Robotic Surgery For Prostate Cancer

Prostatectomy: What To Expect During Surgery And Recovery

If youve been diagnosed withprostate cancer, your doctor will consider many factors before recommending the besttreatment. For many men, that may mean a prostatectomy. In this surgery,doctors remove the entire prostate.

The Johns Hopkins Hospital performs more of these procedures than almostanywhere else in the world. One of the most common questions they hear frompatients: What should I expect after surgery?

Johns Hopkins urologistMohamad Allaf, M.D., explains the surgery and recovery.

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Robotic Surgery For Prostate Cancer

If youre faced with the prospect of having surgery for prostate cancer, Brigham and Womens Center for Robotic Surgery at Brigham and Womens Faulkner Hospital can help get you back to feeling normal again.

If you and your doctor decide on surgery to treat your prostate cancer, you may be a candidate for a minimally invasive surgical procedure called robot-assisted laparoscopic radical prostatectomy. Radical prostatectomy is the surgical removal of the prostate to treat prostate cancer. The robot is a state-of-the-art surgical system, which includes fine instruments that a trained urologist uses to surgically remove your prostate gland through several small incisions.

For most patients, potential advantages with robot prostatectomy over open radical prostatectomy include:

• Improved visualization of the anatomy due to 3-D vision and increased magnification
• Small incisions . Precise, fine surgical maneuvers guided by the surgeon
• Less pain after surgery, decreasing the need for pain medications
• Faster recovery. Most patients are well enough to leave the hospital less than 24 hours after surgery and resume routine activities one to two weeks after surgery
• Removal of the urethral catheter five to seven days after surgery

Advent Of Robotic Surgical Technology

The next significant advance in the surgical treatment of localized prostate cancer was the development of robotic surgical technology. Initially developed by the United States Department of Defense for use in military battlefield applications, robotic technology was adapted for civilian use through the entrepreneurial efforts of 2 rival corporations, Intuitive Surgical, Inc, and Computer Motion, Inc. These companies simultaneously developed robotic interfaces for use in human surgical applications. Computer Motion, Inc, introduced the Zeus Surgical System at approximately the same time that Intuitive Surgical, Inc, developed its da Vinci Surgical System.

Both technologies relied heavily on a laparoscopic patient-robot interface in which instruments were placed through small trocars implanted in the patients skin. The working field was maintained predominantly by insufflation of the peritoneal cavity with carbon dioxide. Subsequently, Intuitive Surgical, Inc, acquired Computer Motion, Inc, consolidating the robotic surgical technology and making Intuitive Surgical, Inc, the sole provider of advanced robotic technology for use in human surgical procedures.

Several other companies also develop and manufacture robotic surgical technology, including single robotic arms for laparoscopic cameras or as part of integrated minimally invasive operating-room systems, but none of these rival technologies can compete with the advanced robotic engineering by Intuitive Surgical, Inc.

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Approaches To Radical Prostatectomy Surgeons Can Use Different Approaches And Techniques Toremove The Prostate They Can Make A Large Incision To Reach The Prostate They Can Also Use Laparoscopic Orrobotic Techniques Which Are Done Through Smaller Incisions In The Pelvis Laparoscopicand Robotic Types Of Surgery Are Less Invasive Than An Open Radicalprostatectomy Men Often Have Shorter Recovery Times Less Blood Loss Lesspain And Shorter Hospital Stays With These Procedures Retropubic Radicalprostatectomy Is Done Through An Incision In The Lower Abdomen The Surgeoncan Also Remove Lymph Nodes From The Pelvis Through The Same Incision Incanada A Retropubic Radical Prostatectomy Is The Most Common Approach Toremoving The Prostate To Treat Cancer

Perineal radical prostatectomyis done through an incision in the area between the scrotum and the anus. This surgery usually doesn’t take as long to do as aretropubic radical prostatectomy, but it may lead to more problems with gettingan erection . In addition, surgeons can’t removepelvic lymph nodes through the same incision so they would have to do aseparate procedure through a small cut in the lower abdomen to remove them.

Laparoscopic radical prostatectomyuses a laparoscope and other surgical instruments passed through small cuts. A laparoscopicprostatectomy has some advantages over an open radical prostatectomy, includingless blood loss and pain, shorter hospital stays, faster recovery and less timewith a catheter.

Robotic radicalprostatectomy is a type of robotic surgery. The surgeon sits near theoperating table and uses remote controls to move robotic arms. The robotic armshave tiny video cameras and surgical instruments that remove tissue throughsmall cuts. The robotic arms can bend and turn like a human wrist. A roboticprostatectomy also has advantages over an open radical prostatectomy includingless blood loss and pain, shorter hospital stays, faster recovery and less timewith a catheter.

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What Is The Difference Between Robotic And Laparoscopic Radical Prostatectomy

Both are minimally-invasive techniques of performing radical prostatectomy for cancer. In laparoscopic radical prostatectomy, the surgeon stands by the operating table and himself manipulates the instruments. In robotic prostatectomy the surgeon is seated at a robotic console near the patient from where he drive the robotic instruments to perform the operation. The robot faithfully and accurately reproduces the surgeon’s sophisticated maneuvers.

Why A Prostatectomy May Be Recommended In Your Case

As you already know, a prostatectomy is recommended for the removal of prostate cancer. This surgical procedure is performed on patients whose cancer is confined to the prostate. The procedure involves the partial or total removal of the prostate gland, along with the seminal vesicles. The seminal vesicles connect to the vas deferens and secrete semen.

Besides prostate cancer, there may also be other reasons for a prostatectomy, such as prostate bleeding, slow urination, urinary retention, bladder stones, etc.

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What Are The Risks Of Robotic Prostatectomy

The risks of robotic prostatectomy are about the same as with an open prostatectomy. The two biggest risks are leaking of urine and erectile dysfunction . Leaking of urine called urinary incontinence usually occurs in the days after surgery but gradually improves. Over 95 percent of men will regain good bladder control. ED is not being able to get or keep an erection. The likelihood of ED after surgery depends on a mans age and how sexually active he was before surgery. Most men experience only temporary ED.

Figure 2 Practice Makes Perfect

The likelihood that a surgeon performing laparoscopic prostatectomy will have to switch to open abdominal surgery in order to complete the operation goes down significantly with practice, measured in the number of operations performed.

Source: Journal of Urology, July 2005.

Did he mention anything about the visualization of the neurovascular bundles?

Yes, he felt pretty confident that with the increased magnification, he would be able to move them aside, and remove the prostate with no problem. He said, If the cancer has spread into the seminal vesicles, then obviously we have to deal with that. And we wont know until the operation. But he seemed pretty confident that after the operation Id be in good shape.

Did you consider having robotic surgery closer to home?

You know, I did look into it. But I did some research, and it looked like there werent many people doing this at the time in the city where I live, and they didnt have a lot of experience. One surgeon had done 50 of these operations. The doctor I met with had done about 400. So Im thinking, Okay, 50 versus 400. I think Ill go with the guy whos done 400.

What kind of logistics were necessary, with you being in one city and the operation being done in another?

There were some logistical challenges. I ended up doing the preoperative testing at a hospital near my home, and then had it sent to the surgeon in the other city. He was willing to accept their medical tests.

How long did you have it in place?

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Sex After Surgery To The Prostate Gland

When your prostate gland is removed, you will still make sperm, but it wonât come out through your penis. It will be absorbed back into the body. You may also have problems with erections or lose interest in sex after prostate surgery. Although you may feel embarrassed, doctors who deal with prostate cancer are very used to talking about these issues and will be able to give you advice. There are treatments that can help with this.

How Many Robotic Prostate Surgeries Has Dr Samadi Performed

Dr. Samadi has unparalleled experience in robotic prostate removal surgery. He has successfully removed over 7000 cancerous prostates with his novel SMART Surgery for robotic prostate removal. He conducts every surgery himself from start to finish. Preservation of sexual function, urinary control, and quality of life after prostate cancer are his top priorities.

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Quicker Recovery Period After Robotic Prostatectomy

When a physician determines robotic prostatectomy is the best prostate cancer treatment option, da Vincis robotic technology optimizes the chances of a quicker recovery time as opposed to traditional surgical prostatectomy. The smaller incisions required to maneuver the operating arms heal much faster require fewer sutures, and, therefore, are less vulnerable to tearing or infection.

The precise movements of the robotic arms allow a more targeted approach for cleaner removal of malignant tissue and reducing damage to healthy tissue during robotic prostate surgery. The operating arms of the da Vinci Surgical System are designed to avoid contact between the operating instruments and the walls of the incision. All of these advantages translate to a speedier and less worrisome recovery period.

Prostate surgery recovery time is substantially improved in comparison to open prostatectomy. As mentioned earlier, the much larger incision required in open surgery means pain is greater and recovery takes longer. Dr. Samadis prostate surgery takes just 1.5-2 hours and almost all of his patients return home the day after having a robotic prostatectomy. Around 80% of open prostatectomy patients leave the hospital within the first week.

What Are The Benefits To Patients Who Have Laparoscopic And Robotic Prostate Cancer Surgery

The benefits are similar between robotic and laparoscopic prostate surgery. Patients are usually able to go home the day after prostate surgery, and can return to daily living activities as early as 7-10 days after surgery. Patients undergoing open surgery generally have 4-6 weeks before they can resume routine daily living activities, generally experience less post-operative pain and discomfort and have a faster recovery. They also experience significantly less intraoperative bleeding. Robotic and laparoscopic prostatectomy uses small incisions and is highly precise the risk of incontinence is low and the surgical technique is continuously refined to improve potency.

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We Are Ready To Support You

Like many surgeries for cancer, this is a life-changing procedure that changes how the body functions. It is normal to experience some changes in the way you see your body and the way you feel. There are many resources that are available to help you cope with the way you feel and how to cope with these changes.

Our Primary Goal Is Cancer Cure

Overcoming cancer is our goal. Secondary goals, which also critically important, include speedy physical recovery, continence recovery, and erection recovery. Statistically, 10% of men can have an erection that supports intercourse within six weeks following surgery. About 50% of men reach this level of function at six months and about 85% will achieve normal function at one year. Recovery of erections is affected by the level of function before the surgery, age of the patient, the presence of other medical problems like diabetes and high blood pressure, while smoking, alcohol intake, stress, your partner, and a few other things are also a factor. In short, it is complicated.

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One Month After Surgery

After a month, most men will be able to return to work, and their operation site will be near healing. Despite this, its recommended that men refrain from strenuous activity, prolonged activity, or activities that may disrupt the operation site for at least 6 weeks.

Some examples of these activities are:

Running Also, try not to sit in one position for longer than 45 minutes.

What Will The Patient Experience After Surgery

We usually take our patients to our intensive care unit immediately after surgery and follow them there for about 6-8 hours. Then we take the patient to his single room in the service. After coming to the patients room, the patient starts taking nourishment orally.

If the bowel sounds of the patient can be heard on the morning of the 1st postoperative day, the patient begins to consume fluid foods. If the patient has pain, painkillers are administered . We ask patients not to walk around as much as possible.

Patients usually switch to normal eating on that day. On the 2nd postoperative day, the drain of the patient is removed and he is discharged if there are no complications.

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The Robotic Prostatectomy Has Higher Survival Rates

Recently, following a study published by the European Association of Urology, radical prostatectomy has been shown to have a survival rate higher than that of patients who choose to undergo radiotherapy.

Currently, the therapeutic option in prostate cancer is strongly influenced by the patient and personal preferences and experience of the treating physician.

But here are survival rates of the patients that had implemented a prostatectomy and other types of treatments:

• prostatectomy 78.1-97.2%
• other therapies 71%

Rise Of Robotic Radical Prostatectomy

Menon et al from the Vattikuti Urology Institute at Henry Ford Hospital in Detroit, Michigan, are responsible for the development and popularization of robotic radical prostatectomy. This technique has been gaining widespread acceptance in the United States and Europe and is increasing in penetration worldwide. Robotic radical prostatectomy offers the advantages of the minimally invasive laparoscopic approach but shortens the learning curve, facilitating and hastening mastery of the procedure.

Although solid basic laparoscopic skills are required for access and assistance, the console surgeon role requires less laparoscopic skill. Therefore, the procedure is accessible to experienced open-procedure surgeons with minimal or no laparoscopic experience. In a published report, Badani et al have performed more than 2700 robotic prostatectomies and have reported a mean operative time of 154 minutes, a mean blood loss of 100 mL, and hospital stays of less than 24 hours in 96.7% of patients.

The following image provides a portion of a minimally invasive radical prostatectomy.

Go to Prostate Cancer and Laparoscopic Pelvic Lymph Node Dissection in Prostate Cancer for more information on these topics.

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Equipment For Robotic Radical Prostatectomy

Currently, the only available integrated robotic surgical system is the da Vinci Surgical System . This computer-aided system has a basic master-slave design. A second generation of this system is currently available .

The surgeon console

This is the user interface of the robot for the surgeon and consists of the following:

• Display system: The system is a 3-D stereoscopic display for the console surgeon and is generally available for view in 2-D form by assistants and observers.

• Master arms: These are the controls the surgeon uses for making surgical movements. Movements of the master arms translate to real-time movements of the instrument tips and may be scaled for fine movements. The master arms also provide basic force feedback to the surgeon but are limited in their ability to discriminate complex haptic feedback. Camera movements are controlled with a clutch mechanism. In the 4-arm systems, the surgeon can toggle between instruments.

• Control panel: The control panel is used to adjust the surgeon console display and control options. The control panel allows toggling between 2- and 3-D display, adjusting various levels of scaling, and choosing the camera perspectives .

• Central processing unit: This is the computer that controls the system and integrates and translates robot control inputs from the surgeon.

Robotic arms

Laparoscopic Prostate Cancer Surgery

Transurethral resection of the prostate, also known as laparoscopic prostate surgery , is one of the most common and oldest surgical procedures performed in cancer treatment. Today, it is still performed in many clinics, depending on the preferences of the surgeon and the physical conditions of the hospital.

This procedure is performed in two ways as using a scalpel to remove prostate tissue or using an electro-resection device called resectoscope, which is equipped with an electric wire loop to remove tissue .

Endoscopic prostate surgery is a procedure performed by accessing the prostate area through the penis. With the help of a camera, the image of the area being operated is transmitted to the monitor. The operation is followed on the monitor. This time, the parts blocking the way are removed in pieces.

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