, visited Kazan. In Russia, he is known as a surgeon who recently operated on chief oncourologist of Tyumen Oblast Nikolay Kazeko in Istanbul. Since 1994, the doctor has performed more than a thousand surgeries, most of which — with the help of robots. In recent years, the Turkish specialist has practically not undertaken simple open operations, using the American development of da Vinci. Cemil Uygur is an ardent supporter of the theory of robotic development of surgery and one of the few European doctors accredited to work with the equipment. In the interview with Realnoe Vremya, the doctor told about how monopoly inhibits progress and gave a forecast of the dynamics of prices for robotic operations, which now start from a million rubles.
It is believed that surgery is almost the most conservative area of medicine, and all innovations in it take root very slowly. Are there any changes in cancer surgery, have any developments appeared that changed the market?
I think that it is wrong to tell about the conservatism of surgery, including cancer one. Surgery is not the most conservative medical field, it is a myth. But medicine, in principle, does not tend to trust unverified, non-certified innovations, to start mass use of any technologies that have not passed tests. Certification in most developed countries of the world, just introducing new technologies to the world, is a very long and complex process. It can be said that to some extent the latest massively implemented novelty, which has changed oncosurgery and surgery in general in many ways, as well as many areas of medicine, is the da Vinci robot. But here it is necessary to make a reservation about the “mass” character. This is, let's say, the technology not available to everyone.
You're talking about the specific robotic equipment, produced by a particular company, not a technology…
The thing is that da Vinci is the only one of its kind, so to say, the monopoly of the American company Intuitive Surgical Inc. That's the question and the problem.
Surgery is not the most conservative medical field, it is a myth. But medicine, in principle, does not tend to trust unverified, non-certified innovations, to start mass use of any technologies that have not passed tests
What is da Vinci and what operations are carried out with it?
da Vinci — it is a robotic surgical system, in fact, four interactive “hands” with different variations of attachments and tools, scissors, scalpels, clamps, which are controlled with the help of console by a surgeon, who at the time of the operation is in the same room as the operated patient. The design of “the hands” of da Vinci allows to make movements and all surgical procedures much clearer and more accurate. For surgeons who previously had to make precise cuts, standing with a scalpel in their hand, now with da Vinci, it is more comfortable to work, the viewing angle is greater. With this robot, they can perform very complex operations with a minimally invasive approach, that is, to minimize the number of cuts. This reduces the number of medical errors, significantly reduces the time of rehabilitation of the patient after surgery, there are all the advantages.
About a third of operations using da Vinci are urology and gynecology, thoracic surgery, especially associated with malignant tumours. The robot was in many ways a discovery for oncologists because it allowed to carry out ectomy of high complexity, removal or partial amputation, which not every surgeon previously undertook because of too high risks.
How did this monopoly da Vinci develop? Did other companies present similar developments?
Here it is necessary to clarify: now the robotic equipment, which bears the name da Vinci, is really produced by Intuitive Surgical Inc. The foundations of robotic surgery were laid by the US Department of Defense in the late ‘80s — early ‘90s, by one of its offices, which is engaged in research for the needs of the army. They tried to create a robot with which it would be possible to carry out operations in difficult conditions, and remotely.
At some point, the project was curtailed, and the development was bought by an American company, now known as Intuitive Surgical, specially opened for this project. It took several years for testing and prototyping, and eventually, da Vinci was created. Initially, it had three “hands”, the camera was much worse, but over time it improved and in 2000 was certified, it became possible to use it in the United States.
As for the second part of the question, then the research, of course, is underway — in the US, Germany and Japan. But none of the prototypes, none of the projects have even shown about the same results as da Vinci shows. No other has managed to do it the criteria of accuracy of design, software. Today we can say that there are no analogues in the world, and this is not very good.
All across Europe, there is no even half of the number of da Vinci, which the United States has. In the countries where medicine is state-owned and maintained by taxes, of course, the probability of acquiring da Vinci reduces
When you spoke about “the technology not available to everyone”, did you mean the cost of the device?
Absolutely. Different versions of da Vinci, of course, were evaluated by the developer in different ways, but the approximate price per unit — console, tools, robotic “hands”, software — is about $2 million. Now this price has become even higher.
In addition, you need to understand that da Vinci is a smart robot, and this mind is used, I think, to increase profits of Intuitive Surgical Inc. In addition to that the company is engaged in the maintenance of its equipment, which is understandable and logical, “one-time” tools are used to work with da Vinci — nozzles and attributes to perform the operations themselves. They are disposable not in the literal sense of the word, they can be used repeatedly, but a very limited number of times, conditionally, 10 operations. Once this number is reached, the da Vinci system does not allow the tool to be reused. You need to purchase a new one, and it is about 1,000 US dollars. Although, I think it would be possible to use at least twice as long.
What is the cost of the simplest operation using da Vinci?
I cannot tell about the cost of operations using da Vinci for patients, prices — outside my area of competence, but it is a considerable amount we asked (the cost of operations specified in the introduction to the interview, we enquired in the Kazan office of the Turkish clinic, which employs Dr Uygur — editor’s note). Because of the high cost of this robot and consumables to it, the cost of operations will not be able to decrease for sure, otherwise, such investments simply will not pay off.
Are there data on the geography of da Vinci distribution — which countries of the world are already familiar with it, and where it remains an unattainable technological novelty?
It is obvious that it has received the greatest distribution in the USA. As far as I know, almost half of the clinics are equipped with da Vinci there. It's easy to explain: first, it is clear that the robot as a domestic development is cheaper for them. Second, it is necessary to take into account the structure of social systems in different countries. In the US, medicine is in the vast majority is private, there are many clinics with good funding, which are able to buy such technologies and invest in equipment because it quickly pays off.
All across Europe, there is no even half of the number of da Vinci that the United States has. In the countries where medicine is state-owned and maintained by taxes, of course, the probability of acquiring da Vinci reduces. To be honest, in Russia I cannot say (according to official data of the supplier company of da Vinci in Russia, in the country at the end of 2017 there were 29 units, in the US at the same time — about 3,000 — editor’s note).
One should understand that robotic oncosurgery, as well as all robotic surgery in general, will not become more accessible until the monopoly of da Vinci is broken up by other companies, presenting comparable in level and efficiency developments and reducing the prices
How many da Vinci units are currently operating in the world and how many doctors have the skills to use them? As far as we know, this requires special training?
Currently, about 6,000 da Vinci units are working, on which about 10,000 doctors work. This is not many on the scale of the entire population of the planet and all those in need of such operations, so in many cases of cancer operations, we are faced with medical tourism.
What is the forecast for the development of robotic oncosurgery in the near future you would give? Can it become more accessible, at least in the perspective of 10-15 years?
One should understand that robotic oncosurgery, as well as all robotic surgery in general, will not become more accessible until the monopoly of da Vinci is broken up by other companies, presenting comparable in level and efficiency developments and reducing prices. We hear about certain successes in this area, but unfortunately, we're are not sure of that and it will not happen very soon, I think.