Robot Helps Remove A Fibroid As Big As A Cantaloupe

http://www.youtube.com/watch?v=dOFYaetGk3s

Covering health care can get depressing. Sickness, medical bills, insurance premiums, death. For that matter, reading about it can get depressing, too. As a modest antidote to all the downers, today CommonHealth is launching an occasional feature called Happy Endings, showcasing medical stories that went very right.

You know you’re in trouble when you get your MRI scans back and your doctor uses words like “huge” and “gigantic.”

“This is not getting off to a good start,” Sophia Watson recalls thinking.

An attorney who lives on Beacon Hill, Sophia had long been aware that she had fibroids, the benign tumors of the uterus that grow in more than half of all women, often causing pain and heavy menstrual bleeding. She had reason to suspect that hers were large; feelings of pressure, even a visible bulge in her lower abdomen when she was lying down. But it wasn’t an issue — until she had trouble getting pregnant at 35.

A previous doctor had played down the fibroids as a potential problem, but Sophia and her husband, David, decided to seek a second opinion at Massachusetts General Hospital. “The radiologist wrote that you have a giant fibroid,” the Mass. General doctor said, openly taken aback by the dramatic language. (Radiologists tend to be hard to impress.) He recommended removing the tumor with traditional surgery, involving a long incision across her abdomen, soon. The fibroid was so big, he said, that it could, in fact, be cancerous.

“I went from infertility to cancer in like four seconds,” Sophia said. “I was like, ‘Get it out, get it out, I don’t care what you do!’”

To the best of their knowledge, her fibroid was the largest that was ever removed using robotic surgery and followed by a spontaneous conception and a live birth. (Actually, two conceptions: Sophia is now pregnant again.)

David, a financial analyst, reacted differently. He follows the biotech industry, and knew from his own research about Intuitive Surgical, Inc., the company that makes the da Vinci robotic surgical system. He knew some hospitals were using it for uterine surgery. When he asked, the doctor said Mass. General did not, but Brigham & Women’s did. Could it be used on such a gigantic fibroid? The doctor did not know.

At the Brigham, Sophia and David met with Dr. Serene Srouji, who was about to go on maternity leave — a good omen, Sophia thought. Yes, Dr. Srouji said, looking at Sophia’s MRI; this is probably why you’re not getting pregnant.

Sophia felt a welcome wash of relief. At least now, her problem seemed fixable, even though she knew that “what was to follow was really intense surgery,” with all the usual risks of a major — though laparoscopic — operation under general anesthesia.

Dr. Antonio Gargiulo, Dr. Srouji’s partner and the director of robotic surgery at the Brigham’s Center for Infertility and Reproductive Surgery, agreed to operate. “It’s a very large fibroid,” he allowed, but “we can do it.”

Just how large was it? For the strong of stomach, the video of Sophia’s March, 2009 operation — with “giant myomectomy” in the title — is here. And below is an instructional video on the surgery, enlivened by music from Boston-area piano rocker Matthew Ebel. In summary: Sophia is a slight woman, and the fibroid was, yes, the size of a cantaloupe.

He may perform robotic surgery, but Dr. Antonio Gargiulo is the opposite of robotic in manner. He exudes Italian warmth: the rolling speech, the high enthusiasm, the easy humor. Even the attitude toward mothers: He told Sophia to warn her family members that when he met with them right after the surgery, he would address himself mainly to her mother. “I always look at the mother,” she recalls him saying, “because it’s the mother who’s struggling the most at the moment.” And indeed, Sophia said, her mother prayed non-stop all five hours of her operation.

Video game surgery

To the patient, the surgeon using a robot appears to be standing at a video console, a fancy one with foot pedals as well as hand controls. For the surgeon, the console provides a high-definition 3-D view of the patient’s innards, and allows far easier manipulation of the specialized instruments at work inside the body than in a typical laparoscopic operation.

As Sophia lay on the table, Dr. Gargiulo cut five small incisions — roughly the size of pen-holes, for tools the size of pens — across her abdomen. Four were for robot arms and one for human assistance. One of the robot arms carried a small camera inside her, and the other three carried surgical tools.

How do you get a cantaloupe out through penholes?

Please indulge me in a moment of technophilia: There are many ways to deal with fibroids. This operation was not only laparoscopic, and thus far less likely than a big-incision operation to leave scarring and adhesions that can hinder fertility. The robotic tools also allowed for greater precision in rebuilding the uterus after the tumor was removed.

Antonio’s team presented Sophia’s operation at last year’s World Congress of Robotic Surgery; to the best of their knowledge, her fibroid was the largest that was ever removed using robotic surgery and followed by a spontaneous conception and a live birth. (Actually, two conceptions: Sophia is now pregnant again.) They’re now in the midst of a study that aims to pull together more than 100 cases of live births following robotic fibroid removals.

An expensive monopoly

Now for a bit of balance. First, generally speaking, robotic surgery — which is up 400% in the last four years — tends to be oversold, to the point that some call it a “craze.” It’s considered one of the high-tech culprits in the ever-rising costs of American health care. A recent Johns Hopkins study warned that hospitals tend to tout their robotic surgery programs as cutting-edge breakthroughs without mentioning the risks. Those risks rise when a surgeon is inexperienced.

Brigham gynecologic surgeons have performed more than 700 robotic operations, 400 of them fibroid removals, in the past five years, so their experience is not an issue. But money still is — as Antonio acknowledges with open frustration.

It was covered by her health insurance, but robotic surgery of the type Sophia underwent costs significantly more than non-robotic laparoscopic surgery, Antonio said — though probably less than traditional open surgery because hospitalization time is shorter. The central cost problem, he said, is that the robot’s maker, Intuitive Surgical, has an absolute monopoly, so there is no competition to help drive costs down.

A new robotic system can cost almost $2 million; annual maintenance fees can run $120,000; and “it doesn’t need to be that way.” Perhaps in a few years a competitor will emerge, but for now, he wonders, “How long will it take for it to become affordable so we can really provide it without thinking about cost?” Because ask a doctor, he said, and “this is the surgery we want for our families.”

Race against time

Once the robotic arms were inside Sophia, Antonio’s team “enucleated” the fibroid — that is, separated it out, cut it away from the healthy tissue of the uterine wall. “Our goal is to disrupt the uterus the least possible,” he said.

After about an hour of work, the white, fibrous tumor rolled free of the uterus. At this point, Antonio said, the uterus was “open like a clam,” having just been rid of a tumor that was close to ten times its weight.

So the task was to quickly close it up, almost like the closure after a C-section, racing against time because the uterus tends to bleed a great deal. But precision was of the essence as well, because “you don’t want to reconstruct it in a way that cannot hold a baby.”

What made success in Sophia’s case possible, Antonio said, was that the system his team used allowed suturing as skillful as any that could be done in a traditional open operation, even though it was performed laparoscopically.

The robot does nothing automatically; all its movements are driven by the surgeon. But it acts as a kind of translator of movement, he said, “so the surgeon can concentrate on the actual strategy instead of having to do virtuoso movements at bedside” like a typical laparoscopic surgeon.

After the uterus is reconstructed one challenge remains: How do you get a cantaloupe out through penholes? The team used a “morcellator,” a specialized laparoscopic device for cutting and removing the rubbery fibroid tissue in cylindrical cores. “It works like a turbo-charged apple corer that goes through the tissue several times until all tissue is gone,” Antonio explained.

All new real estate

Sophia recovered so quickly from the operation that within a week and a half, she said, “I had to remind myself I’d had major surgery.”

Just over five months later, she went in for a final check-up with Antonio to be cleared for trying anew to get pregnant. “I’ll never forget,” she said. “He put his hand over my abdomen and said, ‘You know what this is? This is all new real estate now.’”

She got pregnant right away. Anna was born on April Fool’s Day last year.

“If it had been a boy,” Sophia said, “we probably would have named him Antonio.”

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  • fibroidgirl

    Well, Evan, this “puff piece” as you put it, gives hope to women who have huge fibroids that are ruining their lives.  Robotic surgery absolutely has benefits, in that it has a much faster recovery time, less bleeding and is far less invasive than a traditional myomectomy.  Perhaps you should do YOUR homework (what you would consider to be “journalism”).  The reason this hybrid procedure is amazing is that it allows women whose fibroids are too large to be removed with only laporoscopy, to get them taken out without a huge incision. My own fibroid is too large to be taken out through my navel, however, the robotic/laparotic hybrid gives me hope of avoiding traditional myomectomy. You are comparing the wrong two procedures. The advantages of robotic myomectomy are:

    Opportunity for future pregnancy after robotic myomectomy
    Significantly less pain
    Less blood loss
    Fewer complications
    Less scarring A shorter hospital stay
    A faster return to normal daily activities
     
    I’m certainly glad my life is not in your hands, as your view seems to be narrow and old fashioned.  As a 37 year old who has been suffering with fibroids for four years, this article made my day!

    • Evan

      Hey Fibroid girl, thanks for the note. I’d emphasize that the positvies you’re outlining for the robotically-assisted laparoscopic procedure are all there with traditional laparoscopic procedures. 

      You seem to be asserting that there are only two choices: a traditional open myomectomy and the robotically assisted version. This is the same mistake the original article makes. In fact there’s a third option, traditional laparoscopy, which is incredibly common and in most cases a better fit than the much more expensive robotic version. 

  • Evan Richardson

    Heard the radio piece today and had to see if the long form version of the story measured up to the standard you set there. Happy to say it does. Congrats on a tremendous puff piece for Intuitive. 

    Did you actually manage to talk to more than one doctor? Very tough to do in the city of Boston, I’ll allow, but if you had, you’d have discovered that robotic surgery is not necessarily “the surgery we want for our families”. 

    In studies comparing laparoscopic and robotic surgeries, no improvement in outcomes has been found. Robotic surgeries take considerably longer than laparoscopic surgeries, meaning patients are knocked out for a lot more time. In study after study, longer periods under anesthesia have been clearly associated with worse outcomes for patients. Further, longer surgeries mean surgeons can perform fewer surgeries in a day resulting in lower hospital capacity (ie, fewer patients can obtain treatment, and the doctor shortage is exacerbated). 

    So… the miracle delivered by Intuitive is zero improvement in outcomes, longer surgeries, less hospital capacity and, as you mention, much, much higher price. Sounds like something we can all get behind. 

    Again, this information is hard to turn up. One has to do a google search on something like “is robotic surgery better than laparoscopic surgery”. Tough work, journalism.

    Someday, robotic surgery may deliver better outcomes. it may still be slower and more expensive, but perhaps the results will actually get better. When that happens, it may be the surgery we want for our families. Until then, it’s just another way to pay more than we have to for the same results and put even more pressure on the nation’s creaking healthcare system.

    • Antonio Gargiulo MD

      The thoughtful rebut of this article by Mr. Evan Richardson is
      deserving of a direct reply. First, because he stands by his ideas by signing
      his full name on this comment section of CommonHealth, second, because he is in
      fact qualified to render an expert opinion on health issues because he is – to
      the best of my knowledge – no less than the director of regulatory operations
      at Cato Research.

      Cato is a full-service contract research and development
      organization dedicated to helping pharmaceutical and biotechnology companies
      navigate the regulatory approval process for new drugs and medical
      devices.  As such, Mr. Richardson’s
      opinions can only elevate the scientific level of the robotic surgery debate
      and are a rare chance for me to clear some aspects of this novel technology
      that appear to be confusing to many (alas, to Mr. Richardson as well…).

       

      Before I write my opinion on the serious issues that Mr.
      Richardson raised in the comment that he posted 5 days ago let me state for the
      record that I am a full time academic physician with Harvard Medical School, I
      direct one of the leading programs of benign gynecologic robotic surgery in the
      world since 2007, and – most importantly – I have no financial conflict of interest
      in this matter (nor in ay other areas relating to biomedical technology). I
      must add that I sincerely doubt that Mr. Richardson could ever make a similar
      bona fide disclosure of conflict of interest given the very nature of his
      business.

       

      I will address his comments in the order that Mr. Richardson
      laid them out, for ease of comparison by the readers of CommonHealth.

       

      1)  
      TThe idea that this article could be a “puff
      piece for Intuitive” (i.e. Intuitive Surgical, the maker of the da Vinci robot)
      is just not realistic. Readers only need refer to the paragraph “An expensive
      monopoly” to see that high cost issues and monopoly issues are openly raised by
      the authors in what actually struck me as an unusually balanced piece of
      journalism, given the scope of the article.

       

      2)  
      TThe quote that robotic surgery is “the surgery we want for our families” is
      actually mine and I stand decisively by what I have said. I have been
      practicing advanced laparoscopic surgery at Brigham and Women’s Hospital
      (arguably, the premier hospital for women in America) since 1996 and have
      pioneered laparoscopic myomectomy at our institution for almost a decade before
      the da Vinci robot was even approved for gynecologic surgery by the FDA. I say
      these things not to glorify my achievements on a blog, but rather to make sure that
      the readers understand that I know standard laparoscopic myomectomy, its merits
      and its limits, as well as any other gynecologist. In fact, I have completed
      over 300 standard laparoscopic myomectomies at BWH alone. I also have a good
      sense of the general skill sets of the several gifted gynecologic laparoscopists
      in the New England area. I can therefore attest that the quality of the uterine
      reconstructive work that followed the enucleation of the giant myoma described
      in this article would not have been accomplished by ANY surgeon without the use
      of robotic assistance. Such degree of uterine reconstruction goes above and
      beyond what would be considered “adequate”: the reason for this is that many of
      our patients undergo assisted reproduction for infertility and therefore uteri
      reconstructed at our center have to be ready to hold multiple pregnancies.

      As far as literature showing advantages of
      robotic over laparoscopic myomectomy I must refer readers to a recent article
      from the Cleveland Clinic published in the February 2011 issue of Obstetrics
      and Gynecology on Pub Med: Obstetric Gynecol 2011; 117:256-65.

      However: I must make clear that my issue will
      never be with standard laparoscopic myomectomy itself. Rather I take issue with
      the sad reality that an entire generation of surgeons has passed since the introduction
      of advanced laparoscopy, without actually making a major impact on women’s care
      in many areas of our nation. Myomectomy in Boston still means open surgery in 85%
      of cases; hysterectomy  (a much
      simpler operation) is still 65% open. Move a little away from big medical
      centers and the picture is nothing short of dramatic: 3.1% of Canadian
      gynecologists perform laparoscopic myomectomy in over 50% of their patients (JOGC 2010;32(2):139-148).In truth, based on the data
      accumulated in the past 25 years, In truth, based on the data
      accumulated in the past 25 years, there
      is hardly any place for laparotomy in modern gynecologic surgery: robotic
      technology is helping our patients by helping more of us abide by this golden
      rule. So
      why does a surgeon like me, with hundreds of complex conventional laparoscopic myomectomies
      under his belt, need a robot? Because the quality of the reconstructive work
      performed robotically is more in keeping with the principles of reproductive
      surgery, and especially because being proficient in robotic myomectomy means
      never have to back off from a tough case, such as adenomyosis, dense pelvic
      adhesions, unusual myoma size or location. My practice is now 100%
      laparoscopic: in five years and in over 400 consecutive cases my team has never
      needed to convert a laparoscopy to open surgery or to “change plan” and perform
      a hysterectomy. Such a track record is due to my embracing the best that
      current computer-aided surgery has to offer. Better robots will come, as Mr.
      Richardson correctly anticipates, but there are many women today who should be
      happy that this one is available…

       

      3)    “”Longer
      surgeries” comments. The correlation Mr. Richardson refers to between the
      increase in time observed with gynecologic robotic surgery and increase in
      complication has simply never been reported. Quite the contrary, in fact. He must
      be misinformed.

      Similarly, lower hospital capacity because
      of longer surgeries is an artificial concept. Let me tell you about long
      surgeries: laparoscopic myomectomies are long surgeries and surgeons are TIRED
      after even one of those! Robotic myomectomies are somewhat longer in some
      studies (not in the one by Cleveland Clinic cited above, by the way) but most surgeons
      emerge from them just as fresh as when they started, because of the lack of strain
      to their joints caused by the anti-ergonomic environment of conventional
      laparoscopy.  Why do you think
      surgeons place their toughest cases as first case of the day? Because we are
      BETTER surgeons in the morning than after hours of physical strain at the
      table. When I go home after 8-10 hours of robotic surgery I feel like a
      teen-ager coming out of a Nintendo marathon: I want more! New data indicates
      that 98% of American laparoscopic general surgeons suffer from occupational
      injury directly related to the antiergonomic laparoscopic environment… just so
      you know that I am not exaggerating [J Amer Col Surgi
      2010 Mar;210(3):306-13].

       

      4)  
      SSo the issue here is after all is money. Not a
      trivial one, granted, but let it be clear that money is what we are talking
      about. Whose money, by the way? Are we just counting hospital charges (and
      which ones) or are we considering lost revenue and loss of members to the work
      force? Clearly, a nice old open myomectomy will cost less to the third party
      payer but the four to six weeks out of work for that patient will have to be
      paid somehow. As far as standard laparoscopy goes we must also understand which
      expenses we are comparing: why so much outrage over a $1.5 M robot but not a
      peep over a $1.5 M integrated operating room for conventional laparoscopy? Why
      a lament over $1.000 of disposable robotic instruments per case when a
      disposable laparoscopic scalpel or similar can cost $1.500? The story of cost
      analysis is more complex than what Mr. Richardson seems to want the public to
      understand.

       

      In conclusion, Mr. Richardson is clearly entitled to his
      peculiar style of high-energy writing and to scold NPR for writing a positive
      piece on truly great medical story gone well. However, the high level of
      sarcasm of his commentary is not supported by deep knowledge of the published
      medical literature, of the medical data currently being presented at national
      conferences, of the technical day-to-day aspects of advanced laparoscopic
      surgery and especially of the struggle of women against a medical establishment
      that has traditionally put a cheap price on the care of diseases threatening
      their reproductive organs.

      These objective considerations – together with a general
      sense of unease about having a consultant working directly for biotech
      companies lecture NPR on how to structure a piece of medical journalism -
      prompt me to recommend to readers of this column to take Mr. Richardson’s
      respectable advice on this matter with a (very big) grain of salt.

       

      Antonio Gargiulo, MD

      Director of Robotic Surgery

      Center for Infertility and Reproductive Surgery

      Brigham and Women’s Hospital

      Harvard Medical School

       

       

  • Mstones

    I had my fibroids removed by Dr. Srouji in Dec 2009 and my husband and I were so grateful to welcome our son into the world in December 2010. They have a great team at Brigham and Women’s and I cannot thank them enough.