The Kindest Cut

October 21, 2015

Improving outcomes and patient comfort with robotic-assisted surgery.

The trouble started with a backache. When San Fernando Valley resident Bradley Williams, 58, complained to his doctor about it last February, he got an MRI that revealed three bulging discs, the possible culprits. But the imaging test also showed something unexpected and more ominous: a nearly two-inch mass on his left kidney.

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Bradley Williams recovered quickly after undergoing robotic surgery to remove a kidney tumor.

Williams, who works in the security industry, recalls the doctor telling him that he needed surgery and that the whole kidney might have to be removed. Worse, the tumor might be cancerous, requiring additional treatment and an uncertain prognosis. And doctors wouldn’t know whether it was malignant until they could put it under a microscope. “I was gobsmacked,” says Williams, who plays soccer and softball recreationally throughout the year. “I said, ‘Are you sure you have the right records?’ I’m kind of a healthy guy, I don’t smoke or take drugs, and I don’t drink much alcohol. Hearing something like that really rocks your world.”

Williams was referred to Mayank Patel, MD, a urological surgeon at Providence Tarzana Medical Center, who has extensive experience with the da Vinci surgical robot. The da Vinci was approved in 2000 for laparoscopic surgery and is now used for a growing number of procedures, thanks to its advantages for doctors and patients.

ROBOT BENEFITS

To use the robot, surgeons sit at a console to control the device’s arms via its mainframe computer. The camera provides 10 times magnification and high definition 3-D vision—greatly improving the doctor’s field of vision. The robot’s “hands” can reach into tighter spots and move in ways that human hands can’t, and the machine’s software corrects for any extraneous tremor.

“The robot has been a game-changer with kidney surgery. It allows us to do the operations we used to do as open procedures through a minimally invasive route.”

The robot may also reduce physicians’ fatigue since they can sit rather than stand over the patient for hours. Like other minimally invasive procedures, surgeons operate through tiny incisions, which results in less blood loss and faster recoveries because the incision is smaller. The success of robot-assisted surgery, however, is highly dependent on the surgeon and his or her training. Studies show that better outcomes are obtained by surgeons with substantial experience using a robot and in institutions where a higher number of robot-assisted surgeries are performed.

However a growing number of conditions are being treated with robot-assisted surgery as physicians become more familiar with the technology.

“The robot has been a game-changer with kidney surgery,” says Dr. Patel. “It allows us to do the operations we used to do as open procedures through a minimally invasive route. That’s where the freedom of motion and technology comes in.”

In particular the robot allows skilled urological surgeons to perform partial nephrectomies, the removal of just the portion of the organ where a tumor is nesting, leaving the remainder of the kidney to function normally.

“Traditionally we made a 15- to 20-inch incision, which had higher infection rates, greater blood loss and obviously more pain for the patient,” adds Dr. Patel. “Patients typically spent five to seven days in the hospital. With robotic surgery, they may go home in one to two days and end up using very little narcotic medicine.”

Not everyone with a kidney tumor is a candidate for the procedure, however. According to Dr. Patel, it depends on the size and location of the tumor. Luckily Williams fell in that group. “He had a complex mass in a very difficult location on the kidney,” says Dr. Patel. “But with the robot, we were able to save his kidney, and his kidney function was not affected.”

Williams went home the next day and needed little pain medicine. “I was the poster boy for how things should go,” he says. “I took a few regular Tylenol—not even extra strength—and I have just four little scars. Two of them you can hardly see.”

PROSTATE SURGERY

Surgeons treating other urological issues are seeing similar success with the da Vinci. It’s particularly beneficial for surgeries for which there was not a good minimally invasive version, such as prostatectomies—removal of all or part of the prostate gland as treatment for cancer—and other cancer surgeries.

“It allows us to be able to perform more technically challenging surgeries than we were able to do without the robot,” says Tim Lesser, MD, a urologist at Providence Little Company of Mary Medical Center Torrance. “It allows for much better visualization and careful dissection, which is critical for cancer surgery.”

“The robot allows us to take a surgery that is physically and mentally demanding and make it more consistent, reliable, precise and reproducible,” adds Timothy Wilson, MD, a urologist at Providence Saint John’s Health Center in Santa Monica and a pioneer in minimally invasive and robot-assisted prostatectomy. “Like other laparoscopic surgeries, there’s typically very little blood loss. We’re inflating the abdominal cavity with carbon dioxide, which acts similarly to a compress. In effect it’s like pressing a cut on a finger. In addition, everything is magnified in 3-D and in high definition. You can get very close to the tissue with the telescope, so you can do very fine work.”

“The robot allows us to take a surgery that is physically and mentally demanding and make it more consistent, reliable, precise and reproducible.”

Because robot-assisted prostatectomy involves tiny incisions, patients recover more quickly. And most patients—and particularly those under age 65—recover urinary control after surgery, as compared to open surgery. Plus “recovery of bladder control after surgery used to be measured in years,” says Dr. Wilson. “With the robot, it can be weeks.”

“Erectile dysfunction was a big problem with open surgery, and it still can be a problem,” Dr. Wilson adds. “But many more men regain the ability to have natural intercourse with robotic surgery, than when it’s done as an open procedure. And the effectiveness is the same.” Most men facing prostate cancer surgery are candidates for robotic prostatectomies.

OTHER UROLOGIC PROCEDURES

The da Vinci can be useful for other urologic surgeries, including pyeloplasty, surgery to repair the kidney, specifically, the ureteropelvic junction—where the kidney and ureter connect.

“As with other robotic-assisted surgeries, patients avoid large incisions, have minimal pain and often go home the next day,” says Dr. Lesser. “Visualization is amazing with the robot. It’s as if you’re inside the abdomen looking right on top of the tissue of the patient. You can really appreciate the subtleties of the anatomy, so the results with pyeloplasty are usually excellent.”

Surgeons are now setting their sights on the bladder. “The next hurdle is radical cystectomy, removing the entire bladder due to cancer,” says Dr. Lesser. “Right now there’s some conflicting data on whether it improves outcomes. It takes some time for these things to be hashed out.”

GYNECOLOGIC SURGERIES

The da Vinci robot is already being used for some gynecological and urogynecological conditions, including prolapse of the bladder, uterus or vagina. “The most common surgery I perform with the robot is sacrocolpopexy,” says Alison Tate, MD, a urogynecologist at Providence Saint Joseph Medical Center in Burbank. The surgery restores pelvic organs to their normal position, using synthetic mesh to hold them in place.

According to Dr. Tate, performing the procedure with a robot has some significant advantages. “The robot makes it technically easier,” she says. “Sacrocolpopexy is a suture-intensive procedure, and I find the robot very helpful for it. The greater visualization helps keep me away from areas that are close to the aorta and veins.”

The da Vinci is also playing a greater role in routine gynecological surgeries like hysterectomy—the removal of the uterus for benign conditions or cancer; myomectomy—the removal of bothersome fibroids (benign growths on the uterus); and the removal of painful endometrial tissue that has migrated outside the uterus in people with endometriosis.

“Like other procedures, open gynecological surgeries are associated with longer hospital stays and a greater risk of complications,” says Marlon Brooks, MD, an obstetrician and gynecologist at Providence Holy Cross Medical Center in Mission Hills. “With robotic procedures, we are able to send patients home sooner and they have less pain.”

Physicians are still working out the most effective and cost-effective ways to perform such surgeries, including traditional laparoscopic, vaginal and robotic approaches, Dr. Brooks says. The best approach varies according to a patient’s needs and other variables, such as their body mass index and the surgeon’s experience.

Providence hospitals have strict training and proctoring protocols to protect patients undergoing robotic surgeries. Once surgeons have reached proficiency with the robot, they are required to keep up their skills and achieve certain benchmarks in order to maintain their surgical privileges. “You can’t do two surgeries a year and expect to maintain your competency,” says Dr. Brooks.

Dr. Patel’s surgical skill was a key consideration for Bradley Williams going into surgery for his kidney tumor. But no matter how well the surgery went, he still faced a big question after his operation: whether or not the growth was cancerous. It took three days after the procedure to finally get the answer.

“Fortunately the mass was not cancer,” says Dr. Patel. “It would have been a huge loss if the kidney was taken out completely for something that wasn’t malignant.” “This was a life-changing event no matter what the outcome,” Williams says. “I’m a very lucky guy, which I attribute to having a good surgeon and a good team. I couldn’t have asked for anything better.”

For more information about robotic surgery or a physician referral, contact us online or call 1-888-HEALING (432-5464) .