This week, we’re going inside the operating theatre.
Professor Prasanna PS Sooriakumaran, a world-leading robotic surgeon with 2,000+ procedures under his belt, reveals the truth about the $200B robotic surgery market. Is Intuitive Surgical’s moat unbreakable, or is their “Ferrari strategy” leaving the door wide open for a new wave of competitors?
Get ready for a masterclass on the future of medicine, investing, and AI in the operating theatre.
🤖 Da Vinci 5 Deep Dive: Is the new 10,000x processing power an iPhone update or a true game-changer? Prof PS shares his hands-on experience and the real innovation: AI safety systems.
🎯 Intuitive’s $200B Blind Spot: The shocking “92/8 problem” – 92% of robots serve just 8% of the world. Why this opens the door for hungry competitors.
📈 The Patient Revolution: How robotic surgery turned a brutal 2-week hospital stay into a next-day discharge.
🔒 The Unbreakable Moat?: After 16 years, Prof PS reveals the brutal reality of switching systems (Hint: It’s harder than ditching a Ferrari).
🧠 AI: Enhancement or Replacement? Will AI make surgeons obsolete? Prof PS explains why AI’s real job is to prevent “schoolboy errors,” not replace human skill.
💸 The 84% Recurring Revenue Model: A deeper look at the “razor & blades” business model that makes $ISRG a cash-printing machine for investors.
🔮 The Tesla Parallel: Badger’s thesis confirmed! How Intuitive’s 17 MILLION procedure database creates an AI data moat just like Tesla’s driving miles.
🚀 Monkey’s Secret Stock: Krzysztof unveils his research on Procept Biorobotics – a company creating waves with superior outcomes, founded by an Intuitive co-founder. $PRCT
About Our Guest:
Professor Prasanna (PS) Sooriakumaran, MA(Oxon) BMedSci(Hons) BMBS(Hons) PGCertMedLaw ADCertClinInv(Cornell) FRCS(Urol) FEBU USMLE PhD, globally known as Prof PS, is a world-renowned Consultant Urological Surgeon, specialising in robotic surgery for prostate cancer at University College London Hospital (UCLH) and the Cromwell Hospital.
He is one of the world’s highest-volume robotic surgeons, specialising in complex, primary, and salvage prostate cancer procedures. What makes Prof PS a unique voice is his role as a leading academic and global proctor – he is one of the expert surgeons who trains other consultants around the world on how to master the da Vinci surgical system. He was also the clinical lead for the UK’s National Institute for Health and Care Excellence (NICE) on their first-ever guidelines for robotic surgery.
He is a Visiting Professor at the University of Oxford and the All-India Institute of Medical Sciences, and has published hundreds of papers, making him one of the foremost clinical experts on the real-world application, benefits, and limitations of the technology discussed in today’s episode.
You can find his work at professorps.co.uk and connect with him on LinkedIn at:
https://www.linkedin.com/in/prasanna-sooriakumaran-prof-ps-597a6b20/
Segments:
00:00 Welcome & The Robotic Surgery Revolution
03:29 Surgery Then vs Now: Whiskey to Robots
08:15 Are Robots Now Standard of Care?
10:50 Meeting the Intuitive Leadership
14:07 The Da Vinci 5 Hands-On Experience
19:00 Can Robots Make Anyone a Surgeon?
22:00 The Tesla Data Advantage in Surgery
26:00 AI Critique: Will Surgeons Lose Their Skills?
32:00 Radiologists Parallel & Learning Curves
34:00 Telesurgery: Technically Possible, Practically Complex
38:02 The Unsolved Problem: Preventing Basic Errors
40:50 The Moat Question: Can Competitors Catch Up?
46:30 Hospital Cost Pressure & Alternative Platforms
49:21 Switching Costs Reality Check
52:03 Video Games & Surgical Skill
53:34 Force Feedback: The Reverse Braille Phenomenon
55:34 Total Addressable Market Analysis
59:26 Procept Biorobotics $PRCT
01:04:15 Investment Strategy
WSW – EP105 – With Ads
[00:00:00] Profesor Prasanna: 92% of robotic surgical devices serve 8% of the world’s population. and so the vast majority of the world is still underserved hugely by robotic surgery in, in places like the developing world
[00:00:11] Luke: AI was essentially doing the, the performing, the role of radiologists. And
[00:00:15] everybody said, well, radiologists can be gone. And now like we have these tools that we have more radiologists than ever.
[00:00:21]
[00:00:21]
[00:00:21] Krys: you know, from the investment standpoint, I’m obviously no surgeon. I know very little about. this field. But when the co-founder of Intuitive surgeon of Intuitive surgical buys massive amounts of shares, my thinking is he’s certainly doing it for good reason
[00:00:38] Luke: For an advertising free version of the show, check out patreon.com/wall Street Wildlife.
[00:00:44]
[00:00:49] Luke: Welcome to the Deep Investing Jungle with your hosts, Christophe and Luke. Today we are digging into one of the most powerful, dominant companies in modern [00:01:00] medicine, intuitive surgical ticker, ISRG. This is a company that’s been a mainstay of my personal investing portfolio since 2006. I bought stock then.
[00:01:12] I haven’t sold a single share, and this has really set me up quite nicely for decades. Intuitive’s Da Vinci Robot has had an iron grip on the operating theater, and today this is a company with a $200 billion market cap built on the classic razor and blades business model, but on steroids, and they just reported another stellar quarter with revenues up 23% year over year.
[00:01:39] The scale is staggering. Over 17 million procedures performed cumulatively, almost 90,000 surgeons trained, and now over 11,000 Da Vinci systems installed worldwide and growth isn’t slowing. Procedures were up 19% last quarter over the prior year, and their newest [00:02:00] ion platform, so procedures explode by over 50%.
[00:02:04] This is a hell of a moat that this company has, but the space is heating up. Competitors are landing and intuitive, have fired their biggest shot in years with the brand new DaVinci five system, which already accounts for over half of all their new placements. So to understand if this company can keep its crown, you can’t just read an earnings report, you’ve gotta talk to a true power user.
[00:02:30] Someone who has spent literally thousands of hours with their hands and their head in the machine. And today we have. For our listeners, one of the very best Professor Prana. Ps Soya Kumaran, who is one of the world’s leading robotic surgeons based right here in London at UCLH.
[00:02:52] He doesn’t just use the Da Vinci robot. He’s a global proctor who teaches other surgeons how to use it. We’re gonna ask him, is Da [00:03:00] Vinci five a genuine game changer or just an iPhone update? Is force feedback. A gimmick? Is AI in the operating room, science fiction, or near future reality, and a competitor’s really a threat or his intuitives moat just too deep to cross prof.
[00:03:18] PS is an absolute pleasure to have you. Welcome to the Wall Street Wildlife Podcast.
[00:03:23] Profesor Prasanna: Thank you so much for having me, Luke. It’s a real pleasure to be here and uh, I’m excited to speak to you both.
[00:03:29] Krys: Fantastic. So can I start with the first question? Back in my day when I had to have surgery, they gave me a shot of whiskey. They had tied me down to the bed and you know, they cut, cut open some things and they, you know, sent me on my way. Uh, what’s this, what’s this AI robotics thing, you know, how has the world changed?
[00:03:50] Profesor Prasanna: so your day was before 1909 or whenever Ether was used for anesthesia, first of all, at Harvard Medical School in, in the early 19 hundreds. So, um, yeah, it’s a pleasure to meet you [00:04:00] Christoph. Uh, but yeah, surgery has changed a lot since the open surgery, um, kind of era. Uh, now we do things through much smaller cuts.
[00:04:09] So rather than having a big knife and making big cuts up and down and putting you to sleep for long periods of time and blood loss and needing transfusions and all of those sorts of things. Lots of days in hospital while you recover and slowly walk and slowly start to eat and stuff. We’re able to typically do surgery robotically for a lot of different, um, you know, a lot of different, uh, procedures, a lot of different indications.
[00:04:33] And what that means is that we make small cuts. So, for example, I, I do an operation called robotic prostatectomy for prostate cancer surgery. And the prostate lies deep, dark, in the deep, dark pelvis. So surrounded by the pelvic bones, it’s really hard to reach areas. So in the old days. Not quite your old days, Christophe, but maybe the eighties, nineties, two thousands, early two thousands, you had a cut sort of going from all the way up the belly, [00:05:00] all the way down to the pubic bone, and then the surgeon would guzzle his hands inside, underneath the pelvic bone, try and fill the prostate and try and take it out without causing major hemorrhage, major bleeding, 10% often transfusion rates, hospital stays of two weeks, you know, off work for, for months, et cetera.
[00:05:18] Lots of continence problems where you’re leaking urine constantly. Uh, completely impotent patients who don’t have, uh, erections afterwards because the erection nerves and the apparatus that keeps you dry are all in the pelvis next to the prostate. And so because you’ve got no good, you know, dexterity, no good vision in this deep, dark hole, you’re guzzling to get the prostate out.
[00:05:40] It comes at quite a cost in terms of side effects and complications. Now we passed little, make little cuts in the belly and we. Put robotic instruments through those little cuts with, uh, a magnifying, uh, effectively like a, a three dimensional stereoscopic vision with timestamp, magnification, [00:06:00] immersive technology vision.
[00:06:02] So you can see much better up to times 12 magnification, and you’ve got much more dexterity with these little robotic instruments going into the, in through these arms, robotic arms like chopsticks going into the, into the pelvis. In my, in my circumstances, the prostate cancer surgeon. And you’re able to get much better dexterity, much better vision, and therefore much better precision when you operate.
[00:06:26] And therefore you’re able to do the operation with far fewer side effects, far fewer complications, and an operation which would’ve typically led to a 10 to 14 day hospital. Stay with the open approach. An open prostatectomy is typically a 24 hour hospital stay now with a robotic approach. Uh, and patients are back to work the next week.
[00:06:44] Um, and so huge advances in terms of recovery and in terms of lack of side effects, as well as better outcomes in terms of cancer control and success of the operation itself.
[00:06:56] Luke: it is incredible actually. My dad had prostate [00:07:00] cancer two years ago and he’s made a full recovery and actually prostate cancer got my grandfather. So you, you and I might get more closely acquainted in the future. Who knows?
[00:07:08] Profesor Prasanna: Obviously much younger than Christophe ’cause he was born before the early 19 hundreds. But if you’re 50 yet Luke, it would be worth getting a blood test called A PSA because you’ve got at least one first degree relative and actually you’ve got one first degree and one second degree relative. And as a white man, you would anywhere have a one in eight lifetime risk of prostate cancer.
[00:07:27] That doubles with your father to one in four, and it goes up to one in three because of your grandfather. So across your lifetime, your risk of developing significant prostate cancer is around the one in three mark. So it’d be worth getting a baseline PSA blood test done for you. So there you go. Free consultation for you luke.
[00:07:44] Luke: I’ve got, I’ve got five years worth of PSA results I’m sitting on right now. But, but that’s, that’s a really good message for all of our listeners. If you haven’t, if you’re getting to that age and you haven’t had your PSA done, go get a baseline. It’s, oh, it’s super easy. You can [00:08:00] get it done as part of your regular medical check in the uk.
[00:08:03] It might cost you an extra few pounds, or you can get free on the NHS.
[00:08:05] Profesor Prasanna: Yeah, just like when you get your blood pressure checked and your cholesterol and check with your diabetic, your hba one C, check your body mass index. You should also get your PSA done.
[00:08:15] Luke: Very good. So robots, are they now the standard of care in your field of sort of treating conditions like prostate cancer?
[00:08:25] Profesor Prasanna: Yeah, I would say they are. So the Royal College of Surgeons recently came up with this kind of future of surgery initiative. Took a bunch of surgeons and they took a bunch of policy makers together. And then they, you know, made this kind of document, which has shown that robotic surgery is not only the future of surgery, but is the present of surgery from many surgical specialties.
[00:08:48] So things like pelvic surgery, like prostate cancer surgery, some abdominal surgeries like general surgery, some gynecological surgeries like hysterectomy. Robotic surgery is the kind of market leader [00:09:00] because it gives you that ability to have minimally invasiveness and therefore quicker recovery for patients with less side effects and feel complications, but also more precision and therefore better outcomes in terms of cancer control, uh, and, you know, surgical success.
[00:09:15] So yeah, for many specialties, many indications, robotic surgery is now the market leader. So, back, for example, I’ll give you an, I’ll give you an example. So, you know, I, uh, was on the, you know, I published a. Paper in the British Journal of RA International, looking at the British data for robotic prosta or for all radical pros, ectomies.
[00:09:35] And about 15 years ago, it was a very small percentage with being done robotically. About 10 years ago it was already sort of 50%, and now it’s at least 90% of all of all prostate cancer surgeries are done robotically in the uk. So, you know, the, it’s totally revolutionized the market and as you know, the kind of the, the exponential growth of robotic surgery has actually been faster than that of the [00:10:00] internet.
[00:10:00] So it’s gone from, and you’ll know because you invest in the early days, so you probably are a multimillionaire now, Luke, but, you know, the, the growth of robotic surgery has been huge and continues to, to grow with new, uh, players in the market coming in. But also with, as you rightly said, the introduction, the, the market leader, intuitive, continue to innovate, continue to come up with new devices and better technology, both software and hardware to keep pushing the field forward.
[00:10:27] Luke: Oh, we’re gonna go deep into Intuitive today, but, and you, you know, you mentioned, um, the company’s been around for a long time and it’s been led, uh, by Gary Ghat for a, a long time as one of the, the original co-founders, and he, Gary handed over to his employee number nine, Dave Rosa, last year, and I think you’ve met Dave.
[00:10:50] Is that right?
[00:10:51] Profesor Prasanna: I have, yeah, I met Gary a couple of, well I met Gary probably half a dozen times ’cause I was the, uh, I was one of the few, in fact the only UK at the time, [00:11:00] urology Fellow sponsored by Intuitive for my fellowship, which I did in New York at Cornell, um, uh, back in 2010. Uh, and so I met Gary back then and I met him a number of times over the last 15 years.
[00:11:12] And then I met Dave Rosa just before he took over as the CEO and President, uh, a few months ago. So, yeah, I have met both of them.
[00:11:19] Luke: And um, and what’s your sense like knowing some of these guys and the sort of like, Gary has definitely been a visionary leader for intuitive surgery and he’s driven the whole field. He’s kind of pulled it along with him. He’s invented this field pretty much.
[00:11:34] Profesor Prasanna: Absolutely, absolutely. I mean, I’m very impressed by both of them. I’m very impressed, generally by all the intuitive leadership ’cause I’ve been to Intuitive HQ in Sunnyville in Silicon Valley a number of times. Uh, and actually intuitive leadership have always struck me as being very, very, uh, intelligent, very thoughtful, very patient focused, of course commercial driven as well, but always bearing in mind that.
[00:11:58] In order to be successful commercially in the field of [00:12:00] robotic surgery, you have to put the patient fast. Because if you don’t put the patient fast, then the surgeons are not gonna follow suit. Uh, and so, you know, they have, they have, whether that’s because they genuinely want it, which I believe they do, but they have been very patient focused generally.
[00:12:14] Um, they’ve been very smart. They’ve done come up with some great innovations. I think one of the great things about it as a company is you don’t see a huge amount of turno turnover. You know, you see a lot of turnover in a lot of, you know, companies generally in life, uh, as well as you do in private hospitals that I work in and or wherever or that I used to work in.
[00:12:35] Um, and so, you know, that’s a marker I think of how strong the company may, may be when you have people like Dave that have risen the ranks from, you know, product engineer when he started all the way now to CEO and president, uh, and has, uh, is sort of, you know, intuitive. Flows, flows in his veins, basically from, you know, you can see that from the moment you meet him.
[00:12:57] And it’s not, you know, it’s not like some of these [00:13:00] CEOs who’ve been hired externally that come in, don’t really have industry specific knowledge of kind of CEO knowledge, but are not, you know, industry experts. The way that David’s
[00:13:10] Krys: You know, by the way, you just named one of the key investing, what am I fishing for? Um, Badger Help me out. Um,
[00:13:19] Luke: principle or you
[00:13:20] Krys: principles. Yeah. Principle is when you said, you know, that intuitive surgical flows through his veins.
[00:13:27] Profesor Prasanna: Yeah.
[00:13:27] Krys: That’s actually in the investing world. You know, when you hear that, uh, hearing nothing else, probably you’re gonna do well.
[00:13:36] If you know nothing else about a company, because so many financial people are mercenaries, they’re sort of in and out. They’re, they’re not aligned with, uh, shareholders. They, you know, they’re in it for the buck or whatever, but, but those kinds of people whose lives become the company. And of course if it’s tied to the, to the welfare of o of others, it seems to me like a different kind of [00:14:00] breed of, of leadership and owner and stakeholders.
[00:14:03] So no wonder you’ve been holding this for so long, badge.
[00:14:07] Luke: Well, so I guess the company, let’s, let’s focus on intuitive now and the company’s on the fifth major iteration of its its robot, essentially. And they launched the Da Vinci five just over a year ago, I think. So, um, pro PS you’ve spent thousands of hours working, operating with its predecessors. Have you had your hands on the Da Vinci five yet?
[00:14:30] Is this a nice to have update?
[00:14:32] Profesor Prasanna: Yeah, so my journey, just to quickly expand on that is, you know, I, I went and did a fellowship in New York in 2010, which was actually sponsors, I say as an intuitive fellow at the time I worked on the 10th robot. Ever released. And that time the robot was called a standard. It only had three arms.
[00:14:49] There was no fourth arm to that robot. So it was a much more rudimentary robot than we currently have. And then it went from the standard to the SI worked on that, uh, I learned on that when I moved to [00:15:00] fellowship to the ker in Sweden. And then from the s. I went onto the SI and then the X and then the X si, which is the current market leader, Multiport robot.
[00:15:10] And now the Da Vinci five has been released. It’s available in the us it’s has had FDA clearance for a little while. It’s just got CE marking back in the beginning of July. Uh, there’s yet to be a system installed in the uk, but that will be, uh, coming in the near future. Um, and so that’s the next step.
[00:15:28] But along that they’ve also created a parallel stream of a single port robot as well, which has already got CE marking and where you can do the whole operation through one single incision, hence the name Single port. Um, and so that robot has also been available in the uk, uh, for a little bit of time.
[00:15:46] And there are a couple of private hospitals in the UK as well as one NHS hospital in the UK that has that robot. So now Intuitive have innovated in two different streams. They’ve. Increase their multiport offering with the Da Vinci five, which you mentioned. But they’ve also got a [00:16:00] parallel robot with the single port robot for single port surgery, which of course, uh, as it says on the tin, means that it’s even less, uh, invasive and it’s even more minimally invasive.
[00:16:11] ’cause you now just have one cut that you can put all the instruments through. So they are innovative. And I guess they’ve had a 20 year head start on, on all the, all the newer companies that have come into the field. Uh, and so they, they continue to in, uh, innovate. And I have used the Da Vinci five in the Sunnyvale, uh, intuitive headquarters, uh, in California, uh, you know, in the dry lab and played around with it because I was, uh, considered one of the intuitive European leaders.
[00:16:37] So I was taken there before it was c marked, uh, just to give some thoughts and ideas in a confidential forum with the leadership and a few other kind of, you know, expert European surgeons. And so I have used it, but not on patient.
[00:16:52] Luke: And, and what’s your sense of it having used it in the, in the kind of demo lab? Is this a incremental update or is this like a step [00:17:00] change?
[00:17:00] Profesor Prasanna: I mean, I think, I think it’s very difficult to answer that because it’s difficult to define what you consider enough to be step change compared to incremental. But what I would say about it is it looks very similar to the current market leader of the XXI robot, their current, you know, fourth generation robot.
[00:17:18] Um, it, it has slightly better optics, but not that would be incremental. The fidelity of the instrumentation would be incrementally, uh, improved. I think the two main kind of big innovations are, one is force feedback, which basically means that you can. Feel, for lack of a better word, the tissues. Whereas before you couldn’t, you relied purely on visual cues.
[00:17:43] Now you have that kind of tactile or haptic feedback force feedback on the robot so you can feel the tissues. So that’s one. And the other thing is it’s got much better computing power. And so that means that in future it’ll be more equipped to be AI [00:18:00] ready, uh, and to have more innovations to come in on lays of MRI scans or CT scans or other things.
[00:18:08] So it is, it is future proofed, I guess, for those innovations. Now those innovations are not ready for prime time yet. And so the robot itself isn’t able to incorporate those innovations currently, but it’s a platform on which one can build for the future with software improvements, with AI integration, uh, to help with that.
[00:18:30] And then the other thing, as I say, is the force feedback, the tactile feedback, which I have a view on as well.
[00:18:35] Krys: Prof, can I ask you a, a, a basic question to take a step back in a sort of a stereotypical sense? Anytime I hear. People talking about surgeons, you know, to make it to that level of, uh, call it artistry. We’re usually talking about manual dexterity and a kind of genius, perhaps, I don’t know, you could speak to this more like that you actually need to have [00:19:00] exquisite off the charts, call it, uh, hand eye coordination or something like that.
[00:19:04] And I don’t know if that’s a stereotype of, or if that’s true to whatever degree, um, the way say athletes, you know, some athlete, you know, there’s only tiny percentage of people that could hit a fast ball going at you. Um, uh, is, is it the case that these robotics, uh, uh, can make more people effective surgeons than before?
[00:19:28] And the Neanderthal, like myself, could one day, you know, get in there and start working on Luke’s prostate
[00:19:33] with enough, uh,
[00:19:35] Profesor Prasanna: so I think that’s a really good point. So I think, you know, I think, you know, I subscribe a bit more to the perspiration rather than inspiration philosophy. Okay. So I am more in the kind of Malcolm Gladwell 10,000 hours, you know, outliers type thing. So I think most things with surgery are like learning anything, any other craft.
[00:19:57] If you, if you invest enough, you get enough [00:20:00] muscle memory, you learn things. And so when I look at, you know, a picture of, of the insides of somebody surgically and, uh, and my fellow who might be 10 years younger, not needing to wear glasses is sharp, can’t see the tissues that I can see, it’s because my eyes have seen it.
[00:20:17] Hundreds of thousands of, or you know, hundreds of thousands of hours worth of times before. Right? And so that’s why it’s not because my sight is any better, it’s just because I’ve been trained in pattern recognition and my hands have similarly got that muscle memory of making those movements repetitively over and over and over again.
[00:20:35] Just like, you know, I can play golf and I can develop a handicap probably of, you know, 10 or 15, but I’m unlikely to, to get a scratch handicap because I don’t have the technical ability or the talent or the intrinsic natural ability, but I can train up to a certain point. And so surgeries like that, you can train people up to a certain point.
[00:20:55] And what robotics has done is it’s allowed more, as you rightly say, [00:21:00] there’s been a A level, it’s allowed more people to get to that point. So there will still be. The artists and the exceptional robotic surgeons that can do things, you know, quicker, better than, than some other people. Just like you can put a, a golf club in somebody’s hands and they can’t, they can get a handicap of 15 after, you know, five or six rounds.
[00:21:19] And for some of us would need 50 lessons and, you know, a hundred hours to get that kind of handicap. So, you know, everybody learns at different rate. So there will still be those people at that thing, but more and more people will be able to achieve, let’s call it competence or excellence rather than da Vinci le rather than Leonardo da Vinci levels of, you know, artistry.
[00:21:42] And so I think the robot is a real good leveler for surgeons. It allows more surgeons to get through their learning curve quicker and get to a point of expertise even if you don’t consider that brilliance or artistry level of brilliance.
[00:21:57] Luke: I think thinking about that [00:22:00] alongside. The 10,000 times the computing power and things like force feedback. Like I, when I talked about Intuitive last year on the podcast, I likened, I dunno if you would agree with this, I likened the data that they’re now collecting to like Tesla, driving miles like Tesla have had
[00:22:19] hundreds of millions of cars on the road before FSD was even, you know, being rolled out in the states, they were collecting a ton of data on how people were driving the cars, what the streets looked like, how people reacted to certain things.
[00:22:32] And now that data kind of goes into the big monster AI machine. And now we’ve got like, we’re close to having full self-driving and I wonder what your thoughts are on that metaphor in the world of robotic surgery with this massive data from what 17 million procedures now completed on patients with intuitive robots.
[00:22:53] Profesor Prasanna: Yeah, which is why I think they’ve released the Da Vinci five as a platform, which although isn’t, hasn’t got the [00:23:00] software yet. It allows that platform to then develop the, the software. So because as you say, you’ve got all this data, you can then develop safety features. Okay, this is the rectum, this is the ureter.
[00:23:11] You put all of these cases into the model. AI will say, don’t go here. Go there. We, you know, we’ll allow you like a driverless car to tell you where not to go and where to go. Uh, even if the novice ish surgeon can’t recognize those tissue planes or can’t recognize those structures in, in the anatomy of the human body.
[00:23:30] And so I think that’s where all of that data can be plugged in and be useful. Also, it’s also useful because now we’ve got much better patient records than we used to have with electronic health records, which are, you know, ubiquitous in the United States when they’re becoming more and more used in the, in the uk.
[00:23:48] So we can now much, uh, easy correlate intraoperative. Parameters with postoperative outcomes for patients to see what actually has a [00:24:00] meaningful clinical benefit for patients. And not just, can I do this slightly quicker, which may be helpful for me boasting to my surgeon colleague. That takes twice as long as me going, ha ha, look how slow you are.
[00:24:11] But actually what matters to the patient is not whether it took me an hour to do your operation or an hour and a half or two hours, but what the outcome is in terms of er actions at the end. Uh, can I do the same quality nerve s spraying, um, as someone else? Or what difference does the quality nerve s spraying I do make to your erectile function outcomes?
[00:24:29] And so being able to harness all of that interoperative data and correlate it because we now have efficient. You know, electronic patient records with outcomes I think will be a major advance because we’ll then be able to see what steps of our operations need refining, what can we focus on, what things matter, whether traction on the nerve bundle, for example, during a prostate cancer operation matters.
[00:24:53] Things like force feedback will give us some metrics about that, whether that affects outcomes. So I think [00:25:00] yes, having all of that data, like with everything, as you say, with driver’s cars or whatever at the moment, people haven’t yet figured out what data is useful, how to analyze that data, how to collect that data, how to process that data, how to correlate that data.
[00:25:15] But those things will then come and I think in the next, you know, I always thought I was at the golden age of robotic surgery ’cause I learned robotic surgery when it was relatively new. Uh, and when it was. Considered to be the, the, the thing to, to learn. I became pioneer slash early adopter in that kind of learning, uh, stage of that, of the technology.
[00:25:36] Whereas now, actually I think it’s a great time to learn to be a robotic surgeon because actually now the potential for the future is being able to make those tweaks and really optimize patient benefit, um, based upon, you know, all of this data that’s being collected. And there’s a lot more now I think do with big data science that’s being involved in robotic surgery than they used to be.
[00:25:57] Krys: Professor, can I, uh, [00:26:00] take this towards, uh, an investing angle by way of some potential critiques of ai? And what I have in mind is that we’re now investing everything is ai. So, you know, uh, we’re trying to feel out, you know, is this maybe something like legit ai or is it just, you know, slapping a label on stuff.
[00:26:21] But underneath that, is this, uh, from a critical perspective, say when I’m at the university teaching my students how to think and how to write, I know, or at least I think I do that the students who become dependent. On using AI tools will actually deteriorate in their skillset because they won’t actually have learned the things themselves.
[00:26:49] And I wonder to what extent, uh, and if this is a good question or we’re in the right ballpark, that if surgeons start, uh, using AI all the [00:27:00] time, and let’s say this thing becomes automated, to the extent that these robots are kind of now doing most of of things for the surgeon, is this a case where like their skill sets surgeon, the skill sets of surgeons might actually end up, becoming poorer?
[00:27:16] And is this a worry that surgeons are talking about, or is it more this case like that Luke was alluding to with Tesla that, okay, well human errors, what kills people on the road? So we want a world where the robots are doing everything for us. Like, okay, so surgeons are now basically more. Robot overseers, what’s your take on on this kind of.
[00:27:36] Profesor Prasanna: Yeah, I mean, I’m more in the the latter camp because, you know, my children can barely read the time on a clock because they never don’t need to use an analog clock, right? They can just do everything digitally. They can barely write because they type everything, you know? You know, I can’t do an open an open.
[00:27:52] Steady without support from an experienced surgeon that’s at least 10 years older than me because actually, you know, we don’t need to do it. The better we get robotically, [00:28:00] the less we need to do an open operation. So does that mean there’s any point in you investing all my time and effort learning to an operation that I might have to do once in my career?
[00:28:09] Or is it better just to accept that I wanna focus on, on making the robotic surgery even better and making that even less likely to happen? So I think AI is a tool like in any, in any field, just like you know. When you, when you’re a pilot flying a plane, you barely need the pilot there, right? The pilot pretty much doesn’t do anything apart from reassures the passengers, that there’s some, that there’s a human there, the plane can fly, can take off, and can land itself.
[00:28:36] Um, you know, pretty much, and, and, and during the air you can put it on an autopilot. For a lot of it, you need human oversight. And the same will happen with robotic surgery Now. I think with surgery there are some tasks that can be automated, things like suturing. So let’s say you’ve got a, a join between two tubes after taking the prosta, for example, you’ve gotta join the urethra, the tube that goes through the penis to the bladder.
[00:28:58] And so you have to stitch those two [00:29:00] together. That’s an automated tool, that’s just a stitching tool. It’s like having a sewing machine and you know you have functions on a sewing machine now that can stitch things rather than you having to, to take your needle and thread out, right? So the same thing can happen with robotic surgeon, but there are all other steps which where you require quite fine dissection, uh, and where and where you require the ability to see slightly different tissues and be able to handle things slightly differently.
[00:29:25] And I think AI is a long way from being able to replace surgeons in that, but will help enhance. You know, things by saying, don’t go here. Go here by saying these are critical. No go areas. These areas which are safe. Okay, this is a blood vessel. Don’t cut it and then realize it’s a blood vessel and then see all the bleeding and then have to stop the bleeding.
[00:29:47] We can paint this with AI in various colors or whatever to show you so you don’t cause as much bleeding before you have to rectify the mistake. So I think that will all be an advance. Um, you are right in the [00:30:00] sense that as. Surgeons train with these tools, they’ll become more and more dependent on these tools.
[00:30:06] But that is no different to my children being more and more dependent at doing the homework, using a computer and having to learn how to type rather than learning how to write properly. ’cause the handwriting is awful. So, you know, in the old days we had to write. The, the, when you do a, when you do a t, the, the, the top of the T was less than the top of the H right when we were at school, whereas, you know, my kids have no clue about whether the T should be shorter than the H or not.
[00:30:31] What difference does it make? It depends what you put on the, on the computer screen, so, so I think this is all part of progress and anything that reduces human error because. Even with robotic surgery currently, there’s still huge amount of human error because it is still a master slave platform where it is completely un autonomous, whatever the opposite of autonomous is.
[00:30:54] And so the robot is completely under the control of the, of the surgeon. It does nothing autonomously [00:31:00] currently. And I think like with driverless cars, it’ll start off doing more and more things autonomously and providing surgeons with a guide as to, uh, to help them. Um, uh, and then it will take a long time, I think before it, before it takes over surgery.
[00:31:16] And it’s similar with the rest of medicine. I mean, if you think about it now, you know in medicine you can use your, your symptoms. You can put them into an AI algorithm to give you a differential diagnosis, and the doctor can look at that to help make the actual diagnosis. Now that’s not, that didn’t happen when I was at medical school or for most of my career.
[00:31:34] And so I think it is just going to be an adjunct rather than a replacement for surgeons, just the way that. AI or you know, it’s happened with airplanes will happen with cars. You’re not gonna get rid of drivers perhaps, or or rid of pilots, but there’ll be an adjunct to helping, uh, them fly their aircraft or to drive their cars.
[00:31:55] Luke: I think there’s an interesting comparison to what’s happened in the field of radiology.
[00:31:59] [00:32:00] So I think like a while ago, like a AI was essentially doing the, the performing, the role of radiologists. And everybody said, well, radiologists can be gone. And now like we have these tools that we have more radiologists than ever.
[00:32:13] Um, like the tools are making humans better, faster, more efficient. Maybe in your world that means, you know, maybe it is quite important that you can do a procedure in under an hour and you can be onto the next patient.
[00:32:26] Profesor Prasanna: And also it speeds up the learning curve. So for example, as I say, to spot differences in te, in colors of tissue texture between one organ or another organ, or this part of tissue, or that part of tissue. This fascial layer, that fascial layer can take many, many hours. You know, hundreds if not thousands of hours of experience.
[00:32:45] Whereas if you mark them with an AI and you take and you train a fellow, then the fellow will recognize, okay, that’s this and that’s that. And it won’t take ’em as long to get over that learning curve. And so, you know, you know, if you have power steering, if you learn to drive an automatic [00:33:00] car, it’s quicker than not having power steering and learn to drive a manual car. But nowadays, you know, pretty much hardly anybody drives a manual car in the UK and everybody drives automatic cars and they all have power steering. You don’t need to go back to the days of, of learning to do a three point turn or learning to have parking without having, you know, cameras to show you where you are because you’ve got those, those things.
[00:33:23] In the old days when I learned to drive, we didn’t have those things, right. So I think this is all about using the technology with human oversight in a safe way and making sure it’s introduced safely and benefit surgeons in a way that is patient-centered, speeds their learning curve and maintains their skills and is safe.
[00:33:44] But there’s no point training surgeons to do things the old fashioned way just because you want ’em to be able to do it the old fashioned way when the technology is safe and secure and not gonna break down and they don’t need to waste their time learning to [00:34:00] do things that are really challenging. Like tying knots, for example.
[00:34:05] Laparoscopically. I mean, before we had robotic surgery, we used to do things with chopsticks, laparoscopic surgery, and we would spend, typically, we would say it’d take about 80 hours in the lab just practicing doing suturing. That’s a total waste of time, right? If you’ve got a robotic device that you can learn it, do it in 10 hours, and if you then have a device that’s autonomous that can do it, then you can spend your time on other aspects of patient care and on oversight of that robotic, uh, help.
[00:34:31] Luke: Maybe we can stay in this sort of neck of the woods with the conversation because another aspect of. Like said, the sort of autopilot of the robot itself is, is the concept of telesurgery. And I think Intuitive did a demo a few months ago where they had a surgeon in the US and a, a surgeon in France, and they kind of, you know, one was overseeing the other and they were operating in partnership.
[00:34:54] Is it, is that a potential future for surgery?
[00:34:57] Profesor Prasanna: Yeah, I mean, I think the problem is with that is not the [00:35:00] technology. The technology is there. It’s expensive. You need fast internet connections because of course, anything that’s beyond 200 milliseconds, you know, there’s a delay and so you move like this and then it, if it takes a bit of time for those internet connections.
[00:35:14] That are transatlantic or trans across the world or whatever takes a bit longer, then of course that will become a patient safety issue. But I think that technology is there. I think it’s expensive. That will is, is a barrier. But I think the main barrier is regulatory and medical legal currently, because who takes responsibility?
[00:35:34] If you are the surgeon in, in New York, operating on the patient in London, and I’m the the surgeon in London, am I responsible? Does the patient need to be consented by you? What percentage? If you decide you need a, a wee break and you step out of your room in New York and I’m still down in London, am I doing, am I taking over?
[00:35:52] What? How does that all work? What about my GMC registration? If I’m a surgeon in New York and I’m not registered to operate in London, [00:36:00] how can I then take over? Um, responsibility and governance for that patient. What happens when there’s a complication and I’m not physically there to look at the patient and to see the patient and to assess the patient, or I’m not physically there to speak to his wife afterwards when she has questions about how the surgery went and wants to see me face to face, um, or, you know, you know, counsel them properly.
[00:36:21] How do I know that that’s all gonna work? Because at the end of the day, surgery, like the whole of medicine is, is a human interaction. It’s not purely, you know, a technical thing. Like it perhaps can be for other AI driven, uh, endeavors of life. So I think there will always be that human element. And so there will always be, um, you know, uh, some, some kind of oversight.
[00:36:45] So I think when you, when you talk about that, that specific case, it was done for a conference. And so there’s a little bit of kind of, I don’t wanna be rude about live surgeon, but there’s a little bit of surgeons wanting to see. Latest innovations to see what can be done. But from a [00:37:00] patient perspective, um, you know, the patients would feel, I think, more secure if they had a surgeon who was physically in the room competent to do their operation and could have a developer rapport and a relationship with that surgeon.
[00:37:13] And remember, surgery is a journey. It’s not just about what you do in the operating room, it’s about the before care and the aftercare, which of course needs to be delivered and needs to be medical legally, you know, robust as well. So I think we’re away from working out all of those sorts of things, but technologically it is definitely possible to do te telesurgery, not just through Intuitive, but through a lot of the other robotic platforms as well.
[00:37:36] Luke: so if we, so we, as we come out of the, like the, the, the detailed of the future of in Intuitive and what the Da Vinci five can do now, like is if you had a magic wand, like say you’re, you’re having coffee with Dave Rosa at a few weeks time, and if his engineering team could give you one new capability, something you can’t do today, like what’s the unsolved problem that you are facing that [00:38:00] you think will fundamentally improve patient outcomes?
[00:38:02] Profesor Prasanna: So I think you need to, you need to level up. So we’re very good at the top end. Um, we’re very good at sort of, you know, working out how to get all this computing power now getting in on lays of cts, MRIs, developing 3D models, uh, you know, deciding whether we can, um, you know, switch on various fluorescence imaging devices to show us various tissues, et cetera.
[00:38:29] But I think what we’re still not doing is preventing. Basic complications that still happen within the learning curve of robotic surgery. So it doesn’t sound sexy to focusing on, you know, bringing the bottom up. But actually that’s what is going to cause or give the greatest benefit to the greatest number of patients because you still have to remember that 92% of robotic surgical devices serve 8% of the world’s population.
[00:38:53] Uh, and so the vast majority of the world is still underserved hugely by robotic surgery in, in places like the [00:39:00] developing world. Um, and so what we need before we can start worrying about fancy gizmos like a 2.5 or whatever it is, million pound DaVinci five robot with 10,000 times the, the computing power of the current XXI is we need to ha make sure that the robots are safe.
[00:39:18] Even, you know, at the, at a lower level. And so having AI safety, just like when you de de define driver’s cars, you don’t need a driverless car initially to figure out how to drive through a treacherous mounting. You need to make sure that if it sees a child walking in front of it, it stops. Right? That’s step one.
[00:39:35] And so step one needs to be dealt within AI integration for robotic surgery. You can’t cut this ureter, you can’t cut the rectum, you can’t cut the external iliac vein. You can’t do, you know, the, the, the, the AI integration needs to stop the, the kind of. I don’t wanna call them novice, but the, the less experienced surgeons from making, you know, schoolboy, for lack of a better [00:40:00] word, errors during robotic surgery.
[00:40:02] ’cause those things still happen. There are still, without naming names, there are still institutions in the uk even that by robots. And the robotic surgical program gets shut down because on day one or day two, early on in their journey, they have serious sometimes, um, life and death complications. And that’s because they still require a lot of training, not only of the surgeon, but also of the entire robotic team, uh, the entire surgical team.
[00:40:31] And so I think where AI is gonna make the biggest difference is, is leveling that up and therefore stopping those basic, huge errors from happening rather than necessarily focusing on the top end, making already great surgery. Even better, stop the, the rubbish surge from happening at all.
[00:40:50] Krys: So professor, can I thi, can I take you back into the world of investing for a little bit? Uh, reductively, very [00:41:00] reductively. There are lots of ways to be a successful investor, but one of the things that beginners often learn is to look for something called a moat. And that’s almost in opposition to the kinds of things people sell that can be commodified.
[00:41:14] You know, anybody could do it over here, right? And it’s a race to the bottom, just iteration and cost cutting and so forth, versus offering something that is in a sense, irreplaceable and a competitor, even if they want to, you know, they couldn’t quite get there. Uh, do you have a perspective, uh, on robotics and intuitive surgical perhaps, uh, more singularly specifically where, you know, surgeon might say, I ain’t doing this if it’s not one of these robots.
[00:41:49] Profesor Prasanna: Yeah, I think, I think Intuitive has the market share, of course, the largest market share, uh, because it was the only play, it had a monopoly for many, many years, right? You know, [00:42:00] it had patterns that lasted 20 years before other players could come into the market. And now there are a number of players.
[00:42:05] There’s CMR in the uk, there’s Medtronic, which is a huge player. There’s the Indian robot, SSI mantra. There’s Chinese robots, there’s Japanese robots, there’s Korean robots, there’s German robots. There’s all sorts of robotic devices that are now coming out onto the market. And so I think. The, the, the best robot in my opinion, and this is a personal opinion, not a opinion from, you know, my institutions or whatever, but the best robot in terms of quality, in my opinion that’s commercially available, is the intuitive robot and the intuitive robots.
[00:42:41] But they’re also by far away the most expensive robots, which goes back to my previous point that 90% of robotic surgical devices across the world serve 8% of the world’s population. Now that is not necessarily a great business model if you’re talking about a moat of the moat being the whole world. If the moat is just [00:43:00] the US.
[00:43:00] Then great intuitive is done, is done great and will continue to do great. The mode is just the UK or Japan or, or, or, you know, the, the richest parts of the world then great. But if your moat is gonna extend to Africa and, and Asia, where 56%, I mean 56% of the world lives in Africa, right? Or, or, or in Asia.
[00:43:21] And 20% lives in Africa. So, you know, three quarters of the world lives between those two continents. How many robotic devices are there? Fewer in those two continents than in. New York, right? So you are then, you’re then talking about a huge disparate disparity. So if you are just planning to sell Ferraris, absolutely you target what intuitive are targeting, but actually there has to be market for the Ford Fiesta as well.
[00:43:46] And so for that, you know, you need to then think about making your, your robotics not just more innovative, more expensive, more computing power, more this, more that, but actually creating robots that are more [00:44:00] affordable and that are different business models that are, that are perhaps less sexy but can do the job in a trauma situation in a relatively poor part of the world.
[00:44:11] And I think that’s where intuitive are not currently focusing, perhaps whereas other players that are coming into the market are focusing more at where there’s more, uh, more room for maneuver there because Intuitive hasn’t got that market.
[00:44:28] Luke: A, a really way, interesting way we see this play out from, say, the investing point of view is, um, the Razor and blades business model. I, I called it robots and blades when I talked about this last year. So, you know, intuitive sell or sometimes lease the, the. Console the robot to the hospital, but then 84% of their revenues today are recurring.
[00:44:53] It’s not the actual robot, it’s the The consumables, the instruments. And I think there was a push a couple of years ago, if I remember [00:45:00] correctly, to get higher levels of reuse with
[00:45:02] Profesor Prasanna: Yeah. Yeah. Some of those instruments only have 10 live lives. 10. 10 uses They’ve, some of ’em have gone up to 14. The extended use program takes some of them to 18. But that’s still not enough, right? When you’re talking about things that are very expensive. And so, yes, absolutely. It’s not just the capital cost, as you’ve rightly said.
[00:45:19] It’s also that business model of making money on your consumables all the time. And those are perhaps cheaper. And they are cheaper for some of their competitive compared to robot companies. Uh, which is why. For those companies, they’re, they’re getting more traction in, in developing world countries. So, for example, the Indian SSI Man robot, then it’s got a, it’s got some help from the Indian government as well, but has had huge traction across much of the Indian subcontinent and is now spreading further, further, uh, field.
[00:45:50] That’s why CMR versus has got traction in some of the, uh, hospitals in the, even in the uk that are not necessarily the tertiary, uh, centralized cancer [00:46:00] center hospitals. ’cause it can do, you know, minor procedures cheaper and faster than if you were to have a da Vinci doing it. So, uh, da Vinci, uh, helping you doing it.
[00:46:10] So I think there is a market for these different robotic devices just as there’s a market for people who wanna buy a Ferrari or Lamborghini, but there’s also market for people that wanna buy a Ford or a Boxall.
[00:46:22] Luke: do you actually get pressured by hospital administrators, maybe in the NHS to, to try to use the more cost effective platforms, if that’s an option?
[00:46:30] Profesor Prasanna: Yeah, I mean, not directly because I happen to work at UCLH, which is the, the highest volume, you know, robotic prostate cancer center in the country. So we have a huge kind of tertiary influx of patients and, and for, for that specifically very, um, complex operation. You know, I think. The evidence would be in support of the Da Vinci robots in terms of outcomes.
[00:46:55] And so it’s difficult to change that. Uh, and in fact, we’ve purchased more Da [00:47:00] Vinci robots at UCLH and not purchased any of the other, uh, other robots. I think now at UCLH, we have University College of London Hospital. I think we have five or six Da Vinci robots, um, in, in our surgical theaters across the institution, whereas we don’t have any of the others.
[00:47:17] So, so in a high kind of ivory tower institution, perhaps not, but in your less ivory tower institutions then? Yes. So one of the other things I did was I helped set up a district general hospital in the UK called Northampton General Hospital. Set up its robotic, um, services when it didn’t ever have any robotic services.
[00:47:37] So I was on the steering group as the external, uh, advisor of the robotic surgeon. And a lot of the surgeons there and administrators there were like, why can’t we get robot X rather than get the DaVinci or, or robot y rather than get the DaVinci? So I did have those conversations, but at the end of the day, it depends what you want to do.
[00:47:54] If you want to do. Complex cancer work, then I think, you know, the [00:48:00] robot that’s got the most evidence behind it and the best outcomes behind it are the da Vinci robots. But if you’re prepared, you’re not interested in doing that, you’re interested in doing gallbladders and hernias perhaps, or, or appendixes or whatever, then you perhaps don’t necessarily need to spend that kind of money on, on getting that.
[00:48:17] If you want, if you want your car to just run, run you around town, drop your kids at school two miles down the road, you don’t need a Ferrari. But you know, if you, you know, you might need a Ferrari if you, if you have other, other desires or needs. So I guess it’s just it, it’s all about, you know, finding the niche and what your specific hospital wants and needs based upon the landscape.
[00:48:40] Because remember, in the UK the landscape is tending to be that there’s centralization and the more complex cancer operations are done in these sort of centers of excellence, tertiary centers, and they will tend to. Want the Da Vinci robot devices and then the other hospitals, the kind of spoke hospitals going [00:49:00] into that hub, which are left behind in the sense they’re not doing the major cancer work, but they’re now doing some of the benign work.
[00:49:06] The, the more high volume work, which has got, uh, less complexity they might want to, to, to purchase some of the other robotic devices. So I think there’s a, there’s a place for different types of robots within the same healthcare setting.
[00:49:21] Krys: So, I don’t know if this will be redundant to what you just said, but you, you know. When we’re talking about moats and really trying to foolproof an investment, there’s this concept of also switching costs that, uh, it’s just, you can switch, but it, it would just cost you a lot of time and energy and money to do so.
[00:49:38] So why, why do that? Do you find that, uh, there is a high switch in costs, you know, in terms of your own brain and muscles when you like working with, say, the Da Vinci, but, you know, is, is that, does that go into your.
[00:49:55] Profesor Prasanna: Yeah, for sure. I mean, you know, there’s a high switch cost even from change from one DaVinci to [00:50:00] another. So, you know, one of the things that I’m doing is learning how to do the, to use a single port robot in, because one of the private hospitals I work in, the Rommel Hospital uses that, uh, robot is one of the two part hospitals in the country that has that robot as it’s in a, as it’s a very innovative hospital.
[00:50:16] So, you know, I’m learning to, to use that robot and that robot is because I’m so ingrained having done 2000, you know, da Vinci Multiport cases to that way of doing it to try to learn to do it, you know, even with the same manufacturer platform is, is, you know, takes a bit of a learning curve and so changing from.
[00:50:36] The intuitive platform to non-intuitive robotic platforms, again, has a learning curve. The joystick control is, are totally different to Da Vinci. You have an open console for some of these platforms. You have, you have um, uh, uh, uh, you sometimes have to wear glasses if you wanna see things into, in three dimensions.
[00:50:55] The communication is different. How the instruments move, the specific [00:51:00] instrumentation is different. And so, yeah, it is different. It is different. It is, it is harder than going, changing from driving my, my car to my wife’s car. That’s much, that’s a much easier change. You know, changing robotic manufacturers is harder and, and I guess when you’re used to being, when you’re a heavy da Vinci user, as, so I’ve been using Da Vinci since 2010, uh, on fellowship and actually started learning in 2009 the year before I went on fellowships.
[00:51:26] I’ve been involved in, in robotic surgery with Da Vinci for 16 years now, and I use it every week, three, four times a week on average. So, um, you know, I’m a heavy, heavy user of da Vinci. It’s, it’s very difficult to then get your head around using a new robot, which perhaps is not quite as as good if you’re just defining it purely on quality and not on cost.
[00:51:50] Um, because if you, if you’re, if you’re used to driving a Ferrari all day long every day and someone gives you a, you know, Volkswagen Polo, you’re probably not [00:52:00] gonna be very happy. Right.
[00:52:01] Krys: Yeah. Are you a good video game player?
[00:52:03] Profesor Prasanna: that’s a, that’s a really good question. So there have been studies that show that good video game players make, uh, better robotic surgeons with, with, or have shorter learning curves of robotic surgeons. But I actually am not that great a video game player because when I was at that stage, the video games were pretty rubbish.
[00:52:18] They were like Donkey Kong, and, you know. And, uh, you know, um, Tetris and things like that. So not like video games now where my son can beat me on Mariott, you know, hands down with one, probably with, uh, one eye closed. So, you know that his level of video game playing is totally different to mine. But yes, I think video play, video games, playing, playing sports, just having that hand-eye coordination of course will help with robotics edge.
[00:52:42] It’s more about hand-eye coordination because you are doing something here and something’s happening over there. And so that’s why video games is good, because again, you’re doing something here. The actual movements with the joystick are not difficult. The actual movements with the robot are not difficult.
[00:52:55] You could do that. They’re no, you know, tying a shoelaces is just as complicated as any movement you’ll make [00:53:00] with your fingers robotically. But it’s doing it here and, and, and seeing an effect over there without perhaps the tactile feedback, which we haven’t really talked about yet. Um, but whi, which is a major, was a major downside for the conventional, uh, robot.
[00:53:15] So you can’t feel it. So having that hand eye coordination. Um, whether that’s with sport or with video game playing is helpful.
[00:53:21] Luke: And that seems to have made a a big difference. I, as I’ve seen studies that I’ve described with force feedback, now surgeons are using less force and so that’s just giving much better patient outcomes.
[00:53:34] Profesor Prasanna: Yeah, I mean, I, I, I mean, I think those studies are still an evolution, so I don’t think the, the jury is out on that. I think it’s, it’s, you know, one of the papers I published back in the day was a paper called the Reverse Braille Phenomenon, which basically means that, you know, blind people have got a heightened sense of, of touch because they can’t see, okay.
[00:53:54] So that, that other sense gets heightened. Now in, as a robotic surgeon, you can’t feel, but [00:54:00] therefore your sense of sight gets heightened. Reverse brail phenomenon. And so you, you get much more sensitive to visual cues, slight differences in texture in terms of color or how the tissues look to tell you that this is one fascia layer or another fascial layer.
[00:54:15] Uh, and so that becomes heightened with typical robotic. So I don’t necessarily feel that I, as a very experienced da Vinci user will benefit from the force feedback. But I think again, more novice surgeons who are learning will understand, okay, I can now feel this tissue so I’m gonna put less traction on the nerves and that’s gonna cause them to go into spasm less and that’s gonna improve their erectile function outcomes for my patients.
[00:54:40] And so I think it is, as you say, a learning tool just to tell you that okay, I’m putting too much pressure. I can tell this is bone ’cause I can feel this is bone ’cause it feels hard rather than me going, well I can tell that’s bone ’cause I can see it’s a slightly different shade of yellow than, than, than the soft tissue next to it.
[00:54:59] But because [00:55:00] I’ve seen it thousands of times, so they’ve got that touch as well as the sites
[00:55:05] Krys: well, no, I’m gonna take us off course, so maybe you have more natural follow up.
[00:55:09] Luke: so I’m gonna bring another investing concept in, and it’s the total addressable market. And this is like. So when Intuitive started out, it was, I think it was all about Prosta Ectomies. And now they branched out into gynecology and now into general surgery. And I think today, if I look at the most recent investor deck, nearly half of all procedures are general surgery, which are my layman’s understanding.
[00:55:34] That’s just like, you know, appendectomies and all sorts of random,
[00:55:38] Profesor Prasanna: Colectomies all sort of bowel surgeries. Yeah. Yeah. That’s globally, I think you’re talking about Luke, that’s not necessarily country specific where within specific countries that those figures will be different, but, but yes, globally, over, over across the board, it’ll be general surgery is the highest, highest, um.
[00:55:54] Luke: So what kind of, where are we in the adoption curve? Like if I, if I were [00:56:00] recommending to someone, you know, or ask someone asked me the question, should I buy investment investing, intuitive surgical today? Um, and without getting into all the other things around leadership and it’s like competitive edge.
[00:56:12] Just thinking about where we are in the adoption of, say, robotic surgery versus getting your hands dirty, you know, traditional surgery. Are we early, kind of mid game, do you think we’re end game with that now?
[00:56:24] Profesor Prasanna: I think we are in different places, in different specialties and in different countries across the globe. So I think if you talk about, say, urology in the United States, the, the kind of highest volume robotic coun country in the world, surgically, then we’re end game. I mean, you know, if you’re not a robotic surgeon and you’re a urologist in the US doing major complex work, then you are, you are really behind the eight ball.
[00:56:48] So I think, you know, pretty much. It’s taken over. You can’t really be a cancer urological surgeon in the US without learning how to use the robot. Um, so I think it [00:57:00] has become the kind of monopoly that in that, but that’s just a drop in the ocean. If you are in Sub-Saharan Africa and you know, you need to have a hysterectomy, the chance of it being done robotically is perhaps much, much less.
[00:57:14] Um, and so there’s, there’s that. Everything else is somewhere in between those extremes. I would say overall, um, we’re mid game or mid midway through that adoption curve. I think there’s still a lot of growth. And actually, you know, you’ve hit on a really good point. A lot of people think about the competitors for Intuitive or CMR or Medtronic or you know.
[00:57:37] SSI or the avatar robot or Atory robot or whatever. But actually no, because what you need to do is increase the whole pie for everybody. The competitors for Intuitive, or as for all robotic surgical devices are not each other. But as laparoscopic surgery and open surgery, because worldwide, there are still far too many open surgeries and laparoscopic surgeries being done.[00:58:00]
[00:58:00] So rather than fighting for the small section of the pie that you currently have, when you think about global surgery, increase the size of that robotic surgical pie by going into open surgery and laparoscopic surgery for, which is still done across most of the world most of the time. Uh, and so I would say there’s still huge growth potential for robotic surgery worldwide across the board.
[00:58:22] So whether that’s through Intuitive or CMR or Medtronic or whatever, that’s then about, well, which horse is gonna win this race? But you know, there are the, you know. The field is, is is expanding and open surgery is going down and laparoscopic surgery is going down, robotic surgery is going up, and that will continue to to be the case, I think for at least the next decade.
[00:58:46] Krys: Well, that makes, okay, great. That’s a good segue to maybe our, our last question, uh, to bring it back to investing. Sometimes investing can be simple. Um, and I say that, [00:59:00] you know, knowing there’s always 5,000 variables, which you have to overlook, but, uh, Luke and I have a contest on our podcast where we pick stocks and we challenge each other to come up with a better idea.
[00:59:11] And, and one particular thing that’s important to know is that a great company does not always make a great investment. So, you know, it’s, it’s, uh, it’s maybe complicated in that sense, but I’ve been very jealous of Luke’s investment in Intuitive Surgical
[00:59:26] because it’s been.
[00:59:26] Profesor Prasanna: very jealous of it as well actually.
[00:59:28] Krys: Yeah, yeah, yeah. Don’t look at the chart or you, you know, I mean, it’s, yeah, he’s done exceptionally well and, and, uh, he’s held it all this time, which is harder than you think.
[00:59:38] But I’m sitting there, you know, thinking, well, it’s already $194 billion. I’m too late, this, that, and the other thing, I need a, I need a little smaller play that’s sort of close enough. And lo and behold, um, in my research, I found that the co-founder of Intuitive Surgical recently bought a large number of shares in Cept [01:00:00] Robo Biotics.
[01:00:02] Profesor Prasanna: by robotics. Yeah, process
[01:00:03] Krys: Yeah. Yeah, yeah. and you know, from the investment standpoint, I’m obviously no surgeon. I know very little about. This, this field. But when the co-founder of Intuitive surgeon of Intuitive surgical buys massive amounts of shares, my thinking is he’s certainly doing it for good reason. He’s not, he’s not burning his money, you know, and it’s one of these, are you, how familiar are you with,
[01:00:29] Profesor Prasanna: Yeah, it’s another robotic device I’ve used. So that, that’s a, that’s a, the difference about pro bio robotics is they have a, a robot which is used for one specific indication and one specific procedure, and that’s to do benign prostate enlargement operations so that they’re basically pouring a hole through the prostate, not for cancer, for benign enlargement to help men pass urine more effectively as they get older.
[01:00:54] Alright, stop those Water work symptoms. What was pre, previously done with a kind of hot wire, what was called a trans [01:01:00] resection, or can, has been done with steam, has been done with variety of other devices. This is like a high powered water jet, which can be used to, with, with robotic application to, to core a hole through the middle of the prostate.
[01:01:14] And so that, uh, that procedure is called the ablation. The device is manufactured by pro, set by robotics. Um, I. Uh, you do, you do that procedure as well. And so I, I do know quite a bit about it. It has had a huge, uh, increase in, in, in the uk. I can’t speak for other markers, but in the UK it’s really, it’s really creating waves, uh, to use the water analogy, um, uh, and is really doing well.
[01:01:44] And so, yes, I mean, uh, it has few, some fewer side effects. Because it’s water. It’s not using heat, you get less damage to certain structures that help with ejaculatory function. And so one of the main problems with the conventional operations [01:02:00] for, for benign enlargement of the prostate is that they cause problems with ejaculation.
[01:02:04] And for many men, were sexually active even if they don’t wanna have more children. And fertility’s, Nonis issue, they still want to ejaculate normally. And so this procedure has much better outcomes in terms of ejaculatory function. It also appeals. To the clientele of robotic surgeons because it’s a robotic device.
[01:02:23] So the learning curve for, for robotic surgeons like myself is perhaps, uh, not that long. So they’ve also given the people what they want in the sense that they’ve given a, they’ve created something that is good for the patient, but also is what the surgeon also wants to be doing, um, as a robotically trained, uh, specialist.
[01:02:41] So they’ve kind of hit that sweet spot where it is, it is appealing to surgeons and it is appealing to patients because of the improved outcomes it can have. So, yeah, I think, um, I didn’t know that the co-fund founder of Intuitive had invested in it, but, but I can see why.
[01:02:57] Krys: Well, this is fantastic. See you, you give [01:03:00] us all your expertise and we give you hot stock tips.
[01:03:03] Uh, and, and there is, uh, by the way, uh, process is actually the, uh, also. In the process of expanding into prostate cancer stuff, which,
[01:03:15] Profesor Prasanna: They’re doing, they’re running a randomized clinical trial about a star called Water four, which is being led by one of my colleagues at the Royal Marsden, a major cancer hospital in the uk. And they’re now looking to see whether, uh, it can be used for prostate cancer. But the reason I didn’t mention it is because that’s not what it is proven to work for, and I’m an academic after all, so that that randomized trial will have to report before we can say that it can be used for cancer.
[01:03:40] Krys: right. Well, thank you. Thank you. You’re confirming my, my thesis and now I get to make Badger Luke, uh, a little bit jealous of my upcoming thousands of percent gains with this one.
[01:03:51] Luke: you’re getting like a, a microcosm of 105 episodes of the podcast. ’cause I try to find these incredible world changing [01:04:00] companies. On mature, like they dominate their market and Christophe finds these random little tiny things that are half of them don’t make any money and then he’s kind of rolling the dice.
[01:04:10] So hopefully, hopefully you’ve had an endorsement for the, from the expert here. This is a good one, Christophe.
[01:04:15] Krys: Amen. Uh, for for our listeners, uh, the, the new baby is PRCT, ticker wise.
[01:04:22] Luke: excellent. Well this has been a fantastic conversation. I’m really glad we got introduced to you Prof. PS ’cause you’ve made an investment I’ve owned for over 20 years. You’ve actually made it feel much more real to me now I feel like I understand, uh, the company much better. And I now have a go-to buddy.
[01:04:39] I can go and throw my deep, dark questions to whatever. Uh, yeah.
[01:04:43] Profesor Prasanna: Hundred percent. It’s been a pleasure. Do you have any other questions for me or are we, are we, are we good?
[01:04:51] Luke: We’ll take a quick
[01:04:52] Krys: I suppose, uh, no. I suppose, uh, maybe is there anything you would want to ask us? Uh, uh, you know, our audience [01:05:00] is people. We’re trying to help people begin their investing journey and often the, the impediment is they just don’t know how to get started or whether it’s inertia or, uh, usually, you know, experts in fields.
[01:05:12] They, they, they, they think they need to know everything before, you know, taking that first step. Is there anything we could help you?
[01:05:18] Profesor Prasanna: I guess, I guess the question I would ask is how do you know, coming back to your point, Christophe, whether it’s now too late, you’ve missed the wave and or whether in insured will keep going or whether you now need to start looking at these other robotic companies that are now gonna go hopefully for the kind of, you know, emerging markets, let’s call ’em that as opposed to to, to the well-developed US, uk you know, Western European market.
[01:05:41] Is it better to, is it better to put your, to put your dollar where the, you know, where these newer companies that are, you know, slightly more Ford Fiesta, like and less Ferrari like than intuitive? Or is it, is it better to keep investing in the Ferrari that’s already got a Ferrari price tag hoping it will keep on going up and up and up.
[01:05:59] Luke: Well, you know, [01:06:00] as an investor you don’t actually have to choose ’cause you can own them all. You build, you bought build what’s called a, a bucket of stocks built around a thesis. And often, um, if you have expertise or you have access to experts in that area, that can really inform you as to the composition of your bucket, which are the, you know, you want to probably do wanna own like the behemoths, the leaders like intuitive.
[01:06:23] But you probably also wanna have a couple of upcoming companies as well. ’cause that makes like a robust portfolio, uh, where you’ve got the, like a few of the little things and the big guy.
[01:06:33] Krys: Right. Yeah. And I would add too, we repeat this over and over there, uh, tickers out of context or companies, out of an individual investor’s context is, uh, malpractice because each person’s investing context and journey is different. So, so somebody in their twenties is very different from somebody, say in their sixties.
[01:06:56] Uh, different income classes and risk [01:07:00] profiles for this, that, or another reason. So we can’t ever say this company is better than another one. You have to weigh risk reward ratios and stuff like that. But, you know, in, in, in simple terms, what I would encourage you to do is leverage your expertise because you know more about this particular domain than most people on the planet.
[01:07:21] So why not translate that into, uh, into capital gains for yourself with which then you get this, you know?
[01:07:28] Profesor Prasanna: And so would that be doing it myself or would that be having an intermediary, like a stockbroker who I gave his 20 grand invest. 10 grand in intuitive, five grand in here, two grand in here. How does it, how does the, I guess I don’t understand how the kind of mechanics of investing actually work, but we’ll have a chat face to face, Luke,
[01:07:46] Luke: I’d be be delighted to take you through that over lunch. Yeah, and I’m, I’m buying by the way. Yeah,
[01:07:51] Profesor Prasanna: lovely. Thank you. I hope it was helpful.
[01:07:54] Krys: Thank you.
[01:07:55] Luke: this is a, this was a great discussion. so, uh, cross PS for our listeners who [01:08:00] want to follow more of your work, where is the best place to find you?
[01:08:03] Profesor Prasanna: Yeah, so I have a private website which I will highlight some of my work, which is www professor ps.co uk. Uh, and so that will have my secretary’s contact details and which hospitals I work in, but about my research and some of my med tech works. I also do things that are not direct patient care, but involve robotic surgery and, and men’s health.
[01:08:26] Uh, and then also I happen to be, which I suppose is one of my accolades. I happen to be the UK’s most followed urologist on LinkedIn. So I’m always happy to connect and I get bored of just speaking to urologists and oncology all the time. So the more diverse people that I can connect with on LinkedIn the better.
[01:08:43] So really happy for anybody to reach out to me on LinkedIn as well.
[01:08:47] Luke: Fantastic. Well, it, it’s really, it’s truly great to talk to a real expert, so we really appreciate you sharing your time and your expertise
[01:08:55] Profesor Prasanna: No,
[01:08:55] Luke: Street Wildlife Podcast.
[01:08:56] Profesor Prasanna: I really appreciate it. I get, normally the podcast I do are all [01:09:00] about, are all to oncologists and neurologists and, you know, people like that. So it’s really exciting for me to speak to a completely different, uh, type of person and, and, uh, with a different brain. So it’s, it’s brilliant. So thank you so much for having me.
[01:09:11] I.
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