Will da Vinci’s Supremacy of Robotic Surgery End?

• 28 Jul 2020 10:20:14 AM
• |Lap/Robotic Urology

Dear All,

We, Urologists in India, are aiming to embrace Robotic Assisted Procedures and in recent years many centres across in India have acquired Robots and at present the monopoly of Intuitive are evident.

They have monopolized the field from the inception of Robot Assisted Surgeries. They also authored the non development of many other Robots by other manufacturers by timely interventions.

The idea of Robotic Technology for Surgeries commenced in 1990 when Stanford Research Institute developed a prototype which caught the imagination of some notably Defense Advanced Research Projects Administration (DARPA).

Frederick Moll, a surgeon was impressed with the technology and became acquainted with venture capitalist John Freund in 1995.  Together with engineer Robert Younge, Moll and Freund began their enterprise to improve minimally invasive surgery—Intuitive Surgical – da Vinci System. The da Vinci surgical system was commercialized in 1999 in Europe, and a year later came to the U.S, In June 2000.

They introduced modified platforms needed and suited for various varieties of Surgery and in May 2018 introduced the SP Platform.

The system features three, multi-jointed, wristed instruments and a fully wristed 3D HD camera. The instruments and the camera emerge through a single canula and are properly triangulated around target anatomy to avoid external instrument collisions. Surgeons control the fully articulating instruments and camera on the same surgeon console as the da Vinci X and Xi systems.

After nearly two decades holding a near monopoly on the surgical robotics market, new competitors are emerging for Intuitive. TransEnterix Surgical Inc. won FDA approval for its Senhance Surgical Robotic System in 2017. At the time, it was the first new entrant into the abdominal surgical robotic field since 2000. The Senhance augments laparoscopic surgical instrument and endoscopic camera precision, visualization, and control. It utilizes an open architecture so hospitals and surgeons can leverage existing technology in the OR with the Senhance.

Senhance and da Vinci are similar in many respects. Both allow surgeons to perform high-precision surgeries from workstations near the patient by controlling robotic arms. Both target similar procedures. However, there are also some differences that could be significant advantages for TransEnterix.

One of those differences is that the Senhance system incorporates haptic feedback. The da Vinci system does provide subtle physical feedback to surgeons holding the controls, but it doesn't go nearly as far as Senhance does. 

Another key difference between the two systems is that Senhance allows the surgeon to control the camera mounted on the robot arms by moving his or her eyes and head. Da Vinci doesn't support this functionality.

Perhaps the biggest draw for hospitals, though, is that Senhance's instruments are reusable. This makes TransEnterix's system more cost-effective over the long run. By comparison, Intuitive Surgical makes more money from selling replacement instruments and accessories than it does from selling new da Vinci systems. 

Initially, Senhance system was used for Gynaecological and other abdominal surgeries and not for Urological procedures notably RP. This scenario appears to be changing with the publication (Published Online July 25^th) of ‘Extraperitoneal RP with Senhance Robotic Platform first 40 cases’ (Article provided).

There are many newer Robotic technologies likely to enter the market in near future leading us even to consider Microbots as a reality. Jens J. Rassweiler et al (2017) published an excellent article addressing ‘Future of Robotic Surgery in Urology’ in which they have addressed most of the competitors for da Vinci.

https://bjui-journals.onlinelibrary.wiley.com/doi/pdf/10.1111/bju.13851 (PDF available)

This article is complemented by another article published in 2020 by an article by Karl Khandalavala, Dmitry Oleynikov* et al (2020) on ‘Emerging Surgical Robotic Technology Progression towards Microbots’.

http://ales.amegroups.com/article/viewFile/5499/pdf

Reading together, one can appreciate the competition that Intuitive with da Vinci is likely to face in near future. So far da Vinci Robotic systems have resisted all newcomers from entering their monopoly.

The Robotic war is bound to escalate. At present it is like ‘David fighting Goliath’. In the mythology, as is well known David defeats Goliath but in the present Robotic War can this happen. With the penetration that Intuitive had in the past 2 decades, it is unlikely a dramatic change will occur in near future. With most Robotic Urological Surgeons used to da Vinci Platform with its modifications are unlikely to make any changes into other systems in near future. The cost of procuring a Robotic system is very prohibitive even for the most affluent countries; they are not likely to replace them with newer systems that are likely to enter the market. But who knows the reality. If these new entrants can make a foray into the field by proving their ability in the few centres they have entered, then it could become another story. Goliath appears to be winning the war at present but it could be possible that David will win eventually.

With warm regards,

Venu

Comments(3)

• 

  Ravindra Sabnis

  30 Jul 2020 09:43:29 AM

  Respected Sir, 

  You have given a very nice review of how system has started & what is current status today. 

  New robot is coming, almost come, it will be available any time ......all these comments we are hearing for last many years. I know few years back, there was discusssion, someone was buying the robot & he was advised by few pundits that wait , new better & cheaper robot will come . But reality we know, nothing has yet come. 

  However that does not mean, new system will not come. Enormous efforts are being done by giants like google, Johnson & johnson to take lead in this field. Many prototypes are ready. it may come , but noone knows when. 

  Biggest problem is that, Intututive has registered so many patents, that it is difficult to formulate new. US laws are such. In India by now 1000 companies would have copied the robot & prices would have crashed. 

  Often it is said that patent registration is expiring - which is also misleading. What is expiring is primitive or first model. However company is making multiple patent every year. 

  There has to completely out of box thinking to make new robotic system & google & Johnson are probably doing that. Google as you know is far bugger company & has capacity to do that . They are also working on Artificial inteligence. With driverless car becoming a reality, A robitic system without a surgeon is going to be a reality, where in every thing will be fed, AI will take lakhs of feed back every fraction of second & will carry out surgery. Surgeons job is only to stop it.  WIth 5G already ready, & speed of ineternet is going beyond imagination, lag will in microsecond. SO person sitting on console in america & doing surgery in India is now not an imagination but a distinct reality. Those who are doing residency in Urology now, they will be master of this. They will have to be part & parcel of new era of robotic surgery 

  
  

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  Arvind Ganpule

  30 Jul 2020 06:43:39 PM

  Respected Sir

  Your article is as usual very thought provoking and brings forth a number of issues, a robotic platform user faces in this part of the globe. A few points worth noting:
  

  1.The need of the hour is to "democratise surgery'. I mean any new technology/startup/organisation should have the willingness and capability to reach  the "last man" standing. Unfortunately this does not happen.Any new technology eager to be on the forefront or enter the market has to keep this thing in mind.With the current exorbitant costs of  robotic disposables and reusables this is not possible unless the programme is heavily subsidised or is operational in a government set up.
  

  2.The common perception is that once new platforms would enter the market , it would dismantle the monopoly and bring down the cost. The coming years would make us realise, if this will be a truth or a remain a dream.The pendulum could swing either ways.

  3. Last but not the least,Malcom Gladwell in David and Goliath had quoted."The act of facing overwhelming odds produces greatness and beauty". We all agree the  potential new entrants are facing overwhelming odds but naturally their persistent efforts would  produce something formidable  which is beneficial to all stakeholders.

  
  

  
  

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  Ravindra Sabnis

  30 Jul 2020 07:56:52 PM

  Somehow now a days market forces & commercial aspects are so vital that companies try to monopolise their researched items. They do not want to be copied by others . Their argument is that, the amount that they put in for R & D needs to be recovered & more & more money needs to be pumped to do further research. However I feel there should be balance . New technology must reach common man. Researching cheaper technology is of paramount importance in terms of mass benefit. because mobile is cheap - it has reached masses & technology has become useful to mankind. Similarly as stated by Dr Ganpule, unless Robot becomes cheap & affordable, it will not be possible to be utilised by all. IN vast country like India still after decade of robot coming to India, still we have only 70 installations - which itself speaks how restricted it is . 

  Monopoly makes things costly. Unless another robot comes in, Da vinci will not reduce its cost. I am quite sure in 1/3 cost, they will be still profitable. We have seen this so many times. Medicines when are introduced are very costly but suddenly when competitors are there, they become cheap. Even Enzalutamide now is available for 20000 per month. which was un imaginable few yrs back. 

  Threat of another robot itself will make Da vinci reduce its cost by half. & therefore it is very much necessary that new robot has to come.