TRENDS TOWARDS
LAPAROSCOPY FOR PROSTATE CANCER
We are still working to minimize the major risks of
complications involved in minimally invasive prostatectomy. This becomes even
more important as more patients undergo these procedures. How has the training
and certification process impacted our success and what improvements can we
expect in this minimally invasive technique for prostate cancer in the years to
come. Welcome to the Clinician's Roundtable.
I am your host, Dr. Mark Nolan Hill, Professor of Surgery
and Practicing General Surgeon, and our guest is Dr. Jim Hu, Assistant
Professor of Surgery at Harvard Medical School and Director of Minimally
Invasive Urologic Oncology at the Brigham and Women's Hospital and the Dana
Farber Cancer Institute in Boston.
DR. MARK NOLAN HILL:
Welcome Dr. Hu.
DR. JIM HU:
Hi Mark, thanks for having me on ReachMD.
DR. MARK NOLAN HILL:
We are discussing trends towards laparoscopy for prostate
cancer. Dr. Hu tell us a little bit about your background. I believe you are
one of the few surgeons in the United States, who had a fellowship exclusively
in robotic surgery.
DR. JIM HU:
That’s right, although I think its becoming more and more
commonplace. I completed a 6-year urology residence training program at UCLA
and then did a 1-year fellowship in robotic urologic oncology at City of Hope
in Los Angeles area.
DR. MARK NOLAN HILL:
And your research that you are involved with. What
specifically are you studying?
DR. JIM HU:
I am studying outcomes for minimally invasive radical
prostatectomy, as they compare to open radical prostatectomy and when I use the
term minimally invasive, I mean both laparoscopic as well as robotic-assisted
laparoscopic radical prostatectomies. We also looked at the trend and
diffusion of the minimally-invasive approaches from a period of time from 2003
to 2005.
DR. MARK NOLAN HILL:
What happens when you are teaching your residents about
robotic surgery and they have the instance where they have to open up the
patient. Can they handle an open radical prostatectomy as well as someone who
has been doing it for 30 years?
DR. JIM HU:
I think that's certainly a very valid concern and one that a
lot of training centers around the country, residency training programs are
facing as more and more radical prostatectomies are done via the robotic
approach. I certainly think that naturally as less and less people do the
open, it will be a more and more rare event to need to covert to open surgery;
however, certainly it may be the case where one needs to consult with a more
experienced surgeon if there is a conversion in the future or in the present
day I should say going from robotics to open surgery. I don’t think that there
is a panacea, but if the trend continues, I think open surgery will be the
exception rather than the rule.
DR. MARK NOLAN HILL:
These patients who undergo the robotic surgery, how long are
they in the hospital?
DR. JIM HU:
Typically 24 hours, however, I have to be fair and say that
there are centers that perform open radical prostatectomy that will discharge
their patients in a 24-hour timeframe as well. So a lot of physician practice
patterns, individual practice styles may dictate length of stay and its
difficult to just make the generalization that minimally invasive radical
prostatectomies will go home sooner than open radical prostatectomies.
DR. MARK NOLAN HILL:
And generally how do these patients with robotic surgery do?
DR. JIM HU:
Generally they do very well. I am speaking from personal
experience. However, when we also look at what our data showed, however, I
think when you look at the experience of all surgeons that are doing
minimally-invasive radical prostatectomy across the country, our study showed
that there is an increased risk for needing other procedures to control the
cancer, short period after surgery. So I think that, and furthermore what our
study showed was that increasing surgeon experience led to a lower need for
such salvage therapies such as radiation or hormonal therapy after surgery for
minimally-invasive surgeons.
DR. MARK NOLAN HILL:
If a patient presented to you and needed a prostatic
operation for cancer and they said well tell me really that the main reasons I
should do a minimally-invasive approach or robotic approach, what would you
say?
DR. JIM HU:
Well I tell them to try to separate the technique or the
sexiness of the approach. In other words, this is a new technology, but try to
separate yourself from being <_____> to new technologies. In other words
the analogies that I always use for them which maybe applicable to a lot of
medical professionals, who like to play golf is that if you look at Tiger Woods
playing with a golf club from 20 or 30 years ago would still do much better
than me playing with a newest golf club today. I try to make the point that
technology is not a substitute for surgical experience. However, I do try to
convey to them that the advances in technologies such as laparoscopy or the
robotic approach do lead to potential advantages should the surgeon be able to
take advantage of them.
DR. MARK NOLAN HILL:
And is this general philosophy and understanding felt by all
urologists in the United States?
DR. JIM HU:
I don’t think so. I think certainly everyone is somewhat
biased towards what they do or what they have to offer and there certainly are
stake holders and their positions depend on what they do in terms of how many
radical prostatectomies they perform open versus via robotic or laparoscopic
approach. I think that if you spoke to most people in leadership positions
around the country, who are chairman of respective departments, those
individuals tend to be the open radical prostatectomy surgeons and hence may
not have been an early adoptor to laparoscopic or robotic radical
prostatectomy.
DR. MARK NOLAN HILL:
If you have just joined us, you are listening to the Clinician's
Roundtable on ReachMD. I am your host, Dr. Mark Nolan Hill and our guest is
Dr. Jim Hu, Assistant Professor of Surgery at Harvard Medical School and
Director of Minimally-Invasive Urologic Oncology at the Brigham and Women's
Hospital and the Dana Farber Cancer Institute in Boston. We are discussing
trends towards laparoscopy for prostate cancer.
Dr. Hu you have a fellowship specifically in robotic
surgery, what does the practicing urologist do if they want to learn the
robotic approach?
DR. JIM HU:
Currently the food and drug administration requires a
surgeon or urologist, who is interested in offering robotic radical
prostatectomies to take a 2-day course and that's the mandate. Now after the
2-day course, often times a surgeon will have proctoring from other surgeons,
who have done robotics, a robotic prostatectomy and so they will book a case
and have a proctor that may just direct them through the case, giving them
feedback or else at times should they require or called upon to intervene, they
can jump on the surgeon console and get them out of trouble. So realistically
that's the current state of affairs for the training of practicing surgeons in
terms of adoption of robotic radical prostatectomy.
DR. MARK NOLAN HILL:
Well what if you are in an area of the country in a rural
area where there are no proficient robotic operators.
DR. JIM HU:
I think certainly as a patient and I see this all the time
to patients if you are in an area where there is not an experienced robotic
surgeon, you have to look at what your long-term goals of therapy are and that
is again to cure the cancer, to remain continent, and to remain potent, and if
those are your primary goals rather than to have surgery done with latest and
the greatest technology or getting out of the hospital a day sooner then you
have to go someone, who has a lot of experience doing open surgery in that
rural area.
DR. MARK NOLAN HILL:
Are the hospitals having standardized credentialing
parameters or is this based really individually on each hospital?
DR. JIM HU:
I think each hospital certainly looks at whether or not the
surgeon has done the 2-day course, but I think that there is a great deal of
variability in what the surgeon experience should be before they go out and put
cases on their own or do things without a proctor. I think again the autonomy
that surgeons enjoy in this country probably have a great deal to do with that
as well as the fact that a lot of hospitals are eager to recoup their fixed
costs on a rather very expensive piece of capital equipment. So I think that
there is certainly enthusiasm from a hospital administrator, who has recently
plopped down $1.7 million to get some return on their investment.
DR. MARK NOLAN HILL:
Are these procedures being done in other countries?
DR. JIM HU:
Yes they are. I think that initially great deal of the
volume came from the United States, but when you look at the installation of
robotic systems across the globe. In Europe, there is certainly been a lot of da
Vinci robots that have been installed as well as in Asian countries as well,
but I think that because of the more free market economy of the United States,
we have been the most rapid adoptor of robotics, we have been the most free
spending certainly in that instance and I think in other healthcare systems
where cost carries a bit more ration than here and things are a bit more
planned, there has been slower adoption of robotic surgery.
DR. MARK NOLAN HILL:
I hate to bring up remuneration, but do all insurance
companies cover robotic surgery for prostatic cancer?
DR. JIM HU:
I don’t that really the payers reimbursed a greater extent,
robotic surgery versus an open surgery in general; however, I think that the
reimbursement for just on the surgeon side for a laparoscopic robotic surgery
based on what Medicare will reimburse is roughly about $150 more than for a
open radical prostatectomy. So at least at the surgeon fee level you are not
seeing a significant difference in reimbursement and on the hospital level
again I don’t think that there is a significant difference either. I think
that a lot of hospitals are trying to charge a facility fee as well in terms of
the robotics, but its variable in terms of how successful they are in getting
the payer remunerate based on that facility fee.
DR. MARK NOLAN HILL:
So if I am a urologist, who has been taking out prostates
for a million years and good at it and I am in a small hospital in the country
and I call you up and I say, Dr. Hu I really would like to start doing the
robotic surgery and our hospital is thinking of getting one, but there is no
one for 200 miles around who has done robotic surgery. What would you say to
this urologic surgeon?
DR. JIM HU:
I'd say that as with adoption of any approach or achieving
excellence in anything you do is a matter of commitment and in this case
without any supporting surgeons close by or anyone that one could easily go
watch, certainly there exists a lot of DVDs or videos now of robotic surgeries
and have high volume robotic surgeons that the device manufacturer actually
makes readily available, so I think studying those videos will help a great
deal. There is also the option of doing a mini fellowship in minimally-invasive
surgery or robotics that some centers offer around the country, which is about
1 week of dedicated exposure to the robot and robotic-assisted surgery. So I
think those would be the main options in terms of someone who is looking to
have greater exposure to robotics.
DR. MARK NOLAN HILL:
And what about in the future, perhaps I am doing a robotic
surgery in a small town and I video conference you in Boston and have you look
in through the electronic marvels and actually see what I am doing and advise me,
is that feasible?
DR. JIM HU:
That’s a very interesting point, Mark. The original intent
of the da Vinci robot and it was actually developed with a lot of money from
the Department of Defense, but the original intent was for the surgeon to be
faraway from the battlefield and then using a high-speed internet connection to
have the slave device robot to operate on a wounded soldier there closer to the
battlefront and so as our technology continues to improve, I think that there
is opportunities for an experienced robotic surgeon not only to teleconference
in, but also to have a form of proctoring whereby he may be able to take over
controls over high speed internet connections from far distances.
DR. MARK NOLAN HILL:
And finally 10 years from now, looking in your crystal ball,
how many prostate surgeries are going to be done robotically?
DR. JIM HU:
Well I think that there are several issues, #1, I think
honestly we probably over-operate on men with prostate cancer, so hopefully we
will have a better marker that will allow us to have better predictive ability
in terms of who really needs the surgery, but as far as people getting the
surgery go, I think that it will be close to 95 or 100% of men having
robotic-assisted laparoscopic surgeries compared to an open radical
prostatectomy.
DR. MARK NOLAN HILL:
I want to thank our guest, Dr. Jim Hu. We have been
discussing trends towards laparoscopy for prostate cancer.
I am Dr. Mark Nolan Hill. Be sure to visit our web site
at reachmd.com featuring on-demand podcasts of our entire library, and thank
you for listening.
