Technology expands the tools available to surgeons.
By Kari Bohlke, ScD
The term robot-assisted surgery may conjure up images of a futuristic operating room, but surgeons who perform these procedures are quick to point out that surgery remains in the hands of a surgeon: “It’s not the robot operating on you,” explains Khurshid Guru, MD, director of the Roswell Park Center for Robotic Surgery at Roswell Park Cancer Institute in Buffalo, New York. “It is a machine operated by a surgeon.”
Although the engineering behind robot-assisted surgery is complex, the idea is simple: the surgeon sits at a console in the same room as the patient. From the console the surgeon controls robotic arms that hold the surgical instruments. The instruments and a camera are inserted into the patient’s body through several very small incisions. The magnified, three-dimensional view provided by the camera, in combination with very small surgical instruments and highly maneuverable robotic arms, enables trained surgeons to work with precision. “The technology allows you to work much more delicately and much more precisely,” explains Dr. Guru, “especially in areas like the pelvis.” Organs in the pelvis—such as the bladder, uterus, and rectum—are closely crowded together; when operating on one organ, it’s important to avoid damage to neighboring ones.
Robot-assisted surgery was introduced more than a decade ago and was initially used primarily for prostate surgeries. Since then its use has expanded to include surgery of the bladder, uterus, colon, rectum, and other organs. Compared with traditional open surgery (in which a single large incision is made), potential advantages of robot-assisted surgery include less bleeding, shorter hospitalization, and a quicker recovery. A key point for patients to be aware of, however, is that the use of robot assistance does not, by itself, guarantee a good surgical outcome. The success of the procedure depends mainly on the training and the experience of the surgeon. “It is not easy to learn to operate, especially when you have lost all your tactile feedback,” says Dr. Guru. Because surgeons do not actually touch the organ or tissue while performing robot-assisted surgery, they must learn to rely more heavily on visual cues. “It’s a totally different skill set,” continues Dr. Guru, “and it’s very important that we make sure that people are trained before they use this machine.” To facilitate training, the Center for Robotic Surgery at Roswell Park Cancer Institute and the University at Buffalo School of Engineering and Applied Sciences produced a simulator (similar in concept to a flight simulator for pilots) that allows physicians to learn and practice robot-assisted surgery techniques before using them on patients. When asked how patients should go about choosing a surgeon for robot-assisted surgery, Dr. Guru responds, “Number one is the experience of the surgeon. Number two is the experience of the institution and the team. With robotics, it’s not just the surgeon; it’s also the team who assists the surgeon in doing the operation.” Dr. Guru adds that not all surgeries should be done robotically and that it’s important to have a surgeon who recognizes this. “There’s not just one solution,” says Dr. Guru. “There are some patients who would be well served with a traditional open approach.
“It is a terrific tool,” he concludes. “I think it’s an engineering marvel. But it has to be used wisely, in skilled hands.”
Considering Options, Making Choices
Ruth Lasure was initially diagnosed with a bladder infection. When her symptoms didn’t resolve, her physician assistant immediately referred her to a urologist. “First they do a cystoscopy,” explains Ruth, “where they put a camera in and see what’s in the bladder.” When the cystoscopy identified a tumor that proved to be cancerous, the diagnosis came as a shock: “I had no cancers in my family,” says Ruth, “so cancer was the last thing on my mind. I always thought I was going to have heart trouble. That’s what my parents had.”
The tumor hadn’t invaded the walls of the bladder but did appear potentially aggressive. Ruth was given BCG—which stands for Bacillus Calmette- Guérin, a type of immunotherapy—that is administered directly into the bladder. When her symptoms returned after the completion of treatment, another cystoscopy revealed additional cancer and the need for a cystectomy (surgical removal of the bladder).
“I started looking into my options,” says Ruth. She talked to people and went online to learn more about her treatment options. Her research led her to robotic surgery, which appealed to her because of its minimally invasive approach, and to Dr. Guru at Roswell Park Cancer Institute. “I read about Dr. Guru, who was teaching other doctors about this,” says Ruth. “I said, ‘I want that guy. If I have to do this, that’s who I want.’”
Ruth requested a referral to Dr. Guru from her urologist and was scheduled for robot-assisted surgery a short time later. “I did not have pain after the surgery,” says Ruth, who returned to her normal activities roughly five weeks post-surgery. Regarding the several small incisions that are required for robot-assisted surgery, Ruth says, “You have a lot of them, but they heal quickly.”
Because of the location of the cancer, Ruth also needed to have a urostomy (an opening to the outside of the body for urine to pass through; urine is collected in an external pouch). Describing her adjustment to having the pouch, Ruth remembers thinking, You know what? I’m alive. This is not a big deal. I’m walking out of here cancer-free. “It was a really quick adjustment when you think about those things. I have nothing to complain about. All these things put your issues in perspective. I’m very lucky. Yes, I live with a pouch, but it’s not a big deal. Actually, it’s kind of nice because I can play golf and pee in the woods like the guys.”
Asked about her advice for other patients, Ruth points out that people who need a urostomy should not fear it: “Nothing in my life has changed except sleeping.” She’s also pleased with the outcome of her surgery: “I think it’s an amazing process. Just the fact that you don’t have a big incision that has to heal is huge.” _
Bladder Cancer: The Numbers
Although bladder cancer is diagnosed more often in men than in women, women can develop the disease and should not ignore symptoms such as blood in the urine. In 2010 bladder cancer was diagnosed in roughly 53,000 men and 18,000 women in the United States.
Source: Cancer Facts & Figures 2010. American Cancer Society website. Available at: http://www.cancer.org/docroot/stt/stt_0.asp. Accessed July 1, 2010.