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, 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.

The robotic system has already transformed the field of prostate surgery, for which it was approved in May 2001. That year it was used in less than 1 percent of all prostatectomies. This year more than 20 percent 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 (UIC).

The first major study to compare open and robotic prostatectomies was published in the British Journal of Urology in 2003 by Dr. Mani Menon, head of the Vattikuti Urology Institute at Detroit's Henry Ford Hospital. (The hospital has now done about 2,050 of the robotic procedures--more than any other in the nation.) The study of 300 patients found that those who had open surgery 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 robotic surgery. 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," Menon says 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. And the tide began to turn. "Dr. Menon and a few others showed excellent results with the da Vinci, and then they showed that their results are reproducible," says Dr. Reza Ghavamian, director of urologic oncology at New York's Montefiore Medical Center, which purchased a system this fall. "There's no question this [system] has revolutionized the surgery."

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 nowto 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 laparoscopic procedures, for which the system was just approved this spring. There are about five times as many hysterectomies as prostatectomies performed each year, and surgeons say the complex procedure could benefit from the robotic system'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. "I'd heard these stories about how they cut you right down the middle," says his patient Gilbert Minacci, a 65-year-old retired school principal from Glen Rock, Pa. But he had just a single two-inch incision on the left side of his chest. A week and a half after the surgery, Minacci was walking 30 minutes a day, and tests show his heart function is normal again. "I think even my doctor was surprised that I bounced back so quickly," he says. "If you have to go through this, I don't think it could have been much better."

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." Insurance companies usually pay the same amount regardless of the type of procedure a patient picks, Sutter says, so the hospital is left picking up the tab for the more expensive robotic surgery.

Also, some surgeons are reluctant to commit the hours necessary to learn robotic techniques. "There are a lot of surgeons who do what they do, and do it well, and don't want to spend time learning a new skill set," says Scott Goldman, surgery chairman of Main Line Health, which owns the Heart Center at Lankenau. "But I think the people with the strongest objections have never tried it."

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. "It's great 'gee whiz' technology that's staggering in its complexity and promise," says Finlayson. "But the onus is on the advocates of da Vinci to prove that there's enough benefit to justify the huge cost."

There's also some concern that once a hospital invests in such an expensive system, surgeons might feel pressured to use it and steer patients toward surgery over other treatment options. "It's not inconceivable that the threshold for operative intervention would be lowered by the introduction of this new technology," says Finlayson. "We saw that with laparoscopy in terms of how people would manage gallbladder disease."

That's not necessarily a bad thing, if the surgical results are markedly better. Proponents say data have already shown that's the case for prostatectomies. Now surgeons who use the system are hopeful that the success demonstrated in urology will be replicated in other areas. "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 more than 600 times for procedures ranging from prostatectomies to kidney transplants. "This is the beginning of a revolution. I have no doubt about it."