Dr. Harry C. Sax first used a surgical robot at the University of Rochester in New York, and after joining The Miriam Hospital as surgeon-in-chief he led an effort to buy a $1.7 million Da Vinci Surgical System robot for the Providence facility.
“Leo” was introduced in November 2006, initially approved by the state only for prostate surgery, mitral valve repair and a type of esophagus surgery. A year later, the Miriam applied to expand the robot’s use, and while prostatectomies still dominate its schedule, Leo now provides a minimally invasive option for a wide range of delicate surgeries.
In a recent interview with Providence Business News, Sax offered a progress report.
PBN: What has happened since the state approved an expansion of the robot’s use?
SAX: The state approved any surgeries that we could do with the robot. … Then we began a relationship with Women & Infants [Hospital] and with our colorectal surgeons, and we expanded urology.
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PBN: What makes robotic surgery so helpful?
SAX: The first issue is that this is minimally invasive surgery, so instead of a long, open incision, we’re able to operate through small incisions of a half an inch. And it’s an advancement beyond laparoscopy – the difference is like between eating with chopsticks and having your wrists back and being able to eat with a fork. What the robot does is it gives us six degrees of freedom so we can mimic the motion of our wrists and our hands, and it gives us a three-dimensional view, whereas in laparoscopy you’re looking at a flat screen. With a robot, you actually have your head in a console, so you can see what tissues are ahead and behind.
PBN: Why is it so well-suited for prostate, colorectal and gynecologic surgeries?
SAX: The reason is that you’re operating deep in the pelvis, so if you think about the pelvic bone like an ice cream cone … you’re limited by the walls of the cone, so when you’re working deep in the pelvis, on the uterus, on the bladder, on the lower rectum, you don’t have the same space that we do when we’re operating in the middle of the abdomen, so it’s especially good for going deep into places where you couldn’t even get your hands in.
PBN: How many surgeries are you doing at this point with the robot?
SAX: We just in the past month completed our 500th prostate surgery, which for a program that is slightly over two years old is remarkable. We have done about 550 surgeries total [as of March 17] and it grows every day. We’re doing between seven and 10 a week, and with urology, in addition to prostates, we’re doing surgery on the kidney that allows us to, instead of taking the whole kidney out for tumors, we’re able to remove just the part that has the tumor and preserve function for the patients. We’re also doing something called pyeloplasty, which is a way to take care of obstructed ureters, the tube between the bladder and the kidney.
PBN: In prostate surgery, is this now the norm?
SAX: I think nationally and certainly here in Rhode Island, it is becoming the predominant method. There are still occasional patients … who will have an open prostatectomy, but I would say that in the state, about 80-85 percent of surgeries are being done robotically now.
PBN: Has that driven more people to have prostate surgery at the Miriam?
SAX: Absolutely, and I think it’s kept a lot of patients in Rhode Island. When we looked at the market, we were losing a lot of patients to Boston, Hartford and Baltimore. Prior to the robot, the Miriam was averaging between 40 and 50 prostatectomies a year. We are now doing about 175 a year. So it’s been a huge increase.
PBN: Through your Women & Infants partnership, you’ve expanded access to robotic surgery without their having to buy their own machine. But do you think other hospitals are going to buy robots in the near future?
SAX: In Rhode Island, this kind of investment requires a certificate of need, so what we want to do, looking overall at the state, is we want to make this technology available to any physician who wants to use it. And anybody that’s suitably trained and is willing to be monitored on their outcomes is welcome to come use the machine. I think certainly we are reaching the point that we would like to get a second robot here, both to make it further available to others as well as to increase our own efficiencies.
We have a specialized team, and the Miriam has developed some unique, collaborative ways to make it very efficient and very safe.
PBN: How much more can you do with this one robot?
SAX: Depending on the complexity of the surgery, I think that once you get to 350 or 400 cases a year, you’re getting pretty close to capacity. We are doing one to two a day; in some cases we’ll expand to three a day; as surgeons do more and more of these, we’re all getting more efficient. But we’re getting very close to needing a second one, no question – the demand is there both from a patient point of view and from physicians.
PBN: Has the robot accomplished what you hoped it would?
SAX: To get people to come to Rhode Island and stay here as physicians, you have to offer them the latest in technology, so to attract the next generation of urologists, of gynecologists, of colorectal surgeons, we have to make these training facilities available to them, we have to give them these opportunities during residency, and we need to make sure they have access to it when they finish. •
