Robotic surgery gets new push
Long-term prostate benefits unclear
 Dr. Simon McRae sat at the controls of the da Vinci this week as he performed surgery on a patient with prostate cancer. (Tom Landers / Globe Staff) |
Pioneering surgeons long have believed that the precision of remote-controlled surgical ''robots" might improve results, but the technology has been slow to catch on. Now, hospitals are snapping up a new $1.2 million robot and heavily marketing robotic surgery to men with prostate cancer, a group that is eager for treatments with fewer disabling complications.
The California company that makes the robot, the da Vinci, estimates that 10 percent of the roughly 60,000 radical prostatectomies performed in the United States are done by a surgeon seated at a console in the operating room, pumping foot pedals and moving levers to signal a robotic arm to slice and stitch. Advocates say robots eliminate the unsteadiness of a surgeon's hands and are more flexible than the human wrist. Some doctors are using them for other procedures as well.
But the results have not shown robots to be superior to the human hand for removing cancerous prostate glands. While surgeons say patients who have robotic surgery seem to recover more quickly -- because the incisions are smaller -- the procedure is so new that there is no evidence that robotic surgery reduces the incidence of a prostatectomy's most dreaded side effects: impotence and incontinence. Or, that it allows surgeons to more effectively remove the cancer.
And drawbacks exist: Surgeons cannot touch the patient's skin, muscles, and organs with their fingers, which helps them decide whether a section of tissue is thick enough to hold sutures, for example.
The bottom line for the US healthcare system is that robotic surgery appears to cost more -- $1,726 more per case, according to one recent study -- for an unknown benefit.
''This is now a complicated dilemma for patients," said Dr. Jim Hu, a urologist who Brigham and Women's Hospital hired in July partly because he is trained to do robotic radical prostatectomies. ''There is research showing patients have less blood loss, shorter stays in the hospital, and quicker recovery with the robot. But the longer-term results? We're not sure."
Boston Medical Center bought a robot last winter -- paying as much as for some MRI scanners -- and is using it mostly for prostatectomies. Surgeons, who take training classes at
Robot surgery received an early push from the US Department of Defense, which began funding start-up companies and academic laboratories during the 1980s. Government officials envisioned remote-controlled portable robots as a way to operate on soldiers wounded in hard-to-reach locations and on astronauts during space missions. Venture capitalists also began investing in the idea, and two companies developed robots and received US Food and Drug Administration approval to market them in the late 1990s; they merged into Intuitive Surgical in 2003.
Robotic surgery made its biggest splash in September 2001, when a surgical team in New York removed the gallbladder of a patient in France by sending high-speed signals through fiber-optic lines on the ocean floor to a robotic arm in the operating room. The surgery was a success and the patient recovered normally, but doctors admitted it was the most expensive gallbladder removal ever done. And while the team did it to prove long-distance robotic surgery was possible, colleagues questioned the benefit.
Surgeons experimented with robots for cardiac bypass surgery, but found it took longer to do the operation, which is risky when the heart is stopped, said Dr. Ralph Damiano, who was one of the first surgeons to test robotic bypass surgery and is chief of cardiac surgery at Barnes-Jewish Hospital in St. Louis. Brigham and Women's originally bought its robot for bypass surgery three years ago, but it had largely sat unused.
Now surgeons use the robot for gastric bypass surgery, hysterectomies, and removing uterine fibroids, but by far the fastest growing procedure is radical prostatectomies.
''Prostate surgery is one of the things patients really shop for," said Dr. Jeffrey Steinberg, chief of surgery at St. Vincent, explaining that many men question surgeons about their success at preserving potency and continence. ''We want to show that we're a technology leader and that patients don't have to go into Boston."
The robot is particularly well-suited for prostate cancer surgery, which is normally done with a long incision down the belly. The robot allows surgeons to do the operation with several small cuts. A camera projects an image in three dimensions, with three to five times the magnification. Surgeons cite another advantage: Laparoscopic instruments used in other types of minimally invasive surgery look like a chopstick with a fixed jaw on the end; with the robot's instruments, the jaw rotates numerous ways.
James Griffith, 63, a highway inspector who lives in Milford, was diagnosed with prostate cancer in May and his primary care doctor referred him to Dr. Simon McRae, a urologist with Fallon Clinic who operates at St. Vincent. Griffith thought the idea of a robot ''sounded odd" at first. But he said McRae told him ''recovery is a lot faster. He said robotic surgery may be better at preventing incontinence or impotence. But he said there are no guarantees."
During Griffith's surgery last week, McRae sat at a console resembling a video game about 10 feet from Griffith, looking into a 3-D screen. He pushed pedals and opened and closed his thumb and index fingers -- which were fitted with straps that controlled levers attached by wires to three robotic arms -- to focus, cut, and cauterize blood vessels. But he still needed human help: chief resident Brett Carswell sat on a stool next to Griffith, changing the instruments on the robotic arms and suctioning away blood.
McRae has done about a half-dozen cases, but he believes there are advantages, one being that the magnified view allows him to cut the urethra away from the prostate and reattach it to the bladder more precisely. He usually removes a patient's urinary catheter in two weeks, but for robotic surgery patients, it's been 5 to 7 days.
Dr. Richard Babayan, chairman of urology at Boston Medical Center, said he's found no difference in continence rates in the 30 robotic cases he's done, compared with traditional surgery: 95 percent of patients have no leaking and do not need to wear a protective pad after three to six months.
Long-term randomized trials comparing impotency and cancer recurrence in patients undergoing both types of surgery don't exist. In the best hands, 85 percent of traditional prostatectomy patients are able to have sexual intercourse by 18 months after surgery.
One leading surgeon, Dr. Mani Menon of Henry Ford Hospital in Detroit, has done 1,900 robotic prostatectomies and is about to publish four-year results; he said his rates of preserving patients potency and continence are equal to or better than when he did the procedure the traditional way. But it's unclear whether other surgeons will be able to duplicate his results, and even he said the technology is too expensive.
''It's very interesting technology," said Damiano of Barnes-Jewish Hospital, ''but it has not proven to have enough clinical value to warrant the tremendous expense."
