Schuab 4:00, L07
TREATING PROSTATE CANCER: CAN WE TRUST ROBOTICS IN
SURGERY?
Thomas Skamai (tjs85@pitt.edu)
prostate and surrounding tissues. Although there are
benefits and deficits to either method, I have found that
the laparoscopic method is not the wisest choice.
Laparoscopic prostatectomies are a poor choice due to
the long term side effects after surgery. I fear that some
patients are unaware of the risk that they are putting
themselves into when they choose this method over the
open surgery. Who is to blame for this: the engineer
and/or the surgeon? Before we start pointing fingers, it is
imperative for you to gain a greater understanding of the
issue.
A RISK CLOSE TO HOME
About a month ago, my family threw a surprise
birthday party for my father. He reached a milestone as he
turned a whopping sixty years old. The day was filled
with family, friends, laughter, dancing, hugs, cake,
presents, good times, and worry. Yes, it was filled with
worry. There is always concern for the health of your
loved ones; and as age increases, poor health almost
seems inevitable. With my father now sixty years of age,
one concern really conquers my mind: prostate cancer.
Family history and genetics are a factor that can put
men at risk for prostate cancer [1], which is frightening
since my grandpa is a survivor of prostate cancer. Also, 1
in 6 men are affected by prostate cancer (1 in 15 for ages
60 to 69) [1]. One study estimated that by the end of 2012
there will be over 28,000 deaths from prostate cancer in
the United States [2].
With so many reasons to worry, I knew there must be
a glimpse of hope to cling on to. I found this hope when I
researched the treatment methods for prostate cancer.
PROSTATECTOMY: OPEN SURGERY vs.
LAPAROSCOPIC
As previously stated, a prostatectomy is a surgery in
which the prostate gland is removed along with some
tissue around it. Open surgery is the more customary
route to take for a prostatectomy. The incision can be
made in one of two places, depending on the situation.
One is the lower belly, and the other is the perineum
between the anus and the scrotum. The more modern way
to perform a prostatectomy is through laparoscopic
surgery, which is also known as minimally invasive
surgery. This form uses many small incisions to reach and
remove the prostate [3]. Recently, the use of robotics in
laparoscopic surgery is increasing.
Prostate Cancer: Treatment Techniques
Prostate cancer is very treatable when it is detected
before it spreads outside the prostate. The most common
procedure in this scenario is a radical prostatectomy, an
operation to remove the prostate gland and some of the
tissue around it [3]. Open and laparoscopic surgeries are
the two methods used to complete a radical
prostatectomy. Open surgery involves a larger incision
while laparoscopic uses many smaller incisions and, at
times, the help of a da Vinci surgical robot.
Using either an electrical or a mechanical engineering
degree, I wish to eventually work with medical
equipment. I could end up striving to improve surgical
robots that perform radical prostatectomies. However,
first I must question if there is any value in working with
these particular surgical robots. In an attempt to ease my
mind and determine my possible career, I went on a
search for this answer, and my discoveries were abundant.
I realized how complicated matters are in engineering
fields. I was reminded of the purpose behind all the work
I have been putting into school. And most importantly, I
discovered that both open and laparoscopic methods are
known to be very effective in removing the cancerous
The da Vinci Surgical System
A common robot used in laparoscopic prostatectomies
is the da Vinci surgical robot. In this scheme, the surgery
is executed by a surgeon who sits at a console separate
from the patient and controls every move of the robot.
The main parts of the system are a cart for the patient, a
console for the surgeon, a high-definition 3D vision
system, and four robotic arms equipped with “EndoWrist”
instruments.
“EndoWrist” technology provides many advantages.
Their range of motion is superior to a human wrist.
Clamping, suturing, manipulating tissue, and other
surgical movements can be done by respective
“EndoWrist” instruments.
University of Pittsburgh, Swanson School of Engineering
Oct. 9th, 2012
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Thomas Skamai
Within the first 30 days after surgery, men who had
laparoscopic surgery were more likely to report problems
with genital or urinary functions. The erectile dysfunction
and incontinence rates remained heavier from
laparoscopic patients even after 18 months [4]. The rate of
genital or urinary complications is twice as frequent in
laparoscopic surgery as it is with open surgery [9]. This is
an astonishing rate. Yet, some doctors do not seem to
notice it; and this is where ethical concerns come into
play.
FIGURE 1, “ENDOWRIST” INSTRUMENTS
These instruments are a diverse and vital part in the da
Vinci system [7].
WHO IS BEING UNETHICAL?
Many men choose laparoscopic surgeries that include
the use of robots, and then suffer the consequences of
their decision. The first question that comes to mind is
whether or not the patients knew about the differences in
risks between the two options. If they did know the
consequences and chose the laparoscopic surgery anyway,
then neither engineer nor doctor was being unethical. But,
if the patient was never aware of the heightened risks with
the laparoscopic surgery, then someone made a mistake.
These arms are controlled by a surgeon who sits
behind a console near the patient. The doctor’s surgical
vision is provided by an endoscope, a flexible tube with a
camera and light at the tip. This tool gathers the visual
display of the area under operation and displays it on a
high-definition 3D screen for the surgeon. This image is
also shown on a large widescreen display for the rest of
the operating room to see [8].
The Engineer did it!
Comparing the Basics
Blame the engineer, right? It’s the easy thing to do.
After all, we’re just a bunch of arrogant nerds that always
play on our computers and don’t have any real friends; so
few are hurt when we take the fall. First of all, the
previous statement is not true. Second, the engineer is not
to blame in this situation.
I thoroughly read the “Code of Ethics for Engineers”
from the National Society of Professional Engineers [10]
as well as “A Code of Ethics for Robotics Engineers”
[11]. Neither document held any evidence that engineers
were at fault for the sufferings of men who were treated
by a laparoscopic prostatectomy.
At first glance, I thought the robotics engineer may
have done wrong. The code of ethics for robotics
engineering states, “As an ethical robotics engineer, I
understand I have the responsibility to keep in mind at all
times… the expectations and the safety of the
customer”[11]. I thought that if these robots are causing
harm to the patients, then the engineer should have done a
better job to eliminate that. The reason the engineer is
NOT at fault is because these troubles cannot be
controlled by the engineer. Their job was to create a
machine that removes the prostate with reasonable safety,
which they did. Therefore, the engineers of these surgical
robots did not cross any ethical boundaries.
My feeling of innocence toward the engineer was
confirmed by the National Society of Professional
Engineers’ code of ethics. Part of this code stated that
“engineers shall avoid the use of statements containing a
material misrepresentation of fact” [10]. Through all of
While the goal of either prostatectomy process is the
same, the two options differ in numerous ways. On
average, three nights are spent in the hospital after an
open prostatectomy as compared to two for laparoscopic
[4]. A laparoscopic procedure consists of five small
incisions that are 5 to 10 millimeters long, whereas open
consists of one incision that is 4 to 5 inches long [5, 6].
This incision size is significant since it is directly related
to the amount of blood loss during surgery. As expected,
the small incisions combine for less blood loss opposed to
the one large incision. On the other hand, due to the
locations of the small incisions, they often cause problems
that can be more unfavorable for the patient than blood
loss. Later portions of this paper contain more detail on
this matter. Last, open surgery usually implements
traditional tools and laparoscopic uses modern surgical
technologies such as the da Vinci robotic system.
The Laparoscopic Downfall
Nowadays, people tend to be attracted to modern
technology. This makes it easy for somebody to miss the
drawbacks that take place when fresh technology is used
for laparoscopic surgery. The problems that occur after
either method of a prostatectomy are fairly similar.
Typical complications are difficulties getting erections,
involuntary urination, internal scarring, damage to the
urethra, or damage to the rectum [4, 3]. The point that
people seem to be over-looking when debating the two
types of surgeries is the frequency of glitches.
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Thomas Skamai
my research on surgical robots used for laparoscopic
prostatectomies, I did not see any claims from the
companies that mentioned a lowered risk of erectile
dysfunction or urinary incontinence. The problems lie
within the method itself, not the tools used to complete it.
Hence, the engineer did no wrong.
If I were offered a job in the area of surgical robotics,
there is a decent chance I would accept it. With how much
room this region has for improvement, it would be very
exciting to have the opportunity to contribute to future
success.
Nonetheless, at the moment I do not trust surgical
robots for prostatectomies. They cause too many long
lasting problems. Surgeons must enlighten their patients
of the facts in order to help them avoid making a choice
that will have a negative impact on the rest of their lives.
Ignorant Doctors
If men choose laparoscopic prostatectomies without
knowing all of the risks, the doctors are at fault.
According to the College of Physicians and Surgeons of
New Brunswick’s code of ethics, surgeons acknowledge
the responsibility to “provide [their] patients with the
information they need to make informed decisions about
their medical care” [12]. I was unable to find statistics of
the number of men who fully knew the long term risks of
laparoscopic prostatectomy before they picked that
method. Thus, I am unable to definitively state that the
surgeon broke ethical guidelines when their patients had
laparoscopic prostatectomies. If the surgeon informed the
patient of the severity of risks, then the surgeon followed
the code of ethics. On the contrary, if the patient was
never informed of the increased potential for malfunctions
after surgery (which is what I suspect), then the surgeon
broke the code of ethics.
Molding
For the final portion of this assignment, I was
instructed to assess the educational value of my task.
When I first heard of this, I was excited. I was finally
given the opportunity to inform the engineering
department of how “stupid” this assignment was. Then, I
really started to think about everything I have gained
through this assignment.
Sure, I learned a lot about prostatectomies, but that
was not the most beneficial part. This assignment taught
me how complicated the engineering field is outside the
aspects of the actual product. I realized that many things
must be considered, such as cost, efficacy, demand, and
ethics, among others.
This assignment inspired me. During the grind of this
semester my focus has become selfish. I have only been
concerned about getting the next assignment done, doing
decent on the upcoming test, etc. Now I’ve been reminded
of the reason I am here: to help others by fulfilling my
potential in life. This paper made me consider the fact that
my efforts today will set me up with the opportunity to
positively impact society in the future; and that is a great
source of motivation.
I absolutely recommend that this assignment be a part
of the future freshman engineering curriculums here at the
University of Pittsburgh and in engineering schools
around the world. I will admit that I feel sorry for the
future freshman that must complete it, because it was
brutal. However, students truly benefit from assignments
like this.
Two of the course goals listed on the Swanson School
of Engineering webpage are “to introduce [students] to
what engineering is” and “introduce [students] to required
library research skills and communication skills used by
all engineers”[13]. I strongly believe that this assignment
took a big step toward fulfilling these objectives. This is
encouraging, since I am finally noticing evidence that I
am being molded into the person and engineer that I
dream to be.
CONCLUSION: THE CHOICE IS CLEAR
It is unnecessary to go into detail about how sexual or
urinary problems would distress a man. We all understand
that this would be horrific. And if you cannot relate,
please take my word for it. These problems would be
incredibly depressing.
When all the factors are taken into consideration, the
choice between open and laparoscopic surgery is obvious.
The temporal sufferings are definitely less for
laparoscopic surgery. The hospital stay is shorter and the
pain is less among other minor benefits. On the other
hand, the long lasting effects of laparoscopic surgery are
more likely to be detrimental. If men know they have a
greater chance to avoid long term erectile dysfunction and
urinary incontinence, their choice will be easy to predict.
Open surgery is clearly the best choice of methods for
prostatectomies. This procedure can be trusted to cure a
man and return him to his “manly” stature.
Hypothetically Speaking…
If I had to make the choice between an open or
laparoscopic prostatectomy, I have no doubt that I would
choose open. The benefits simply do not outweigh the
deficits. I refuse to be deceived by how “great” this
modern da Vinci system is.
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Thomas Skamai
http://www.engineering.pitt.edu/Freshman/ENGR_0011/F
all_2012/Layouts/Course_Objectives/
REFERENCES
[1] (2012). “Prostate Cancer Risk Factors.” Prostate
Cancer Foundation. (Online article).
http://www.pcf.org/site/c.leJRIROrEpH/b.5802027/k.D27
1/Prostate_Cancer_Risk_Factors.htm
[2] (2012). Cancer Facts and Figures. Atlanta, GA:
American Cancer Society. (Online book). p. 6.
http://www.cancer.org/acs/groups/content/@epidemiolog
ysurveilance/documents/document/acspc-031941.pdf
[3] C. Nickel. G. Thompson. (2010). “Radical
Prostatectomy.” WebMD. (Online article).
http://www.webmd.com/prostate-cancer/radicalprostatectomy-operation
[4] (2009). “Robotic prostate surgery comes with tradeoff.” NBC NEWS. (Online article).
http://www.msnbc.msn.com/id/33291388/ns/healthcancer/t/robotic-prostate-surgery-comes-tradeoff/#.UGu1YE070WI
[5] J. Zatzkin. (2011) “Prostate Cancer: Laparoscopic
Prostate Surgery”. WebMD. (Online article).
http://www.webmd.com/prostate-cancer/laparoscopicprostate-surgery
[6] W. See. (2009). “Open Prostatectomy.” Medical
College of Wisconsin. (Online Article).
http://www.froedtert.com/SpecialtyAreas/ProstateCanc
erProgram/ProgramsAndServices/OpenProstatectomy.ht
m
[7] (2012). “Cardiac Surgery in the Age of IT.”
Hospitalmanagement.net. (Online Photo).
http://www.hospitalmanagement.net/features/feature1067
10/feature106710-3.html
[8] (2012). “The da Vinci Surgical System”. Intuitive
Surgical. (Online article).
http://www.intuitivesurgical.com/products/davinci_surgic
al_system/#components
[9] P. Peck. (2009) “Shorter Hospital Stays but More ED
with Robotic Prostatectomy”. MedPage Today. (Online
article).
http://www.medpagetoday.com/Urology/ProstateCancer/1
6406
[10](2003). “Code of Ethics for Engineers”. National
Society of Professional Engineers. (Online article).
http://www.mtengineers.org/pd/NSPECodeofEthics.pdf
[11]B. Ingram. D. Jones. A. Lewis. M. Richards. C. Rich.
L. Schachterle. (2010). ”A Code of Ethics for Robotics
Engineers”. Worcester Polytechnic Institute. (Online
article).
http://ieeexplore.ieee.org/stamp/stamp.jsp?arnumber=054
53245
[12] “Code of Ethics”. College of Physicians and
Surgeons of New Brunswick. (Online article).
http://www.cpsnb.org/english/code-of-ethics.html
[13] (2012). “Course Objectives”. Swanson School of
Engineering. (Online article).
ACKNOWLEDGMENTS
First and foremost I would like to acknowledge my
parents. They have sacrificed so much for me throughout
the years. I would like to thank Dr. Schuab for the
constant motivation he provides. Last, but certainly not
least, I would like to thank my excellent writing
instructor, Janine Carlock, for generously giving her time
and advice in order to improve my writing skills.
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