May 25, 2006
"Some doctors believe that robotic surgery for prostate cancer and other conditions causes less pain and fewer side effects than conventional techniques."
By Marie McCullough
Inquirer Staff Writer
David Lee, the chief of urology at Penn Presbyterian Medical Center, is performing surgery with his bare hands and stocking feet.
He sits at an arcade-game-size console, peering into a viewfinder while manipulating hand grips and foot pedals. His movements control surgical instruments attached to four robotic arms that have been inserted through small incisions into William Penney, the patient lying five feet away.
After a few hours on this May morning, Lee uses a robotic arm to pull a drawstring baggie through Penney's belly button. His cancerous prostate gland is tucked inside it.
The da Vinci Surgical System represents an influential advance in "minimally invasive" techniques designed to reduce the wounds, complications, and recovery time of conventional cut-open-the-body surgery.
Approved by the U.S. Food and Drug Administration six years ago, the robotic system has become a coveted commodity for American hospitals trying to stay technologically competitive. About 350 centers worldwide have installed the system, including eight in the Philadelphia area and seven in New Jersey.
Intuitive Surgical, the Sunnyvale, Calif., maker of the da Vinci, estimates 18,000 robotic prostatectomies (prostate removals) were performed last year in the United States, accounting for 15 percent of all prostate cancer surgeries. Several thousand other robotic procedures were done on cardiac, gynecologic, pediatric and general surgical patients, the company says.
Like almost every high-tech, high-price medical innovation, robotic surgery is not without controversy. The da Vinci costs $1.5 million, plus maintenance and upgrades. Depending on the type of surgery, it may increase operating room time. And it is no guarantee of good results.
"If you're a lousy surgeon, you'll be a lousy robotic surgeon," said Li-Ming Su, director of laparoscopic and robotic urological surgery at Johns Hopkins Medical Center in Baltimore.
But for early-stage prostate cancer patients such as Penney, 51, the less invasive approach has obvious benefits. Besides less scarring and blood loss (transfusions are rarely needed), patients report less pain, easier recoveries, and faster returns to work than those who undergo open operations. As for the feared side effects of prostatectomy - incontinence and impotence - studies show the outcomes of robotic surgeries are at least as good as with open surgery.
Penney, owner of Philadelphia Orthotics and Prosthetics Inc., researched his options and talked to other patients before deciding. Although it's still too early to know whether he will have any permanent side effects, 10 days after surgery he had "no complaints." He went home the day after the procedure, never had pain "above a 'two' or 'three,' " and returned to work in just eight days.
"Without a doubt, this is the approach I would recommend," he said from his Voorhees home. "I feel fine."
The evolution of less-invasive surgical techniques has been going on for decades.
Operations such as hysterectomy, appendectomy, hernia repair and prostatectomy can now be done with laparoscopy, sometimes called "bandaid" or "keyhole" surgery. The surgeon inserts long, slender instruments and fiber-optic cameras into a body cavity through small skin cuts. The patient goes home with a few stitches.
But laparoscopy is extra challenging. Depth perception and working area are limited. There is no fingertip contact to judge tissue resistance. Eye-hand coordination is tricky because watching the video display of instruments inside the body is like looking in a mirror.
The da Vinci system seeks to alleviate those problems. It provides brilliant illumination; a computer-enhanced, magnified, three-dimensional view; the ability to rotate instruments more than 360 degrees; elimination of hand tremors; and natural eye-hand movements as in open surgery (thus the company's name, Intuitive Surgical).
Although the physician can't feel tissues, he or she can see them with unusual clarity.
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