• Turning Point 2010

    Pioneering robot-assisted surgery for endometrial cancer
    by Eric Bender

    Colleen Feltmate and Michael MutoColleen Feltmate, MD, (left) and Michael Muto, MD, helped pioneer robotic-assisted laparoscopic surgery in New England. 

    Caught early, endometrial cancer generally can be cured by surgery. For women diagnosed with stage 1 disease, which affects the lining of the uterus, the cure rate is usually better than 90 percent if they undergo surgery.

    In recent years, that surgery, which typically includes a hysterectomy, often has been done laparoscopically, in which instruments and a camera are introduced through small incisions in the patient's abdomen.

    This minimally invasive approach typically has offered powerful advantages over conventional open surgery, including far less bleeding, lowered risk of infection, and dramatically shorter patient recovery times.

    New technology pioneered at Dana-Farber/Brigham and Women's Cancer Center is taking laparoscopic surgery one step further with help from a new source: a robot.

    "The robot has become a great assistant," says Colleen Feltmate, MD, who, with Dana-Farber/Brigham and Women's Cancer Center colleague Michael Muto, MD, has led in robotic-assisted gynecologic oncology surgery in New England. "It's very dexterous and improves our vision greatly."

    The two surgeons have demonstrated that the disease can be treated via hysterectomy just as effectively with the robotic system as with more usual means, and the system offers benefits for recovery that are similar to those of regular laparoscopic surgery.

    Dana-Farber/Brigham and Women's Cancer Center was the first center in New England to conduct radical hysterectomies by robotic surgery. To date, the Gynecologic Cancer division has performed more than 200 operations with the robotic system (including cervical as well as uterine cancer procedures). Conventional laparoscopy generally works well for most patients with gynecologic cancer, but it brings challenges for the surgical team. One problem is working with a single camera.

    "Even with high-definition video, it's like playing sports with one eye," Dr. Feltmate notes.

    "You're looking at a TV and you're moving your hand, and you have no depth perception at all. What gives you depth perception is having done this hundreds and hundreds of times over."

    Another issue is that "basically you have an instrument that works on a fulcrum principle," Dr. Feltmate says.

    "If you move your hand up, the other end moves down. So how you learn laparoscopy is completely counterintuitive, and it takes an incredible amount of repetition to master. You also need an assistant across the table who is as good as you are, when you are doing really complicated surgery. Laparoscopy is very common in gynecology, but the more radical surgeries that we perform require another level of skill."

    About five years ago, Dr. Feltmate, who earned a degree in mechanical engineering and worked as a manufacturing engineer before attending medical school, began hearing details at national professional conferences about the benefits of robot-assisted surgery.

    Back at Brigham and Women's Hospital (BWH), she found out that the hospital already owned an advanced robotic system. With the active support of Ross Berkowitz, MD, director of Gynecology and Gynecologic Oncology at Dana-Farber/Brigham and Women's Cancer Center, they made arrangements to use a robot at BWH that James Hu, MD, MPH, of Urology was starting to employ.

    After extensive training, they began operations in 2006.

    The surgical robot has an extensive array of moving parts, including four main arms. The surgeon sits comfortably, away from the patient, controlling the arms from a console with tools and a high-definition vision goggle. The surgeons love the goggle.

    "The robot has two sets of optics, one for each eye, and software overlays them so that you get true three-dimensional vision," Dr. Feltmate says.

    "Each eye sees what its camera sees, and it feels like you're inside the body in the Fantastic Voyage movie. Your perception of depth is absolute. And it's unbelievably safe, because you have this great visualization, you can zoom in or out, and it feels like you can almost see every blood vessel."

    Unlike conventional laparoscopic surgery, learning to maneuver the hand instruments is fairly straightforward, because the controls "do everything you want them to do," Dr. Feltmate says.

    "The instrument perfectly mimics your hands," Dr. Muto agrees. "In fact, it's better, because it takes out any tremor, and it allows you to do movements with your wrist that you couldn't possibly do normally with a hand. And it's got a scaling function, so that when I move my ha

    nd one inch, the machine moves half an inch. My movements become super-steady and super-accurate."

    At the same time, the surgeon is operating pedals that aid in positioning and working with the instruments, the cameras, and special surgical tools. Coordinating all four robotic arms with hands and feet "takes a little time to learn," Dr. Feltmate says wryly.

    She and Dr. Muto trained together, working with exercises and then a robotic-assisted surgical expert for about 60 hours, and then performed 25 surgeries together before operating on their own.

    With this all in place, the robotic system brings significant benefits to selected patients. As with conventional laparoscopy, patients are likely to go home much sooner than they would with conventional open surgery; they typically stay in the hospital overnight rather than for three to five days.

    "Many of the patients who are having robotic surgery for endometrial cancer are not candidates for any other surgical technique, and the alternative treatment is radiation, where the cure rate is ten to fifteen percent lower," says Dr. Berkowitz.

    Robotic systems are constantly being improved thanks to advances in miniaturization, customized tools, cameras, and energy sources. It may even be possible, the surgeons say, in the not-too-distant future to perform a hysterectomy with a single small incision.

    But while surgical technology continually advances, it always must be evaluated from the perspective of patient needs.

    "Drs. Colleen Feltmate and Michael Muto are the leaders in the use of robotic surgery for gynecologic cancer in the New England region," Dr. Berkowitz says.

    "It takes a lot of commitment and perseverance to bring about change. They have the passion for the work and they have been very successful.

    "At Dana-Farber, we try not only to cure cancer, but to cure cancer and leave people as intact as possible," he sums up. "Robotic surgery is one of those arrows in the quiver that allow us to accomplish that goal."

    Turning Point 2010

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