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Robotic Prostate Surgery Keyhole to the Future

Source: The Sydney Morning Herald

The uptake of robotic prostate surgery is growing worldwide, but opinion on its efficiency is divided.

When urologist Justin Vass scrubs in for surgery, he and his team are not alone. These days they are joined by surgical robot, the da Vinci.

At first glance, the da Vinci appears like a man-made praying mantis. It comprises a surgeon console, a patient-side cart with four interactive robotic arms and offers 10-times three-dimensional visual magnification.

Alongside auto-reverse parking, PayPass and Siri, we have veritable robots working for us to improve every facet of life.

“I think the jury is still out. ”

Why should our operating theatres be any different?

Even as a robotic surgeon himself, Dr Vass says it is a technique to be approached with caution.

''Saying robotic surgery is the best way of performing surgery is like saying, 'I've just bought a racing car and therefore I'm a good driver'.

''It is purely a tool, which needs to be used well. So you can really do a poor operation with the robot, as you can drive poorly the racing car,'' he says.

One of its most common uses, among many, has been in urology performing robot-assisted laparoscopic prostatectomies; the removal of cancerous prostates.

But while the global use of robots has increased dramatically over the past decade, the medical community still awaits definitive results on the success of the robot and a justification of its increased cost for hospitals and patients.

Sydney-based Dr Vass has been a laparoscopic surgeon for more than 12 years.

Having always had a keen interest in minimally invasive surgery, it was no surprise that his first encounter with the robotic technique stuck with him.

''I thought it was just head and shoulders above anything I'd seen before in a routine fashion,'' he says. ''And so I've realised this technique in the right hands had merit.''

Prostate cancer is the most common cancer in Australia. Each year about 20,000 new cases are diagnosed, and of every nine men, one will develop prostate cancer in his lifetime.

But handling prostate cancer has always been a hot topic; and with radiotherapy, radical surgery or even just surveillance all possible treatments, where does the robotic approach fit?

Traditionally, radical prostatectomies have been performed by a surgeon making a 10 to 15cm incision in the stomach.

A robotic approach however leaves just five keyhole incisions, through which the arms of the robot are inserted.

Melbourne urologist Mark Frydenberg is the vice-president of the Urological Society. He says there can be no denying the benefits that come with robotic surgery.

''It's certainly a great technology,'' he says. ''One can only imagine this is the beginning of the evolution. But looking at prostatectomy as an isolated operation I think the jury is still out.''

Commonly patients who have robotic surgery will go home a day earlier than those who have the open approach, but Dr Frydenberg says the relative advantage of a robot over an open procedure is always going to be reasonably marginal.

''Because an open operation is actually done through a relatively small incision and in a part of the body that doesn't cut any muscles, the recovery from an open radical prostatectomy when it's done well is also extremely rapid,'' Dr Frydenberg says.

For patient Don Alexander, there were few questions when it came to deciding on which surgery he would choose.

''I would recommend anybody to have the robotic surgery. Just purely from the fact of being able to see what was there, with the 3D camera,'' he says.

The 67-year-old fire safety engineer was the first in his family to be diagnosed with prostate cancer. He was pleased with his recovery.

With all prostate surgery, removing the cancer is the priority. But the second aim lies in avoiding the two unspoken evils that can be part and parcel of prostate cancer: incontinence and impotence.

Is it possible the da Vinci can do more to minimise the risks of these two surgical side effects?

Of his experience, Mr Alexander would say yes.

''My surgeon also did a nerve sparing procedure. I said to him, before the operation that, you know, I needed to be sexually active and he did what he said he'd do.''

Whilst Dr Vass feels the precision and delicacy of robotic prostatectomy is an evolution of surgery, he says we must remember it is just a tool.

''Once you're able to utilise the benefits of the robot I think it's a great technique but simply using it without the skills will give you a poor result,'' he says, stressing that it's ''not really the robot that gives you the good operation, it is completely the surgeon using that tool. It's an expensive hammer.''

A $3 million hammer at that, for any hospital purchasing the robot, in addition to ongoing annual technology fees.

But with its extensive marketing and business model, who's pushing the da Vinci and how much of a role has this model played in the global uptake of the robot?

Developed by American company Intuitive Surgical, the da Vinci robot has been in use for about a decade.

Since 2007 the percentage of prostate surgeries performed robotically in the US has doubled to 80 per cent.

''In America it's taken off in a relatively unregulated way, so what's happened is there has been this explosion of robots all over the country, with everybody rushing around to do it [robotically] before it's actually been proven to be better,'' Dr Frydenberg says.

Dr Vass suggests the marketing of the robot in the US has led to an over-estimation of surgeons' skills.

''I think it's clear to say that the uptake of robotics in the States has outpaced their training and credentialling. This has led to perhaps less than ideal promises with regard to outcomes, and that has subsequently led to lawsuits,'' he says.

But Dr Frydenberg says Australia's experience is different, deeming our training and credentialling standards to be some of the strictest in the world.

In Australia surgeons training to use the robot will participate in the da Vinci skills simulator.

Surgeons then attend a live animal workshop, before being mentored for a series of cases.

Following this they are credentialled to begin working on patients independently.

Sydney urologist Andrew Brookes, of the Royal College of Surgeons, believes the present training model is sufficient in Australia.

''The people who are doing it are highly skilled surgeons who have extensive experience in all aspects of surgery.

''So the transition is really to adapt a new piece of technology to what they've been doing,'' he says.

Dr Vass feels it is not a technique that comes down to numbers, but skill. ''In the right hands one would be enough.

''But I guess my concern is that this is a platform some surgeons may struggle with and there's no formal accreditation process,'' he says.

So beyond the credentialling processes of individual hospitals, questions remain about who is keeping robotics in check.

Dr Brookes says it is ultimately the role of individual hospitals to monitor the usage of robotics.

''The credentialling authority is actually the individual hospital, so the hospitals have the responsibility, once they get the technology of incorporating [training and credentialling] into their practice,'' he says.

Then there is the question of worth. The robotic surgery costs patients up to $4000 more than the open procedure.

In Brisbane and Melbourne there are two major trials being completed comparing the two procedures, to determine the cost benefit.

''They're really going to be internationally significant studies because we're one of the few places in the world where we are still able to do studies of this sort, comparing the technology and really seeing if one is better than the other,'' Dr Frydenberg says.

But for a research vision in the long-term he points to independent state schemes such as the Victorian Prostate Cancer registry.

''The registry allows for an independent group of people to enter patient characteristics during and after their treatment, comparing their success rates according to the different surgical techniques,'' he says.

While all individual hospitals will keep data on the performance of their surgeons, Dr Vass and Dr Brookes agree that an equivalent state registry system in NSW would be invaluable.

''Surgeons are busy,'' Dr Vass says.

''It's very hard to keep your own data and it's also hard to trust a surgeon's own data.

''Having an independent body would be an excellent way of judging your results compared to your peers.''

Funding may have halted progress for a NSW-specific registry but the future for collecting the relevant data is not all bleak.

Recognising the opportunities for research and improvement, the Movember foundation is investing in a national prostate cancer clinical registry. Dr Brookes says this can only mean good things for Australia.

''The power of an independent body first of all is numbers,'' he says. ''You get bigger numbers and with bigger numbers you get more statistical validity so you can see the trend.''

Not all surgeons are adopting the robotic technique as quickly as others. Dr Frydenberg says: ''The issue isn't so much for people who are new trainees. Because there will be some people that will effectively be taught to do this operation on a robot right from the beginning.

''It's a little bit more difficult for someone like me, who has done a large number of open prostatectomies, because we're already over the open learning curve.''

He bears the obvious concern that for those doctors switching to do something robotically for the first couple of hundred cases ''the quality of the outcome may actually not be as good as if you'd stuck and done it in an open fashion because you've already done it thousands of times in that fashion''.

Mr Alexander admits that he didn't know much about the surgery going in, but the good news for him is that it worked. ''The day after the operation I was able to walk up a set of stairs in the hospital and back down again. I had no pain, and I was virtually back working after just three days off. After that I've just been onwards and upwards,'' he says.

Yet the jury remains out on whether robotic surgery is more effective.

But with the aid of the coming national registry and ongoing research, results are expected as soon as early next year.

So, should research point in the robotic direction it seems all doctors will have to learn how to drive the car.

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