Remote-control prostate surgery shows advantages over conventional surgery
It was no conventional operating room at Swedish Medical Center on this day: The lights were low. Rod-like devices that poke from the patient's...
Seattle Times medical reporter
It was no conventional operating room at Swedish Medical Center on this day: The lights were low. Rod-like devices that poke from the patient's closed abdomen moved sporadically.
The surgeon was off in a corner, his head buried in a boxy, cabinet-size console.
"Hold down on the bladder, please, Chris," Dr. James Porter told his assistant, as he remotely cut away tissue around the patient's cancerous prostate.
Inside the console, Porter watched a 3-D picture as a camera deep in the patient's body showed the surgeon's every move with remote-controlled instruments.
Two scissors-like instruments inside the man move in response to Porter's moves on the console's controls. When he pinched his right index finger and thumb together, the right instrument moved the same. When he rotated his right wrist, the device on the right side moved concurrently.
Porter was in the midst of a four-hour operation using a robotic system to remove Ron Williams' prostate, so the cancer will not spread. It is the latest technology for "radical prostatectomies," one treatment for the disease. The operation is the most common use of the robotic system, made by da Vinci Surgical Systems, of Sunnyvale, Calif.
Prostatectomies using the da Vinci system also are performed at Virginia Mason Medical Center and University of Washington Medical Center.
Studies have shown the system may have some short-term advantages over conventional "open" surgery in which an eight-inch incision is made in the abdomen. Using the robotic system, only five, one-half-inch incisions are made — just big enough to insert the instruments and camera, which are mounted on the ends of the rods inserted into the body.
Patients undergoing the robotic operation average one to two days in the hospital, compared with two to three days for conventional surgery. Less blood is lost, decreasing the chance of needing a transfusion; pain is reduced and patients are likely to return to work sooner.
"There is no disadvantage to the patient. The operation may take longer, but there is no down side," said Porter, who has performed about 80 of the robotic procedures, including many he did while at the University of Washington before going into private practice.
Robotic system versus conventional surgery
Doctors have been using the robotic system since 2000, when it was approved by the federal Food and Drug Administration. Because it is still relatively new, only limited studies have been conducted comparing it to conventional prostate surgery.
But experts and those few studies say using the robot results in about the same cancer control as conventional surgery. About 20 percent of patients will have small amounts of cancer remaining in tissue around the prostate and will need additional treatment, usually radiation.
The rates of continence — the ability to control urination — also are about the same as with conventional surgery. From two-thirds to more than 90 percent of patients are continent by the end of a year.
As for sexual function, experts say it is difficult to assess overall because it depends on several factors, including the age of the patient, whether he was fully functional before the surgery, how many nerves were saved in the operation and whether erectile dysfunction medications are used.
Some experts in prostate surgery aren't as enthusiastic about the new robotic system.
Use of the system "is not any worse [than conventional surgery], but nothing makes it magic," says Dr. Louis Kavoussi, vice chairman of urology at Johns Hopkins University and one who has used the system. "It still depends on who's driving the bus ... on how much knowledge and skill the surgeon has."
The da Vinci robotic system adds more technology to laparoscopic surgery — an operation in which a two-dimensional camera and three other arms holding instruments extend through small abdominal incisions. In that older system, only the camera is robotic — using voice commands. The surgeon must manually manipulate the instruments.
Using the da Vinci system, the surgeon controls three instrument arms and the camera, while an assistant manually operates another instrument arm. The robotic surgery affords live, televisionlike action from inside the patient's lower body.
In the dimly-lit Swedish Medical Center operating room, little puffs of smoke rose as Porter expertly steered a hot cautery knife to slice away tissue around Williams' walnut-sized prostate. As he used a scissors-like instrument, the snipping could be heard inside the patient, about 10 feet away from where Porter sat.
"Chris, move to the left, if you can," he said to his assistant, Dr. Christopher Garlitz, who stood over the patient and hand maneuvered a small tube to suction away blood. Later, Porter delicately separated two bundles of blood vessels and nerves which ran along the side of the prostate. A false move could damage the patient's ability to have erections. After removing the enlarged prostate, he restructured the opening of Williams' urinary bladder, so it could be reattached to the urethra with a series of stitches.
The robotic system floods the surgical area with light, magnifies it 10 times, eliminates any small tremors that might occur in the surgeon's hands and can scale the doctor's movement down, if desired.
"It feels like you're able to move the instruments with more control," says Porter, who is paid by Intuitive Surgical Inc. to instruct other surgeons in use of the da Vinci system.
Such surgery is appropriate for patients whose cancer does not appear to have spread out of the prostate. Some medical centers use another procedure called brachytherapy, in which radioactive pellets are implanted in the prostate to kill cancer cells. Studies have shown about two-thirds of patients are cancer-free 10 to 12 years after the treatment.
The robotic procedure has brought great relief to Williams, a 55-year-old accountant from Olympia.
For years, his enlarged prostate made it increasingly difficult for him to urinate. Last August, he had to go to the emergency room with the problem, and he later was diagnosed with early-stage prostate cancer.
After the operation last month, Williams bounced back quickly. He was discharged from the hospital the next day. After three days, he no longer needed a prescription pain killer. In five days, a catheter could be removed. He no longer has problems urinating.
Regular testing will monitor whether the cancer has spread outside the prostate.
"I'm in awe over how well I was able to recuperate and feel," said Williams.
An expensive operation
While advocates of the robotic surgery tout its fast patient recovery time, some experts are critical of the expense.
Including the surgeon's fee, the charges at Swedish total about $43,000, compared to about $30,000 for the conventional, open surgery. Both are covered by private insurance or Medicare.
Some of that extra cost is because the da Vinci system cost the hospital $1.5 million, plus more than $100,000 in annual maintenance.
"It's a tremendous financial burden on the system," said Kavoussi, who has extensive experience in laparoscopic surgery.
Another Swedish patient, Marlowe Gilmore, 41, never had any symptoms before he was diagnosed with early prostate cancer last summer. He found out only because a physical exam revealed elevated levels of Prostate-specific antigen (PSA) in his blood, which, with other factors, can indicate that cancer may be present.
Because he is relatively young, and African American, his cancer could have been fast growing, so his doctors recommended removal of his prostate.
His surgery, by Porter, was much like Williams'. Gilmore was out of the hospital and off prescription pain medications in a day, and soon had his catheter removed with no incontinence.
Gilmore was back at his civilian job at Fort Lewis 12 days later. He now has no signs of the cancer, and has had no problems with sexual function.
"The good news is they caught it early," Gilmore said. "I'm the biggest fan of this surgery."
Warren King: 206-464-2247 or firstname.lastname@example.org
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