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For prostate removal, robots rule Add to ...

Assaad El-Hakim saddles up to the console, grips the hand controls, tests the foot pedals, then peers into the viewfinder to make sure the image is clear.

"This is my PlayStation," he says with a chuckle.

But this is no game. It is state-of-the-art robotic surgery.

Moments earlier, Dr. El-Hakim, a surgeon at Sacré-Coeur Hospital in Montreal, made a series of small incisions into the belly of a patient lying on an operating table two metres away.

In one, just above the bellybutton, he has inserted a tiny camera that projects a 3-D image onto the screen. In the others are miniature forceps, surgical scissors and needle drivers (instruments used to hold suturing needles), all of them attached to the robotic limbs dangling above the patient.

Dr. El-Hakim controls the camera with the foot pedals. With the hand controls, he manipulates the instruments deftly - cutting, cauterizing and suturing - to remove the man's cancerous prostate while causing the least amount of damage possible to surrounding nerves and tissue.

"I don't offer my patients traditional surgery any more because I can't look them in the eyes and say it's the same," Dr. El-Hakim says. "Robotic prostatectomy is better in many ways."

For patients, the attraction of robotic surgery is that recovery is faster. Men who have their prostate removed go home within one day, instead of three to four days. Because there is less cutting, blood loss is decreased, so there is rarely a need for transfusion, and postsurgical infections are less common. The use of urinary catheters after surgery is also reduced from two weeks to one.

Best of all, there is some early evidence that the most-feared side effects of prostate surgery - incontinence and impotence - are far less common after robotic surgery.

"I had the surgery on Friday and was back at work the next Tuesday," says James Hughes, a Toronto business executive who had robotic surgery in March at St. Michael's Hospital in Toronto.

He opted for surgery rather than radiation or watchful waiting because he had suffered from painful prostate enlargement and infections.

When robotic surgery was offered, he did not hesitate for an instant. "It's not a robot doing the surgery, it's a human with an extension to his hand that makes the surgery more precise, so who can argue with that?" Mr. Hughes says.

Patients notice little difference with the surgery itself, other than faster recovery.

"I know people who had prostate surgery and were out of commission for six weeks," Mr. Hughes says. "I had a little discomfort and that's all."

Kenneth Pace, the urologist who performed his operation at St. Michael's, said the robotic technology does not replace surgical skill but provides a huge technical boost.

"The robot takes the human hand and miniaturizes it to about one centimetre," he says. "It gives you an incredible ability to be precise when you cut delicate tissues and put them back together again."

The robotic device magnifies vision by about 15 times, and the hand controls allow surgeons to rotate instruments in ways that that they could not with the human hand alone. It also corrects for tiny, almost imperceptible tremors.

In addition to prostate surgery, robotics are being used for hysterectomies, pelvic surgery and some heart surgery such as mitral valve replacement. In the future, the technology, which was initially developed by NASA, could be used to perform surgery in remote locations such as in space or battlefield hospitals.

Robotic surgery, however, has more down-to-earth concerns: It is more expensive than conventional operations.

The da Vinci Surgical System (a product of Intuitive Surgical Inc. of Sunnyvale, Calif.) costs about $4.5-million. The surgical instruments must be changed routinely, which adds between $3,000 and $5,000 to the cost of each procedure.

To date, no provincial ministry of health has agreed to cover these costs. So all robotic surgery in Canada is subsidized by hospital charitable foundations; that is the case in Toronto, Montreal, Vancouver, Edmonton and London, Ont.

"The only way we can do this is with donor money," Dr. Pace says. It is a situation that he and many others consider absurd.

"Three to five thousand dollars sounds like a lot of money but that's about what it costs every time somebody gets a new hip," Dr. Pace says.

He believes that provincial health ministries are taking too narrow a view, looking only at additional costs without considering the savings that come from better surgical outcomes.

Dr. El-Hakim agrees.

"All governments understand is that we're spending more per surgery. They don't understand that we save three days of hospitalization and the costs of treating complications," he says. "And I haven't even mentioned the quality of life of patients."

Dr. El-Hakim also believes, more fundamentally, that robotic surgery is a natural progression of care that should not be held up by shortsighted financial considerations.

"This is the 21st century. It's impossible to think that surgery can only be done as it was a century ago, with forceps and a scalpel.

"We shouldn't think of robotic surgery as the surgery of tomorrow but as the surgery of today."

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