Remote Precision The da Vinci Surgical System Transforms Prostate Cancer Surgery

Surgery isn’t a pleasant thought at any time. But the recovery is often worse.

That’s why surgeons continue to be excited about the da Vinci Surgical System, which has resulted in positive outcomes and quicker recovery times for people worldwide — all with the doctor working not inside the patient, but across the room.

“It results in less pain and blood loss, and in the vast majority of cases, patients actually go home sooner than the traditional way,” said Dr. Donald Sonn, a urologist with the Urology Group of Western New England.

The hospitals that employ the robotic da Vinci system — there are around 1,400 in operation worldwide — have mainly used it for urological procedures, particularly prostate cancer, although expertise with the technology is gradually spreading to other fields.

“It’s effective for anywhere you’re working in small corners, like in the pelvis or with gynecologic surgery, or with morbidly obese patients, working in the depth of the abdomen,” said Dr. Stephen Gallo, a urologist with Pioneer Valley Urology Group.

Compared to traditional modes of prostate cancer surgery, he said, “depending on where the cancer is, and whether the cancer is confined to the organ at the time of surgery, you should see equal results with robotic surgery.” And that’s good news in the fight against a disease that kills one in every 35 American men.

Healing Instruments

Radical prostatectomy, the surgical removal of the prostate and surrounding cancerous tissues, is considered the gold standard in eradicating prostate cancer. Surgeons are now able to use one of three approaches to radical prostatectomy: open surgery, laparoscopic surgery, and robotic-assisted laparoscopic surgery.

An open prostatectomy requires an eight- to 10-inch incision on the patient’s abdomen for direct access to the operative site. In contrast, conventional laparoscopic and robot-assisted laparoscopic approaches require several dime-sized incisions, which are used to introduce narrow-shafted instruments. The surgeon and assistants maneuver the instruments from outside the body, under vision provided by a surgical camera.

According to Intuitive Surgical, developer of the da Vinci technology, one drawback of conventional laparoscopy it relies on the use of rigid, handheld instruments and visualization provided by a standard 2D video monitor, which can limit the surgeon’s sense of depth of field, dexterity, and precision. In contrast, da Vinci prostatectomy provides a more natural depth of field in the monitor used by the surgeon, and allows his hand movements to be translated into precise micro-movements of tiny instruments at the operative site.

Despite misconceptions around the word ‘robot,’ da Vinci cannot perform any task on its own. Instead, the system is designed to seamlessly replicate the movement of the surgeon’s hands with the tips of micro-instruments. The system cannot make decisions, nor can it perform any type of movement or maneuver without the surgeon’s direct input.

“Traditional surgery,” Sonn said, “entails taking a very large incision and cutting through muscle barriers in order to get to the organ, so there’s a lot of trauma and manipulation of tissues. That can result in several consequences, like blood loss and more pain after the procedure. With robotic surgery, the surgeon is now able to remove these same organs with a very tiny incision the size of a dime.”

In terms of the outcome, Gallo said, robotic surgery is very similar to traditional surgery.

“Studies have shown that, just as high-volume open surgeons deliver a very good product, high-volume robotic surgeons have a similar success rate in terms of curability and confidence and erectile dysfunction,” he said. “The dexterity of the arms allows you to work in very fine corners, and work with very sensitive structures.”

Furthermore, “as a minimally invasive procedure, robotic surgery has eliminated a lot of the morbidity of the surgery,” Gallo said. “There’s rarely even blood loss, and most people don’t even take pain medications after they go home. They get back to normal in a matter of weeks as opposed to months. It’s just less impact on their overall life.”

Tough Choices

Gallo said that, while da Vinci holds benefits for many surgical patients, not everyone is the best candidate for the robot.

“Every patient is an individual, and we look at specific factors, such as their age, how aggressive the cancer is, what their life expectancy is if they did not have cancer, and what their overall medical condition is,” he said. “We also discuss all treatment options that are available. It’s a complicated discussion, ranging from radiation to robotic surgery to doctor surveillance.”

“I think it’s ideal for younger, healthier men,” Sonn added. “However, we have operated on older men, and they’ve done very well” — not to mention a growing number of men and women undergoing other types of surgeries.

“We’ve also expanded to operations on bladders and reconstructing kidneys, and I think as long as a patient can tolerate laparoscopic surgery, they’ll be able to tolerate robotics pretty well,” Sonn said.

“Other fields are now using it — gynecology, cardiothoracic surgery … there’s a huge expansion of the actual procedures being performed. Now, the caveat to that is that the surgeon really should be very experienced using these procedures. I think it is a pretty complicated operation, so you have to have someone with experience to do that.”

Gallo agreed. “The biggest concern of someone undergoing this operation is that the average urologist might do 10 or 12 of these a year, but you want to go to someone who’s doing a minimum of 30 to 40 a year, and has preferably done at least 300 cases,” he said. “In the beginning, there’s a learning curve, and there’s a higher risk of complications when you’re going through that learning curve.”

And the education never stops, he added.

“You always have to keep up with the latest technology, get up to speed with recent techniques. Even now I’m constantly going back and re-educating myself, going to conferences, watching how some world experts are doing things. You always have to stay on top of this.”

Because even robotics can’t obscure the importance of the human element.