Interview with Joseph Wagner, MD
Could you first give us some background information about your work?
I currently work at Hartford hospital which is in the University of Connecticut’s sort of healthcare system. I’m sort of associated with the university medical school. It is a big sort of tertiary care hospital in Hartford, Conneticut.
How did you first become involved in robotic surgery and why did you choose it?
I did a fellowship on the urologic oncology in the National Cancer Institute and that was from 1995-1997. It was there that I learned how to do laparoscopic surgery which is minimally invasive surgery, the thing that they take out gall bladders and things like that. And at the National Cancer Institute, we were doing a lot of renal and adrenal surgery laparoscopically. When I went into practice, the Europeans were doing laparoscopic prostatectomy in the late 1990’s and so I learned how to do them laparoscopically also. And when the robots became FDA approved and available in 2001, I was very fortunate that the hospital I was working at in NYC had a robot and obviously realizing the utilities that would have if performing prostatectomy and started doing them in 2001. I have been doing them regularly since then.
Which robot are you working with right now?
We use the da Vinci which is made by Intuitive Surgical.
What do you use the da Vinci for? How many digital surgeries have you performed in the past?
I performed hundreds of surgeries with it. Really any surgery that the urologist does with a diaphragm, I can do with the da Vinci. So I do radical prostatectomy, which is removing the prostate with the prostate cancer, uretero-pelvic junctions obstruction, partial nephrectomy,…pretty much you name and I’ve done it with the robot. I currently do about 4-6 procedures a week.
Do you have any criteria when selecting your patients?
Yes and no. Right now I would say that virtually anybody who is a candidate for open surgery is also a candidate for robotic surgery. Relative contraindications are, if they have a lot of surgery in their abdomen, it will make it difficult for me to place the hollow tube through which I do the surgery and if a patient has severe other health problems which makes them a poor candidate for open surgery in general, they might be a poor candidate for robotic surgery. But really nothing firm.
What are the patients’ feelings towards using the da Vinci? Do they feel more or less safe that a robot is working on them?
In the beginning the reason people picked robotic surgery because it’s new and for lack of a better term it’s cool, new technology. And they are attracted to something that is new which might be better. Now that we have 4 years experience with it what we can definitely say is the robot results in less blood loss than open surgery, that’s definitely true. The robot results in people going home more quickly than they do with open surgery and they’re back to their usual routine more quickly with robot than open surgery, that’s definitely true. There are some studies suggesting that the robot might be doing a better job in getting all the cancer out, although, that remains to be seen. So right now there is certainly data to support people who are choosing robotic surgery.
What are the disadvantages and limitations with robotics, in particular the da Vinci? Risks associated with it?
The advantages of the robot are Visualization. The cameras that I have inside the abdomen has a lot more magnification than my naked eye. And because I can put it a few millimeters away from wherever I’m operating on, I see 20-30 times better than I would with open surgery. That is the biggest advantage. Another advantage is the tools, the instruments of the robot, have all the movements and reticulation as my wrist so I can do more complex surgical maneuvers than I can with standard laparoscopic instruments. The only disadvantage of the robot is the cost. It is $1.5 million machine. And when you compare it to open surgery the only disadvantage is that you don’t have any sense of feel because your hands aren’t inside.
Are their any techniques that you wish the da Vinci could do that aren’t available now?
I wish that the robot has a sense of feel. If there was some way that it can transmit back to me more how the patient feels would be great. There’s studies technology underway, where maybe what you can do is overlay the radiographic image, such as CT scan, MRI, whatever, can overlay that information on top of what I’m actually seeing with the robot. To give me a better idea of where blood vessels, nerves, and different things might be. That’s a while down the pipe, but that would be good. They’re working on making the instruments even smaller, so that holes that we make are even smaller. That’s nice but not crucial. I think what would be amazing is the technology overlay that someday will happen.
Is there something better with your hands than a robot?
Not really. Suppose if there are any cases where you think you need a sense of feel, your hands would be helpful. The only one in my sort of area that comes to mind is cystectomy, removing bladder. Sometimes it’s beneficial to have your hands in there in a big open incision. But pretty much, the majority of the surgery that I do now a days are either laparoscopic or robotic.
Who is liable for peri-operative problems should they arise?
I suppose that when things happen with equipment, equipment breaks down…when we say liable, liable means a legal issue. The lawyers go for everybody they can go for. So for instance if something were to ever happen, though it never has with the robot during the case, I’m sure that they will sue me, sue the hospital, sue da Vinci, they’ll sue everybody they can sue. Who would end up being liable, legally for it, obviously it us up to them to decide.
How does the recovery time compare for robotics surgery time versus other forms of surgery?
Well it depends on the procedure. But for instance, with radical prostatectomy, if I do open surgery most patients go home in 2-3 days, while they go home in 1 day after the robot. So it’s quicker. As compared to other forms of minimally invasive surgery, it is the same, no difference. Doesn’t give you any advantage. If I do a case laparoscopically they live just as quick if I do the robot.
Does the da Vinci seem like a routine procedure to you now?
Yes. I can tell you that in 2004 10% of all the radical prostatectomy done in the US were done using the da Vinci. That pretty amazing when you consider that there was 0 in 2000. And these numbers are going up and up every year.
What are some difficulties you came across at the beginning. How long was your training and what did it entail?
For most of these procedures, when you’re sort of learning how to do them when nobody else has there’s a 20-30 case learning curve so that you’re fairly comfortable. You have to figure out how to set up the robot, where the best place is for the robot arms to go, and there are a lot of issues that go along with doing that –
Did you begin training on the machine before it was FDA approved? And if so how long was your training?
Yes. The training was in an inanimate lab with the company and then we would do drills on our own for months before we did our first case.
Do you still perform non-robotic surgeries? In what scenarios?
I do. But not very often, for the reasons that I talked about.
What are the costs of robotic surgery for the patient and for the hospital?
Overall, the cost for the patient is the same assuming that their insurance company is paying for it. But for the hospital, once you add up everything it is $150 more expensive to use the robot because of the disposables. But they’re pretty much equivalent. You lose some money in the added expense but you get that money back because the patient go home quicker and don’t need blood transfusions, etc.
Do you consider the cost a problem? Do you expect it to be affordable for all hospitals in the near future?
Right now, at a cost of $1.5 million dollars, it is not feasible for all hospitals to get it. I think down the road, the cost will cut back once there’re competitors in the market, just like everything, computers, calculators. They’ve all gone that way , and this will to.
Do you think the benefits are worth the investment?
I do. I do. I can tell you that at our hospital, our radical prostatectomy rate in which the first year we had the robot last year has went up by 38%. Is that making money, I don’t know, but it is certainly helping a lot of people.
Who else is involved other than you when using the da Vinci during surgery?
I have a physician assistant at the robot switching instruments for me and do whatever needs to be done at the robot site.
What percentage of doctors in your hospital use the da Vinci?
Well right now at our hospital, there are only two of us. But that varies by hospital. But certainly a minority of doctors are trained on it and are confident at it.
How fast do you think robotic surgery will become mainstream?
Well, I think it depends on the cost. If it’s not too expensive and hospitals have it, patients are going to want it for the reasons we already talked about. I think that it will be cost, economically driven. If another company gets into this and makes it a competitive product, prices are going to come down and it will be more widespread.
Why do so few doctors in your hospital use the da Vinci?
Well, more and more surgeons are doing laparoscopic procedures. But it takes a lot of dedication and there is a learning curve. And doctors don’t want to risk the health and well being of their patients while they’re learning how to do it and also the added time that it takes to do it, they can be doing other things.
For general surgery using the da Vinci, what is the cost for the first year and then the following years for the patient?
I have no idea, it totally depends on the surgery you’re doing, the disposables you’re using, etc. That’s is not a number I have.
When patients come in, do they come in knowing about the da Vinci?
For the most part, given that I’ve been doing this and I have one of the largest experience in the country, people pretty much come to me only because of that. I saw 4 people today, one guy from Providence actually. They come to see me because they know that I do these and I do a lot of them.
Is there anything else that you believe is important that was not mentioned?
Not really. The best analogy I can give people when looking at open vs. laparoscopic vs. robotic , the advantages of laparoscopic surgery over open surgery has clearly been shown. Nobody gets their gall bladder out, has knee surgery, etc, with big open surgery when they can avoid it. But when you move from laparoscopic to robotic surgery, I can do the same job laparoscopically as I do with the robot. But the robot is a much better tool to do it. It lets me do it more easily and with more confidence which probably translates to better results. So its like having an oversized tennis racket as opposed to a regular size. It makes tennis easier. If you’re a good tennis player, you’re probably good with each, but its just the piece of equipment that makes your job easier and better.
What do you think is the future for robotic surgery?
I think that robotic are going to be the way to go. Anytime you have technology that makes things easier usually it comes into the mainstream. The question is cost and competition and how much it is needed; those are the three things that are going to determine that. It’s needed because the patients want it, the cost is somewhat prohibited right now, but after competition comes into the marketplace, that will come down.