Prostate surgery - Interview
Master of the robot

Dr Jim Hu, a bright, young star in the field of robotic-assisted laparoscopic prostatectomy, has performed more than 400 of these procedures since 2004 using the Da Vinci robotic system, the only surgical robot of its kind in the world. He was recruited to Brigham and Women’s Hospital in Boston, United States to jumpstart their robotic surgery programme two years ago. Callan Emery spoke to the surgeon about robotic-assisted laparoscopic prostatectomy while he was in Dubai for the Arab Health Congress in January.

Dr Jim Hu is a specialist in robotic-assisted laparoscopic prostatectomy at Brigham and Women’s Hospital, Boston, United States. He has a quiet, calming presence, an attractive characteristic for any patient in his care and a crucial asset for a surgeon who requires extremely deft hands to perform this delicate robotic-assisted surgery.

His apparent youth belies his expertise in robotic surgery, which is at the cutting edge of minimally invasive prostatectomy procedures.

Prostate cancer is a major health issue. Worldwide around 400,000 men are diagnosed with the disease every year. In the United States it is the most common form of cancer among men after skin cancer and it is the second leading cause of cancer deaths of men, after lung cancer. The demand for prostate cancer surgery is high.

Dr Hu explained that there are a number of ways of treating prostate cancer.

“Regarding localised prostate cancer, as opposed to metastasising prostate cancer, there are a number of treatment options,” he said. “In the US surgery is still the most common form of treatment for localised prostate cancer.” Surgery options include open radical prostatectomy and the minimally invasive options of laparoscopic prostatectomy and roboticassisted laparoscopic prostatectomy, “which has been popular for the past four or five years”.

“There is also brachytherapy, which is an implantation of radioactive seeds into the prostate. Another option is external beam radiation.

“There are pros and cons with each therapy and everyone has their ‘indifference curves’. In other words they know someone who has had a good or bad experience with one or the other treatment and this particularly affects their decision-making,” Dr Hu explained.

“The most commonly used therapy at the moment is open radical prostatectomy. However, the popularity of roboticassisted prostatectomy is growing fast. Estimates in 2006 show that 40% of all prostate surgery is done using the Da Vinci system. If those projections continue this year, then it will be over 50% or more with the robotic system. This is quite amazing since it was about 1% back in 2001, so you’ve seen an exponential growth in the use of this technology,” Dr Hu said.

Prostate surgery on the whole is an extremely tricky procedure and any slight error or complication can result in loss of sexual potency and urinary continence.

“There is a delicate balance between trying to remove all the cancer, but at the same time trying to preserve the muscle fibre for continence as well as the nerves that control sexual function,” Dr Hu said.

In the United States the most common application of the Da Vinci robotic surgery system is for prostate cancer surgery.

This is Dr Hu’s specialty, although he also does conventional laparoscopy without the Da Vinci system for kidney cancer transplants and some other procedures. “But I’d say the majority of my practise is treating prostate cancer.”

He said his patients in most cases self-select his practice so they can have prostate cancer surgery using the Da Vinci system. They’ve chosen their treatment before they go to see him. And in many cases they select his practice via the Internet.

“I work in a multi-disciplinary setup with medical oncologists and radiation oncologists, where patients can be more open to other therapies, but in most cases they come saying ‘this is what I want’.” Dr Hu explained the intricacies of prostate surgery and why he believes it beneficial to use the Da Vinci system.

“In the open surgery you still have about a 7-8 centimetre incision in your lower abdomen. There is the spreading of tissues that is required to get to the prostate that is deep in the pelvis and there are a lot of small venous vessels that ooze quite a bit during surgery. So your typical blood loss during open surgery, on the low side for high volume surgery, is about 600 millilitres of blood. In contrast with laparoscopic, or minimally invasive surgery, you’re using CO2 to inflate the abdomen to contain your exposure. You’re using 1cm ports, about five or six of them typically. And so the difference for the patient is that the blood loss is markedly less because the CO2 pressure has an effect on these very small venous vessels in that it prevents them from oozing constantly during the 2-3 hours of surgery.

“And given that the incision is smaller and the tissues do not need to be spread open, the patient is less likely to suffer as much pain or discomfort after surgery and as a result will require less pain medication and can return to normal daily activities much sooner.

Precision

“The difference between conventional laparoscopy and surgery using the Da Vinci system is that there is a wristed movement with the Da Vinci system, which you lack with the laparoscopy.”

By ‘wristed’ movement Dr Hu explained that the instrument used by the Da Vinci system has a greater degree of freedom proximal to where they open or close, like a scissor or grasper which can rotate.

“I think this makes your surgery more precise in that you have finer movements and are able to achieve certain working angles you cannot have with conventional laparoscopy. And for surgeons that are accustomed to conventional laparoscopy you don’t have some of the difficulties, such as the fulcrum affect. In other words in conventional laparoscopy to make the instrument move left inside the body you actually have to move your hands to the right, somewhat like a lever. And that is absent with the Da Vinci system as the display mimics the procedure controlled from the consol.”

Dr Hu said there were several estimates out there about how long it would take to learn to use the surgeon console of the Da Vinci system, if the surgeon was already familiar with prostate surgery.

“Some estimates put it at 15 to 20 procedures to get comfortable. However, a more recent report estimates it takes about 150 procedures just to get comfortable with the device. I think part of it is that it takes some time for it to become second nature.

For example not thinking about what you actually want to do. Do you have to step on a pedal or move your hand in a certain way? So I think it takes quite some time before it becomes second nature. “Also the anatomy looks very different compared to that in open surgery. There are two cameras which create a 3D image of the anatomy and the magnification is 10 times larger.

The lighting is also different compared to open surgery. It takes some time for the surgeon to get used to looking at the anatomy a little differently.

“So I’d say it takes around 150 cases to get used to it, but everyone is a little different of course.” He said the most tangible benefits of using the Da Vinci system are illustrated in a prospective study of eight high-volume centres in the United States which indicate that the blood loss is definitely much less – 150 cubic centimetres for robotic surgery as opposed to around 800 cc for open surgery.

“The operative times are longer with the robotic system but not significantly – about half an hour,” he noted “The length of stay is also shorter. I’d say typically about 90% of patients are discharged within 24 hours, keeping in mind in the US there is this ‘quick push of patients out the door’ so to speak. With conventional open surgery patient stay is about two days.

“The other outcomes in terms of sexual and urinary function – continence and potency – are not as clearly worked out yet, but there haven’t, at least in our cohort, been any differences of urinary function between robotic and open surgery. Sexual function is less clear, though this appears to be slightly better with the open surgery.”

Referring to the study, he added one must bear in mind that users of the robotic-assisted laparoscopic prostatectomy were still early in their experience of using it and that as they become more experienced this slight difference related to the maintenance of potency should improve with robotic surgery.

He said one of the main disadvantages of robotic surgery was the higher cost because of the instrumentation. “The manufacturer of the robot is a monopoly and so they kinda get away with charging what they want.” “Hopefully, another player will enter the market soon,” he quipped.

Dr Hu said the Da Vinci system was fairy wide spread in the United States. “There are a couple of centres that have very high volumes, like over 100 prostatectomies a year. And because of the increased patient demand the installation of the systems across the United States has mushroomed.

Asked about advice for patients he said they should investigate ‘how many procedures the surgeon has done’. He explained that this was not only pertinent to robotic surgery, but also radical open prostatectomy, where a study he was involved with at UCLA (University of California Los Angeles) shows that surgeons who had performed more than 40 procedures had half the complication rate of those that performed less than 40.

“I anticipate that this threshold is even higher with robotic surgery as the learning curve is greater.”

                                  
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