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    Thursday, December 29, 2005

    The daVinci: Not the code, but the robot:

    A new surgeon at a Bronx hospital has very steady hands - four of them, to be exact, and all made of metal.

    Surgeons at Montefiore Medical Center are now using a four-armed surgical robot to help remove cancerous prostate glands, a delicate surgery in a crowded area of the lower abdominals where steadiness can minimize erectile and bladder control complications.

    'It's a tremor-free operation,' said Dr. Reza Ghavamian, who has been using the da Vinci surgical system to perform prostatectomies since the $1.5 million machine arrived at the hospital a little more than a month ago.

    What's it like to use one?

    At the start of the operation, the surgeon guides one of the robot's arms to insert an instrument with two tiny cameras and a light into an incision in the patient's abdomen. The cameras send the surgeon live magnified 3D images of the operating field.

    "It looks as if you are swimming in the patient's body," Ghavamian said.

    That sounds sweet, but does the robot increase the cost of surgery, and by how much? And does it provide better outcomes for the patient? In most settings it's more expensive. But, according to this small study, although the robot surgery takes longer, patients experience less pain and get to go home sooner. And this study suggests that the overall outcome is the same as traditional prostatectomy - though at a higher cost.

    A video of the surgery is available here.

    P.S. My husband says that the price will go down once they figure out how to have a surgeon in India or China operate the controls for a patient in the United States. He might be right. Could this kind of technology be the harbringer of outsourced physicians?

    UPDATE: Urologists in the comments are making the case against the robot. Here's Dr. Bob:

    This device requires significant experience in laparoscopic skills--which most urologists in practice don't have. Furthermore, early studies suggesting better continence, potency, shorter hospital stays, etc, aren't holding up with larger studies....

    posted by Sydney on 12/29/2005 08:45:00 AM 6 comments


    If the device itself is $1.5 million, then it's going to be cost prohibitive for most institutions. What's the average cost for a prostatectomy?

    I'm not so sure that this particular device would bring about the outsourcing of surgeons. If it was $150,000 vs $1.5 million, then I'd perhaps start to worry about telemedicine clinics between here and Bangalore. Unless they can produce non-FDA approved clones...

    By Blogger Nick, at 10:06 AM  

    Open prostatectomy can be done by good surgeons in under 2hrs. The robot takes 5hrs. There is no difference in postop pain, going home, erectile status and continence. Most patients go home 1 day after using the robot or not. It is just an expensive gimick for those that don't have good surgical skills.

    As far as outsourcing is concerned. I am not too worried as a surgeon. I would be more worried if I were a flea or radiologist.

    By Blogger kwickrelease, at 3:52 PM  

    Below is a good prospective study comparing the robot to open. No difference in pain. Plus I feel I get better urinary continence results with the open approach because I can feel the bladder neck whle operating allowing me to better preserve it.

    I sold my ISRG stock 1 month ago. Time to get out.

    Robotic assisted laparoscopic radical prostatectomy versus retropubic radical prostatectomy: a prospective assessment of postoperative pain.

    J Urol. 2005 Sep;174(3):912-4; discussion 914.

    By Blogger kwickrelease, at 3:59 PM  

    Our local hospital bought one of these puppies, then immediately began marketing it as the greatest thing for prostate surgery since surgeons were created. Problem is, the only urologist in town using it is dangerously inexperienced in laparoscopy, and has a long history of the highest complication rates in town with open surgery. This machine ain't gonna make a silk purse out of a sow's ear.

    This device requires significant experience in laparoscopic skills--which most urologists in practice don't have. Furthermore, early studies suggesting better continence, potency, shorter hospital stays, etc, aren't holding up with larger studies, as kwickrelease pointed out.

    By Anonymous Dr Bob, at 9:11 PM  

    Does your husband really believe that having a surgeon in India will decrease the cost of the operation? There is a lot of voodoo accounting in healthcare, but any way you look at it, the surgeon's fee is a very small portion of the cost of an operation, especially one that requires a several day hospital stay. For radical prostatectomy, that urologist's compensation is probably 5% at most of the cost. Some people get really cheap surgery by traveling overseas for the whole package, enough to pay for transportation and still come out way ahead. Saving 5% by having a surgeon you can not ever see and will not be available to manage the postop course is not anything that we have to worry about.

    By Anonymous jb, at 3:30 PM  

    Machine operation of this sort can't be outsourced to India. That's because even at the speed of light, it takes about a tenth of a second for the video to reach India, and another tenth of a second for the operator's response to return.

    2 tenths of second may not seem very long, but it would ruin any kind of delicate work.

    By Anonymous Rich Rostrom, at 2:28 AM  

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