Cutting Edge

Medical progress is measured in many ways. As robotic surgery comes of age..... A look ahead.

Photo illustration by Newsweek; photograph by Adam Friedberg for Newsweek (stereo viewer); courtesy of Intuitive Surgical Inc. (3-D image)

Dec. 12, 2005 issue - Stuart Forbes celebrated his 60th birthday on April 11. A week later, he was diagnosed with prostate cancer. "It was quite a month," says Forbes, a blunt Vietnam veteran who runs a consulting firm outside Boston. When biopsies confirmed he had an aggressive form of the disease, Forbes started looking for a surgeon. The first recommended a traditional radical prostatectomy, which would require an eight- to 10-inch incision and at least two days in the hospital. Forbes was also warned that he would likely lose almost all the nerves on the left side of the prostate, which could permanently affect his sexual function. "I thought, 'I need to really look at all my options'," says Forbes. He considered high-intensity focused ultrasound ablation, a relatively new technology that's been used in Europe. But it's expensive and would require transatlantic trips. He looked into various forms of radiation, as well as proton-beam therapy. Then, in June, his girlfriend took him to a symposium on robotic surgery. "I saw the machine and how it worked," remembers Forbes. "It was just incredible. I said, 'That's it'."

In August, Dr. Ashutosh Tewari, director of robotic prostatectomy at NewYork-Presbyterian Hospital/Weill Cornell, removed Forbes's walnut-size prostate and lymph nodes and reattached his bladder to his urethra without once putting his hands inside the patient. Using Intuitive Surgical's da Vinci robotic system and operating through five tiny incisions, Tewari conducted the entire procedure from across the room. He sat at a console and turned two knobs to remotely manipulate tiny surgical instruments attached to adjustable robotic arms. Forbes was walking within hours of his surgery and was discharged the next day. He compares the discomfort from the largest incision (about two inches long, and the only one to require stitches) to a bad pimple. By midweek he was walking three miles daily. In 10 days he was back at work. After three weeks he was playing golf again; by late October he'd regained normal urinary, and most sexual, function. "I'm about as excited as anyone can be about this procedure," he says.

Using robots to perform surgery once seemed a futuristic fantasy. Not anymore. An estimated 36,600 robotic procedures will be performed this year—from heart-bypass surgeries to kidney transplants to hysterectomies. That's up nearly 50 percent from last year, and analysts predict the figure will nearly double in 2006 to more than 70,000 procedures. Since the da Vinci was approved by the Food and Drug Administration in July 2000 (the only robotic system to get the FDA nod), about 350 of the units have been purchased, including 30 in the last quarter alone, at about $1.3 million apiece. Surgeons who use the system have found that patients have less blood loss and pain, lower risk of complications, shorter hospital stays and quicker recovery times than those who have open surgery—and even, in many cases, laparoscopic procedures.

To get additional information, please call 212 746 5638 or 5643

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Dr. Tewari leads the robotic prostatectomy program and has been intimately involved with over thousand of robotic prostatectomies.  His technique of nerve sparing has one several awards including first prize by American Urologic Association.  He has been invited to perform surgeries at at international institutions such as Cambridge, UK, Guy's hospital, UK and University of Innsbruck, Austria.  He has published hundreds of publications about Robotic Prostatectomy and prostate cancer. His book on robotic surgery is in press and another book on prostate cancer is being prepared.

He was trained by worlds premier surgeon on Robotic Prostatectomy- Professor Mani Menon at Henry Ford Hospital. With Professor Menon, who is considered the father of robotic surgery, he co-authored several key techniques and publications about robotic prostatectomy.

Prospective patients can call 212 746 5638, 212 746 5643, 212 746 5658 for more details (detailed list of contact is at the bottom of this page).

More reading:

• About Dr. Tewari

• Brief CV

• Awards

• Publications

• Research

• Why choose robotic prostate surgery

• Treatment selection for prostate cancer

• Cornell resources

• Am I a candidate for robotic surgery?

• Frequently Asked Questions

• First visit to Dr. Tewari's office at Cornell

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Comparison of various surgical treatments

Pooled Analysis of Published data

Nerve Sparing Technique

General overview

Advance Robotic techniques of Prostatectomy (ART)

Robotic Prostatectomy Program at Cornell Institute of robotic surgery

The goal of Robotic Prostatectomy is to completely remove prostate cancer while minimizing the side effects of conventional surgery. Robotic Prostatectomy has been proven safe and effective for men with prostate cancer. The information provided here is based on the  published work in which Dr. Tewari was a co-author with his mentor, Professor Mani Menon, Director, Vattikuti Institute of Urology. Dr. Menon has pioneered the field of robotic urology.

Cornell Robotic Prostatectomy Program offers

• Latest robotic technology with the da Vinci^® Surgical System
• Trained team of surgeon, fellows, nurses and robotic coordinators performing 7-10 cases/week
• Lead surgeon (Dr. Tewari) is American Board of Urology certified surgeon who has been involved with over 2000 robotic procedures including those in his training.  he performs over 500 cases every year.
• Pioneer work in robotic nerve sparing procedures- ART Prostatectomy.
• Noel continence preservation technique
• Individualized Program for Oncologic optimization- Protocol and technique to minimize positive margin rates.
• Integrated continence recovery program involving modern techniques and state of art equipments.
• Integrated early sexual recovery program
• Preoperative image guided treatment planning to optimize surgical technique for an individual patient to adjust for his unique internal anatomy
• Basic and clinical research on robotics by Dr. Tewari
• Leading hospital with trained staff- New York Presbyterian Hospital is amongst top 10 hospitals according to US News rating
• Dedicated 3 D operating room with wall of knowledge
• Multiple DaVinci robotic systems

The New Frontier

Surgical removal of the prostate and surrounding tissue (radical prostatectomy) has long been recognized as one of the most effective forms of therapy for prostate cancer. A conventional radical prostatectomy involves an open incision across the abdomen.  The Cornell Institute of Robotic Surgery in the Department of Urology at NewYork-Presbyterian Hospital has entered the next generation of prostate surgery by performing robotic laparoscopic prostatectomy using the daVinci™ computer-enhanced minimally invasive surgery system.

Team

The Robotic Prostatectomy Program at Cornell is directed by Ash Tewari, MD. The Robotic Prostatectomy Program team includes laparoscopic fellowship trained surgeons, dedicated operating room team, a robotic coordinator, a nurse practitioner, two physician assistants, several research coordinators and data base administrators.

Technology

This procedure uses computer enhanced minimally invasive daVinci™ surgical system.  The system is empowered with I-Max like three-dimensional vision. The surgeon controls robotic arms that hold special surgical instruments and are inserted into the abdomen through small openings. A camera (a long, thin, lighted telescope) is inserted and connected to the computer monitor that allows the surgeon to see inside the body.  The vision is stereoscopic and magnified ten to fifteen fold.

The Stereoscopic 3-D magnification helps the surgeon to identify the delicate nerves and muscles surrounding the prostate. The depth perception provides precision during the surgery and allows meticulous surgical dissection. Every structure can be identified and precisely separated from the prostate. The camera can be negotiated in very narrow corners of the body, which can be hard to visualize when looking with the naked eye. The augmented image perspectives help the surgeon in minimizing damage to erectile nerves.

The robotic arms can rotate a full 360 degrees in various planes, allowing the surgeon to manipulate instruments with greater precision and flexibility. These instruments are mounted at the tip and thus could be controlled with high fidelity and dexterity. This ability to move small instruments in any possible direction helps tremendously in performing delicate surgical moves which involve the ability to rotate, turn, flex, extend, push, twist, abduct and adduct while performing a complex surgical task.
 

Procedure

The prostate, pelvic lymph nodes, seminal vesicles and adjacent tissue are removed through the small incisions, which are closed with a few stitches. Just like conventional open surgery in aggressive cancers, robotic prostatectomy includes removal of lymph nodes that drain the prostate. Indications for removal of lymph nodes depend upon the cancer grade, the PSA level and the digital rectal examination. In addition to removing the prostate, seminal vesicles also are removed. Men can no longer father children following the procedure.  However, NYP hospital is a premier center for infertility and assistance is available for patients who wish to.
 
Patients usually are discharged within 24 hours and return to normal activity in approximately two weeks.  Most patients start walking on the same day of surgery and are able to drive soon thereafter.

After the operation, patients have a catheter to drain the bladder (Foley). When the prostate is removed, the bladder has to be connected to the urinary channel within the penis (urethra). The catheter helps protect the connection during the healing process. In most patients, the catheter is removed in 7 days. There is a very small chance that it has to be reinserted because of temporary swelling at the connection site.  Robotic Prostatectomy leads to a rapid recuperation in most patients. Patients begin walking the evening of surgery and begin a liquid diet one day after surgery.

Who is the candidate for this surgery?

Patients with clinically localized prostate cancer who are medically fit to undergo surgery are candidates for this procedure.

Potential benefits of Robotic Surgery

·        Cosmetics- small key holes

·        Less pain- four fold reduction in pain than open surgery

·        Minimal blood loss- one tenth of open procedure

·        Lowering the need for blood transfusion and associated complications. Rarely do  patients require blood transfusions while they are under going robotic surgery.  However during open surgery, approximately 67% patients require blood transfusions.

·        Greater post operative hemoglobin- The patients go home with 30% more hemoglobin, which reduces the fatigue and patients feel much more energetic and less tired.

·        Minimal disruption in their life style, as patients stays in hospital 1/3^rd the time than conventional procedure.

·        Shorter duration of catheterization- there is 50% reduction the duration of catheterization following robotic prostatectomy.  However, few open surgeons also specialize in removing the catheter early.  Shorter catheterization usually translates in less discomfort and early return to life style.

·        Proven safety in trained hands-There is four fold reduction in complication rate in trained hands.  Early robotic series usually reports higher complication rates.  Most complications are minor and require minimal care.

References

1.         Menon, M., Shrivastava, A., Tewari, A. et al.: Laparoscopic and robot assisted radical prostatectomy: establishment of a structured program and preliminary analysis of outcomes. J Urol, 168: 945, 2002

2.         Tewari, A., Srivasatava, A., Menon, M.: A prospective comparison of radical retropubic and robot-assisted prostatectomy: experience in one institution. BJU Int, 92: 205, 2003

3.         Jourdan, I. C., Dutson, E., Garcia, A. et al.: Stereoscopic vision provides a significant advantage for precision robotic laparoscopy. Br J Surg, 91: 879, 2004

4.         Sarle, R., Tewari, A., Shrivastava, A. et al.: Surgical robotics and laparoscopic training drills. J Endourol, 18: 63, 2004

5.         Tewari, A., Menon, M.: Vattikuti Institute prostatectomy: surgical technique and current results. Curr Urol Rep, 4: 119, 2003

6.         Tewari, A., Peabody, J. O., Fischer, M. et al.: An operative and anatomic study to help in nerve sparing during laparoscopic and robotic radical prostatectomy. Eur Urol, 43: 444, 2003

7.         Tewari, A., Peabody, J., Sarle, R. et al.: Technique of da vinci robot-assisted anatomic radical prostatectomy. Urology, 60: 569, 2002

8.         Menon, M., Tewari, A., Peabody, J.: Vattikuti Institute prostatectomy: technique. J Urol, 169: 2289, 2003