Chris Knoedler, MD
The era of robotic surgery has hit the medical marketplace nationwide, including the Twin Cities, and it is here to stay. The most high-profile system in use at present is the da Vinci® Surgical System made by Intuitive Surgical. This system was first approved by the FDA in July of 2000 for general laparoscopic surgery, but it’s most prolific application to date has been in the performance of robotically assisted radical prostatectomies (the “da Vinci® Prostatectomy”).
The da Vinci® prostatectomy was first developed in Europe, but rapidly made its way to the United States and is presently on track to virtually eclipse the traditional “Open Radical Retropubic Prostatectomy” in terms of numbers performed. In 2003, approximately 3% of all radical prostatectomies performed in the United States used robotic technology. In 2004, this number rose to 15%, and in 2005, the number rose to approximately 30%. Estimates for 2006 show a 50% market penetration.
Besides the da Vinci® Radical Prostatectomy, other urologic applications include pyeloplastys, nephrectomies, and ureteral resections and ureteral reimplants. Additional urologic procedures will undoubtedly become applicable, although significant future growth for this technology will likely depend on procedural techniques currently being developed in other surgical fields.
FDA-approval for mitral valve repair was obtained in November 2002, but its use in cardiac and thoracic surgery has expanded to revascularization procedures, Esophagectomy, Lobectomy, and Thymectomies. General surgical applications including Roux-En-Y Gastric Bypass, Nissen Fundoplications, and Heller Myotomies are becoming more commonplace. In gynecology, significant experience has been developed with myomectomies and hysterectomies. Success in implementing robotics in any of these fields, however, is dependent not only on having access to the technology, but also on becoming skilled and proficient in its use. It takes great time and commitment on the part of the healthcare team to achieve that end.
The da Vinci® system involves what is referred to as a “master-slave” robot, with the surgeon controlling the movements of the instruments. Typically, the surgeon’s “console” is in the OR suite about ten feet or so from the patient’s bedside. Instruments are snapped on to the robotic arms and inserted through traditionally appearing laparoscopic trocars. An assistant is required at the bedside to facilitate exposure and change out instruments when necessary.
Compared to traditional laparoscopy, major advantages of the system include a three-dimensional view of the operative field, and three, multi-joint robotic arms, with multiple degrees of movement. These multi-joint arms allow for far greater dexterity of movement, facilitating fine dissection and suturing not possible with traditional laparoscopy. In addition, all motion is free of tremor and can be scaled down to allow for even more precision if so desired.
The patient benefits from the minimally invasive nature of the incisions are the same as traditional laparoscopy. Consequently, clinical experience has demonstrated less analgesic usage, shorter hospitalizations, and quicker return to normal activities as compared to “open” surgical techniques. These findings are certainly consistent with our experience.
The initial da Vinci® Surgical System used by Metro Urology was purchased by the HealthEast Foundation and placed at St. John’s Northeast Hospital in Maplewood, MN, in May 2004. The first robotic prostatectomy was performed by Metro Urology physicians in May 2004, and to date, we have performed over 500 prostatectomies, 33 pyeloplasties and 2 nephrectomies using robotic techniques.
Our initial approach involved two urologic surgeons, and a dedicated anesthesia and OR nursing teams. Experience begets efficiency for everyone involved, and by limiting the initial number of team members, inefficiencies were reduced with the team’s skill set progressing to an acceptable level within a relatively short period of time. From that point on, new team members were introduced one or two at a time in an attempt to disseminate the skills and technology without taking a step backward in efficiency and patient care.
Initial length of stay (LOS) data within our institution revealed a drop from over 3 days for a traditional open prostatectomy to 1.7 days for the robotic approach. More recent LOS data from the last 100 procedures now stands at 1.18 days per robotic prostatectomy, with 85% of the patients being discharged the following day.
Average total case time for the procedure is now 2 hours and 2 minutes (122 minutes), with actual operating time of the robotic arms (“robot time”) at 1 hour and 29 minutes (89 minutes).
Seven patients out of over 500 have received a blood transfusion. Figure 1 reveals the average blood loss (97 cc vs. 564 cc) for the robotic approach vs. the open procedure, with postoperative hemoglobins averaging 12.0 gm vs. 10.5 gms (fig. 2) during a 2005 series. Average blood loss per case stands at 100 cc.
Contraindications to the robotic prostatectomy procedure are few, and surgical indications basically follow similar guidelines to the open procedure. Patients with prior sigmoid resection for divirticular disease or an open abdominal aortic aneurysm repair are excluded as candidates for robotic surgery and are treated with a traditional open procedure. In contrast, prior upper abdominal surgery, history of appendectomy, or prior hernia repair have not posed any issues surgically.
Preservation of the neurovascular bundles responsible for erectile function is routine and enhanced by the 3-D magnification of the operative field. The watertight nature of the urethral anatamosis has reduced the postoperative catheterization time to 7 days and obviated the need for placing a surgical drain.
Our initial experience favored patients with a Body Mass Index (BMI) of under 30. With more experience, patients with a BMI of over 30 are easily handled and presently the robotic approach is our preferred approach for obese patients due to the ease of access to the deep pelvis.
Financially, the new technology represents a challenge for hospital systems and the health care system at large. Single-unit costs for the machines are upwards of 1.5 million dollars, with additional yearly service contracts and case-by-case disposable costs. Costs to the institutions involved may be potentially recouped with shorter lengths of stay and increases in volumes of procedures performed. Additional savings at a societal level may be realized with quicker recovery times and return to work. Most patients in our experience are back to normal activity or work within 14 to 21 days post-operatively.
At present, four da Vinci® systems are in place for clinical use in the Twin Cities hospitals, with another two delivered and soon to be up and running. Urologic use will likely predominate initially, but expansion to other fields should be expected.
Urologic residencies have quickly integrated this technology into their training programs. Consequently, the next generation of urologists, as well as specialists in other surgical fields, can be expected to bring this skill set with them into practice. In addition, we can expect competition and new product development from other vendors within the industry. Continued refinements in instrumentation and additional procedure development will likely further expand the indications and usage of robotics, making robotic surgery a routine extension of many if not most surgeon’s practices.
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