When Dr. Del Ashcraft sat down and grasped the two gamelike hand controls to perform his first robot-assisted hysterectomy at Parkridge East Hospital, he didn't get up for more than two hours.

More than 200 robotic surgeries later, Dr. Ashcraft now can whip through the procedure in 20 to 50 minutes.

Even after his extensive preparations for the robot - known as the da Vinci Surgical System - that first surgery was "mentally exhausting," said the 44-year-old gynecologist.

Adapting to the new techniques two years ago was "intense," he said. Watching a 3-D magnified video image of his patient's internal organs, he painstakingly worked to detach his patient's uterus, knowing that five inches of hand movement translated into one inch of motion at the end of the robot arm, buried inside his patient's abdomen across the surgical room.

He tapped a foot pedal to make a tiny video camera zoom in, another pedal to activate a blood vessel cauterizer. Manipulating the robot arms to tie sutures, he watched the video feed to see when liquid stopped seeping from the vessels to know when he'd pulled tightly enough.

PDF: Hu's study in JAMA

Article: Robotic medical arms race

Article: Researchers say more study needed


* 2003 - 210

* 2004 - 286

* 2005 - 394

* 2006 - 559

* 2007 - 795

* 2008 - 1,111

* 2009 - 1,395 (1,028 in U.S., 248 Europe, 119 rest of world) - 73 percent in U.S.

SOURCE: Intuitive Surgical SEC filings


* Hysterectomies:

Open surgery - 35

Vaginal - 45

Robotic surgery - 69

Laparoscopic without a robot - 154

* Prostatectomies:

Open surgery - 9

Robotic surgery - 179

Laparoscopic without a robot - 0

Source: Memorial Hospital


The purchase and maintenance of da Vinci equipment doesn't come cheap.

In addition to the $1.7 million purchase price and annual maintenance fees of $140,000, a robot-assisted prostatectomy can cost a hospital about $2,000 more per patient, since the procedure can take longer and replacement equipment, purchased through the device manufacturer, is more costly.

That extra cost is diminished as patient volumes and physicians' proficiency with the equipment increase, physicians said.

For leaders at Parkridge Medical Center, the first hospital in Chattanooga to get a da Vinci system in 2002, the ability to offer a minimally invasive option to more patients is more than enough to justify the expense.

The da Vinci's increased agility allows surgeons to navigate in different ways than laparoscopy, giving a minimally invasive option to patients who previously would have needed open surgery, said Adam Royer, executive director of surgical services at Parkridge, which has two da Vincis.

"With that alone, I think that's certainly a benefit," he said.

In Chattanooga, like much of the United States, the number of da Vinci robotic surgical systems is exploding. Three hospitals in Chattanooga and one in North Georgia have at least one da Vinci robot, which now cost $1.7 million each.

Robotic surgeries, particularly in urology and gynecologic-oncology, are being promoted as the new standard of care. Hospitals are marketing it, patients are asking for it, and young physicians are expecting to be trained on it.

The number of da Vinci robotic surgical systems installed worldwide has ballooned from 210 in 2003 to 1,395 last year, with 1,028 of those in the United States, according to records from Intuitive Surgical, which makes the da Vinci robot.

For Dr. Ashcraft, his patients' rapid recovery times and little to no reported post-operative pain have sold him on the da Vinci.

But some researchers are concerned that the popularity of the technology has outpaced the clinical evidence of its superiority over standard - and less costly - treatments.

New medical technology can spread like wildfire, as hospitals strive to keep up with their competitors and patient demands, even before the benefits are proven, said William Lowrance, urologist at Memorial Sloan-Kettering Cancer Center in New York City. He recently published a study in the Journal of Urology comparing minimally invasive prostate removal surgeries, including those that used the da Vinci, to open surgeries.

The proliferation of da Vinci systems is "not atypical of how new technologies are taken up in medicine," Dr. Lowrance said. "Marketing, combined with Americans' desire for new technology, in a way fuels people's demand for those type of procedures."

For Debbie Littlejohn, who works at the Bank of LaFayette in Georgia, the popularity of robotic surgery is well-deserved. She got a robotic hysterectomy at Parkridge East Hospital in January and left the next day.

The 41-year-old LaFayette resident said she didn't even need any pain medicine once she got home.

"I was so shocked at how easy it was to come off of this and recover," she said.

Parkridge Medical Center got the first da Vinci robot in the region in 2002 and its second in 2008. Erlanger hospital is planning to buy its second robot in the upcoming fiscal year. Memorial has one, so there soon will be five in Chattanooga alone, plus one at Hamilton Medical Center in Dalton, Ga.


Today, it's more of a necessity than an option for hospitals to have a robot, some researchers and hospital officials said.

"Hospitals feel like it's kind of an arms race or they're going to lose market share," said Dr. Jim Hu, urologist at Brigham and Women's Hospital in Boston.

That was the case at Hamilton Medical Center in Dalton, which was losing hundreds of both urology and gynecology patients to Atlanta or Chattanooga for robotic surgeries, said Jan Keys, vice president and chief nursing officer. So despite the tight economy, the hospital decided to invest in the equipment, which arrived in September.

"You just can't afford not to do it," she said. "It's going to become the standard of care. You have to ... just to stay competitive."

The latest equipment can help hospitals maintain volumes in other service lines as well, Dr. Ashcraft said.

"Hospitals are not just looking at what those robots cost. They're looking at their whole book of business," he said. "That's why they have robotic surgery billboards all over the place. They want to get you in the door with that and keep you with all the other stuff when you have a good experience," he said.

Extensive marketing of the technology is another driver for the growth in robotic surgery, as hospitals strive not only to lure patients but to attract new talent, said Dan Kara, editor at Robotics Business Review.

"Individual hospitals are using it as a marketing tool to get top, primarily young, talent. The young physicians coming out of medical school want to be tied into the latest technology," he said.

Hospitals everywhere are feeling the pressure, said Dr. Amar Singh, a urological oncologist who joined Erlanger three years ago with the specific goal of developing the hospital's use of robotic surgery in kidney and bladder cancer treatments.

"It's the keeping-up-with-the-Joneses phenomenon," he said.


Still, despite benefits of the robot in some areas, a worrisome number of advertisements - including a billboard he spotted in Macon, Ga., that reads "Miracle Surgery" - have overstated the long-term outcomes and uses of the robot, Dr. Singh said.

"When I talk to patients, they expect this is a miracle," he said. "At the end of the day, is it a great technology? Fantastic. Is it used properly in most cases? Of course. Is there a lot of marketing bias? I don't doubt it."

The role of direct-to-consumer marketing is a new and growing concern among U.S. clinicians, said Dr. Matt Smith, OB-GYN at Hamilton Medical Center.

"Marketing in medicine, it's kind of a scary thing," he said. "I think it's up to the surgeon to explain to the patient what the expectations are. You may have somebody that's not a good candidate for the robot."

The robot has a "steep learning curve," but once a surgeon becomes adept at using the technology, the robot has authentic benefits that only increase as a surgeon gains experience, said urologic oncologist Dr. Lee Jackson, who came to Memorial Hospital from the Cleveland Clinic in Fort Lauderdale, Fla., to develop its robotics program. He has done more than 700 robotic prostatectomies.

Still, criticism of some marketing claims about have been valid, Dr. Jackson said.

"There has been some rather distasteful and overreaching marketing associated with this, and that opens it to that kind of criticism," he said. "It's got a gee-whiz factor to it and the assumption would be, 'Well, this is new and this is highly advanced, therefore it's better.' Well, not necessarily."