Da Vinci Robotic Prostatectomy is used in treatment of prostate cancer. Using this method, the surgeon is able to perform Laparoscopic Radical Prostatectomy with great precision. Da Vinci Robotic Prostatectomy is the most accurate and precise way to surgically treat prostate cancer. This robotic system utilizes a three dimensional viewing system and endowrist technology to provide the surgeon with incredible ability to navigate the male pelvis, dissect the prostate, save the neurovascular bundles, and preserve the pelvic floor muscles.
Da Vinci Robotic Prostatectomy results in high cure rates for prostate cancer, while minimizing side effects of surgery. This minimally invasive prostate surgery for prostate cancer is associated with less blood loss, faster recovery, less pain, faster return of continence, and faster return of erections.
Nerve Sparing Prostatectomy is performed very accurately with the Da Vinci Robotic System. Therefore, development of long term impotence is unlikely with the use of the Da Vinci Robot in performing Laparoscopic Prostatectomy.
Bladder Neck Sparing Prostate Surgery is also performed more accurately using the Da Vinci Robot. The pelvic floor muscles are visualized and dissected very accurately, thus preventing injury to these delicate muscles. Subsequently, Da Vinci Robotic Prostatectomy results in faster return of continence and bladder control.
It is very important that this surgery be performed by highly skilled robotic surgeons. Cancer cure, negative margins, nerve bundle preservation, bladder neck preservation, and quality of life preservation are direct results of a surgeon's level of experience.
Robotic Prostatectomy
Questions and Answers
What is Robotic Laparoscopic Prostatectomy?
This is a minimally invasive laparoscopic procedure performed for early stage (clinically confined) prostate cancer, done by placing pencil thin instruments and a camera through small incisions with the aid of surgeon controlled robot. A large abdominal incision is avoided and open surgery is avoided. In this procedure the prostate gland and seminal vesicles are removed intact (in one piece), and in proper candidates, the nerves for
sexual function are preserved. In selected patients, the pelvic lymph nodes that may contain spread of prostate cancer are also removed.
A small telescope is placed into the abdomen through the umbilicus and pencil thin instruments are introduced via small incisions in the abdomen. The operation is performed by the surgeon controlling these microscopic instruments, gently freeing the prostate and seminal vesicles and avoiding trauma to the surrounding tissue. The prostate and seminal vesicles are removed intact (in one piece) and delivered outside the body through the umbilicus. Lymph nodes are similarly removed. The bladder is then attached back to the urethra. Nerve Sparing Prostatectomy is accurately accomplished to maintain the patient’s pre-surgical level of sexual function and erections.
In the hands of experienced surgeons, the state-of-the-art Da-Vinci surgical system has made this procedure extremely precise. This computer enhanced surgical system is comprised of two components, robotic arms that hold the pencil thin surgical instruments, and a surgeon’s console that controls the robotic arms. The robot’s surgical instruments move to the direction of the surgeon’s hands, while the surgeon views the operative field
through a 3-D TV screen. The tips of these tiny instruments have six degrees of freedom, allowing for movements like a tiny wrist around the prostate. Non-robotic surgical instruments (open or laparoscopic) cannot move in this manner and do not have this degree of range of motion and flexibility. The highly magnified 3-D viewing screen allows the surgeon to feel “immersed” within the patient, allowing for better visualization of the surgical field than open or standard laparoscopic surgery. There is more
precise differentiation between healthy and diseased tissue, thereby making this surgery highly effective in curing prostate cancer. In effect the surgeon accurately removes the prostate and pelvic lymph nodes, while preserving the vital structures such as the neurovascular bundles responsible for erections and pelvic floor muscles responsible for quick recovery of bladder control.
Is Robotic Laparoscopic Prostatectomy experimental?
No. This procedure is FDA approved. Over 50,000 Robotic Prostatecotmies have been performed in the United States in the past 5 yrs. RLP is the fastest growing field in prostate cancer treatment. In 2005 340,000 Robotic Prostatectomies were performed. More and More surgeons are learning how to do this procedure.
Why is it necessary to be able to feel the prostate in open surgery but not in robotic surgery?
In open surgery, the surgeon relies on feeling the prostate and surrounding tissues, because of difficulty in visualizing the vital structures deep in the pelvis. Since the prostate is located underneath and deep to the pubic bone, the prostate and tissues surrounding it are difficult to see. Therefore, surgeon has to rely on “feeling” his/her way around the prostate for a successful surgery.
In Robotic surgery, the camera can be placed underneath the pubic bone or any other location deep in the pelvis and near the vital structures. The field of vision is 3-Dimensional and magnified 15 times. The robotic viewing screen allows for the surgeon to be virtually placed inside the patient’s body. Since the surgeon’s visualization is far superior in robotic surgery than in open surgery, the need for “feeling the tissues” is a mute point.
Do all Urologists perform Robotic Laparoscopic Prostatectomy? No. Since laparoscopic robotic prostatectomy is only about 7 years old, most urologists have not been trained in this advanced type of surgery. Consequently, they are unable to offer robotic surgery as a treatment option.
What qualifications are important in a surgeon who performs Robotic
Laparoscopic Prosatectomy?
Qualifications of the surgeon should include experience, excellent results, and a desire to mend a personal relationship filled with compassion and personal attention towards the patient. It takes a large number of Robotic Prostatectomies before a surgeon would be considered highly experienced and skilled in performing such operations. A highly qualified surgeon must have done at least 150 Robotic Prostatectomies. He or She must be willing to share his/her personal results. Furthermore, as a physician, the surgeon must make a personal relationship with the patient, and not view the patient as another opportunity to do surgery. A patient with prostate cancer deserves respect, compassion, and personal attention by his doctor.
Is it true that the surgeon can see better with robotic surgery than open surgery for prostate cancer?
Yes. The field of visualization is better with robotic surgery for three reasons.
1. The location of the prostate makes it difficult to visualize in open surgery. The prostate is located deep in the pelvis, underneath the arch of the pubic bone, which is very wide. In open surgery, a long incision is made to ease the field of visualization. However, the surgeon is still forced to rotate his/her head in order to see underneath the arch of the pubic bone. The urethra and the muscles that wrap around the urethra are even deeper under the arch of pubic bone and not seen very well. This increases the chances of injury to these structures and causing post operative incontinence. On the other hand, the robotic telescope which is placed in the abdomen can be moved anywhere within the vicinity of the prostate and the pelvis. Therefore, one can see the prostate and other vital organs much better. In fact one can even see underneath the prostate, which is not a possibility with open surgery. The muscles that wrap around the urethra, the urethra itself, and the nerves that control erection are visualized much better, making this method a more accurate surgery. It is important to note that an experienced surgeon in robotic prostatectomy can better understand the anatomy and the vital structures under vision than a surgeon that has recently started to perform robotic surgery.
2. There is less blood loss in robotic laparoscopic prostatectomy as compared to open surgery. The average blood loss in open surgery is around 500 to 1000 cc’s (16 to 32 ounces). The average blood loss in robotic laparoscopic surgery is 150 to 250 cc (3 to 8 ounces). The chance of needing a blood transfusion with robotic prostatectomy is less than 1%, while it is about 10% -15% in open surgery. Since less blood accumulates
around the prostate in robotic laparoscopic surgery, the field of vision is cleaner and better visualized.
3. Field of surgery is highly magnified in robotic surgery. The 3-dimensional robotic telescope (laparoscope) magnifies the field of surgery 15 times greater than open surgery. This makes the field of surgery even \more accurate and better seen than open surgery. To compensate for this difference, some open surgeons use “surgical loops” or magnifying lenses during open radical prostatectomy. These loops usually magnify the field by two to five times, still not as high as robotic surgery. Field magnification can
help the surgeon dissect the vital structures such as neurovascular bundles (for erection) more accurately.
Can nerve sparing surgery be done with Robotic Laparoscopic
Prostatectomy?
Yes. Nerve sparing surgery can be done with a high degree of accuracy using the Da-Vinci Robotic Surgery system. This system allows for accurate nerve dissection for many reasons. The field of surgery is magnified 15 times, making it easier to recognize the small, delicate neurovascular bundles. Also, the tips of the microscopic instrument can turn, swivel, bend, and rotate, just like the human wrist. This is known as the “Endowrist Technology”. The ability to have wrist like movement around the prostate
gland allows the surgeon to dissect the neurovascular bundles more accurately. In experienced hands, nerve sparing surgery can be successful in as much as 90% of men.
What are the advantages of Robotic Laparoscopic Surgery?
1. Faster recovery
2. Very little pain
Patient can walk the same day
Patient may exercise such as playing golf or tennis within one week
Patient may drive in 2 days
Faster return to bladder control
Less incontinence
Excellent chances for return of erections
Earlier removal of urinary catheter:
5 days after surgery versus 2 – 3 weeks with open surgery
3. Very little bleeding: less than 1% chance of transfusion
Not Disfiguring: incisions are very smal
Excellent chance of prostate cancer cure
Very small rates of positive margins
What are important factors in choosing a doctor?
1. Must be a Board Certified Urologist
2. Fellowship trained in minimally invasive surgery
3. Fellowship trained in Oncologic (cancer) surgery for the urinary tract
4. Must have done at least 200 cases
5. Must be willing to provide patients with personal results on
a. Rates of continence
b. Rates of potency
c. Rates of negative margins
d. Complication rates
6. Must work at a center of excellence and robotic surgical team
7. Must have a skilled assistant surgeon
8. Must be able to provide personalized attention to patients
Robotic Prostatectomy
Who is a candidate?
Must have clinically confined prostate cancer:
A patient's prostate cancer should be in the early stages of cancer, meaning that there is no evidence of cancer spread and no extension of the cancer beyond the prostatic capsule
Should have at least a 5 to 10 year life expectancy
In general prostate cancer surgery is recommended for those who are healthy enough that would likely live more than five to ten years, if their cancer is cured.
Patient with the following conditions are also eligible to
undergo robotic prostate surgery
Morbid obesity
Previous surgery for prostate like TURP
History of hormone therapy
Previous radiation for prostate cancer
High grade prostate cancer (gleason 8 -10)
Previous history of heart disease
Statistics
Prostate cancer is one of the most common cancers in men. About 140,000 new prostate cancers are diagnosed yearly in the U.S. and about 40,000 men die of prostate cancer each year. It is estimated that one in every ten men in the U.S. will develop prostate cancer in his lifetime.
Risk Factors
Age- As a man ages, his risk of developing prostate cancer increases
Age Risk (%) Risk (ratio)
40 0.01% 1 in 10,000 men
50 0.3% 1 in 333 men
55 1% 1 in 100 men
60 2.5% 1 in 40 men
65 5.1% 1 in 19 men
70 8.5% 1 in 11 men
75 12.0% 1 in 8 men
80 14.8% 1 in 7 men
85 16.6% 1 in 6 men
90+ 17.5% 1 in 5 men
Family History- Having one first degree relative (brother or father) with prostate cancer doubles the risk of developing prostate cancer. If a person has more than one first degree relative with prostate cancer, his risk will increase four to nine fold.
Ethnicity- African Americans are at highest risk for developing prostate cancer. Asian Americans have the lowest risk.
Hormones- Prolonged exposure to testosterone is believed to be associated with prostate cancer. Testosterone is a hormone made naturally by the testicles and adrenal glands. Testosterone is responsible for development, growth, and preservation of a man’s
sexual organs, hair pattern, muscle/bone density, and sexual drive. Men who lose both testicles before puberty have virtually no chance of developing prostate cancer.
Minimally Invasive Surgical Methods for Prostate Cancer
• Da-Vinci Robotic Laparoscopic Prostatectomy
• Standard Laparoscopic Prostatectomy
Standard Laparoscopic Radical Prostatectomy (LRP)
This is a minimally invasive procedure that removes the entire prostate like open surgery, but is associated with minimal pain and faster recovery. In this procedure, a small telescope is placed into the abdomen through the naval. Pencil thin instruments held by the surgeon are introduced via small incisions in the abdomen. Using these microscopic instruments, the surgeon performs the operation, removing the prostate and seminal vesicles, while avoiding trauma to the surrounding tissue. The prostate and seminal vesicles are removed intact (in one piece) and delivered outside the body through the naval. A nerve sparing procedure can be performed to maintain the patient’s pre-surgical level of sexual function.
Advantages of Da-Vinci Robotic Laparoscopic Prostatectomy
Since this is a minimally invasive procedure, there is relatively less pain and faster recovery compared to open surgery. Furthermore, the 3-D imaging and the Endowrist technology makes the surgery more accurate and precise than open or standard non
robotic laparoscopic prostate surgery. This results in higher chance for cancer cure,
more precise dissection of nerve bundles and preservation of erectile function.
There is also less blood loss and shorter hospital stay. Patients usually stay 1 to 2 days in the hospital, followed by 2-3 weeks of recovery at home before resuming all normal activities. Many patients return to work and sports activities such as running, weight lifting, golf, tennis within two weeks after surgery.
Nerve Sparing Prostatectomy is accomplished with high degree of accuracy. Patients have an excellent chance at maintaining their sexual function, thus avoiding long term impotency. Bladder Neck Sparing techniques can also be used. This allows faster recovery of urinary control. Subsequently, patients regain bladder control very quickly after DVP.
As with open surgery, this technique is highly effective and offers a high chance of cure from prostate cancer. Some urologists would argue that surgery results in the highest chance of cure from prostate cancer. Da Vinci Robotic Laparoscopic Prostatectomy (DVP) achieves rapid removal of PSA from blood stream, and provides accurate information on the true stage and grade of the cancer, including the status of lymph node involvement
The patient will know if he is cancer free within a month after surgery, as opposed to up to two years after radiation. Upon removal of the prostate gland and the cancer, the PSA rapidly drops and reaches an undetectable level within a month. Therefore, the patient can rest assured of his cancer free status very early after surgery.
Because this surgery is minimally invasive, many of the disadvantages associated with open surgery are alleviated. Patients are relatively pain free. There is relatively much less chance of bleeding complications. Da-Vinci Prostatectomy is an excellent surgery for Jehova’s Witnesses with prostate cancer. Those who want to avoid the need for transfusion, are excellent candidates for this procedure, since it is associated with minimal blood loss. Furthermore, return of bladder control, resolution of incontinence, and return of erections generally occur rapidly.
Disadvantages of Da-Vinci Robotic Prostatectomy
This procedure is highly technical. Most physicians performing prostate surgery have not been trained in this procedure. Therefore, it is not available at all locations, requiring the patient to travel to an experienced surgeon and robotic surgery center. It is recommended that these procedures be performed by urologic surgeons trained in oncologic surgery with extensive laparoscopic and robotic surgical experience. It is recommended that the surgeon performing robotic laparoscopic prostatectomy have done at least 200 of these procedures. The procedure should be done at centers of excellence, supporting high tech robotic programs. Although adverse effects are rare, they could include incontinence, erectile dysfunction, possible formation of blood clots in the leg veins, and infection.