Hearing the words ‘master’, ‘slave’ and ‘robot’ in the same sentence conjure images of alien invasion but Professor Tony Costello is describing an invaluable addition to his surgical team. A mammoth robot with multiple surgical arms operates on his patients while he sits at a control consol several feet away; manipulating it’s every move.
“When the surgeon moves his hand in a particular way, the robot mimics that: it’s what they call a master-slave robot - a scenario that reverses when I go home,” laughs the Australian surgeon, who spoke to Scope during a recent trip to Ireland where he was awarded an Honorary Fellowship of the RCSI.
A Professor of Urology in the Royal Melbourne Hospital and University of Melbourne, Tony is one of the leading prostate specialists in Australia. He pioneered the use of laser surgery in the 1980s as a viable alternative to traditional transurethral resection and in 2003 he became the first surgeon in the Southern Hemisphere to perform a Robotic Assisted laparoscopic Prostatectomy (RALP).
“I’m very proud to be awarded an honorary fellowship of the RCSI, partly because of my Irish heritage and partly because the RCSI is such a prestigious insitiution. It’s very validating thing for me to be given such an honour, it’s a very big deal, I’m very excited about it,” he affirms.
Surgeons from around the world, including Ireland, travel to Melbourne to train with Tony and his team at the Richmond campus, Epworth Hospital, where more than 700 cases of robotic laparoscopic prostatectomy have been performed.
Designed by NASA and the US Department of Defence to facilitate remote-controlled surgery in space and on the battlefield, this groundbreaking surgical robot provides unprecedented laparoscopic vision and precise robotic instrument manipulation. Its makers call it the "da Vinci" and it has been cited as number one in Forbes Magazine's "Five Robots That Will Change Your Life".
“It takes surgery beyond the limits of the human hand. We now have a robotic programme responsible for outstanding results with regard to return of urinary continence and preservation of sexual potency. And a couple of our best surgeons have some to us from Ireland,” says Tony, who is very proud of his “100 per cent Irish” heritage. His dad hails from Mayo and his mum from Clare.
He explains that, with a high-tech device like the da Vinci Surgical System, patients can experience smaller incisions and quicker recovery times. Surgeons can sit rather than stand for lengthy surgeries and have their skills enhanced through the precision of the robot.
Robotic surgery also reflects a broader push to reduce the risk of infections and other complications, to shorten hospital stays and to get patients on their feet in days rather than weeks.
“It’s the logical next step; surgery is very technology driven. It has been a sea change in abdominal surgery and it is starting to break through into other disciplines - cardiovascular surgery and gynaecology cancer, head and neck cancer. We’ve now set up a programme for cancer robotics for gynaecology cancer and colon cancer with the da Vinci robot,” he adds.
Surgical robotics was little more than a medical curiosity until 1999, the year California-based Intuitive Surgical introduced the da Vinci Surgical System. Today, this revolutionary technology is being used in a wide variety of surgical procedures, including mitral valve repair, cardiac revascularisation, gastric bypass surgery, radical prostatectomy (da Vinci Prostatectomy), hysterectomy, myomectomy and sacrocolpopexy, cardiac tissue ablation, and epicardial pacemaker lead placement for biventricular resynchronisation.
More than 1,000 da Vinci robots have been installed in hospitals worldwide, including two in Ireland - Cork University Maternity Hospital and the Galway Clinic – with a third recently purchased by the Mater Private Hospital in Dublin.
“Surgeons who use the da Vinci just love it; once you start, it’s a very beguiling technology. You can see ten times better, you have a three dimensional view of the surgical field, and you can be far more dextrous.” Tony remarks, expounding that it achieves this by scaling down and filtering out any tremors of the surgeon’s hand and translating his or her actions into the seamless movements of the instruments.
The patented surgical instruments also have a wider range of motion than a human hand and wrist, making it easier for a surgeon to manoeuvre in tight areas. Furthermore, the surgical robot employs a variety of overrides and fail-safes that prevent harmful mishaps. For example, if the surgeon were to suddenly swing her arms outward while keeping her hands in the gripper stirrups, this movement would be disastrous for the patient. But the da Vinci doesn’t translate such erratic motions to the robot arms at the patient cart. It knows to keep the instruments within the fixed positions of the incisions.
“We first introduced the da Vinci robot to our hospital in Australia in 2003. The technology sort of came on in 2001 in the US in one centre, and in 2002 in two centres, we were about the sixth centre in the world.”
His RALP unit’s complication rate has been reduced from 12 per cent in its first 100 cases to around about 2 per cent in the last 300 cases. “And we have had no deaths related to our surgery,” Tony stresses. By comparison, open radical prostatectomy carries a complication rate of 10 per cent and there is one death in every 200 surgeries.
“It’s amazing to see how far we’ve come and how much we’ve achieved in those few years. We have performed about 710 robotic assisted prostatectomies at the hospital. Between myself and one of my colleagues, we do about 300 cases a year, and we have trained lots of surgeons from America, seven from Ireland, and from all over Europe.
“We give a very didactic and modular learning on robotics and then they go back and usually their hospitals, because they have someone who is fully trained, will then install a robotic programme, so it’s working pretty well. I’m really pround of our surgeons.
“Basically, the surgeons who are accepted onto our programme come for a year to train and they receive what we call a robotic fellowship. At first the fellows get to use the machine without a patient underneath it. They will perfom basic drills with it so they can get use to the technology, and then we get them to be what we call a bedside assistant, who changes the robotic instruments and introduces sutures when required.
“They then transition to the consol and we divide the operation into a number of steps, the easier steps they do. I sit beside them and assist if they need it, and then take over, so it’s very structured learning, it’s like teaching a pilot,” he offers. “In fact, using the da Vinci feels like flying a plane. It’s very similar to using your hands and feet to flying a plane, that’s what I would say.”
Tony’s fellows can usually take their first patient after six to eight months of training. The training programme he has developed at Epworth is light years ahead of his own training experience in 2003 at the University of California Irvine: “When I was being taught, the surgeon had only done 60 cases himself, so it was a very new technology and there were no textbooks to guide you through, it was really more of a ‘seat of the pants’ thing. We would watch the procedure being done and then we did cadavers. The first time I operated on a live patient with the da Vinci I felt privilaged but also pretty scared because I wasn’t sure this would work. Now it’s very teachable, it’s very structured and it’s much easier for the doctors to learn the surgery.
“I’ve trained seven Irish surgeons so far,” he continues. “There are a lot of intellectualy bright people here in Ireland. I always welcome them to come and work with us in Australia and make it better for us. I have another surgeon coming to work with me from Dublin called Stephen Conway, he’s starting in July and I’m sure he’ll get involved in the robotics when he comes back here after his training. Two of the Fellows have stayed with me and the others have returned to Ireland with a new skill that can offer so much more to many patients than traditional surgery.”
Two of his prodigies, consultant urologists Drs Paddy O’ Malley and David Bouchier Hayes, who were the first to return to Ireland following their fellowship training, performed the first robotic assisted prostatectomy in Ireland in November 2007 and soon after established the country’s first robotic surgery unit for the treatment of prostate cancer, based in the Galway Clinic. The unit’s €2.2 million Da Vinci system is the largest capital investment in the treatment of prostate cancer in the history of the state.
Now in its third year, the unit has yielded encouraging results comparable to international standards. “Between David and myself, we have done about 100 cases to date and I’d say our complication rate is about 5 per cent,” Paddy tells Scope.
“The machine was funded locally. We had a unique sitation where the entire cost was underwritten by a group of 20 local business men, on the basis of the business case we gave them that the robot would pay for it’s self over a number of years. They guaranteed that if there was a shortfall they would pay, and they have been released from that already because we have reached ort target for the first three year. It is currently being paid off at the projected target,” he says.
The major thrusts in surgery today are to develop more precise and minimally invasive procedures. Tony is convinced that it is through increasingly sophisticated technology that surgeons will find the best treatment for their patients.
“No doubt about it, I think our improvements in surgery are technology based, so I can’t see us going backwards. I think it’s going to be very rare that a patient will get an incision in their tummy or their chest, it’s going to be a thing of the past.
“With the proviso that this technology is expensive and it will take some time before the cost comes down, once that happens you’ll see the technology spread through all surgical departments, in the western world anyway,” he predicts.
Tony adds that patients are far from daunted by the conceivably intimidating apperance of this huge octopus-like robot. “They don’t mind at all in fact,” he points out. “I think most patients are attracted to high-tech, provided of course there is the caviat that it’s actually better for them. It is very enticing for patients to think that they have got the latest in technology that will make a better outcome. They love the da Vinci; patients really love it. It makes a big difference for them too. With only a tiny incision to deal with, the patient can get out of bed the afternoon after the surgery or in the morning after surgery, so you don’t get the DVTs or the pheumonias or the cardiovascular complications. And they don’t need any blood. Typically, when I did open surgery, probably about 80 per cent of patients would have to have a blood transfusion but now we never or very rarely have to give a blood transfusion.”
He also points out that a RALP procedure takes the same length of time as traditional surgery, perhaps even a little quicker under the right circumstances. “Once you have all the nurses and everybody is familiar with it, we can move very quickly. It takes us about an hour and forty minutes. It has actually developed a good team relationship; the nurses really took to it; they love the technology and they get to do a bit more as scrub nurses than normally. So it has been a great thing for the team and quite a moral booster for the hospital I think as well.”
As a pivotal member of his surgical team, does his mechanised surgical assistant have a name? “We wanted to give it one, we even had a competition but there were so many different versions we never came up with one. Robodoc was the closest we got,” laughs Tony.
Prostate cancer surgeons 'feel' with their eyes
Robotic surgical technology with its three-dimensional, high-definition view gives surgeons the sensation of touch, even as they operate from a remote console. A new study describes the phenomenon, called intersensory integration, and reports that surgical outcomes for prostate cancer surgery using minimally invasive robotic technology compare favouurably with traditional invasive surgery.
Led by physician-scientists at New York-Presbyterian Hospital/Weill Cornell Medical Center and appearing in the March 2010 issue of British Journal of Urology International, the study is the first to show that a lack of tactile feedback during robotic surgery does not adversely impact outcomes in patients with prostate cancer. It also identified various visual cues that surgeons can use to improve clinical outcomes.
"Anatomical details and visual cues available through robotic surgery not only allow experienced surgeons to compensate for a lack of tactile feedback, but actually give the illusion of that sensation," says Dr Ashutosh Tewari, the study's lead author; professor of urology, urologic oncology, and public health at Weill Cornell Medical College; and director of the Lefrak Center of Robotic Surgery and the Institute of Prostate Cancer at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.
"For patients, this means the safety of knowing the benefits of a robotic approach, including a quicker recovery, don't compromise the surgery's primary mission of removing the cancer."
In recent years, robotic-assisted laparoscopic prostatectomy (RALP) has become a popular surgical method for treating prostate cancer because it is less invasive than traditional surgery. No studies have shown that RALP leads to worse outcomes, but doctors have wondered whether this was the case because surgeons often use their fingers to feel the prostate during traditional surgery to refine how much they cut to achieve the best outcome.
Cancer cells produce changes in tissue firmness that surgeons can sense. Because this tactile evaluation is not possible for surgeons using RALP, clinicians have wondered whether the robotic approach could lead surgeons to miss some cancer, and thus subject patients to a greater risk of cancer recurrence.
To find out, the investigators videotaped 1,340 RALPs. After every couple hundred procedures, they examined the pathology results of the prostate that was removed to determine the incidence of positive surgical margins, an indication that a surgeon might not have removed all of the cancer. In this study, the investigators focused on the posterolateral surgical margin (PLSM+), the area where the prostate is attached to the nerves.
"When you look at the entire specimen after surgery is done, you want to see cancer inside of the prostate but you don't want to see cancer touching the surface," Dr Tewari says. "After surgery we look at the specimen, and if there are no cancer cells touching the surface, we call that a negative margin. If cancer is touching the edge, then we say it has positive margins. This means there may be some cancer left in the patient."
The investigators then studied the videotapes to determine what refinements in the procedure resulted in negative margins. Using this new knowledge to refine the surgery, they conducted the next couple hundred RALPs, reviewed the videotapes, refined their techniques, conducted the next round of RALPs, reviewed, refined and so on.
The investigators found that robotic surgery did not compromise outcomes. The incidence of PLSM+ was 2.1 percent, which gradually declined to 1 percent in the last 100 patients. Positive PLSMs are found in 2.8 percent to 9 percent of patients undergoing traditional prostatectomy.
The researchers say that the enhanced vision allowed by the robotic approach brings about a "reverse Braille phenomenon" or the ability to "feel" when vision is enhanced. They have also identified a number of visual cues that clinicians can use to improve outcomes, including the colour of tissue, the location of veins as a landmark for the location of nerves, signs of inflammation, and appreciation of so-called compartments outside the prostate.
"As someone with 30 years of experience as a pathologist, I, too, have developed the ability described in this paper. I can look at a tissue sample and know if it is firm or soft and what to expect in its pathology - something that helps me to home in on the area with the abnormality," says Dr Maria M. Shevchuk, the study's senior author, associate professor of pathology at Weill Cornell Medical College, and a pathologist at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. "It is only natural that this ability would also be present in experienced robotic surgeons."