What is robotic surgery?

For select patients, surgical removal of the prostate gland, along with the prostate cancer, can be performed using a laparoscopic approach. "Laparoscopic prostatectomy" offers the benefits of a minimally invasive approach to surgery. These benefits generally include: reduced pain, shorter hospital stays, and a faster recovery. These advantages are attractive to both surgeons and patients, and reports of excellent rates of cancer control, urinary control, and sexual potency, already established by open surgery, have been equaled or surpassed with these minimally invasive approaches to prostate removal.

The arrival of robotic technology has dramatically enhanced a surgeon's abilities to perform minimally invasive surgery with precision and speed. With the da Vinci robot system, the surgeon is seated comfortably a few feet away from the patient at a control console, while his assistant stands by the operative table. Surgery is performed through tiny incisions, like standard laparoscopic surgery. However, the robotic instruments, about the diameter of a pencil, have wrist-like maneuverability, allowing the surgeon to move them like his own hand, as opposed to standard laparoscopic instruments, which have a much more limited range of motion. The advanced optics allow the surgeon to view the operative field at high magnification, while maintaining a three-dimensional perspective unlike standard laparoscopic surgery. Finally, the dexterity of the surgeon's hand is enhanced by the robotic system, scaling motion to allow microsurgical movements, unequaled with either open or standard laparoscopic surgical approaches.

   


Overview

The Surgeon Console: Using the da Vinci Surgical System, the surgeon operates while seated comfortably at a console viewing a 3-D image of the surgical field. The surgeon's fingers grasp the master controls below the display with hands and wrists naturally positioned relative to his or her eyes. The technology seamlessly translates the surgeon's hand, wrist and finger movements into precise, real-time movements of our surgical instruments inside the patient.


Patient-side Cart: The cart provides the three or four robotic arms -- two or three instrument arms and one endoscope arm -- that execute the surgeon's commands. The laparoscopic arms pivot at the 1-cm operating ports eliminating the use of the patient's body wall for leverage and minimizing tissue damage. Supporting surgical team members assist in installing the proper instruments, prepare the 1-cm port in the patient, as well as supervise the laparoscopic arms and tools being utilized.

EndoWrist™Instruments: A full range of instruments are provided to support the surgeon while operating. The instruments are designed with seven degrees of motion that mimic the dexterity of the human hand and wrist. Each instrument has a specific surgical mission such as clamping, suturing and tissue manipulation. The instruments are small and typically fit within the circumference of a dime. Quick-release levers speed instrument changes during surgical procedures.
         

InSite™VisionSystem with high resolution 3-D Endoscope and Image Processing Equipment: The component provides the true to life 3-D images of the operative field. Operating images are enhanced, refined and optimized using image synchronizers, high-intensity illuminators and camera control units.
         

What are the potential advantages of robotic prostatectomy?

Results with open radical retropubic prostatectomy have steadily improved over time. Currently, at The Texas Prostate Center, where we have completed thousands of these operations, we perform this operation through a mini-laparotomy incision, extending from the pubic bone upwards about half-way to the belly-button. Cancer control rates, and recovery of potency and continence are excellent in most patients.

Our experience with robotic prostatectomy, now almost 600 cases, suggests that these outcomes are at least equaled with robotic surgery, with less postoperative pain and a more rapid recovery for the patient. After robotic prostatectomy, which can be performed without the requirement for epidural anesthesia, patients are often walking and eating on the evening of the day of surgery, and are routinely discharged the next morning, after breakfast. The urinary catheter is removed after one week, and many patients return to work shortly thereafter.

What are the potential drawbacks of robotic prostatectomy?

After thousands of open radical prostatectomies performed at the Texas Prostate Center over decades, the long-term results of this operation with respect to cancer control, potency and continence recovery are well established. It is clear now from several studies that successful outcomes after prostate cancer surgery are directly related to the skill of the surgeon, including the specific techniques utilized and the volume of cases performed yearly by that surgeon. There is nothing magical about robotic prostatectomy, and our data suggests that these principals still hold valid. Prostate cancer surgeons who have demonstrated excellent cancer control and quality of life outcomes in their patients can use the da Vinci robot system to translate these excellent results into their patients operated using this minimally invasive technology. However, the da Vinci system will not automatically improve the outcomes of less experienced surgeons. It is always prudent for any patient to explore the experience and specific outcomes achieved by his specific surgeon. At the Texas Prostate Center, we have learned that proper patient selection is important in achieving excellent outcomes. Not every patient is a good candidate for robotic prostatectomy and currently 20% of our patients, after a comprehensive evaluation, are recommended to undergo the open, mini-laparotomy approach.

Am I a candidate for robotic prostatectomy?

There many excellent options available to patients for the treatment of localized prostate cancer. We try and tailor treatment for each individual patient that matches each unique circumstance. Ideal patients are of normal weight, without extensive prior abdominal surgery or radiation therapy, with a less extensive cancer burden in the prostate. Those patients with higher grade, larger tumors, who are at a higher risk for lymph node involvement, should probably undergo an open approach to their surgery, so that a more extensive, potentially curative LN dissection can be performed, which is more difficult using the robotic approach.  Our data, soon to be published, suggest that for these patients, a more extensive lymph node dissection can lead to improved cure rates that would be difficult to achieve with the robotic approach.

Outcomes after robotic prostatectomy

We are actively studying patient outcomes after this procedure. We reported our excellent cancer control rates, equivalent to open surgery, with robotic prostatectomy at last year’s American Urological Association meeting, as well as presented a video of our technique.  This year, we plan to report an updated analysis of our results, which continue to demonstrate the highest quality reportedly achievable by any surgical approach to prostate cancer.   The most recent analysis of our data demonstrates excellent long-term cancer control rates and quality of life after both open and robotic prostatectomy, although there is a clear trend towards more rapid return of both erections and continence within the first six months after surgery, with the robotic approach.

How does the Texas Prostate Center 's Robotic Prostatectomy Technique differ from others?

Our philosophy is to maximize cancer control rates without sacrificing the patient's quality of life with regards to potency and continence. Furthermore, we strongly believe that both cancer control and quality of life outcomes are more dependent on the surgeon's knowledge of the natural history of prostate cancer growth and spread in the prostate, the intricate surgical anatomy of the prostate and surrounding structures, and the surgeon's experience in this specialized type of surgery. Less important are the tools or methods used to perform the surgery.

With this philosophy in mind, we have performed close to two thousand radical prostatectomies over the past 15 years and are recognized world leaders in the field of the treatment of localized prostate cancer. We have published extensively regarding innovative ideas and techniques related to prostate cancer screening, prostate biopsy, prostate nomograms, novel markers to predict prostate cancer outcomes, nerve sparing radical prostatectomy, sural nerve and collagen tube grafting, the proper role for standard vs. extended lymph node removal during surgery, and the importance and specialized techniques of minimizing positive surgical margin rates for tumors of all stages and grades.

Through a careful process of quality improvement that includes systematic capture of cancer control and quality of life data on every patient beginning prior to their surgery, and continuing at every follow-up visit afterwards, we continue to accumulate a comprehensive database that allows us to measure the impact of even the smallest changes in technique, keeping those that demonstrate a clear benefit and discarding those that don’t add significantly to the quality of the results.  Some key maneuvers that we have validated using this approach include both anterior and posterior reconstruction of the urinary rhabdosphincter, maneuvers that reconstruct both the natural suspension and angle of this important sphincter, measurably speeding the rate of return of urinary continence after Robotic Prostatectomy.

Through this methodical, data driven process, we have made a myriad of additional subtle changes, resulting in unique techniques for performing both open and Robotic Prostatectomy. We are one of only a few centers that perform the surgery without actually entering the abdominal cavity. We believe this makes the surgery safer for the patient, speeds the patient's recovery after surgery allowing him to return to normal activity and work more rapidly, and avoids potential complications for the patient down the road related to intra-abdominal surgery.  We have now demonstrated in a new study soon to be published that we have maintained our low positive margin rates, traditionally seen with our mini-incision open radical prostatectomy technique with robotic laparascopic-assisted radical prostatectomy. Furthermore, we have adopted approaches that minimize the use of electro-cautery near the neurovascular bundles to improve the quality of our nerve sparing techniques. Careful study, using questionnaires, of all patients who have had surgery with us, has led us to make fine adjustments in our surgical technique that have led to clear, measurable improvements in our outcomes. Finally, regardless of the approach (open or robotic), we work intensively with all patients post-operatively to improve the rate of return of both erectile function and urinary control.

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