Abstract
It started with two patients. These were surgical triumphs: Patients who had undergone open radical prostatectomy in 1998 with impeccable results—no transfusion, no complications, continent, potent and with undetectable prostate-specific antigen levels. These men had achieved the “trifecta,” although we had not realized it; the word would not enter the prostate cancer world for quite a few years yet. Ralph Clayman had introduced laparoscopy for renal surgery in 1990, but it had not yet become standard of care. I asked the patients, “What do you think about using laparoscopic surgery for prostate cancer.” They said, “Yes, we wish you had used it on us.” I was stunned. These men had stellar outcomes, what more could they possibly want? “Did I not do right by you?” I asked them. One said, “Yes, doctor, but you cost me $300 million in lost revenue.” He was a prominent contractor in commercial real estate, and many of the contracts he got depended on the confidence and body language that he was able to project during the deal-making process. In the 6 to 12 weeks after his open radical prostatectomy, he thought he was missing a beat, and his customers picked up on it. Hence the $300 million in lost contracts. The second patient rolled up his trousers. On one knee was a healed scar from an open knee operation, on the other, a small incision from arthroscopic surgery. Same procedure, same outcomes, but totally different recuperation! Case closed.
Armed with this knowledge, I approached Raj Vattikuti, a prominent philanthropist. The Vattikuti Foundation was contemplating a major gift for prostate cancer, and I managed to persuade him that a substantial part of this gift should go to developing laparoscopic surgery for prostate cancer (LRP). Astonishingly, Vattikuti agreed. But, there was one problem. By 1999, I was an experienced open surgeon, with more than 1500 open oncologic procedures under my belt. I had trained with Bill Scott and Hugh Jewett, pioneers of the perineal prostatectomy, and with Pat Walsh at the time he was perfecting his techniques for open radical prostatectomy. I was Bill Catalona's junior resident. I was a good open surgeon, but I had no laparoscopic experience. So I called Alan Partin and Lou Kavoussi at Johns Hopkins to ask them what they thought about my idea (I was scared to ask Walsh!). They both thought there was no role for laparoscopic surgery in prostate cancer. In fact, Kavoussi alluded to an article that he was preparing that showed LRP was a long, difficult operation fraught with complications. I then called Ralph Clayman in St. Louis. Ralph said, “Mani, you are crazy to do this, but knowing you, you have made up your mind to pursue this craziness. Do yourself a favor: Talk to Bertrand Guillonneau in Paris.”
And so I did. By 1999–2000, I knew of three French groups who were performing LRP on a regular basis: Gaston in Bordeaux, Abbou in Creteil, Guillonneau and Vallencien at Montsouris. But no one in the United States. Based on Clayman's suggestion, I flew to Paris to meet with Guillonneau and Vallencien. I spent a month observing them performing LRP and came back impressed, even awed. The vision was spectacular, the blood loss negligible, and the recovery impressive. I invited the Montsouris surgeons to come to Detroit and help me start an LRP program. They agreed to spend 1 week a month operating on my patients at Henry Ford Hospital and training me in laparoscopy.
Robert Burns wrote, “The best-laid schemes o’ mice an’ men/Gang aft agley” (often go awry). And so it was with us. In a short while, two things became evident: First, operating on a 200 lb+ Michiganian was vastly more difficult than operating on a 150 lb Frenchman, even for the world's best laparoscopic surgeons. Second, I myself was no laparoscopic surgeon. After seeing me spending hours struggling to tie knots in the laparoscopic trainer, my wife said succinctly: “This is pitiful! Try something else before you drive yourself and everybody around you crazy.”
I was destroyed. What should I do now? I had received the Vattikuti grant, but had no laparoscopic program. Luckily, I had seen Vallancien test-driving the daVinci robot in Paris and had liked what I saw. I negotiated with Intuitive Surgical, the manufacturer, to lease a robot for the Vattikuti Institute. Three days after it was cleared for abdominal surgery by the Food and Drug Administration, I assisted Prof. Vallancien and his team in performing the first robot-assisted prostatectomy in the United States. I could do this operation! Now I needed a robot full time. I flew to California to meet Intuitive Surgical's CEO, Lonnie Smith. “Are your cardiac surgeons on board? Lonnie asked me. “No,” I said. “You know that this is a cardiac machine, don't you? How about your laparoscopic surgeons,” he continued. “No.” “Well, how many laparoscopic prostatectomies have YOU done?” he asked. “You mean, personally? Zero, but I have watched more than 50.” “You must be out of your mind, Mani, but if you insist, we will build you a robot—for a price,” Lonnie said.
And so it started. We became the first urology department in the world to own a daVinci Surgical System, as it was then called. By the end of 2001, Jim Peabody and I had performed 110 robot-assisted radical prostatectomies and established the foundations of robotic surgery in oncology. Within 3 years, our team had performed more than 1000 such operations. We never looked back.
Why did we succeed? We put a team together—the same assistants (Jim Peabody, Ash Tewari, Alok Shrivastava, Rich Sarle, and Ashok Hemal), the same nurses (Sofia, Editha, Anna, and Pete), the same anesthesiologist (Bala). We batched our cases, and videotaped them all. We pored over the videos before and after each operation. By the time we had performed four cases, our operating times were comparable to those of most expert laparoscopic surgeons.
We invited Ralph Clayman to visit us, and he helped Tom Ahlering and his team get started. We held the first robotic conference (International Robotic Urology SYmposium 2002) with live cases transmitted in 3-D. We built an augmented reality operating room (OR) where everyone, not just the console surgeon, could see in 3-D. Vipul Patel visited us, so did Jay Smith, Li Ming Su, Alex Mottrie, Richard Gaston, Randy Fagin, Koon Rha, and surgeons from all over the world. These surgeons, in turn, polished the procedure and refined it.
From the beginning, our goal had never been to duplicate what we had been doing in open surgery—it was to improve it. We made several technical modifications to LRP. I had been taught to perform the entire operation with the zero degree lens. And then, one day, the surgical assistant dropped the lens on the floor. I had no choice but to use the 30-degree lens. Eureka, it made the operation easier, with greater depth perception. We felt more familiar with an anterior approach (the Vattikuti Institute Prostatectomy technique). We developed a technique of nerve sparing that preserved the prostatic fascia, an approach independently confirmed by open surgeons in Munich and Innsbruck. A patient asked me if I could avoid leaving a Foley catheter. I agreed, and 2000 patients later, we preferentially avoid using a Foley catheter. We thought of using the barbed suture for the urethrovesical anastomosis. We use a GelPoint for specimen extraction,and for real-time palpation of the prostate. We continue to learn and try to improve every day that we are in the OR.
We had thought that robotic technology should not be confined to the prostate, nor even just to urology. With the support of Profs. Ghoneim and Abol Enein, we took the robot to Egypt in 2002 and developed an approach to radical cystectomy. In 2006, with Prof. Shahabuddin in Kuala Lumpur, Malaysia, we worked on the robotic approach to the kidney.
As I reflect on the past 12 years, robotic surgery works because it allows the surgeon to see better, and there is less bleeding. Not everyone agrees. Many think that the technology is unproven because there have been no multi-institutional randomized trials demonstrating its superiority. Many think that widespread marketing has sacrificed the scholarly process. All think that the technology is expensive. And there is some truth in these statements. Hundreds of thousands of patients, however, can't all be wrong, and I often think of one of Ronald Reagan's favorite stories.
There were two boys: One a pessimist, the other an optimist. Worried about their personalities, their parents took them to a psychiatrist. First, the psychiatrist tried to improve the pessimist's outlook by taking him to a room filled with shiny mechanical toys. To the psychiatrist's surprise, the little boy burst into tears. “Don't you want to play with any of the toys?” the psychiatrist asked. “Yes,” the little boy cried, “but they are expensive and I may break them.” Next the psychiatrist filled the room with horse manure. He turned to the optimist. The boy squealed with delight and began gleefully digging out scoop after scoop of manure. “What are you doing?” the psychiatrist asked, puzzled. “With all this manure,” the little boy replied, “there must be a pony in here somewhere!”
Ultimately this may be the story of robotic surgery. Twelve years ago, some of us thought there was a pony somewhere.