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!’”
[module align="right" width="half" type="pull-quote"]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.)[/module]
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.
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.”