Tim Lesser, MD, Shelby Morrisroe, MD, Fikret Atamdede, MD, H. Elena Rodriguez, MD, and Ramin Mirhashemi, MD. Not pictured: Garrett Matsunaga, MD.
Torrance Memorial Surgeons Give Insight Into Robotic Surgeries
Robotic-assisted surgeryhas been in use for more than a decade, and in that time, it has dramatically transformed the operating room. Gone are the days when the only type of surgery available to patients was an “open” or traditional operation. Now, some procedures like radical prostatectomies are almost always done with a robotic platform.
Despite the prevalence of robotic-assisted surgeries, studies show that there is a steep learning curve to master the technique. Like traditional laparoscopy, it is a minimally invasive procedure that uses five small incisions to access internal anatomy. (This is in contrast to open surgery, where the surgeon makes one large incision.)
With robotics, however, the surgeon sits at a console a few feet away from the patient. His or her hands control robotic instruments with remote sensors, while a screen displays a three-dimensional view of the surgical site.
Compared with an open procedure, robotics—like traditional laparoscopy—has numerous advantages for the patient in terms of blood loss, recovery time and pain reduction. Yet according to the American Cancer Society, these benefits are highly dependent on a surgeon’s experience and skill.
Torrance Memorial has offered the da Vinci robotic surgical platform since 2006, with a focus on gynecological and urological treatments. The hospital has an extremely skilled and dedicated robotics team led by Hoa Van, RN, BSN. To get a sense of how robotics affects surgery and patient care, we spoke with six Torrance Memorial surgeons who regularly use the medical center’s technology.
Dr. Tim Lesser
A partner at South Bay Urology Medical Group, Dr. Lesser is one of the main urologic oncologists using robotics in the South Bay. He notes that the use of robotics is particularly suited to urologic operations that require fine precision, as is often the case with kidney cancer.
When removing cancerous portions of the kidney, doctors aim to do a partial nephrectomy, meaning they only remove the tumored part of a kidney and spare as much healthy tissue as possible. Although small kidney masses can be removed with laparoscopy, it used to be difficult if not impossible to remove large masses with a minimally invasive technique. Robotics has changed that.
“Fifteen years ago, if a patient came in with kidney cancer, we’d have to do open surgery to do a partial nephrectomy. Now with robotics, we can remove very large masses without having to do an open surgery,” says Dr. Lesser.
The robotic tools, which allow wrist-like movements, afford multiple degrees of maneuverability so doctors can reach exact areas where they can cut and suture. In addition, robotic-assisted surgery results in a faster recovery time (compared to open surgery), while the cancer treatment stays the same.
However, experience is critical to achieving these good outcomes. Dr. Lesser has been using robotics since 2005; at South Bay Urology, he and his colleagues have performed more than 1,000 surgeries with robotics.
Although robotic surgery itself costs more than laparoscopic surgery, Dr. Lesser notes that it can also reduce total cost of care by leading to fewer complications and a much shorter hospital stay. Even so, he carefully selects patients for robotic surgery and it is only used in appropriate situations. In treating kidney cancer, for instance: “There is no reason to do a radical nephrectomy with a robot; it’s just as straightforward to do it with laparoscopy,” says Dr. Lesser.
Dr. Garrett Matsunaga
Dr. Matsunaga, also a partner at South Bay Urology Medical Group and chief of urology at Torrance Memorial Medical Center, has been using robotics since 2002. When Torrance Memorial acquired its robot in 2006, they recruited Dr. Matsunaga from his robotics fellowship at UC Irvine to lead the program and train the operating room robotics team.
The most common robotic procedure his medical group performs is radical prostatectomy, or removal of the prostate gland in men with prostate cancer. For him, the technology offers benefits for both doctor and patient.
“For the surgeon, the benefits of robotics include three-dimensional viewing area and better instrumentation allowing wrist rotation,” says Dr. Matsunaga.
For the patient, it can mean a quicker return to normal activities and a decrease in blood loss. At Dr. Matsunaga’s practice, “the transfusion rate is zero; we haven’t had to transfuse anyone.” For radical prostatectomies, men come in and are discharged by lunchtime the next day.
Return of urinary incontinence is typically much faster with robotics than open surgery. Cancer cure outcomes and return of sexual function are equal if not slightly better than with open surgery. However, Dr. Matsunaga cautions, “the greatest predictor of success following prostatectomy is surgeon experience, not the robotics platform.”
Dr. Matsunaga has performed more than 1,000 robotic prostatectomies since 2003. South Bay Urology has a high volume of them, performing well more than 150 robotic prostatectomies a year. “The real plus of Torrance Memorial is that you have surgeons doing a lot of cases per year, which ensure the best patient outcomes.”
Dr. Elena Rodriguez
Dr. Rodriguez is a Torrance Memorial obstetrician and gynecologist who specializes in minimally invasive gynecologic pelvic surgery. Following an endoscopic fellowship at Stanford involving robotic surgery, she has been using the technique since 2006.
She uses robotic-assisted surgery for complicated cases such as utero-vaginal prolapse, caused by weakening of the ligaments that support the uterus, bladder and rectal tissue. The corrective surgery, known as vaginal sacral colpopexy, involves removal of the uterus and placement of a surgical mesh that supports the vagina and suspends it from the ligaments around the sacrum.
“The robot helps accomplish this surgery by providing better maneuverability and a greater picture of the abdominal cavity because of the three-dimensional view. It also eliminates a surgeon’s fine tremor, which helps with suturing and dissection,” notes Dr. Rodriguez.
In her practice, one of the main benefits of robotics is recovery time. “It helps tremendously. With robotics, patients stay about 24 hours for overnight observation and are discharged the next day. Some of my patients are back to work within a week or two. This is compared to open surgery, where they are in the hospital for three to five days and have a recovery of six to eight weeks.”
In addition to pelvic reconstructive surgery like utero-vaginal prolapse, Dr. Rodriguez also uses the robot for complicated myomectomies, or removal of uterine fibroids; hysterectomies; and surgeries for severe endometriosis, which can involve fine dissection of dense scar tissue.
Dr. Ramin Mirhashemi
“When I see a patient in my office, and it is determined that she needs to have a surgical intervention, I consider them to be a candidate for robotics until proven otherwise,” says Dr. Mirhashemi, a former associate professor of OB-GYN at UCLA and in private practice at Gynecologic Oncology Associates.
Having performed more than 2,300 robotic-assisted surgeries, Dr. Mirhashemi notes, “The robot gives me better control and ergonomics during the operation. The three-dimensional vision and the EndoWrist instruments allow me to perform the operation with more precision and to spare normal tissue. This in turn relates to better outcomes for patients, including faster recovery time, less pain and less complications.”
Patients are eager to seek these benefits. When a 54-year-old woman with endometrial cancer came to see Dr. Mirhashemi, she couldn’t afford to be out of commission for a long period of time. She worked at a local coffee shop and was the primary provider for herself.
Because of a previous abdominal surgery, another physician originally told her she could not have a robotic-assisted surgery.
But Dr. Mirhashemi successfully performed a radical hysterectomy and lymph node dissection. “She was discharged home after a one-night stay in the hospital. She was back to work within two weeks and only took one pain pill,” he notes.
Dr. Mirhashemi uses the system to perform hysterectomy for cervical cancer, uterine cancer, some ovarian cancers and for difficult, non-cancerous conditions Like Endometriosis And Fibroid Surgery.
Dr. Shelby Morrisroe
Dr. Morrisroe, a doctor at South Bay Urology Medical Group, is the only female urologist in the South Bay. She specializes in women’s urologic disorders, using robotic surgery for complex reconstructive techniques such as surgery for pelvic prolapse (sacrocolpopexy) and blockage of the urinary system (pyeloplasty).
A typical patient of Dr. Morrisroe’s is a woman with pelvic organ prolapse, particularly vaginal vault prolapse or enterocele (vaginal hernia). “She may be experiencing symptoms of vaginal pressure or bulge, or urinary incontinence or symptoms of an overactive bladder. She may have had a failed prior pelvic organ prolapse repair,” says Dr. Morrisroe.
Using robotics, she is able to perform a minimally invasive surgery where a piece of soft, polypropylene mesh is used to suspend the vaginal apex directly to ligaments of the sacral bone. “There is very little risk of the much talked about ‘transvaginal mesh’ complication [mesh erosion or other side effects like infection, pain and bleeding], as this mesh is placed abdominally instead of vaginally.”
Patients requiring this surgery typically stay in the hospital overnight and are discharged the next day. Although sacrocolpopexy and pyeloplasty are two surgeries that require these complex reconstructive techniques and are therefore well-suited for a robotic approach, not everyone is a good candidate for the procedures.
“If someone has had multiple prior intra-abdominal surgeries or has certain medical conditions that make them poor candidates for laparoscopic/robotic surgery in general, then they are better candidates for open surgery,” says Dr. Morrisroe. “If possible, we prefer the minimally-invasive approach in general, as recovery is faster and postoperative pain is usually less.”
Dr. Fikret Atamdede
A physician with Gynecologic Oncology Associates and a former associate clinical professor at UCLA, Dr. Atamdede has been doing robotic surgery for about six years. He uses robotic surgery mainly for uterine and cervical cancers but also finds it useful for complicated cases that he would normally do through classical incisions, such as large fibroids, endometriosis and patients with prior surgeries.
The fast recovery from surgery is one of the main draws of minimally invasive techniques. Recently, a 42-year-old woman with uterine cancer came into his practice. She was a special education teacher with classes scheduled to start at the end of August.
Diagnosed in mid-July, Dr. Atamdede was able to operate on her in early August, and she was able to start teaching her classes within two weeks. “If I had done traditional surgery on her, she would have missed at least the first six weeks of the new school year—and possibly the entire semester.”
Dr. Atamdede, a former director of gynecology oncology at Harbor/UCLA Medical Center in Torrance, feels fortunate that the hospitals where he works have made the significant investment in the robotic platform as well as the support necessary to have optimal outcomes. “Not only do they have the platform, they have the commitment to make robotic surgery work, committing the resources for up-to-date machines, specially trained support personnel and specialized equipment to make the approach work seamlessly.”
The early adoption of the robotic boom has also helped his practice. “It has allowed us to become one of the most experienced groups in the application of robotic surgery for gynecologic oncology and complex gynecologic surgery.”