Cutting Edge

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, 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 a 20- to 25-centimeter 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 five kilometers 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 in the United States 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 July 2000, about 350 of the da Vinci 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, and quicker recovery times than those who have open surgery--and even, in many cases, laparoscopic procedures.

The robot has already transformed the field of prostate surgery. This year more than 20 percent of all U.S. prostatectomies will be done with the robot. And that figure is expected to double next year. "It's becoming the standard of care for prostatectomies," says Dr. Santiago Horgan, director of minimally invasive and robotic surgery at the University of Illinois at Chicago.

A 2003 study of 300 patients published in the British Journal of Urology found that those who had prostatectomies lost five times as much blood, had four times the risk of complications and remained in the hospital more than three times as long as those who had robot-assisted prostatectomies. Robotic-surgery patients had a 14 percent higher rate of cancer removal and, on average, regained urinary function in about a month and a half--four times as fast as open-surgery patients. Also, robotic patients were able to have sexual intercourse again in about 11 months, while half of the open-surgery patients had not regained full sexual function even two years later. The response to the findings was skeptical at best. "They didn't believe any of it," says author Mani Menon, head of the Vattikuti Urology Institute at Detroit's Henry Ford Hospital, of some peers. "It just seemed too good to be true." But a year later, Dr. Thomas Ahlering, chief of urological oncology at the University of California, Irvine, Medical Center, published similar findings in the journal Urology using 120 of his own patients. The tide began to turn.

Five years ago, says Dr. David B. Samadi, director of robotic laparoscopic urology surgery at NewYork-Presbyterian Hospital/Columbia Medical Center, 80 to 90 percent of the prostatectomies he did were open, with less than 10 percent done robotically. Now the figures have reversed. "There is much less blood loss and an extremely low rate of complications," he says.

Forbes's procedure required just five small cuts. A surgical assistant inserted a tiny camera and different instruments, all attached to robotic arms, into Forbes's body through pen-size holes. As he remotely manipulated the forceps or scissors, Tewari kept his eyes glued to a 3-D monitor, which showed images captured by the camera and magnified 10 times. "I can see things now to within a fraction of a millimeter," says Tewari, who has done nearly 300 robotic prostatectomies in the past year.

The next frontier for robotic surgery may be gynecological laparoscopy. There are about five times as many hysterectomies as prostatectomies performed each year, and surgeons say the complex procedure could benefit from the robot's precision. Cardiac surgeons have also begun using the da Vinci for a range of procedures, from mitral-valve repair to coronary-bypass surgery. In October, Dr. Francis Sutter, chief of cardiology at the Heart Center at Lankenau Hospital, near Philadelphia, did what he says is the first da Vinci double bypass. A week and a half after the surgery, his patient was walking 30 minutes a day, and tests show his heart function is normal again.

While Sutter is a proponent of the system, he says his peers may be put off by the price tag. His center held fund-raisers to help pay for the da Vinci system in April. "Obviously, I am sold on it," says Sutter, who has since performed 30 coronary bypasses with the system. "But these robots cost a lot of money. That's been a barrier." Dr. Sam Finlayson, a surgeon and assistant professor of surgery and community and family medicine at Dartmouth Medical School, says the question is whether the procedure has enough of an upside compared with established techniques like laparoscopic surgery. "The onus is on the advocates of da Vinci to prove that there's enough benefit to justify the huge cost," he says.

Surgeons who use the system hope to replicate the success they've had in urology in other procedures. "I think we'll see a day when all complex surgeries are done using the robot," says the UIC's Horgan, who's used the da Vinci in more than 600 procedures. "This is the beginning of a revolution. I have no doubt about it."

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