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John J. Otrompke, JD
Editor and Publisher,
Medical Robotics Magazine
The Only Commercial Feature News Magazine Covering All Aspects of Medical Robotics
Publishing Since 2007

All content (c) 2012 John J. Otrompke, JD

Contents of September 2012 Issue of Medical Robotics Magazine

1. Trial of the Cyberknife in Treating Recurrent Gynecologic Patients Shows High Response Rate, but also High Progression at Follow-Up

2. Project Eurosurge: Researchers Expect to Request New Round of Funding to Lay Groundwork for Modular Surgical Robotic System

3. Largest Series to Date Reports on Salvage Prostatectomies with the Da Vinci Surgical Robot

4. Italian Institute of Technology Device Wins 2011 Prize for Best European Mechatronics Article

5. Workshop Highlights Devices like Care-o-bot, and JACO in Assisting the Elderly and Handicapped

6. Researchers Present Discussion Concerning Improvements in Prosthetic Hands

7. ROBOCAST and Other Research Discussed at 2011 EU Robotics Forum

Trial of the Cyberknife in Treating Recurrent Gynecologic Patients  Shows High Response Rate, but also High Disease Progression at Nine Month Follow-Up


The study of the use of stereotactive radiosurgery using the CyberKnife Robotic Radiosurgery System (Accuray, Inc., Sunnyvale, Ca.) in treating recurrent gynecologic cancers found that over two-thirds of patients experienced some benefit from the treatment, according to a presentation at this year’s annual meeting of the American Society of Clinical Oncology (ASCO) in Chicago.

Half the patients experienced a complete response following treatment with the Cyberknife, but upon follow-up, over half the patients had progressive disease in regions not targeted with the robotic radiation, and 36% of the patients in the study subsequently died of progressive disease, according to abstract 5102, “Phase II trial of robotic stereotactic radiosurgery (SBRT) in patients with recurrent gynecologic malignancies.”

The prospective phase II study was the first formal study to assess the device in that disease state that was conducted at Case Comprehensive Cancer Center, in Cleveland, Ohio. Case Western is the institution with the largest experience using the Cyberknife to treat recurrent gynecologic cancers, having treated over 100 women with the technique, according to Robert DeBernardo, MD, assistant professor of gynecologic malignancies, co-author of the study.

Prognosis for recurrent gynecologic cancer varies with the site of the tumor, such as vagina, cervix, uterus, fallopian tubes or ovaries, DeBernardo said. “When it comes back, for some patients we have good options , but for others we don’t.  For example, most ovarian cancers come back at some point, but we have good options with chemotherapy for those patients. However, the textbooks tell us that 80% of patients have advanced disease, in which case about 70% eventually will die from it. With some therapies, patients live 66 months on average, but for those with stage three or four disease, five year survival ranges only from 20 to 40%,” he explained.

In the study, DeBernardo and colleagues followed 50 patients with recurrent and measurable gynecologic malignancy, who were treated with the Cyberknife. The cohort, which was accrued between July of 2009 and September of 2011, included 25 patients with recurrent ovarian cancer, 14 with endometrial disease, nine with cervical, and two with vulvar cancer. Patients received radiation in three daily doses of 800 gray apiece, guided in part by PET molecular imaging. While at a median of nine months follow-up, 25 patients had enjoyed a complete response, 26 patients, or 52%, had progressive disease at other sites, and 18 patients had died from recurrent cancer, the abstract said. However, 33 patients, or 66%, enjoyed a progression-free interval of at least six months.

“We were not expecting to see five year survival for the cohort, because many of these patients had already received between four and six lines of therapy, and a couple of them had also received surgery with the Da Vinci surgical robot,” explained DeBernardo, who himself also uses the Da Vinci surgical robot for some patients.

Use of the Cyberknife is especially helpful in treating patients whose cancer recurs in the abdomen or pelvis, according to DeBernardo. “In the pelvis, recurrences are especially difficult to get to with traditional radiation, without impacting the bladder or the bowel. For those women who receive intravenous therapy initially, the cancer will recur in the abdomen first,” he explained.

The abstract noted that while researchers accomplished excellent control of targeted lesions, high progressive disease rates elsewhere necessitate trials combining radiation with chemotherapy.

“In a new trial, we are combining this technique with gemcitabine and carboplatin administered intravenously,” said DeBernardo, noting that two of three patients sought for the Phase I trial have been enrolled.

The researchers hope to have data to submit at the meeting of the Society of Gynecologic Oncologists, March 9 in Los Angeles, he added.

           Medical Robotics Magazine Presents a Discussion of 
        Research Concerning Improvements in Prosthetic Hands

A presentation at last year’s EU Robotics Week aimed to promote discussion of an important use of medical robotics: prosthetic hands.

While there are at least three poly-articulated prosthetic hands on the market, researchers need to make several improvements to provide relief to amputation patients, according to Emanuele Gruppioni, M.Eng., organizer of the session at EU Robotics Week 2011, ‘New generation prosthetic hands: the poly-articultated hand and its relative training,’ in Bologna on November 28.

“We are working to improve the reliability, the power, the noise and the speed, but these kind of hands also have problems with the gloves, which break much too quickly,” explained Gruppioni, a master engineer in the research and training center at the INAIL Prostheses Center, Italy’s public workers’ compensation authority. “We also need to make the mechanisms much smaller; it's necessary to place a motor with its gearbox into the space of a phalanx,” she added.

Gruppioni and colleagues are currently testing three different hands in about 10 human patients. The hands are the iLimb (Touch Bionics, Edinburgh), beBionic (RSL Steeper, Leeds, U.K.), and the Michelangelo (Otto Bock, Duderstadt, Germany). However, the researchers hope to have enrolled 20 or more patients in the research by the end of 2012, added Gruppioni, who noted that the agency is cooperating with the University of Bologna.

Medical Robotics Magazine is proud to present Gruppioni’s article on her ongoing research, below.

Advances in Prosthetic Hands

by Emmanuele Gruppioni, M. Eng.

The human hand has 21 degrees of freedom (DOFs); therefore, its loss is probably the most traumatic type of amputation, not only given the functional aspects carried out by the hands, but also in consideration of its roles in our social life (such as shaking hands, or using the hand to greet, for example).

The common treatment for a trans-radial or hand amputation is a prosthesis with just one DOF for the hand (one motor drive which opposes the thumb and index and medium fingers) and (eventually) one degree of freedom for the wrist, which is typically controlled by two electromiographic signals coming from the residual muscles of the stump (normally the muscles to flex or extend the wrist). This is a good solution for the reliability, the toughness, and the grasping power, but it has great limitations in the appearance and in performing fine activities (such as using a computer or a cell phone).

For a long time, research has been working on new robotic systems with the aim of overcoming the limitations of traditional tridigital myoelectric prosthetic hands and to decrease, in this way, the gap with the human hand. 

The poly-articulated prosthetic hands are the first answer.

In a few words, poly-articulation is a concept based on a simple consideration: the main distance between actual prostheses and the human joints is due to the number of DOFs, so, what is needed is to increase the number of DOFs.

Simple to say, but not so simple to do.

To increase the number of DOFs means to improve the functionality and the appearance but, on the other hand, also to put much more complexity into the prosthesis structure; it requires extreme miniaturization of the mechanisms and of the motors, and more sophisticated electronics and software. Each one of these issues is a challenge for technology because, in addition, the prosthetic solutions have to be lightweight, with high power grasp and human-like appearance; these specification are obviously in mutual collision.

The commercial poly-articulated hand prostheses mount five motors that drive the robotic fingers through a series of gearboxes that obtain the right velocity, a no-driveback behavior with the minimum loss of efficiency so to reach a good user power and save the battery.

Basically, there are two technical solutions for the polyarticulated hands: one with the motors/mechanisms inside the first phalanx of the fingers and the other one with the motors/mechanisms inside the palm.

The first one is the "expensive" solution that requires special motors and high-level machining of the gearboxes. The functional unit is the single finger; therefore, this device allows treatment not only of complete hand amputations, but also partial hand amputations.

The second one is the "cheaper" solution because it uses more economic, basic components, but, obviously, it is not possible for the the treatment of partial hand amputations. A significant difference is that this solution implements a position closed loop control, whereas the other is simply based on the currents supplied to the motors.

Both the devices are controlled as the tridigital hands (with only two control signals) but the users can put these hands in a series of predefined postures through special strategies and, from there, move the hand in different ways. For example, the electronic unit can be programmed to detect the co-contraction of the muscles and, in this case, to put the prosthesis automatically in "index point" posture (with the index finger totally extended and the other fingers totally flexed, commonly used for computer or cell phone use).

It's important to understand that 1) the patient is not able to control the single finger and 2) there is no correspondence between what the patient thinks/wants to move and the specific joint activation. In fact, it's impossible to obtain from a stump a large number of independent and strong muscle signals that could give to the patients a better control of this type of prosthesis. This is one of the main fields of research in prosthetics.

In conclusion, the first poly-articulated hands are now available on the market and the benefits for the patients are clearly visible. This is just the initial result of the research activity whose final goal is a much more functional, dexterous and human-like prosthetic hand. However, a lot of challenges are still to be faced, particularly from the control viewpoint.

Follow-Up Data from UCSF Suggests Cyberknife Monotherapy Results Improved Slightly Over Time

Original Study Compared Stereotactic Monotherapy, Boost and Brachytherapy

by John Otrompke

(c) 2011 John Otrompke

Follow-up analysis from a small study comparing boost and monotherapy with the Cyberknife and brachytherapy for prostate cancer suggests that some monotherapy results have improved since publication, a researcher from the University of California at San Francisco said.

In the original study, published last year in the International Journal of Radiation Oncology, Biology and Physics, 20 of 38 patients were treated by the Cyberknife with stereotactic radiotherapy as a monotherapy, while 18 received the Cyberknife treatment as a boost (following external beam radiation and hormone therapy). 

The article, ‘Stereotactic Body Radiotherapy as Monotherapy or Post-External Beam Radiotherapy Boost for Prostate Cancer: Technique, Early Toxicity, and PSA Response’ (Jabbari, et al), which was published December 21, 2010, reported results at a minimum follow-up of 12 months.

In the time since publication (nearly a year), PSA nadirs for those treated with Cyberknife monotherapy have come down to more closely approach the lower level achieved with patients who received Cyberknife therapy as a boost. PSA nadir for those who received boost therapy was 0.3 nanograms per milliliter upon follow-up analysis, compared to about 0.5 at the time of the original publication,according to Alexander R. Gottschalk, MD, PhD, associate professor in radiation oncology at the University of California at San Francisco, a co-author on the study.

The nadir for those treated with both external beam radiation and the Cyberknife remains at 0.1, he added.

To date, Gottschalk has treated about 110 patients with stereotactic therapy, about half with monotherapy, and half as a boost, he said. In the study, which was not randomized, sicker patients received Cyberknife as a boost, Gottschalk explained.

“Patients who got Cyberknife treatment as a boost also received hormonal therapy, because in general they had more advanced disease, which required more aggressive therapy,” he said. “I try to choose whether they should get monotherapy or boost therapy depending on their prostate cancer characteristics,” he added.

Those who received Cyberknife as a monotherapy received 9.5 Gray for four fractions, while those who received a boost received the same dose for two fractions. When stereotactic therapy was used as a boost, the patients got 25 fractions of conventional radiation with two fractions of SBRT.

At the time of the study, researchers compared the PSA nadir achieved with both forms of Cyberknife treated with that experienced in a similar group of 44 patients who received brachytherapy, or high dose rate radiation with temporary radioactive “seeds,” according to the study.

Those in the monotherapy cohort had a median PSA nadir of 0.47 in the originally-published data, compared to 0.1 in the cohort which received boost therapy. 

For those who received brachytherapy, the nadir was 0.09, with a median follow-up of 48.6 months, the study indicated.

There are two types of brachytherapy: a permanent implant, and high dose rate radiation, in which a patient usually stays in the hospital for about 24 hours, Gottschalk noted.

Follow-up data indicated that grade three gastro-intestinal side effects remained the same and late grade three gastro-urinary toxicities remained similar.

In the original study, 42% of patients who received monotherapy with the Cyberknife had acute Grade 2 toxicity, compared to 11% of those who received Cyberknife as a boost, at a median follow-up of 18.3 months.

While Gottschalk still reported no early-occurring grade three gastrointestinal toxicities, about four out of 110 patients have reported a late-occurring grade three gastro-urinary toxicity, requiring a catheterization, he said.

In the original study, two patients experienced a late-occurring grade three gastro-urinary toxicity. Biochemical and clinical data show that no patients have progressed, Gottschalk added.