EQUIPMENT and TECHNOLOGY in ROBOTICS. Declan Murphy, Ben

UROLOGY ROBOTIC SURGERY

Arch. Esp. Urol., 60, 4 (349-354), 2007

EQUIPMENT AND TECHNOLOGY IN ROBOTICS.

Declan Murphy, Ben Challacombe, Tim Nedas, Oussama Elhage, Kaspar Althoefer1, Lakmal Seneviratne1 y Prokar Dasgupta.

Department of Urology, Guy’s & St Thomas’ NHS Foundation Trust, and King’s College School of Medicine Department of Mechatronics1, King’s College London, UK.

Summary.- We review the evolution and current sta- INTRODUCTION tus of robotic equipment and technology in urology. We also describe future developments in the key areas of vir- We have reached an interesting time in the tual reality simulation, mechatronics and nanorobotics. ﬁeld of surgical robotics. Over the past 5 years the The history of robotic technology is reviewed and put imagination of patients and surgeons alike has been into the context of current systems. Experts in the asso- captured by the arrival of robotic-assisted surgery, ciated ﬁelds of nanorobotics, mechatronics and virtual telesurgical manipulators, and telepresence surgery. reality simulation simulation review the important future Robotic-assisted laparoscopic surgery in particular, developments in these areas. has dominated headlines and symposium procee- dings throughout the world in recent years, and lead to increasing patient demand for “robotic surgery”. Keywords: Robotic. da Vinci™. Technology. The bulk of this demand is due to the proliferation of Nanorobotics. da Vinci™ surgical systems (Intuitive Surgical, CA), especially in the USA where over 400 systems have been installed.

Urologists have been quick to embrace this technology and robotic-assisted laparoscopic radical prostatectomy (RALRP) is the most commonly performed robotic procedure performed worldwide. From 766 cases performed in 2002, over 48,000 are pro- jected for 2007 (1). This accounts for 39.5% of the radical prostatectomy market in the USA.

But the monopoly which the da Vinci™ system holds has led to stagnation in the development of the ﬁeld of robotic-assisted surgery. This technology has its roots in the Stanford Research Institue (SRI) Green Telepresence System which was developed in the early 1990’s by Philip Green and other researchers at Declan Murphy, M.D. Stanford. The commercial licence for this technology e was subsequently acquired by Fredrick Moll, MD, to Department of Urology found Intuitive Surgical in 1995. The prototype da 1st Floor Thomas Guy House Vinci™ system was launched in 1997 and little has Guy’s Hospital been done to update the system since its Food & Drugs London SE1 9RT (UK) Administration (FDA) approval in 2000. Therefore the technology remains very expensive, very bulky, and

Correspondenc [email protected] somewhat outdated. 350 D. Murphy, B. Challacombe, T. Nedas et al.

This paper outlines the interesting developments whi- while ensuring very steady images. They also enable ch have led to the current status of robotic technology the concept of solo-surgery, dispensing with the need and equipment today. However, as much of this has for surgical assistants (11). been described before (2,3), we will concentrate on the very exciting future technologies in development, Master-Slave Systems: especially the areas of virtual reality simulation, me- It is the daVinci™ surgical system (Intuitive chatronics and nanorobotics. Surgical, CA) which has generated the most headlines with regard to robotic-assisted surgery. It developed Definitions and history: in the mid-1990’s from the SRI Green Telepresence A surgical robot has been defined as “a com- System, while a competitor, the ZEUS™ system (Com- puter-controlled manipulator with artificial sensing that puer Motion initially; now owned by Intuitive Surgi- can be reprogrammed to move and position tools to cal), was also undergoing clinical evaluation. This is carry out a range of surgical tasks” (4). Strictly spea- a master-slave system (“on-line” robot) rather than a king, the current popular surgical “robots” do not sa- true autonomous robot. The surgeon sits at a console tisfy this definition, and some authors have suggested remote from the patient, controlling 3 or 4 robotic the term “computer-assisted surgery” more accurately arms, which are docked through the laparoscopic describes the current generation of robotic devices ports. Three dimensional (3D) vision, 7 degrees of (5). A description of “off-line” and “on-line” robots freedom (DoF) of movement, and intuitive movements has been used to discriminate between machines ca- of the robotic instruments are among its proposed be- rrying out pre-programmed tasks and those carrying nefits over conventional laparoscopic surgery. The da out actions in response to ongoing commands (“mas- Vinci™ technology, its advantages and disadvanta- ter-slave” type devices) (6). Whatever the conclusion ges are described in detail elsewhere (3). of that pedantic debate, the term “robotic” is in popular use to describe the range of technology under Force Sensing and Tissue Identification - Current and discussion here. Future Developments With the advent of specialised surgical ro- The early pioneers in this field included Wic- bots such as the da Vinci™ surgical system, surgeons kham et al from Guy’s Hospital and Imperial Colle- are given advanced tools that assist during complex ge, London, who developed the PROBOT in the late operations and help to improve the outcome of sur- 1980’s. The PROBOT used a robotic frame, which gical procedures. These highly sophisticated robotic guided a rotating blade to complete transurethral re- devices incorporate advanced technologies such as section of the prostate (TURP). Initial studies on prosta- precision mechanics, enhanced stereo vision and ad- te-shaped potatoes were followed up by clinical trials vanced motion control algorithms enabling tremor-free in patients to demonstrate safety and feasibility of the and intuitive handling of the operating tools. However, technology (7). This was a truly autonomous device there are limitations. Most notably, the surgeon loses (“off-line robot”), satisfying the definitions outlined all tactile sensation when operating with the aid of a above. However convincing differences over conventional TURP were not demonstrated.

Other urological robots have included the percutaneous renal access robot, PAKY-RCM which demonstrated superior accuracy but longer operating (access) times when compared to humans in a rando- mised control trial of transatlantic tele-robotics (8,9).

Robotic laparoscope manipulators: The development of laparoscope manipulators such as the Automated Endoscopic System for Optimum Positioning (AESOP™, Intuitive Surgical, CA) and EndoAssist™ (Armstrong Healthcare, UK) has certainly found a niche in laparoscopic urological procedures. These devices hold the laparoscope under voice, pedal or infra-red motion control and provide steadier images with less instrument collisions than a human assistant (10). These are particularly useful in procedures such as laparoscopic radical FIGURE 1. Indentation device employing wheeled prostatectomy, freeing the assistant to use 2 ports, probe for rapid soft tissue characterisation. 351 EQUIPMENT AND TECHNOLOGY IN ROBOTICS. robot. The sense of touch which is readily available tems. Exploiting this, a three degree-of-freedom opti- during open surgery provides the surgeon with valua- cal fibre force sensor was used in an MR-compatible ble information about the operating site. The inability neurosurgery robot to measure tool-tissue interaction to palpate organs during an operation can lead to a forces (19). misjudgement of interaction dynamics between tool and soft tissue. Recent studies have revealed that the Accurate sensors and appropriate actuators lack of tactile sensation during robot-aided surgery that reconstruct the measured forces in the user’s can lead to an increase in tissue trauma and acciden- hand are both necessary components of haptic inter- tal tissue damage, and surgeons provided with for- faces that realise truthful remote touch sensing. An ce feedback significantly improve their performance alternative feedback mechanism is the use of force (12,13). sensors for the identification of soft tissue (i.e. areas of increased stiffness or softness) providing the sur- Current research at a number of research ins- geon with visual cues on the location and severity of titutes aims at equipping surgical robots with sensors any organ abnormalities. Attempts to identify tissue and feedback mechanisms to re-establish the surgeon have let to the development of a number of devices. with tactile perception. A uni-axial stretching device is used by Brouwer et al. to measure porcine tissue response both in-vivo Owing to advances in micro-technologies, and ex-vivo (20). Another device was developed to there is now a clear trend towards developing minia- investigate the in-vivo viscoelastic properties of tissue turised sensors that can measure the manipulation for- under uni-axial small deformations (21). A motorized ces at the point where the tool comes into contact with endoscopic grasper which was used to test abdomi- soft tissue. Recently, a surgical gripper at the end of nal porcine tissues in-vivo and in-situ with cyclic and a laparoscopic tool has been integrated with a stra- static compressive loadings is also described (22). in gauge sensor (14). The sensor’s hexapod structure A mechanical probe developed by the Harvard Bio- made from an aluminium alloy provides a light weight robotics Laboratory, attempts to identify the location and rigid solution to acquire force and torque signals and properties of tumours based on static indenta- along all six axes with a high resolution of 0.05 N tion tests (23). Recently conducted research at King’s and 0.25 N in radial and axial direction, respectively College London aims at the development of devices with a range of up to 20 N. A MEMS micro grip- that consider a series of distributions measured as a per driven by a piezoelectric actuator integrated with wheeled probe (see figure 1) slides across the tissue semiconductor strain gauges mounted on a microfa- surface. This approach departs from the previous one bricated elastic surface (flexure) has been developed of static indentations, allowing the identification of allowing soft tissue property characterisation and rea- whole regions of organ tissue in short time (24). listic palpation using a haptic interface (15). Nanotechnology: Advances have also been made in emplo- In the same way as the development of micro- ying piezoelectric materials to measure the contact technology in the 1980s has led to new tools for sur- forces at the tip of surgical tools. Micro-machined gery, emerging nanotechnologies will similarly permit force array sensors have been developed that can further advances providing better diagnosis and new be mounted on surgical tools (16,17). The developed devices for medicine. Nanorobots are expected to sensors claim to have a high sensitivity and linear be- enable significant new capabilities for diagnosis and haviour over a wide range of up to 15 N, allowing treatment of disease for patient monitoring and mini- realistic palpation feedback. mally invasive surgery (25,26).

Very promising results have also been achie- The ability to manufacture nanorobots may ved based on fibre optic measuring principles. Mi- result from current trends and new methodologies in niature force sensors can be created using fibre optic fabrication, computation, transducers and manipula- cables that carry light signals -which are modulated in tion. The hardware architecture for a medical nanoro- response to the applied forces- from a sensing region bot must include the necessary devices for monitoring to an opto-electronic converter. Recently, a 5-mm dia- the most important aspects of its operational workspa- meter force sensor integrating three fibre-optic sensor ce: the human body. elements into the tip of a surgical tool was developed. This sensor can measure forces along three axes with Teams of nanorobots may cooperate to per- a sensitivity of 0.04 N and a range of up to 2.5 N form predefined complex tasks in medical procedu- (18). The main advantages of these sensors are that res (27). To reach this aim, data processing, energy they are not affected by electromagnetic interference supply, and data transmission capabilities can be and compatible with magnetic resonant imaging sys- addressed through embedded integrated circuits, 352 D. Murphy, B. Challacombe, T. Nedas et al. using advances in technologies derived from nano- which are spread throughout every single organ or technology and Very Large System Integration (VLSI system comprising our body. design) (28). Complementary Metal Semi-Conductor (CMOS) VLSI design using deep ultraviolet lithogra- Factors like low energy consumption and phy provides high precision and a commercial way high-sensitivity are among some of the advantages for manufacturing early nanodevices and nanoelec- of nanosensors. Nanobioelectronics using nanowires tronics systems. The CMOS industry may success- as material for circuit assembly can achieve maximal fully drive the pathway for the assembly processes efficiency for applications regarding chemical chan- needed to manufacture nanorobots, where the joint ges, enabling new medical applications (30). Using use of nanophotonic, carbon nanotubes and nano- chemical sensors nanorobots can be programmed to crystals, may even accelerate further the actual levels detect different levels of E-cadherin and beta-catenin of resolution ranging from 248nm to 157nm devices as medical targets in primary and metastatic phases. (29). The appropriate interdisciplinary effort will im- Integrated nanosensors can be utilized for such a task pact on assembly nanodevices and nanoeletronics to in order to find different concentrations of E-cadherin build nanorobots (30). To validate designs to achieve signals (33-35). Beyond sensors, nanorobots may be a successful implementation, the use of Verification designed with appropriated space to carry chemo- Hardware Description Language (VHDL) is the most therapy for future cancer drug delivery. Such appro- common methodology utilized in the integrated circuit ach allows maintaining the drug carrier for a time manufacturing industry. Nanorobots can be useful in longer as necessary into the bloodstream circulation, a large range of biomedical applications for future avoiding the current resulting extravasation towards drug delivery applications, such as dosage regimens non reticuloendothelial-located cancers and the high based on predicted pharmacokinetic parameters for degenerative side-effects (36). chemotherapy in anti-cancer treatments (31,32). A range of different signals are directly correlated to Figure 2 demonstrates a nanorobot develo- specific medical problems. Chemical signals can ser- ped by Adriano Cavalcanti at the CAN Center for ve for medical target identification and actuation. A Automation in Nanobiotech, Sao Paulo, Brazil. single tumor cell can be characterized as a typical endothelial cell mutation with profound consequences The role of virtual reality simulation and robotics for patients suffering from cancer. Endothelial cells Minimally invasive surgery has long been as- have a large number of functions and may play an sociated with training issues. At their inception novel important role in human health. They also serve as surgical techniques must be learned by all grades of part of the structure forming the inside blood vessels, surgeon and once in wide use trainees must be able

FIGURE 2. A nanorobot employing nanosensors and FIGURE 3. Virtual reality simulator for laparoscopic re- advanced nanorobot control design features. Courtesy nal surgery. Courtesy of Mentice, Goteborg, Sweden. of Adriano Cavalcanti, www.nanorobotdesign.com 353 EQUIPMENT AND TECHNOLOGY IN ROBOTICS. to learn techniques safely. From this point of view the clear that such technology is in its infancy, at least in evolution of laparascopic surgery training provides a clinical surgery. The exciting potential developments good template for robotic techniques. in mechatronics, nanotechnology and virtual reality simulation outlined in this paper will lead to a huge Robot assisted procedures are complex ope- leap to the next generation of robotic technology and rations in which precision is vital, a far from ideal equipment. learning environment; hence the need for other training environments. Also with robot assisted surgery there is a huge infrastructure cost associated with ACKNOWLEDGEMENT both the docking robot and the operating console. It is not within the budget of many institutions to provide Special thanks to Dr. Adriano Calvanti of the a fully serviced training robot. CAN Center for Automation in Biotech, Sao Paulo, for his contribution on nanotechnology. Virtual reality has been shown to be effective for surgical training and has the beneﬁts of providing a reproducible operating environment in which metric parameters can be used to monitor operator perfor- REFERENCES AND RECOMMENDED READINGS mance (37,38). The ability to regularly incorporate (*of special interest, **of outstanding interest) individual patient anatomy into a surgical simulator and practice prior to surgery is only a few years away. 1. PEPLINSKI, R.: “Past, present and future of the Da Vinci robot”. 2nd UK Robotic Urology Cour- Virtual reality has shown itself as the premier se, 2006. training option in laparascopic surgery due to the 2. CHALLACOMBE, B.J.; KHAN, M.S.; MUR- evolution of haptic feedback instruments, these ins- PHY, D. et al: “The history of robotics in urolo- truments provide the operator with tactile sensations gy”. World J. Urol., 24: 120, 2006. akin to real surgery. *3. CHALLACOMBE, B.J.; KHAN, M.S.; MUR- PHY, D. et al: “Robotic technology in urology”. The prospect of using virtual reality to simu- Postgrad. Med. J., 82: 743, 2006. late robot assisted procedures is incredibly exciting. 4. DASGUPTA, P.; JONES, A.; GILL, I.S.: “Robo- From the development point of view haptic feedback tic urological surgery: a perspective”. BJU Int., is not required thereby removing a great deal of pro- 95: 20, 2005. gramming time and research from any project which 5. GUILLONNEAU, B.: “What robotics in urolo- is necessary in order to incorporate the increased gy? A current point of view”. Eur. Urol., 43: 103, number of degrees of freedom. For a VR robotic simu- 2003. lator only the operating console is required saving the *6. SIM, H.G.; YIP, S.K.; CHENG, C.W.: “Equip- expense of the robotic device. ment and technology in surgical robotics”. World J. Urol., 2006. Current developments in VR software are pro- 7. DAVIES, B.L.; HIBBERD, R.D.; TIMONEY, gressing towards the fully interactive abdomen and A.G. et al: “The development of a surgeon robot pelvis; the ability to alter the software to include robo- for prostatectomies”. Proc. Inst. Mech. Eng., 205: tic instruments is not far off. Figure 3 demonstrates a 35, 1991. VR simulator for laparoscopic renal surgery currently 8. CHALLACOMBE, B.J.; KAVOUSSI, L.R.; under development by Mentice, Goteborg, Sweden, DASGUPTA, P.: “Trans-oceanic telerobotic sur- and Guy’s Hospital, London. gery”. BJU Int., 92: 678, 2003. *9. CHALLACOMBE, B.; KAVOUSSI, L.; PATRI- The future of robotic surgery in conjunction CIU, A. et al: “Technology insight: telemento- with VR may include a surgeon “pre-operating” on ring and telesurgery in urology”. Nat. Clin. Pract. the same patient where the VR anatomy has been pro- Urol., 3: 611, 2006. duced directly from the patients imaging. 10. KAVOUSSI, L.R.; MOORE, R.G.; ADAMS, J.B. et al: “Comparison of robotic versus human laparoscopic camera control”. J. Urol., 154: 2134, CONCLUSIONS 1995. 11. ANTIPHON, P.; HOZNEK, A.; BENYOUSSEF, The introduction of robotic technology into A. et al: “Complete solo laparoscopic radical urology in the late 20th and early 21st century has prostatectomy: initial experience”. Urology, 61: heralded an exciting time for surgeons. However, it is 724, 2003. 354

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