The operating theatre is dimly lit and completely silent apart from the gentle
beep of the heart monitor. The patient lies strangely angled with his feet
in the air, his head near the ground. Around him are seven nursing and
medical staff and three raised video screens, revealing the intimacies of
his organs. And above him looms a large spider-like object wrapped in
transparent plastic, its arms passing into small holes in his abdomen.
I'm witnessing surgery conducted by the amazing Da Vinci robotic surgeon at
Addenbrookes Hospital, Cambridge. Despite its forbidding appearance, it is
the most advanced piece of surgical equipment in the UK, offering the man on
the table a chance of recovery from prostate cancer that he would never have
had five years ago. He is having his prostate gland removed because of a
cancerous growth. But there is no need for the patient to be “opened up”.
The three abdominal holes accommodate Da Vinci's camera arm and two
operating arms. To the side of them, two more abdominal holes allow nurses
to drain fluids, feed in clips to stem bleeding and push organs out of the
way.
Controlling the robot at a console four metres from the patient is the cancer
surgeon Professor David Neal, his head pressed against stereoscopic
eyepieces conveying 3-D pictures of the abdomen's contents from the central
camera leg of Da Vinci: the robot's eyes are his eyes throughout the
surgery. Professor Neal tells me it's like having your head inside the
patient. His hands are swivelling, tweaking and pinching joystick-style
controls, controlling the tiny robotic hands at the end of Da Vinci's two
other arms. He looks more like a seamstress than a surgeon.
Every movement he makes is scaled down into the far smaller, shakeless,
movements made by the 7mm, multijointed pincers, deep inside the patient's
abdomen. You can see everything in high magnification on those screens
above, though to the untrained eye it's hard to tell bladder from bowel, a
bit of fatty tissue from a major vein.
Professor Neal, a Cancer Research UK professor of surgical oncology, is
working his way down from the middle of the abdomen, past the bladder, to
its deepest recesses in the pelvis, where the prostate is located. Gravity
has pushed the upside-down patient's bowels out of the way, up under the
ribcage.
There's the occasional magnified whoosh of red as Professor Neal nicks a blood
vessel and, more surprisingly, little puffs of smoke. The little robotic
hands have super-heated edges, which mean they burn through tissue (rather
than actually cutting it) and cauterise veins as they go. It's quite
overwhelming on the senses. The burning tissue looks like pork crackling and
there's a whiff of burnt meat. My vision starts to bleach and my head begins
to whirl. I have to sit down for a minute.
Prostate removal can cause impotence
Eventually, an hour into the operation, the prostate is revealed, a crimson
globe sitting behind a deflated bladder. Now comes the tricky bit.
Traditionally, one of the great problems of removing a prostate gland
affected by cancer is that the nerves controlling urination and penile
erection are tightly and intricately wrapped around it. Removing the
prostate the conventional way means cutting nerves, often resulting in
impotence or incontinence.
But so dextrous are Da Vinci's cutting hands, and so clearly visible is the
noodle-like mesh of nerves attaching to the prostate, that it can be
detached intact before the prostate is removed. “Outcomes aren't great when
you remove the prostate using conventional open surgery,” says Professor
Neal. “After four years, half of men will have lost erections, or
continence, or their cancer will have returned. But with this type of
surgery, 90 per cent of patients are completely dry. The finer dissection
that robotic surgery allows means that patients are more comfortable after
the operation, there are fewer complications and they get better more
quickly.”
Professor Neal has conducted 230 radical prostatectomies at Addenbrookes using
Da Vinci since it was bought three years ago. Remarkably, half of Professor
Neal's prostate operation patients go home the next day. “My star patient
was back on his tractor in a week.”
This is one of only six Da Vinci machines in the NHS, compared with 350
operating in the United States. If such surgery were to become more widely
available, the implications for men with prostate cancer could be profound.
On diagnosis, only 20 per cent of men opt for prostate removal. Because many
tumours are slow growing, specialists often recommend watching and waiting,
and not risking the permanent sexual and urinary problems that surgery can
bring. But this causes uneasiness in many men, who simply want to be rid of
the cancer. Da Vinci changes the odds, and makes prostate removal a more
feasible “play it safe” option.
The patient loses only a glassful of blood
Now Professor Neal is pushing, dabbing and stroking the prostate as he cuts it
away, detaching it from the urethra (which passes through it), pushing it
away from the big veins coming up from the penis. Finally, it's released.
“Just pop it up under the ribs for now,” he tells the nurses, and using
keyhole probes, they manipulate it into a plastic bag, and push it up out of
sight of the camera. (After the operation, they will pull it out, through
one of the keyholes.)
Meanwhile, Professor Neal has more intricate work to do. He has to remove
lymph tissue in case there are any cancer cells there and, finally, stitch
the bladder back to the urethra. It's incredibly fiddly work, but the tiny
robotic hands, holding a needle and winding thread into loops and knots,
work fast. Robotic surgery minimises blood loss and transfusions are rarely
required. The patient lying in front of me has lost less than 100ml of
fluids - just a small wine glass full - during the operation.
After an intense two hours, the operation over, Professor Neal takes me for a
cup of tea and a biscuit - his lunch before the next Da Vinci operation
begins in just over an hour.
THE MAN ON THE OPERATING TABLE WAS . . .
Michael Mills, 65, a building contractor from Cambridge
“The prostate cancer was picked up after a routine health check. The
specialists said I might be OK for 15 years and there didn't seem to be any
spread outside the prostate, but I didn't want it hanging over me. When I
was told that recovery was quicker with robotic surgery, I thought that was
a good reason to go for it.
“I went in to hospital on Monday, had the operation on Tuesday, and went home
on Wednesday lunchtime. I've had no pain at all and not a single painkiller.
It was a little uncomfortable where the holes
in my abdomen were. The only problem I've had is controlling my urine, but
that seems to be getting better.
“I was back to work in three weeks. To be honest, I feel as if nothing has
happened.
CANCER DRUGS OR SURGERY? THERE REALLY IS NO CONTEST
Why are we so obsessed with new cancer drugs? Surgery is the real and
unacknowledged hero in the battle against cancer, according to an increasing
number of experts, including the Health Minister Lord Darzi. They point out
that only 10 per cent of cancers are cured by drugs, while surgery cures
half.
Currently, the £700 million spent annually by the NHS on cancer drugs dwarfs
the amount spent on surgery. Yet innovative techniques such as robotic
surgery not only improve survival and quality of life for people with cancer
but give more bang to the NHS buck than expensive drugs.
“Local therapies such as surgery and radiotherapy cure ten times as many
people as chemical means,” says Professor Gordon McVie, a senior consultant
at the European Institute of Oncology in Milan and former director of the
Cancer Research Campaign. “Medical oncologists get all the money spent on
them, but the surgeons are the unsung heroes. Surgery is more cost-effective
and, if done well, it has a significant effect on improved quality of life.”
In the past decade there have been vast improvements in surgery. Increasing
expertise in cancer surgeons, the development of keyhole (laparascopic)
surgery and, perhaps most spectacularly, the rise of the robot have meant
that cancers can be removed far more cleanly, with less trauma, than ever
before. There's evidence that this is having an impact not just on how long
people are living but, arguably more importantly, on the quality of the rest
of their life.
Better surgical techniques
In prostate cancer, for example, the pinpoint accuracy of the Da Vinci robot
(see left) in removing the prostate gland without damaging surrounding
veins, nerves and tissue means that patients are free to get on with their
lives within days and are considerably less likely to suffer the disabling
side-effects that often accompanied traditional surgery, such as
incontinence and impotence. The success of this, and other new keyhole
surgery techniques, has contributed to a 335 per cent rise in prostate
cancer surgery rates in the past ten years. Recent trials have also
indicated the efficacy of Da Vinci at performing radical hysterectomies for
gynaecological cancers.
In bladder cancer there has been a drop in mortality rates of about 10 per
cent in the past 15 years, partly as a result of more advanced surgical
techniques being used to remove lymph nodes that may carry cancer cells.
And the fact that more surgeons are choosing to specialise in operating on
particular types of cancer has also had a wide effect on cancer mortality
and complication rates. The number of patients dying in hospital after
removal of oesophageal cancer halved between 1997 and 2005, largely because
the surgery was increasingly performed by specialists rather than
generalists, according to the Department of Health.
Yet the money allocated to advancing surgical practice can pale into
insignificance compared with new cancer drugs. The NHS spent about £100
million on the breast cancer drug Herceptin in 2006, but some estimates say
that only about 500 patients actually benefited. That kind of money could
train hundreds of surgeons to specialise in the latest techniques, or
transform research into new surgical techniques each benefiting thousands of
people. One Da Vinci machine costs £1 million to buy and maintain over five
years, helping hundreds of cancer patients in that time.
“The thing that is improving cancer cure rates is specialised surgeons
focusing on particular operations, doing them more often and getting better
at them,” says David Neal, the Cancer Research UK Professor of Surgical
Oncology at Addenbrookes Hospital, which houses one of the six Da Vinci
robots in the UK. “But until five years ago there weren't the surgeons here
trained to do prostate removal properly. Surgery needs an investment of time
for training in the latest techniques. I get fed up with the current
emphasis on cancer drugs. It gets forgotten that surgery is the single most
effective treatment for cancer. The NHS has fallen behind on equipment. In
the US, 65 per cent of radical prostatectomies are done using a robot. In
Europe it's one in three. But here it's just 1 or 2 per cent.”
Drugs have a limited impact
Professor Neal has high-level support. Cancer experts such as Professor McVie
and Karol Sikora, a professor of cancer medicine and honorary consultant
oncologist at Hammersmith Hospital, in West London, point out that the days
of discovering block- buster drugs helping millions of people are gone, and
drug development is becoming increasingly focused on specialist drugs that
will help ever-smaller groups of people.
There are signs that the contribution of surgery to curing cancer may finally
be acknowledged. Lord Darzi,
the consultant surgeon at St Mary's Hospital, London, who introduced the Da
Vinci robot to the UK, is a Health Minister. His input is clear in the
Government's new
Cancer Plan, with proposals to establish a new programme to train more
surgeons in laparascopic surgery. The Department of Health has promised a
£250 million investment in “capital equipment” for cancer over the next
three years, but how much of that will be spent on surgery is as yet
unclear.
As both a minister and a director of the new Hamlyn Centre for robotic surgery
research at Imperial College London, Lord Darzi has to tread a careful line.
But he says he agrees that the amount invested in surgery is “minuscule”. He
would like to see much more money going into research into the effectiveness
of new surgical techniques, then the case for investing in robotic and
laparascopic techniques would be unanswerable.
“People don't realise that their only chance of a cure from cancer is through
an operation that removes it completely,” he says. “There has always been
more emphasis on drugs because the pharmaceutical lobby is so strong. We've
got to remember that in pharmaceuticals we have yet to find a magic bullet
that has the potential to cure most cancers. But in surgery we already have
that.”
