時　間：2009年8月29日 (六) 10:40 ~ 11:20
地　點：急診大樓六樓第五會議室
座　長：歐宴泉醫師
領　域：Minimal invasive surgery
講　題： 1000 Robotic Prostatectomies at Yonsei University : Lessons Learned
主講人： Prof. Rha, Koon Ho, M.D., FACS, Ph.D. （ Korea）
Associate Professor of Urology and Robotic and Minimally Invasive Surgery Center

此外，Dr. Rha也將手術試範達文西攝護腺根除術

Live Demonstration: Robotic Radical Prostatectomy
Prof. Rha, Koon Ho, M.D., FACS, Ph.D. （ Korea）
時　間：2009年8月30日 (日) 7:30 ~ 9:30
Opening: 張心湜 教授
Moderator: 楊啟瑞 教授, 邱文祥 教授,  歐宴泉 副教授
Panel: 林嘉祥主任, 吳勝堂主任, 吳俊德主任

記者施靜茹／報導

開刀房裡，傳統畫面大多是穿著綠色手術服的醫師、護士，圍在手術台周圍，全神貫注地為躺在手術台上病人開刀。

3D遙控 靈感來自達文西
但近年的開攝護腺癌、心臟外科手術房有點不一樣，在病人傷口忙碌進出的，是四支架設在手術台車的機械手臂，一旁一台有如行控中心的手術控制台，主治醫師埋首注視3D畫面，映入眼簾是如同在手術台看到立體組織，雙手使用主控制器給予機械手臂手術指令。
義大利文藝復興時期藝術家達文西，一張膾炙人口的「維特魯人」手稿，人體站在正方形和圓形裡張開手臂，被譽為黃金比例；五百多年後，醫界發明達文西機械手臂手術系統，替代人手開刀。

第一、二期 可選擇手術
國人一年約2300例攝護腺癌病例，其中1/3屬第一、二期可開刀的病例，可選擇傳統開放性手術、腹腔鏡或最新的達文西機械手臂手術；1/3為第三期病例，較建議進行放射線治療，加2年荷爾蒙療法；1/3病例，為癌細胞轉移至其他部位的第四期，則建議進行荷爾蒙治療。
切除攝護腺癌組織的傳統開放性手術，泌尿外科醫師已用它20多年，它開的傷口較大，約10到15公分，但好處是健保有給付；問世已十年的腹腔鏡手術，透過五個小傷口進入切除癌細胞，對術中出血少、術後疼痛、尿失禁、性功能保留，都較傳統開放性手術佳。

操作精密 費用約20萬
而2002年在美國問世，2004年引進台灣的達文西機械手臂手術系統，較腹腔鏡又更進一步，在小便控制、性功能保，又優於腹腔鏡，唯手術費較高，前者約3至5萬元，後者約20萬元。
機械手臂手術提供主刀醫師立體視野，更精確進行器械操作，機械手臂的7個自由度，模擬人的手指靈活度，消除主刀者不必要的顫抖，並操作人手不能觸及的狹小空間和精細手術動作，醫生在縫合膀胱及尿道時，更為順利，有別於傳統開放性手術和腹腔鏡手術。

主開攝護腺 也用於心臟
它的四支手臂，一支負責拿內視鏡；另外兩支隻手臂，配合主刀醫師在主控制器，拿燒灼器、夾子和縫針等；另一支為備用手臂，隨時遞上手術時需要的器械。
機械手臂手術在國內主要做攝護腺癌手術，有些醫院做心臟冠狀動脈繞道術、心中膈缺損、二尖瓣膜修補術、膀胱切除術和胃繞道手術等，也會用到它。
目前國內醫院具有該設備者有：三總、林口長庚、振興醫院、台中榮總、台北市立忠孝醫院。截至目前為止，國內已完成約400例達文西機械手臂攝護腺根除術。

術後回診 需測PSA指數
做了攝護腺癌手術後，病患都關心癌症能否獲得控制，醫師會建議病患回診抽血驗攝護腺特異抗原（PSA）指數，如指數大於0.2，較可能有復發跡象，或許是癌細胞殘存或潛藏，必要時需回診做放射線或荷爾蒙治療。
「醫師，我不想做切片，聽說這樣癌細胞會擴散？」門診中，醫師常聽攝護腺病患憂慮地詢問，醫師要澄清，取得攝護腺癌組織，是不會造成癌細胞擴散，有切片，才有助於對病患做出較好的治療判斷。

諮詢對象 台中榮民總醫院泌尿外科主治醫師歐宴泉、三軍總醫院泌尿外科主治醫師吳勝堂

• 手術多方發展: 攝護腺切除術, 腎臟手術, 小兒, 膀胱, 腎上腺, 婦科, 及婦女泌尿等方面手術.
• 實用報告改進預後的先進手術技巧.
• 多場機械手術現場轉播 包括: 根除性攝護腺切除術, 根除性膀胱切除術, 及部分腎切除術.
• Dr. Mani Menon利用三維立體高解析影像發表他的達文西攝護腺切除術病例報告
• 特別課程:腎臟手術, 根除性膀胱切除術, 及尿改流手術, 婦科手術, 小兒泌尿, 機械手臂手術開刀房管理, 及機械手臂手術的履行, 計畫, 及其經濟效應.

OR Live將從University of Michigan Health System傳播複雜性的子宮切除術教學, 病患有嚴重子宮內膜異位, 曾動過手術及子宮體積異大等複雜病史. 主刀醫師為Arnold P. Advincula, MD.

Dr. Advincula是婦產科副教授也是婦產科微創手術部門主任. 他將探討手術處理複雜病理的策略及如何充分運用達文西機械人系統的優點. Dr. Advincula會利用達文西機械人系統的四隻手臂完成全腹腔鏡子宮切除術.

美國FDA於2001年通過第一代達文西機械人系統並於2006年通過第二代達文西機械人系統. 達文西機械人不是自主性的, 達文西機械人是一套主僕系統, 它只依照主刀醫生的指示動作.

Surgical Tutorial on Complex da Vinci® Hysterectomy: http://www.or-live.com/daVinci/2270/#

日期: 2008年8月29日 星期五
時間: 18:40-19:30
地點: 台大醫院國際會議中心 201室
地址: 台北市徐州街2號

主講者:
林口長庚 吳俊德醫師
台中榮總 歐宴泉醫師
三軍總醫院 吳勝堂醫師
北市聯合醫院 忠孝院區 盧星華醫師 

CNN提到達文西攝護腺切除術過去幾年快速成長 已由2004年的10,000台增加到2008年的70,000台(預估)。其他運用達文西機械手術系統的術式還有子宮切除術、腎切除及一些心臟手術。

機械人手術的主要優點是較少手術副作用及回復期較短。

服務於亞特蘭大St. Joseph Hospital的Dr. Nikhil Shah已經完成600例達文西攝護腺切除術，Dr. Shah認為達文西是一個提高手術精準度的工具，可以減少對控制排尿及勃起神經的傷害，”我可以幫助男性保留尊嚴同時除去癌細胞” Dr. Shah表示。

研究發現達文西攝護腺切除術比傳統手術多出許多優點，失血量及傷口小是明顯地優點，但將達文西攝護腺切除術稱為治療攝護腺癌的”黃金標準”還言之過早。並不是所有病人都適合達文西攝護腺切除術，太過肥胖及癌細胞已擴散的病人就可能不適合。”跟你的醫師討論哪種治療方式適合你的病情是很重要的”Dr. Shah說。

達文西攝護腺切除術收費平均為美金$15000約新台幣47萬

http://edition.cnn.com/2008/HEALTH/conditions/08/05/robotic.prostate.surgery/#cnnSTCVideo

台灣有提供達文西攝護腺切除術的醫院為三軍總醫院、振興醫院、台中榮民醫院及林口長庚醫院。自費收費約為新台幣20萬。

去年秋天，醫生告訴我，我得了前列腺癌，他的口氣充滿同情又有些緊繃，彷彿料準我下一秒鐘會崩潰。

毋需擔心，我沒崩潰，而是立刻和他討論有哪些療法、結果各是如何。

一如既往，深入研究總能讓我擺脫擔憂。討論的結果，我們認為最好的療法是透過醫療設備製造商Intuitive Surgical生產的機器人動手術——一套稱為「達文西機器人」（da Vinci robt）的微創手術系統。（編按：微創手術指的是與傳統手術相較，手術的傷口小，因此對身體組織的破壞也較小的手術方式。）

我知道Intuitive Surgical這家公司是近來極為熱門的成長股之一，於是，我決定將得病這件事轉變成一項工作任務；我閱讀了一大堆醫學期刊，並且訪問很多很多醫生。

我還是沒辦法告訴你，我對自己得癌症的感覺；不過我可以告訴你，我對Intuitive Surgical這家公司的看法。

第二季營收出爐：較第一季成長逾五○％

Intuitive Surgical在七月二十三日公布的第二季財報顯示，該季營收較前一季成長超過五○％，再次優於市場預期，該公司股價當天立即大漲超過五十美元（編按：從每股二百八十美元上漲到三百三十一美元）。

目前Intuitive Surgical股價已經來到每股三百二十二美元（編按：七月二十五日收盤價），本益比以今年的獲利預估計算高達七十五倍，讓這支個股成為S&P五百當中，本益比最高的個股之一。

這麼高的比益比，反映出這家公司生產的「達文西機器人」，在機器人微創手術領域獨步全球的地位。

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本文未結束，請購買雜誌

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英文原稿如下

Robot Dreams

By BILL ALPERT

Prostate cancer put our man up close and personal with a surgical robot made by Intuitive. But does a terrific technology justify the stock’s valuation?

WHEN HE TOLD ME I HAD PROSTATE CANCER, my doctor’s tone was sympathetic and vigilant — as if ready to catch me should I collapse. He needn’t have worried. I instantly reverted to reporting mode, grilling him about treatments and outcomes. Diving into the research, I could escape my angst, just as I’ve always done. All the better, then, when it turned out the best treatment would be surgery with a robot from Intuitive Surgical . I knew it was one of the hottest growth stocks of our time. I was elated to find a way to turn my sickness into a work assignment. There were stacks of medical journals to read, doctors to interview.

I still can’t tell you how I feel about the cancer. But I can tell you about Intuitive. Its stock jumped more than 50 bucks Wednesday, after the Sunnyvale, Calif., company reported better than 50% growth in June-quarter sales and once again beat earnings estimates. At 322 each, the shares now go for more than 75 times trailing 12-month earnings, giving Intuitive one of the handsomest multiples in the Standard & Poor’s 500. That multiple reflects the alacrity with which surgeons have adopted the company’s da Vinci robot, a four-armed marvel the doctor controls from an operating-room console. Patients have less bleeding and scarring, and can get back on their feet without a long, expensive hospital stay.

But Intuitive’s volatile and pricey shares also bespeak the desperation of investors mobbing a quality growth story in a lousy economy and stock market. That momentum mob seems heedless of how suddenly this expensive stock could become a victim of the robot’s success.

You can gauge the market for robotic surgery better than you can for some other new technologies…like Google’s, for example. About 40% of the country’s large hospitals already have at least one da Vinci robot. When Intuitive (ticker: ISRG) finishes placing its robots, it will see a falloff in the systems sales that have contributed more than half of its revenue.

Sales of disposable instruments and accessories for each operation will continue, but the growth rate of those revenues will also decline once the da Vinci gets its share of the relatively fixed number of surgical procedures performed each year.

In its report last week, Intuitive allowed that procedure growth has slowed for the kind of robotic prostate surgery that I had last fall. The robot took seven years to garner the majority of the 90,000 prostate procedures conducted annually.

Robotics is gaining share more quickly in the rather larger market for hysterectomies and other surgeries performed by gynecologists.

But after that, there are only a handful of remaining high-volume procedures in the U.S. and abroad. Each of these additional kinds of procedures will contribute, perhaps, a buck a share in earnings from ongoing sales of instruments. That would just about offset the earnings hole from slowing sales of systems, leaving Intuitive with maybe the same $8 or $9 a share in annual earnings that Wall Street predicts for the next couple of years.

What stock multiple investors would put on such steady-state earnings is harder to predict. Shares of profitable medical-device makers that saturated their markets, like coronary-stent maker Boston Scientific (BSX), have settled into earnings multiples in the high teens. Even if that earnings arithmetic proves too stingy, Intuitive shares could fall by at least 25% once most people get their surgery robotically, as I did. The volatile stock has fallen as much twice this year already, as it changes among momentum investors’ fickle hands.

The company and its fans say growth is far from slacking. “We don’t think we are anywhere near saturation in anything,” says Intuitive’s vice president of finance, Benjamin Gong.

MY BIOPSY FOUND CANCER, BUT THE DISEASE probably hadn’t spread beyond the prostate. That made me a lucky cancer patient. By having the prostate cut out completely, I could probably get rid of the cancer. As with other surgeries, studies show that the doctors who do the most prostate procedures have the best success. So I began looking for a high-volume surgeon in the New York area. It’s exactly this sort of active search by patients that has driven market share to da Vinci procedures.

I found my way to Ash Tewari, the cheerful director of the robotic prostatectomy program at Weill Cornell Medical Center. Tewari does more than 600 prostate surgeries a year. Unlike other da Vinci surgeons I’ve interviewed, Tewari owns no Intuitive stock. “I want to keep my life simple,” he says.

He trained at Henry Ford Hospital in Detroit, where doctors perfected the prostate operation that put Intuitive on the road to success. Engineers had long tinkered with surgical robotics for NASA and the military, but it wasn’t until 1999 that Intuitive introduced a really useful system — the da Vinci.

Other minimally invasive tools can require that the surgeon stand and move awkwardly, lowering his hands to raise the instrument.

The da Vinci instruments have wrists, allowing the surgeon to work the controls more intuitively, while sitting comfortably at a console that gives a 12-times magnified, 3-D view of the surgical field. Hand tremors can be filtered out and movements scaled down. “It boils down to two things,” says Tewari. “I can see things better, and I can go into very narrow corners.”

Prostate surgery suits the robot. In a narrow area, the doctor must do a lot of precision work to avoid rendering the patient incontinent and impotent. Those possibilities scare guys into shopping around for the very best surgery. And the evidence so far shows that da Vinci prostate surgery is as good or better than the traditional approach.

I have only four small scars from my operation instead of a big gash. My recovery was quick. Tewari made me walk a mile in the hospital corridor before going home the day after surgery. He had me walk three miles a day thereafter. In a week, I was ready to go back to work.

Urologists rate prostate surgeries in terms of what they call the Trifecta: potency, continence and cancer control. Studies show that after da Vinci surgery, success rates are comparable to traditional open surgery for the first two measures. Cancer control takes longer to prove because prostate cancer develops slowly. It can take seven years to know if one kind of prostate-cancer treatment is failing more often than another, and the da Vinci has been in wide use for only a few years.

The early signs are good, however, with blood tests taken five years after surgery showing no evidence of recurrence in about 84% of da Vinci patients (whose cancers were caught when still confined in the prostate, like mine) — which is comparable to open surgery. Tewari says the most important factors in a successful outcome are the stage of the cancer and the skills of the surgeon, regardless of whether the surgeon uses the robot.

AS GUYS HAVE CLAMORED TO HAVE A ROBOT CUT out their prostates, da Vinci procedures have burgeoned. About 55,000 fellows around the world went under the da Vinci in 2007. With other kinds of da Vinci surgeries, there were a total of 85,000 robotic operations last year, an increase from 2006 of almost 75%.

That demand drives hospitals to invest in robot systems. The worldwide installed base of da Vinci robots grew 42% last year, to almost 800, with about 600 of those in North America. A system sells for more than $1.3 million. The hospital pays another $135,000 a year for service and support. Each procedure consumes $1,500 to $2,000 in disposable instruments and accessories.

Intuitive became profitable within a couple of years of its $9-a-share initial public offering in 2000. Revenue grew 61% in 2007, to $600 million. Of that revenue total, about 54% came from system sales, and the remainder was the recurring revenue from instruments and service.

Chief Executive Lonnie Smith has run a thrifty business. Gross margins on both systems and consumables are 70%. Operating margins are almost 35%, and if you add back noncash charges for stock options, cash margins from operations approach 45%. Net income in 2007 was about $140 million, or $3.70 a share.

Last week, when Intuitive reported its excellent financial results for the June quarter, the company raised its guidance for the current year. Revenues could grow 45% to 47%, to reach $871 million to $883 million. Investors received the news cheerfully, boosting the shares 18% to as high as 331. Analysts boosted their price targets. Tao Levy of Deutsche Bank increased his target from 360 to 365, arguing that the stock should trade at 46 times his estimate for the next 12 months’ earnings of about $7.90 a share.

Others are even more bullish. Lazard Capital Markets analyst Sean Lavin thinks Intuitive deserves a multiple of 60 times his 2009 earnings estimate of $7.05, yielding a price target of $420.

To get the stock to such levels, Intuitive has to sell a lot more da Vinci systems and doctors have to perform a lot more procedures. At investor meetings, Intuitive executives sketch out the number of systems they think they can sell.

The thousand largest hospitals in the U.S. (those with more than 325 beds) should be good for three systems each, says the company. The next thousand hospitals could have one da Vinci apiece. Hospitals in the rest of the world could buy 2,000 more, Intuitive says, for a worldwide total of 6,000 robots. Through June, the company had sold 946 da Vincis worldwide, so Intuitive thinks it has penetrated only 15% of the hospital market.

THE COMPANY’S MEASURE OF THE MARKET FOR ROBOTS may be far too optimistic. Jose J. Haresco, an analyst at Merriman Curhan Ford in San Francisco, thinks there’s room for about 1,800 da Vinci robots in the U.S. and 600 more abroad. Intuitive’s dream of three robots in every big hospital isn’t yet supported by the evidence. One hospital near me, in Hackensack, N.J., has five da Vincis. But the average among large hospitals so far is 1.3 robots each.

Early-adopter hospitals and surgeons have been able to keep their da Vincis pretty busy. My surgeon, Ash Tewari, for example, works two machines to capacity almost single-handedly.

In San Antonio, gynecologist Vincenzo Sabella and his associates have done hundreds of procedures with the two da Vincis at St. Luke’s Baptist Hospital. That hospital had an exclusive concession on San Antonio from Intuitive until just recently, says Sabella. All the other hospitals in town are now getting robots. As their exclusives expire, will Intuitive’s early adopters — and everyone else — keep as busy? For every high-volume program like Tewari’s in New York, there is a hospital that uses its robot only a few times a month.

The company, in its financial presentations, suggests that the world could keep 6,000 robots busy. Intuitive figures that consumables and service contracts could bring in $573,000 a year per system, resulting in $3.4 billion in annual recurring revenue. At today’s rate of $135,000 for annual service and the consumables average of $1,750 per procedure, those numbers imply five procedures a week per robot — which well exceeds today’s average of about three procedures.

Taking the company’s numbers and projecting a decline in research and selling expenses once the hospital market for robots is saturated, you’d have a profit of perhaps half that $3.4 billion a year. That generous calculus might justify today’s $13 billion market cap.

But those numbers imply that da Vinci surgeons would be carrying out 1.5 million procedures a year, worldwide It’s hard to get to such numbers using a bottom-up model of available surgical procedures. That kind of analysis points to only about one million procedures a year.

Consider some numbers from last Tuesday’s earnings call. While Intuitive raised its guidance for this year’s growth in total procedures from 55% to between 57% and 58%, it tempered its forecast for growth in prostate procedures — the company’s leading market — from 40% to between 35% and 39%. “No surprises here,” said CEO Lonnie Smith. “It’s just a matter of moving through the adoption curve.” The modified growth rate is still strong, but it suggests the da Vinci’s share gains in prostate surgery are slowing after reaching about two-thirds of the 90,000 in annual U.S. procedures.

Finance V.P. Ben Gong, and bulls like Deutsche Bank’s Tao Levy, are quick to change the subject to hysterectomies. There are an estimated 600,000 performed in the U.S. each year. Many of these procedures already qualify as minimally invasive; gynecologists pioneered surgery through laparoscopic key-hole incisions. Yet Intuitive thinks surgeons could use the da Vinci for about 250,000 complex hysterectomies currently done with open incisions.

“The learning curve is much more simple for the gynecological surgeon than for the urologist,” says Jeanne Hassebroek-Johnson, whose practice in Sioux Falls, S.D., has become known for its da Vinci surgery.

Gynecologists who don’t want to take time to become proficient with the da Vinci have argued that their long relationships with their patients will keep the patients from deserting them. Thomas Payne, with a busy da Vinci practice in Baton Rouge, La., scoffs at that argument: When women hear about the quick recovery that robotic surgery allows, they forget their loyalty to their gynecologist.

Intuitive predicts that the number of da Vinci hysterectomies performed this year will increase by 150% over last year’s 13,000. “We’re in the early stages of a very steep curve,” says Gong.

Gynecologists are starting to use the robot for other operations, too. The company hopes to get a fair share of the 60,000 annual surgeries for vaginal prolapse and the 55,000 operations for removing uterine fibroids. Outside of gynecology, the robot is seeing action in some of the 50,000 kidney-cancer surgeries and the 20,000 repairs of the heart’s mitral valve. The company won’t itemize these da Vinci procedures, but subtracting Intuitive’s 2008 forecast for prostatectomies worldwide (75,000) and hysterectomies (33,000) from the forecast total (135,000) suggests that all other da Vinci procedures could amount to 27,000.

Adding up the various kinds of procedures that Intuitive is currently targeting in the U.S., a very generous total might come to half a million da Vinci surgeries a year (see nearby table, The Limits of Innovation). That’s far below the 1.5 million implied by the bullish model.

INTUITIVE’S CHIEF FINANCIAL OFFICER, MARSHALL MOHR, urged me not to overlook the robot’s opportunities abroad. International sales have so far contributed a bit more than 20% of revenue, so there’s certainly upside. The system was approved just this month in China, and has yet to be approved in Japan. “We’re very early in the adoption cycle overseas,” Mohr says.

Many analysts predict that the international market for da Vinci procedures will prove slightly larger than that in the U.S. That would bring the worldwide opportunity above a million annual procedures, still well below 1.5 million.

Don’t allow my ungrateful scrutiny of Intuitive’s stock price to blind you to the terrific benefits that the company delivered to patients like me: less surgical trauma; a shorter and cheaper hospital stay; a quicker return to my supposedly productive work.

But those who buy the stock at these levels may find themselves abandoned by momentum investors when the da Vinci robot’s steep ascent levels off.