Physicians expand capacity, develop new applications for robot-assisted surgery

November 11, 2011

When Arieh Shalhav, MD, section chief of urologic surgery, performed the first robotic operation at the University of Chicago Medical Center in 2002, skeptics said the new device, a $1.2 million da Vinci Surgical System, was just a gimmick.

His patient, a 70-year-old Chicago woman with a tumor in her kidney, proved them wrong. She went home two days after her operation. Two days later, she was walking around her block, trying to convince her doubting neighbors that she really did have major cancer surgery.

Now the Medical Center has four da Vinci systems, more than any other Chicago-area hospital. In October, the urologists--the initial and still most frequent robot users--performed their 3,000th robotic prostatectomy at the Medical Center. (They have completed another 500 at Weiss Hospital.)

"We won't be turning back," said Greg Zagaja, MD, associate professor of surgery and director of the prostate cancer program, who has personally performed more than 1,600 robotic prostate operations. "We still teach the residents how to do the open operation. They need to know, in case there's a complication during surgery. That risk will never entirely go away."

But it has become rare. At the Medical Center, surgeons convert from robotic to open prostatectomy in less than one-third of 1 percent of cases--that's about 3 out of 1,000. This happens only in unusual circumstances, Shalhav said, such as a patient with scarring from multiple previous surgeries or radiation treatment, or difficulties created by extreme obesity.

The immediate benefits of robotic surgery are clear. Patients have fewer complications and infections and experience less pain, blood loss and scarring of the suture line. They also recover faster, getting out of the hospital and back to normal activities in less than half the time. That's why 86 percent of the 85,000 men who had prostate cancer surgery in 2009 had robot-assisted operations.

While many surgeons believe there are long-term benefits, there's no way to be sure. Knowing the short-term benefits of robot surgery, patients request the procedure. That means a controlled study cannot be conducted. There may be long-term benefits, but because of the robot's popularity "we can never complete a proper, well-controlled trial," Zagaja said. There are hundreds of case reports and studies comparing impotence and incontinence rates after open, versus minimally invasive, prostate surgery, but patients "will not be randomized," he said. They want the robot. "So, unfortunately, there has not been and there will be no definitive study comparing results on these measures."

Meanwhile, surgeons expect improved results thanks to technological advances to the da Vinci system. Newer models provide magnified, high definition, well-lit, three-dimensional views inside the body. Also, the surgical tools designed for the robot continue to improve, adding flexibility and getting smaller, for use in tight quarters. The newest da Vinci model comes with a dual console, which is useful for teaching.

Use of robotic surgical systems has spread beyond urology. "It's extremely valuable for the type of complicated patients that are referred to our group," said Sandra Valaitis, MD, associate professor of obstetrics and gynecology. "Many of these patients have complex disease. They often have had prior surgery and frequently are obese--which is "one area," she said, "where the robot is really helpful."

Finding new applications for robotic surgery will only increase as the technology evolves and more physicians get trained.

"There is significant and growing demand for the robots," said Wickii Vigneswaran, MD, professor and associate chief of cardiac and thoracic surgery and director of lung transplantation. "This initially came from patients, and now more and more from surgeons."

Few thoracic surgeons around the country were on the robotics bandwagon at first, he said, but "now that we have seen the advantages, there is more interest."

Vigneswaran and colleague Mark Ferguson have the largest experience in robotic thoracic surgery in the Chicago area and use da Vinci for resection of lung nodules and cancers, mediastinal tumors and esophageal surgery. "We adapt the technology to the cases, doing the same operation," he said.

A pioneer in developing new uses for the robot, Mohan Gundeti, MD, associate professor of surgery and pediatrics an director of pediatric urology, is one of a small number of robotic surgeons who operate on young children. He has developed two new robotic operations to repair congenital bladder anomalies. He now has the largest experience in the world for these operations.

In February 2008, Gundeti performed the world's first robotic augmentation ileocystoplasty with Mitrofanoff appendicovesicostomy--a complicated reconstructive procedure for a 10-year-old girl with neurogenic bladder that was causing kidney damage and loss of urinary control.

"This is a major, lengthy operation," he said, "essentially five smaller procedures done in sequence."

The robot enabled his team to operate without a big incision, reduce pain and infection risk, and avoid a big scar. The robotic tools were inserted into the abdomen through five dime-size holes.

The operation went smoothly, and three years later the patient is "loving her first year in high school," according to her mother. "She is much more outgoing and has an overall zest for life."

Gundeti now teaches the procedures he developed to pediatric urologists around the world through courses organized by the Medical Center and the American Urological Association and at the World Congress of Endourology.

The latest Medical Center specialty to join the robotic fold is otolarygnology/head and neck surgery.

"It gives us one more tool to do everything we can for a patient," said Elizabeth Blair, MD, associate professor of surgery. "I work in small spaces, inside someone's mouth or part of the neck. This gives me better visualization and a way to use several tools at once, even in a tight spot. It's almost like having another hand in there."

"Some of the tools are still too big," she said. "But I didn't take this up for what it can do now; I learned it for what it will be able to do very soon. This is a rapidly evolving technology."