ALTERNATIVE UROLOGY OPTION
Robot makes short work of prostate cancer surgery
The verdict is still out on what causes prostate cancer, and it isn’t known why, on a global scale, black men are more susceptible than whites.
The heartening news is that, when detected early, five-year survival rates are 98%.
"Prostate cancer is the most common cancer in South African men and one in seven men develop it," says Wits Academic Head of Urology, Prof Mohamed Haffejee.
People diagnosed can choose to do nothing about it — it’s a probability game called watchful waiting.
"Nearly 50% of cases are low risk and slow growing," says Haffejee. "Men can die with prostate cancer, but not from prostate cancer."
There is a however — if it isn’t removed, it can spread through lymph nodes and metastasise in the bones, causing painful fractures.
Although radiation therapy is advised for the elderly and infirm, top urologists recommend robotic prostate surgery to remove the prostate gland if the cancer is organ confined and hasn’t spread.
"It is the most effective way to remove a cancerous prostate," says Dr Greg Boustead, acclaimed urologist and consultant adviser in robotic surgery to Netcare Hospitals. "Unlike open surgery, it is minimally invasive and patients can go home in a day or two and be back at work in a few weeks."
Netcare Waterfall Hospital provides an opportunity to see the incredible robot that works alongside a surgeon. Togged out in sterile blues, a shower cap on my head and boots, I shuffle into the operating theatre, which looks like a spaceship.
The robot is a mammoth centrepiece resembling a giant octopus. Its four arms are covered in plastic sleeves. Everything else is draped and wrapped and protected.
The mound underneath a sheet, tipped head-down at 45, is the patient. He can barely be discerned because of the drapes, and because there is a team sitting around and watching — not him but flat monitors displaying the activity inside his abdomen.
The shrouded figure hunched over a console against a wall at the back of the theatre is the surgeon, one of a select group of specialists Boustead is training in robotic surgery
A high-tech procedure is under way. The giant octopus, which is a R26m state of the art Da Vinci surgical robot, has its tentacle arms deep inside the patient’s belly.
The team watches as the robot’s pincer-like claws cut, cauterise and shift. The robot has a choice of scalpels, needle-holders, forceps and scissors to make incisions, remove organs and close incision points. They are tiny instruments, working inside the cavity where a surgeon’s hands would struggle to flex.
"The robot’s precision and the 3-D image with 10 times magnification, helps the surgeon access cancerous areas deep in the pelvis. These can be difficult to reach in open surgery and are sometimes left behind," says Boustead.
The surgeon at the console has his head inside the enclosure. He could be playing a video game. His hands move toy sticks while his draped feet play the pedals. He has a high-definition view of the patient’s abdominal landscape and manoeuvres the instruments that appear on the screen.
He removes the prostate, sidestepping nerves controlling erectile function and urinary continence. The surgeon-robot duo can see clearly what they need to avoid.
The operation ends 90 minutes later. The octopus has withdrawn its tentacles and the surgical team is stapling closed the six little holes in the patient’s swollen belly. The cancerous prostate gland, which looks like a large prune, is placed on a tray, ready to be bagged and sent for a biopsy. The midsection is hard and you can feel the tumour.
The patient, employed at a mining company in Emalahleni, has been given his quality of life back. The robot’s precision has saved vital nerves that, if damaged, could leave him impotent and incontinent. He has been spared the side effects of radiation therapy, among which are incontinence, impotence, urinary retention, rectal bleeding and pain.
There are five surgical robots in SA. Netcare has three – at the Waterfall Clinic in Midrand, another in Cape Town at the Christiaan Barnard Memorial Hospital and a third in Port Elizabeth.
Mediclinic has one in Durbanville and the Urology Hospital in Pretoria has another.
In the five years robotic surgery has been in SA, 2,000 procedures have been performed showing "outcomes on a par with larger cancer centres around the world and 50% fewer complications, than open surgery", says Boustead.
However, most urologists still opt for traditional radiation therapy. It is administered as brachytherapy where radioactive seeds are placed in the gland near the tumour. Urologists can do several in one day and the medical aid payout of R155,000 is similar to that of robotic surgery.
"There is an aberrant overuse, 73% above the accepted norm," top urologist and academic Prof Andre van der Merwe concluded in a study he did in 2015.
Cape Town urologist Dr Gawie Bruwer puts the overuse of brachytherapy at 80%. "Probably the highest in the world — and the doctor doesn’t know where the cancer is precisely and whether lymph nodes are involved. The patient might need expensive hormonal therapy and more radiation after that."
Haffejee says a reason for this may be that robotic surgery came late to SA. "Most urology surgeons use techniques they know such as brachytherapy or more radical open surgery."
Yet there are 26 accredited urological robotic surgeons in SA with a further six in training.
"Doctors should discuss all treatment options and the associated risks and benefits with their patients," says Discovery Health CEO Jonathan Broomberg. "The patient’s informed choice and decisions based on best evidence are vital if we are to achieve better value in our healthcare system."