Doctor Robot | Prostate Cancer Surgery with Robotics

Dr. Robot
From The Record Newspaper on May 25, 2004

DaVinci system gives surgeons a finer tool for delicate operations

Dr. Michael P. Esposito is carefully at work on the cancerous prostate in his patient, cauterizing the pink tissue that surrounds the gland, then tying off a vein with synthetic sutures as thin as a piece of hair.

Tiny tools that look like miniature bird beaks pass the thread back and forth. Then a knot secures the stitch.

"It's like tying your shoelace," Esposito says inside the darkened operating room at Hackensack University Medical Center, where other surgeons are observing the procedure.

He continues cauterizing. In a flash, the live tissue turns white, then charcoal as Esposito severs the prostate from the bladder.

It's such delicate surgery, yet Esposito never lays a hand on the 62-year-old patient from Teaneck.

Instead he commands four robotic arms from a con-sole 12 feet from the patient, like a teenager playing the ultimate video game. His feet work pedals, his hands direct the robot to stitch and cut with all the dexterity of a surgeon's hands - minus normal human tremors. Dr. Vincent J. Lanteri stands over the patient, suctioning tiny pools of blood and urine and putting traction on the bladder and prostate.

It's a scene that's occurring in more operating rooms as surgeons opt to perform prostatectomies with the Da Vinci Surgical System.

The black, spider-like machine offers many advantages over traditional open surgery: less blood loss, less painful recovery, shorter hospital stays, and a quicker return to normal activities.

Four days after his surgery last year, Dan Cotto, a 62-year-old Hackensack man, walked two blocks to Esposito and Lanteri's office for a checkup. Once he got a clean bill of health, "I walked three miles that day," Cotto said. "I feel great."

Within a month, the retired Teterboro police officer was back on his beloved golf course. While many pa-tients struggle for weeks or months with incontinence, Cotto had bladder control immediately, he said. He's also back to work at his job as sales director for a computer company.

Inside the operating room, the surgical field - an area the size of a mango in the abdomen - is magnified more than 10 times and ap-pears in 3-D so that every vein looks like the Garden State Parkway on a New Jersey road map, every artery pulsates vividly.

"I can see the springiness of the tissue," Esposito says, poking at it with the tiny surgical tools that are attached to the robot arms. "It's more visual than feel, and it's just as good."

The robotic arms and specialized instruments allow for precise cutting and suturing, which helps maintain the muscles and nerves vital to sexual function and urinary control. Catheters can be removed five days after the surgery, compared with two weeks for the open procedure.

Because of the magnification, surgeons have an easier time seeing the nerves and blood vessels that supply the erections of the penis, neurovascular bundles that are very close to the prostate.

"We can sweep them away from the prostate carefully," said Esposito, co-director of the Prostate Cancer Center at Hackensack and a clinical assistant professor of urology at the University of Medicine and Dentistry of New Jersey - University Hospital in Newark.

In traditional surgery, patients could lose about a liter of blood, Esposito said. With the robot, the average blood loss is about a 10th of that.

Hackensack is one of six hospitals in New Jersey to use the robot to perform a variety of surgeries: gastric bypass, mitral valve repair, cardiovascular surgery, and other operations. At Valley Hospital in Ridgewood, surgeons are also using the robot to operate on prostate cancer patients.

Hackensack is one of four teaching hospitals in the country to train surgeons to use the system for prostatectomies. Last month, Hackensack surgeons assisted urologists in Germany who were performing their first prostatectomies with the Da Vinci. Several times a month, visiting surgeons observe the delicate procedures.

Last week, surgeons from Florida Hospital in Orlando huddled around the patient and followed Esposito's movements carefully from a large monitor. The day before they were in the operating room, they practiced on cadavers. Taking home the refined techniques will benefit patients tremendously, said Dr. Abraham L. Woods, a urologist.

Dr. Jay S. Rosen, a urologist who has performed prostate surgery in Ridgewood and Hackensack, cautions that long-term success rates are about the same for patients who undergo traditional surgery and the robotic procedure.

"The advantages with the robotic surgery are one of truly immediate postoperative care. Patients are back to work more quickly," he said. There can also be less leakage initially for these patients.

However, the robotic surgery can also take three hours or so, potentially twice as long as the traditional surgery, he said. So older patients who have hypertension or cardiovascular disease might be at greater risk to be under anesthesia longer.

An estimated 230,000 men in the United States will be diagnosed with the disease this year, according to the federal Centers for Disease Control and Preven-tion.

In most men, the disease grows very slowly. In seven in 10 cases, patients are 65 and older when diagnosed. The majority of men with early prostate cancer live a long time after their diagnosis. Yet 29,000 men die each year of the disease, making it the fifth leading cause of death in men 45 and older.

About the size of a walnut, the prostate gland produces fluid that becomes part of semen. It's located near the bladder and rectum and surrounds part of the urethra, the tube that empties urine from the bladder.

When a biopsy confirms cancer and the malignancy is confined to the gland, patients can opt for surgery, radiation therapy, or "watchful waiting" in which the patient schedules more checkups and reports new symptoms immediately.

A decade ago, fewer than one in three patients opted for surgery. As surgical techniques improved, though, the number of men choosing operations has grown tremendously.

Dr. Vincent Lanteri, left, during the prostate operation with Dr. Louis J. Di Bella, a Nutley urologist.

The robotic surgeries make up just a fraction of the total number of operations performed, yet the number of procedures is expected to grow to 7,000 by the end of this year, a dramatic increase from the 2,000 performed last year, Esposito said.

However, prostate cancer patients who opt for surgery must carefully weigh the risks. In a survey of patients aged 65 and older prepared by the National Cancer Institute, about 60 percent of the men were unable to maintain erections for intercourse, even though almost all of them had been able to have erections to at least some extent before surgery.

Two-thirds of the patients surveyed also reported urinary incontinence. However, men who are younger at the time of surgery and those who are operated on by the most skilled surgeons may nave fewer complications, the cancer institute survey concluded.

"When you have a relatively young man and we don't have to take one of the nerves, they'll do much better," said Lanteri, co-director of the Prostate Cancer Center at Hackensack and a clinical professor of urology at UMDNJ - University Hospital in Newark.

"We have men in their 40s, 50s, and early 60s who have excellent erectile function," Lanteri said.

One of their patients, Ed Hacker, a 61-year-old captain in the Perth Amboy Fire Department who underwent the surgery in September, reports no complications.

The Woodbridge man, who also installs fire prevention systems, said he returned to work quickly. "I was out doing a job in three weeks," he said.

"My sister is a nun in Florida, and she said lots of novenas for me," Hacker said. "I know they helped. The surgeons had something to do with it, too."