Progression Of Laparoscopic Radical Prostatectomy
The first successful laparoscopic radical prostatectomies were performed by Schuessler in 1992 and 1997. Unfortunately, the technique did not gain widespread acceptance because of its extreme technical difficulty and because it offered no advantage over the criterion standard of open radical retropubic prostatectomy. The initial series reported operative times that ranged from 8 to 11 hours and a mean hospital stay of 7.3 days.
The laparoscopic approach gained new attention when 2 French groups published their experience with laparoscopic radical prostatectomy in 1999 and 2000. They reported modifications to the original technique, resulting in operative times that ranged from 4 to 5 hours and had a mean blood loss of 402 mL. The authors also reported a decreased mean hospital stay, due predominantly to earlier removal of the Foley catheter.
Even in the hands of these skilled laparoscopists, nerve-sparing dissection and construction of the urethrovesical anastomosis were demanding. With advances in medical technology, improved optics, and the widespread use of new laparoscopic instrumentation such as ultrasonic cutting and coagulating devices , laparoscopic radical prostatectomy began to gain acceptance and was increasingly performed in several high-volume centers worldwide. However, the technical demands of laparoscopic radical prostatectomy prevented its widespread use by the average urologist and thus limited penetration.
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An operation called a radical prostatectomy has long been a mainstay of prostate cancer treatment. Offered most often to men whose cancer has not yet begun to spread, it involves removing the entire prostate gland, and can be performed in different ways. With the traditional open method, surgeons remove the prostate through an 8- to 10-inch incision just below the belly button. Alternatively, surgeons can perform a robot-assisted radical prostatectomy. With this approach, miniaturized robotic instruments are passed through several much smaller incisions in the patients abdomen. Surgeons control these instruments remotely while sitting at a console.
At least 85 percent of all radical prostatectomies in the United States today are performed robotically. But how do those high-tech surgeries compare with the traditional open method?
Most studies show no major differences between the procedures in terms of patient survival or their ability to control prostate cancer over the long term. Robotic prostatectomies ostensibly offer quality-of-life advantages for urinary function and sexual health. However, the supporting evidence comes mostly from doctors reports, insurance claims-based data, or studies too small to generate definitive conclusions.
Now, results from a much larger comparative study provide needed clarity.
Types Of Radical Prostatectomy
The prostate gland lies just under the bladder, in front of the rectum. Surgeons choose from two different approaches to reach and remove the prostate during a radical prostatectomy. One is a traditional approach known as open prostatectomy. The other, more recent approach is minimally invasive. There are two minimally invasive procedures used in radical prostatectomy: laparoscopic prostatectomy and robot-assisted laparoscopic prostatectomy.
Open prostatectomy
In this traditional method of radical prostatectomy, the surgeon makes a vertical 8- to 10-inch incision below the belly button. Radical prostatectomy is performed through this incision. In rare cases, the incision is made in the perineum, the space between the scrotum and .
Laparoscopic prostatectomy
In laparoscopic prostatectomy, surgeons make several small incisions across the belly. Surgical tools and a camera are inserted through the incisions, and radical prostatectomy is performed from outside the body. The surgeon views the entire operation on a video screen.
Robot-assisted laparoscopic prostatectomy
Small incisions are made in the belly, as in regular laparoscopic prostatectomy. A surgeon controls an advanced robotic system of surgical tools from outside the body. A high-tech interface lets the surgeon use natural wrist movements and a 3-D screen during radical prostatectomy.
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What Makes The Robotic Prostatectomy A Superior Prostate Cancer Treatment
The da Vinci robotic prostate cancer surgery system is able to provide superior clinical prostate cancer treatment results when compared to non-robotic traditional and scope-assisted procedures.
This is because the da Vinci systems Surgeon Console is equipped to provide the surgeon with a revolutionary, three-dimensional, multi-level magnification spectrum.
More traditional scope-assisted surgery typically provides a much lower resolution image, and a far more limited field of vision. Furthermore, the da Vinci systems sensitive electronics and one-centimeter diameter surgical arms allow the surgeon to make highly precise movements inside the incision during robotic prostate cancer surgery. This means that the malignant tissue can be removed with efficiency and ease unheard of prior to the era of robotic surgery. This greater precision reduces the likelihood of relapse due to missed cancerous tissue.
The precision of the da Vinci system also allows the prostate surgeon to avoid damaging healthy prostate tissue, which improves clinical results, reduces scar tissue build-up, and contributes to an overall shorter recovery period after robotic prostatectomy.
Different Types Of Radical Prostatectomy
There are various types of radical prostatectomy.
- Radical prostatectomy with the retropubic approach
This is the most common type of radical surgery performed by most urologists. By means of this procedure, the surgeon can even remove the lymph nodes if they are also affected by prostate cancer.
If cancer has spread into the nervous area, there may be fewer chances to spare the nerves that are related to erection production. In this case, the surgeon may need to cut the nerves on both sides of the prostate, thus losing the erectile function. But if cancer has not spread to the nerves, then the erectile function may come back to normal in a short while.
- Radical prostatectomy with the perineal approach
Radical prostatectomy with the perineal approach is used less often than the prostatectomy with the retropubic approach. By using this surgical technique, the nerves can not be spared. Also, the lymph nodes can not be removed. However, the advantage of this procedure is that is less time-consuming. Also, it is recommended for men who may not benefit any more from nerve-sparing. Al factors need to be taken into account, as the perineal approach is more painful and esthetically not so good looking.
- Laparoscopic radical prostatectomy
Laparoscopic radical prostatectomy involves several small incisions through which small instruments are being introduced with a video camera inside.
- Robotic radical prostatectomy
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What You Need To Know About Prostate Surgery
What is prostate surgery for?
The prostate is a gland located underneath the bladder, in front of the rectum. It plays an important role in the part of the male reproductive system that produces fluids that carry sperm.
Surgery for partial or complete removal of the prostate is called a prostatectomy. The most common causes for prostate surgery are prostate cancer and an enlarged prostate, or benign prostatic hyperplasia .
Pretreatment education is the first step to making a decisions about your treatment. All types of prostate surgery can be done with general anesthesia, which puts you to sleep, or spinal anesthesia, which numbs the lower half of your body.
Your doctor will recommend a type of anesthesia based on your situation.
The goal of your surgery is to:
- cure your condition
- maintain the ability to have erections
- minimize side effects
- minimize pain before, during, and after surgery
Read on to learn more about the types of surgery, risks, and recovery.
The goal of prostate surgery also depends on your condition. For example, the goal of prostate cancer surgery is to remove cancerous tissue. The goal of BPH surgery is to remove prostate tissue and restore the normal flow of urine.
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Difficulty Getting An Erection
Impotence is more likely to happen if you are older. Nerve sparing surgery and robotic surgery may reduce the risk for some men. Speak to your doctor before you have surgery to get an idea of your risk of problems afterwards.
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* Minimal Blood Loss With Da Vinci Robotic
The average estimated blood loss per patient averages 116 cc. This volume is roughly the 1/3 of the volume of a 12 oz. soda can. Estimated Blood loss has ranged for robotic patients from 25cc to a maximum of 400 cc in the 1st 100 patients. Because of these low blood losses, none of these men required a blood transfusion, nor were they asked to donate autologous blood prior to surgery.
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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Surgical Robots Developed By Vanderbilt Researchers Could Make Radical Prostatectomy Safer And Less Invasive
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Researchers at the Vanderbilt Institute for Surgery and Engineering have developed a minuscule robot that could revolutionize surgical procedures for treating prostate cancer, which affects one in nine men in the United States. Using a lifelike model, the team demonstrated that the surgical robot could not only remove the prostate gland and tissues through the urethra, but also accomplish the difficult step of suturing the bladder to the urethra.
The article describing their research, Transurethral Anastomosis After Transurethral Radical Prostatectomy: A Phantom Study on Intraluminal Suturing With Concentric Tube Robots, was in the journal Institute of Electrical and Electronics Engineers on Oct. 29.
A typical radical prostatectomy, which is the standard treatment for prostate cancer, requires cutting through the abdomen to reach the prostate. This cutting and exposure of healthy tissue and nerves can cause incontinence and erectile dysfunction in some who undergo the procedure. There are no current alternative endoscopic removal techniques because there are no available instruments that allow surgical dexterity at such a small scale.
The research was funded by the NIH grant R01 EB026901.
Surgeon Console For Robotic Prostatectomy
The surgeon operates while seated comfortably at the da Vinci Surgeon Console, an ergonomically designed console viewing a 3-D image of the operative site. As the surgeon moves his hands, wrists, and fingers, the instruments are performing the same movements inside the patients body.
The da Vinci Robotic System is able to scale the doctors motions and translate them into the operating arms during robotic prostate surgery.
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What The Study Found
According to the results, both methods were equally effective at removing cancer from the body, and post-surgical complications between them occurred relatively infrequently. However, there were some short-term differences between the two approaches. For instance, the robotically-treated men had shorter lengths of hospital stay , and they also reported lower pain scores after surgery. Men who underwent robotically-assisted surgery also reported fewer complications such as blood clots , urinary tract infections , and bladder neck contracture, which is a treatable condition that occurs when scarring in the bladder outflow makes it hard to urinate. In all, 45 men experienced a bladder neck contracture after open surgery, compared to nine men treated with the robotic method.
This is an excerpt from an article that appears on the Harvard Health Publishing website.
What Is A Robotic Or Laparoscopic Radical Prostatectomy
Now routine procedures at Cleveland Clinic, laparoscopic or robotic prostatectomy are minimally invasive surgery procedures used to remove the prostate. Both forms of surgery are now routinely offered at the Cleveland Clinic to patients with prostate cancer. Our single-institution experience now exceeds 1000 cases of laparoscopic and robotic prostate surgery performed.
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Benefits Of Robotic Surgery Over Open Surgery
Robotic arms are steadier than any human hand. The wrists of a robotic arm can move in all directions and angles. These advantages along with the magnified view result in these advantages compared to traditional open prostatectomy:
- Less pain after surgery
- Time spent in hospital is as short as one or two days
- Faster recovery at home and 90% of patients return to regular activities in only two to three weeks
- Less need for narcotic pain medication
Rocco And Van Velthoven Anastomosis
We utilized the Rocco stitch as we believe it simplifies anastomosis and significantly reduces postoperative hematuria and reduces bladder neck contractures . A 3-0V-lock begins at the bladder incorporating the cut edge of Denonvilliers and then the posterior bladder detrusor. The next suture is intended to incorporate as much of the muscular structural support behind the urethra as possible. We stress that only the bladder is pulled toward the urethra to avoid pulling and tearing out from the urethral side. The anastomosis is the standard single-knot Van Velthoven anastomosis . We start at 5 o’clock full thickness in the bladder neck throwing six consecutive sutures and then cinching the bladder down to the urethra. The suture continues up to 10 o’clock. The second suture runs up the other side.
Single-knot method for laparoscopic running urethrovesical anastomosis.
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How Does New Robotic Technology Assist The Surgeon During Radical Prostatectomy
The three-dimensional vision system magnifies the surgical field up to 15 times and improves the ability of the surgeon to recognize and control small blood vessels, thereby reducing blood loss. Because of robotic technology, surgeons are able to perform minimally invasive procedures with more precision. Robotic arms remain steady at all times and robotic wrists make it easier for surgeons to manipulate tissue and work from all kinds of angles – positions surgeons would have difficulty reaching otherwise.
What About Problems With Urinary Continence
Urinary continence depends on the internal, involuntary sphincter and the voluntary striated external sphincter. The internal sphincter is removed during all forms of prostatectomy, as it is anatomically at the junction of the prostate and bladder. Performing specialized Kegel exercises after surgery to strengthen muscles enables patients to control their external sphincter and gain continence . This takes several weeks to several months. Overall, significant urinary leakage occurs in only 0.5 percent of UC Davis patients. About 15 percent of patients report mild stress incontinence.
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The Prostate Cancer Outcomes Study
This study involved 1,291 men ages 3979 who filled out questionnaires asking about specific changes in urinary and sexual functioning following radical prostatectomy. When questioned 18 months or longer after treatment, 8.4% of men reported being incontinent, and 59.9% reported being impotent. These percentages indicate incontinence and impotence may be more common than other studies, which relied on patients volunteering specific information, have found.
Source: Stanford JL, Feng Z, Hamilton AS, et al. Urinary and Sexual Function after Radical Prostatectomy for Clinically Localized Prostate Cancer: The Prostate Cancer Outcomes Study. Journal of the American Medical Association 2000 283:354-60. PMID: 10647798.
And what did the radiation oncologists advise?
I was really impressed with both men. They talked about the implantation of radioactive seeds . I said to one of them, You know, Im getting all this information and Im in overload here. So if you were in my position, what would you do?
And he said, Well, Im 20 years younger than you. So if I had prostate cancer, I would have surgery. Because Im most concerned about living a long life.
And I said to myself, Look, pal, I want to live a long life too!
Did he provide evidence that surgery would make an individual patient live longer?
Did either of the radiation oncologists mention external beam radiation?
So then what happened?
Have you talked with him since then? Has there been any improvement?
What impressed you?
Robotic Radical Prostatectomy The Standard In Prostate Cancer Treatment
Robotic prostatectomy is a radical prostatectomy that is also known as Robotic Assisted Laparoscopic Prostatectomy . It is a minimally invasive prostate removal and cancer treatment surgery.
The robotic prostatectomy system is performed with the aid of the da Vinci robot, one of the most advanced medical robots in the health industry.
This high-tech system allows the surgeon to have improved vision, control, and precise movements.
David B. Samadi, MD, is at the forefront of prostatectomy and prostate removal surgery and has performed more than 7,000+ successful procedures to date. His innovative SMART technique uses robotic prostate surgery enhancements to improve vision and precision. In Dr. Samadis skilled hands, patients are assured superior quality of life results in both sex after prostate surgery and urinary control after prostate surgery.
Wtach the video to see how is Dr. Samadi performing a robotic prostatectomy:
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Incontinence After Robotic Prostatectomy: What To Expect
Robotic Prostatectomy is becoming the most prominent choice for the surgical removal of prostate cancer. The popularity of the procedure has increased rapidly since its introduction in 2000.
This rise in popularity is due to Robotic Surgery being accurate and precise. During robotic surgery, there is less trauma to the pelvic muscles. Surgeons aim to minimize injury to the sphincter muscle when removing the prostate gland. Experts also agree that the Urologist is able to visualize the pelvic organs better than in Open Radical Prostatectomy. As Alliance Urology Specialist surgeon Lester Borden explains, robotic prostatectomy patients receive the benefit of smaller incisions, which results in less postoperative pain, shorter hospitalization and quicker recovery. Patients who undergo robotic prostatectomy have significant advantages such as less blood loss, less pain, shorter hospital stays and faster recovery times. This procedure is also designed to be minimally invasive. Recent results have shown the procedure to achieve similar outcomes to an open surgery method for removing cancerous tissue. A large proportion of men choose this procedure in that it is more effective in preserving long term urinary and sexual function.