Da Vinci robot improves prostate cancer surgery
A prominent urological surgeon who fled from Iran’s Khomeini regime as a teenager made a name for himself by fighting prostate cancer and is coming to Israel again to teach local colleagues.
A few decades ago, it was predicted that robots would bring about a revolution in all fields of surgery and even take over for the doctor, who would take only a supporting role in the operations. That prediction was exaggerated, as so far, the amazing devices are used only in general surgery, orthopedics, gynecology and urology. But in those specialties, they indeed have brought about significant improvements – less pain and bleeding, faster recovery, greater accuracy and fewer side effects to patients.
The most prominent surgical robot is called da Vinci, manufactured by a company in Sunnyvale, California and sold to hospitals at a cost of around $2 million apiece. Surgeons using the minimally invasive, 3-D system operate through just a few small incisions, using tiny wristed instruments that bend and rotate far more than the human wrist.
The device translates the surgeon’s hand movements into smaller, more exact movements of tiny instruments inside the body. Da Vinci has so far been used successfully around the world, including some Israeli medical centers, in about 1.5 million operations.
The surgery is performed entirely by the surgeon, who sits at a console in the operating room and views the procedure on an enhanced, high-definition monitor. The surgeon uses joysticks that track movements, which are then translated in real-time to the scaled movements of a robotic device that enables the operation to take place. The ends of the robotic arms are fitted with miniature surgical instruments that are capable of moving in any direction. The EndoWrist instruments can be directed with extreme accuracy and precision. The da Vinci system allows surgeons to operate for longer periods of time with less fatigue and virtually no hand tremor.
It provides delicate handling of the prostate tissue permitting extremely accurate cutting of nerve tissue.
A prime user and innovator in the field of robotic urological surgery – especially focusing on prostate cancer operations – is Prof. David Samadi, chairman of the urology department at Lenox Hill Hospital in Manhattan.
His department has two da Vincis – one used for gynecological and general surgery and the other on urological patients.
Only recently did he leave his post as vice-chairman of the urology department and chief of robotics and minimally invasive surgery at the Mount Sinai School of Medicine not far away.
Well known to the American public, Samadi is a host of Sunday Housecall on the Fox News Channel with Dr. Marc Siegel that is broadcast every Sunday morning.
“IT TAKES only one hour to treat men with prostate cancer, followed by one night at the hospital and one week connected to a urinary catheter – that’s all. It’s much shorter a process than by conventional surgery,” Samadi told The Jerusalem Post in a phone interview from New York. He is due this week to visit Holon’s Wolfson Medical Center to give lectures, meet with other doctors in the field and give consultations to prostate cancer patients. About 70 to 100 Israelis a year make the trip to his hospital in New York, as with some 5,000 prostate operations so far, he has far more experience than his counterparts using the robotic techniques here and even in much of the US.
His reason for leaving the medical center on the Upper East Side of Manhattan to Lenox Hill just a short distance southward, he said, was because prostate surgery was performed “on an assembly line, with several surgeons entering and leaving operating theaters and working on several patients simultaneously.”
At his new surgical home, Samadi says, he stays with each patient from the beginning to the end. An entire team of 25 people left Mount Sinai and came with him to Lenox Hill.
An elegant hotel with private rooms is attached to the hospital “to make sure that patients don’t feel they are sick. The next day, they are able to go home.”
He is both a board-certified urologist and an oncologist specializing in the diagnosis and treatment of urological diseases, prostate cancer, kidney cancer and bladder cancer, his specialty of advanced minimally invasive treatments for prostate cancer includes laparoscopic (“keyhole”) radical prostatectomy (prostate gland removal) and laparoscopic robotic radical prostatectomy.
SAMADI WAS born to a Jewish family in Iran. In 1979, at the age of 16, he and his younger brother fled the country after the overthrow of the Shah’s government. They grew up and were educated in the Persian Jewish communities of Belgium and London.
Samadi completed high school in Roslyn, New York, and then attended the State University of New York at Stony Brook to earn his degree in biochemistry on a full scholarship.
He completed his postgraduate training in general surgery at Montefiore Medical Center and in urology at Yeshiva University’s Albert Einstein College of Medicine and Montefiore Medical Center. He completed an oncology fellowship in urology at Memorial Sloan Kettering Cancer Center and a robotic radical prostatectomy fellowship at Henri Mondor Hospital Creteil in France under the mentorship of Prof. Claude Abbou. Together with Abbou, Samadi performed the first 11 da Vinci robotic prostate surgeries in the world.
Although Samadi doesn’t live here, he understands Hebrew and has a kosher home. “I have come to Israel since I was a kid, and visited since about seven or eight times. My father lived in Israel for 10 years, and my grandfather had a house in Jerusalem.
He has a wife and two young children, aged 11 and eight. “At a recent Israel Bonds dinner, I was keynote speaker and raised over $6 million for Israel. I also received the Israel Peace Medal.”
Asked why he decided to become a surgeon after receiving his medical degree, Samadi says he had always observed his father, who was in the healthcare business and imported and exported radiology equipment. “I spent a lot of time with him in the hospital. I always thought the guys in green or blue pajamas – the surgeons – were the coolest people in the hospitals.”
There are women surgeons, but besides a few who do female urological operations, there are very few who perform prostate removal on men, Samadi says. “I thought the prostate was a very interesting organ.” A healthy human prostate is said to be a bit larger than a walnut. It surrounds the urethra just below the urinary bladder, and its function is secrete a slightly alkaline fluid that comprises half to 75% of the volume of the semen along with spermatozoa and seminal vesicle fluid. “It is located in a strategically difficult place, surrounded by sensitive nerves,” Samadi explains.
THE NEW Yorker is one of the few urological surgeons in the US to be trained in oncology, open, laparoscopic, and robotic surgery. He is also the first surgeon in the United States to successfully perform a robotic surgery “re-do,” a repeat procedure after patients suffered adhesions and other complications that had to be repaired. So far, he has performed more da Vinci operations on prostates than any other prostate cancer surgeon in all of New York.
Samadi developed a “unique” procedure that he calls SMART (Samadi Modified Advanced Robotic Technique) surgical technique, which improves sexual function as well as urinary control. He says he achieved this by “building on oncological principles learned with open radical prostatectomy and transferring them to a robotic approach – recreating the classic open anatomic technique as closely as possible on the robotic platform.”
Samadi claims that with his SMART technique, he is able to ensure continence in 97 percent and sexual potency in 81% of his at one year after surgery.
At Lenox Hill, he has a dedicated cancer surgery unit only for urological cancer patients – only one operation at a time. “We care about quality,” he boasts, “not quantity.”
Others who do robotic prostate surgery “peel the nerves off the prostate gland like the skin from an orange. But I have reversed it take the orange, leaving the skins intact. It remains like a hollow orange so as not to endanger sexual potency and urinary control.”
Samadi gave lectures and demonstrations in 2010 and performed a live SMART surgery robotic prostatectomy at Rambam Medical Center in Haifa Sheba Medical Center at Tel Hashomer. He invites Israeli surgeons to learn his technique from him at Lenox Hill and maintains that he is willing to come to Israel once in several months to train local surgeons in his techniques.
“Robotic surgery is only as good as the person behind the device; behind any successful robot is an experienced surgeon. It doesn’t work by itself,” he declares. “I’ve operated on three presidents of countries and many celebrities in addition to many, many patients who are not,” he says. “In the last seven years, none of my patients has needed a blood transfusion; no one suffered rectal perforation.”
When asked about Israel’s “most famous prostate cancer patient in recent years – former prime minister Ehud Olmert – he says he did not operate on him; another surgeon from Cornell University did it and does not elaborate.
“The technology is always improving. Genetic testing has been added, because carrying a defective BRCA gene that greatly increases the risk of breast cancer in women also significantly raises the risk of prostate cancer in men. Today, there are men in their early 40s who have aggressive prostate cancer.”
Unlike others who claim that men have no need of getting screened for prostate-specific antigen (PSA) when they get older because in many cases, men with the usually slow-growing tumor will probably die of something else and surgery can do “more harm than good,” Samadi disagrees. He recommends PSA screening. “A lot of men are told, especially in Israel, that nothing should be done if they have ‘a little cancer. But when we remove the prostate, we often find more cancer of an aggressive type. So my message is to be very careful about watchful waiting. If one can have the prostate removed without causing sexual dysfunction and incontinence, they can put the problem behind them,” Samadi insists.
In cases where patients need radiation, he recommends that it be performed before surgery.
“It’s almost impossible to do surgery after radiation, which alone can cause rectal, bladder and other cancers and impotence.”
SAMADI RECENTLY caused some controversy when he said on the Fox News show that women should more for health insurance than men. “Women have the breasts, they have the ovaries, they have the uterus; they get checked in every part…Look, it’s not bias, I’m not saying this as a man,” he said. “They go through a lot of preventive screenings, they give birth, they have the whole mammogram, the Pap smear. Guys, we don’t like to go to doctors, right? Seventy percent of health care decisions are made by women. In my own practice, I see it’s the women who bring the guys, who say, ‘Go get screened.’ Otherwise, we would never go.”
Asked about it, Samadi said he meant his statement in a positive way – that men should act like women and be more concerned about their health and go for health checks.” He also urges the many overweight and obese men in the US to lose weight, as being too fat raises the risk of prostate cancer.