Two years ago, when 63-year-old John Lombardo took early retirement from his job as a maintenance engineer at Verizon, he expected to have some fun.
"I thought that my wife and I could go where we wanted to go and do what we wanted to do. But so far, we haven't been very far from home," says the Towson resident.
"In 40 years of working, I had seven days absence due to illness," he says. But soon after he retired, a blood test and subsequent biopsy revealed that Lombardo had prostate cancer, the second leading cause of cancer death in American men.
He scheduled surgery with Dr. Thomas Smyth, a urologist at St. Joseph Medical Center, for January. The fact that Lombardo postponed the surgery turned out to be fortunate, because in the interim St. Joseph began using a new robotic device that has brought a high-tech approach to laparoscopic prostate surgery.
Radical prostatectomy, the removal of the prostate, is accomplished in two main ways. Open surgery removes the prostate through a large incision. Laparoscopic surgery dissects and removes the prostate with small instruments inserted through keyhole incisions less than a half-inch-long in the abdomen.
The open procedure was pioneered at Johns Hopkins Hospital, but Hopkins physicians also have done more than 550 laparoscopic procedures since 2001. "We're currently one of about five centers [nationally] that are doing high-volume minimally invasive prostatectomy work," says Dr. Li-Ming Su, Hopkins' assistant professor of urology.
The robotic device being used at Hopkins and St. Joseph - called the da Vinci Surgical System - takes the laparoscopic procedure one step further.
"Da Vinci does what the standard open surgery of the last 20 years does, but in a less morbid way," says Dr. Marc Siegelbaum, chief of urology at St. Joseph. The robot-assisted surgery significantly reduces blood loss during surgery and post-operative pain.
Also, patients spend one to two days in the hospital after the robotic procedure instead of two to three days after open surgery. This allows them to "get back on their feet and back to normal activities quicker," Siegelbaum adds.
Da Vinci, created five years ago by California-based Intuitive Surgical Inc., was approved for prostatectomy in the United States by the Food and Drug Administration in 2001. There are now about 275 of the machines in use worldwide.
An easier way
Standard laparoscopic prostatectomy has a difficult learning curve, which is why many urologists have shied away from it, preferring the open surgery. But the da Vinci system makes laparoscopic surgery less difficult to master.
For a standard laparoscopic prostatectomy, the physician views the operating field on a two-dimensional video monitor, operating with hand-held instruments placed through five keyhole incisions. Su uses a robotic camera holder to stabilize the telescopic lens in the patient's belly button. The device can be controlled either by voice activation or by a hand-held remote.
The da Vinci procedure begins the same way as standard laparoscopy, with incisions to insert the surgical instruments and camera. A surgeon or assistant remains at the operating table, in part to change the instruments in the robotic wrists at the surgeon's commands.
The surgeon, at a computer console a few feet away, peers into twin eyepieces and controls the surgical instruments, camera and lighting with joysticks and foot pedals. All movements are translated to the micro-instruments held in the four robotic arms that hover like a giant techno-insect over the patient.
The robotic arms mimic the full range of a surgeon's hand movements. The instruments not only open and close, but fully turn and twist. A surgeon's hand movements at the computer console are converted to very small, precise surgical maneuvers.
Such precision is particularly helpful when reconnecting the bladder to the urethra at the end of the prostatectomy.
"Suturing is the most difficult thing in any laparoscopic procedure," says Siegelbaum. "It's very tricky. With the movements you can do with these wristed arms, though, it's truly a da Vinci - it's like a work of art when you suture with this machine."
The da Vinci system uses a three-dimensional color picture and offers 10 times normal magnification. And the equipment works "intuitively," meaning that if the surgeon moves his hand to the right, the robotic arm moves right. For standard laparoscopy, surgeons operate backward - a push to the right makes a move to the left.
"As soon as you put your head in that machine, you realize that you've gone to another level in your ability to help patients," says Smyth. "I really appreciate the magnification the machine gives me."