Saturday, July 14, 2012

Transitioning to Robotic Assisted Surgery

I am a relatively late comer in adopting the robotic assisted surgical approach to radical prostatectomy for prostate cancer. If you look at this piece from the New York Times, you will understand why I have little real choice other than to offer this to my patients ( _r=1&emc=eta1). The article is now a couple of years old but we were able to resist being forced into this new technology in Sydney, Australia until now. This time last year, there was only one hospital with a Da Vinci robotic system. Having surgery performed at that hospital is expensive and compared to some surgeons fees elsewhere, multiples of times greater. Colleagues in Melbourne, where robotic surgery has long been the norm, have reported that they regularly saw patients from Sydney as a result of the cost of surgery there being significantly less, even allowing for flights and accommodation. When consideriing the maximum numbers of patients that could physically be treated at one hospital in Sydney, the finite numbers of men who were prepared to pay the large costs of such treatment and those prepared to travel interstate, these numbers were never going to threaten the viability of a urologist's prostate cancer practice in a city the size of Sydney. Fast forward to less than 12 months later, we now have 4 hospitals with Da Vinci systems that are up and running with another two hospitals likely to have systems installed by the end of this year. The dominos have well and truly fallen, but it was only a matter of time when the last Australian capital city strong hold of open radical prostatectomy surgery would buckle to the market forces. The acquisition of this technology at my hospital has meant that I have had to undergo intense training to make the transition. I am grateful for the fact that as a later adopter, I have had access to training materials that were not available to colleagues only a few years earlier. In recent years, an excellent surgical simulator has been developed and this has made a huge difference to my transition from open to robotic assisted radical prostatectomy. The need to train for robotic assisted radical prostatectomy seemed perfectly timed. I was due to attend the American Urological Association Annual Meeting in Atlanta and this provided a perfect opportunity to attend various live surgery opportunities at that meeting as well as to attend laboratory training whilst in the USA. At the AUA meeting, I made a point of attending a number of interactive live surgical demonstrations of the surgery being performed as well as attend scientific sessions relevant to the technology. Immediately following the meeting, I took a flight to the San Francisco Bay Area and took the opportunity to attend surgery being performed by the renown Professor Peter Carroll at the University of California San Francisco Medical Center. Apart from seeing the actual surgery, it was instructive to see the dynamics within the operating theatre set up. The next day, I attended the Intuitive headquarters at Sunnyvale where they have a large training facility. It was a full day of intensive training with just myself with one Da Vinci system allocated to me, one professional trainer allocated to me as well as one anaethetised pig upon which the surgery was performed. We were quickly reassured and could see first hand that the pigs were dealt with in a completely humane manner. It has been stated that 9 to 10 hours on the simultor ought to be a minimum amount of time spent on the surgical simulator. After I had done this for 9 to 10 hours, I was regularly achieving 100% scores in the numerous exercises offered by the simulator. when I thought carefully about my own progress, I recognised that my 100% scores were really about me having mastered the technique of getting the simulator computer to tell me that I am doing well. In reality, I certainly had the technical basics mastered but I was far from fluent with my economy of motion and where the operation of both the hand and foot controls felt close to being second nature. On this basis, I pushed on and did over 40 hours on the simulator. I also made a point of spacing out the sessions over a number of weeks and using the time in between to reflect upon my progress. Additional to the simulator, an excellent trainer device has been created. A plastic model the shape and size of a human torso houses a plastic bladder and urethra - this formed an excellent model upon which suturing of the bladder to the urethra could be practised. This stage of training was intentionally left until I had completed the hours that I had determined that I would wish to do, and had I attempted this stage after only say 9 or 10 hours on the simulator, I would not have been able to repeatedly join the model bladder to the urethra with evenly positioned and tensioned sutures. Additional to the above were hours spent doing the on-line training modules created by the manufacturers as well as countless hours watching recorded DVDs of the procedures as well as U-tube videos - this was probably in the order of 40 to 50 hours. As we approached the days on which I would perform my first cases, we did a 'dry run' in the operating room to clarify what went where and who did what. A proctor well experienced in this surgery was organised at my expense to attend my first three cases. It is generally recommended that at least three proctored cases be undertaken but I had decided from the outset that this was inadequate. A period of reflection followed my first three cases associated with further numerous hours watching procedural DVDs. A further two proctored cases were performed and these were also completely successfully performed procedures. These additional two cases gave me significant confidence that I was now ready to commence solo practice with this technology. Having done over 1500 open radical prostatectomy procedures in addition to taking the preparatory training well above the minimum requirements has in my mind made an enormous difference. Having said this, I still do not have the fluency that I enjoy with open surgery, but mainly because I am being overly cautious and prefering to take things slowly and at all times having the patient's safety as the priority over surgical pride in how quickly the procedure can be performed. For now I will continue to offer open surgery but robotic assisted radical prostatectomy is offered to those who desire this technology. The conclusions that I reach from personal experience (and clearly not on the basis of a scientific trial) is that the current minimum requirements before a surgeon can independently perform robot assisted radical prostatectomy should be raised to a much higher level. Nobody gets hurt by doing too many hours on a simulator or doing too many proctored cases. Patients will get hurt in learning curves when shortcuts are taken to get onto the bandwagon. Lets also get rid of the threshold of 20 cases to be officially gazetted as a robotic surgeon - all this does is encourage a race to get to this caseload experience which could be at the detriment of patient safety.