Success In Robotic Surgery: Not Just the Institution, but Patient Selection is Key
An Interview with Dr. Raul Parra, the Pioneering Partial Nephrectomist
Many institutions are learning that establishing a successful robotic surgery program can be a hospital-specific endeavor, with a smooth roll-out often depending on whether the hospital is really a good fit with the robot. But in terms of what really counts- improving outcomes for patients with cancer- perhaps it takes a robotic surgeon to establish the important role of patient selection in getting the best cure rate possible.
“It’s all about patient selection,” said Dr. Raul Parra, MD, chief of the department of urology at Cooper University Hospital. “For example, when we do a robotic partial nephrectomy, we limit the cases to tumors less than four centimeters, whereas for larger tumors we are embarking on doing total removal in selected patients.” To date, Parra and his institution have done 21 partial removals, and in doing so, have accumulated the largest experience right now in the country.
The team has also performed about a half dozen total removals, which are a relatively new technique, said Parra, who will deliver a talk on rolling out a robotic surgery program at a medical robotics conference in Philadelphia this June.
Parra’s superior experience is paying dividends in the form of a presentation at the annual meeting of the American Urological Association in Orlando this month, as well as a recent manuscript to the Journal of Urology, comparing the team’s first ten robotic partial nephrectomies to a contemporary group which performed ten open partial nephrectomies.
“Both sets of procedures were done by me during same the period of time,” Parra said. “We found that cancer control, or the ability to remove the entire cancer from the kidney was the same. Robotic surgery is as effective as open surgery to eradicate cancer. Additionally, the operative time was equal to or less than open surgery,” said Parra, who added that the group started using robotic surgery for kidney procedures in September of 2007, and data for the study was gathered between September and November of 2007.
The hospital had already been using the Da Vinci for prostate cases for five years, he said.
The Educated Patient
Having the latest therapies available for patients diagnosed with a serious condition is important from a business point of view, Parra said. “In my experience,
patients who are diagnosed with tumor in the kidney do some sort of research and investigate, then prefer those surgeons providing minimally invasive surgery. The main advantage is that conventional laparoscopic surgery is like operating in two dimensions, like watching TV, and it is very difficult to perform certain maneuvers, in particular suturing,” said Parra. The same difficulties are lessened with robotic procedures, which is more comparable to doing an open case,” he added.
“In today’s health care environment, in the major metropolitan areas, those institutions that are not doing robotic surgery, will probably be at a disadvantage, because patients are very savvy,” said Parra.
Robotic surgery is also preferable from an efficiency standpoint. “In my experience, robotic surgeries for the kidney are taking no more than to do them open, and sometimes less time. And they take significantly less time than for laparoscopic procedure,” said Parra noting that his work showed the average time for a robotic partial nephrectomy is less than two hours, compared to sometimes more than three hours to do them laparoscopically,” he said.
With Parra’s evidence and experience beginning to mount, he said his institution is looking into buying a second Da Vinci. “Now our experience with partial nephrectomies is almost 25 patients, and we’ve done a total of 400 total robotic procedures. The results are very encouraging,” he added. The institution is considering the second Da Vinci primarily because of demand, he said.
The demand for robotic surgery could create a dilemma for some institutions.
“The problem we face is that market forces are such that institutions that want to compete with the one across street, if they’re not going to have a high-volume place you’re not going to have the same outcomes. You’re not going to improve over the results that you have now, and it places a significant burden on the shoulders of administrative departments, the legal department, physicians and everybody, to get by the learning curve,” said Parra, noting the evidence in the literature that shows that it takes between fifty and 100 cases for a surgeon to become adept at performing a robot prostatectomy. “And in my opinion, if you don’t make the prostatectomies, you should not be attempting to operate on the kidney which is significantly more complex, because the kidney is very deep within the abdominal cavity, is well-vascularized and is very fragile,” Parra added.
As one way of dealing with the important learning curve issue, Parra said he was instrumental in creating at his institution all agreed on a strict mentoring program, prior to implementing the roll-out of the robotic surgery program. “Any of the surgeons in this hospital who wants to use the robot has to take a certified course provided by Intuitive Surgical in how to work the machine, and has to perform at least five procedures, beginning with the easier ones, while supervised and trained by an experienced robotic surgeon,” he said.
Parra noted that as the popularity of robotic surgery grows, improvements to the device itself will continue. “For instance, I think the robot is a very large, cumbersome piece of equipment, and it takes up a lot of space. In the future, the Da Vinci will be miniaturized, and more incorporated into the operating room. Improvements in ergonomics and size are all within the current technology,” Parra added.
By John J. Otrompke, JD
Many institutions are learning that establishing a successful robotic surgery program can be a hospital-specific endeavor, with a smooth roll-out often depending on whether the hospital is really a good fit with the robot. But in terms of what really counts- improving outcomes for patients with cancer- perhaps it takes a robotic surgeon to establish the important role of patient selection in getting the best cure rate possible.
“It’s all about patient selection,” said Dr. Raul Parra, MD, chief of the department of urology at Cooper University Hospital. “For example, when we do a robotic partial nephrectomy, we limit the cases to tumors less than four centimeters, whereas for larger tumors we are embarking on doing total removal in selected patients.” To date, Parra and his institution have done 21 partial removals, and in doing so, have accumulated the largest experience right now in the country.
The team has also performed about a half dozen total removals, which are a relatively new technique, said Parra, who will deliver a talk on rolling out a robotic surgery program at a medical robotics conference in Philadelphia this June.
Parra’s superior experience is paying dividends in the form of a presentation at the annual meeting of the American Urological Association in Orlando this month, as well as a recent manuscript to the Journal of Urology, comparing the team’s first ten robotic partial nephrectomies to a contemporary group which performed ten open partial nephrectomies.
“Both sets of procedures were done by me during same the period of time,” Parra said. “We found that cancer control, or the ability to remove the entire cancer from the kidney was the same. Robotic surgery is as effective as open surgery to eradicate cancer. Additionally, the operative time was equal to or less than open surgery,” said Parra, who added that the group started using robotic surgery for kidney procedures in September of 2007, and data for the study was gathered between September and November of 2007.
The hospital had already been using the Da Vinci for prostate cases for five years, he said.
The Educated Patient
Having the latest therapies available for patients diagnosed with a serious condition is important from a business point of view, Parra said. “In my experience,
patients who are diagnosed with tumor in the kidney do some sort of research and investigate, then prefer those surgeons providing minimally invasive surgery. The main advantage is that conventional laparoscopic surgery is like operating in two dimensions, like watching TV, and it is very difficult to perform certain maneuvers, in particular suturing,” said Parra. The same difficulties are lessened with robotic procedures, which is more comparable to doing an open case,” he added.
“In today’s health care environment, in the major metropolitan areas, those institutions that are not doing robotic surgery, will probably be at a disadvantage, because patients are very savvy,” said Parra.
Robotic surgery is also preferable from an efficiency standpoint. “In my experience, robotic surgeries for the kidney are taking no more than to do them open, and sometimes less time. And they take significantly less time than for laparoscopic procedure,” said Parra noting that his work showed the average time for a robotic partial nephrectomy is less than two hours, compared to sometimes more than three hours to do them laparoscopically,” he said.
With Parra’s evidence and experience beginning to mount, he said his institution is looking into buying a second Da Vinci. “Now our experience with partial nephrectomies is almost 25 patients, and we’ve done a total of 400 total robotic procedures. The results are very encouraging,” he added. The institution is considering the second Da Vinci primarily because of demand, he said.
The demand for robotic surgery could create a dilemma for some institutions.
“The problem we face is that market forces are such that institutions that want to compete with the one across street, if they’re not going to have a high-volume place you’re not going to have the same outcomes. You’re not going to improve over the results that you have now, and it places a significant burden on the shoulders of administrative departments, the legal department, physicians and everybody, to get by the learning curve,” said Parra, noting the evidence in the literature that shows that it takes between fifty and 100 cases for a surgeon to become adept at performing a robot prostatectomy. “And in my opinion, if you don’t make the prostatectomies, you should not be attempting to operate on the kidney which is significantly more complex, because the kidney is very deep within the abdominal cavity, is well-vascularized and is very fragile,” Parra added.
As one way of dealing with the important learning curve issue, Parra said he was instrumental in creating at his institution all agreed on a strict mentoring program, prior to implementing the roll-out of the robotic surgery program. “Any of the surgeons in this hospital who wants to use the robot has to take a certified course provided by Intuitive Surgical in how to work the machine, and has to perform at least five procedures, beginning with the easier ones, while supervised and trained by an experienced robotic surgeon,” he said.
Parra noted that as the popularity of robotic surgery grows, improvements to the device itself will continue. “For instance, I think the robot is a very large, cumbersome piece of equipment, and it takes up a lot of space. In the future, the Da Vinci will be miniaturized, and more incorporated into the operating room. Improvements in ergonomics and size are all within the current technology,” Parra added.
posted by John J. Otrompke | 12:52 PM
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