How does a robotic prostatectomy work?

Robot assisted prostate surgery, known medically as the da Vinci prostatectomy, has had a profound influence over treatment during the past decade. Robotic surgical technology was first developed by the military for use in the battlefield. However during the past decade, this technology has been rapidly applied to the general medical setting, notably in the field of prostate cancer.

Surgeon equiped for robot assisted postatectomy.
A surgeon and equipment. Click for large view from Newsweek.

The first reported robot assisted prostatectomy took place in the US in 2001. Now it is the treatment of choice for Americans. In 2009, of the 86,000 men in the US who had prostate cancer surgery, 86 per cent had robot-assisted operations. In the UK, the da Vinci prostatectomy is becoming increasingly popular and widespread, although not yet to the extent within the US.

In describing how a robotic prostatectomy works, the first point to make is that the procedure is not undertaken by a robot. A robotic prostatectomy is carried out by a surgeon using the da Vinci system, which consists of a four armed robot connected to a remote console. The surgeon operates the system while seated at the console.

One of the robotic arms holds a pencil-sized high magnification camera and the other three hold surgical instruments. Like the laparoscopic or keyhole prostatectomy, these instruments are inserted through six small incisions, or 'ports' in the abdomen. Each incision is about 7mm wide.

The robotic arms can rotate a full 360 degrees, allowing the surgeon to manipulate the surgical instruments with full flexibility and range of motion. These instruments have a special robotic 'EndoWrist' which can rotate, mimicking the movements of the human wrist.

Working at the console, the surgeon controls the robot using foot pedals and hand movements, which are precisely translated into movements by the robotic arms. The system is designed to mimic human wrist and hand movements while allowing a greater degree of precision and removing the risk of any hand tremor.

The surgeon is guided by a three dimensional display of the surgical field displayed on the console. It is the clarity of these visuals which surgeons particularly like.

Mr. Marc Laniado, UK specialist urologist.
Mr. Marc Laniado is a urology specialist and consultant in the UK.

"The view is magnified up to 15-fold, affording a very high degree of precision," says Consultant Urological Surgeon Marc Laniado, a member of one of the first UK teams to undertaken robot-assisted prostatectomy.

"This clarity is particularly important in terms of minimising damage to the erectile nerve bundles and muscles which run adjacent to the prostate. By avoiding unnecessary damage, we can reduce the risk of long term erectile dysfunction and incontinence for the patient."

The main criticism levelled against the way the robotic prostatectomy works is that the surgeon loses his or her ability to feel how forcefully he is pulling tissue and how well stitches are holding. This is often referred to as 'tactile feedback'. However Mr Laniado says the quality of the visuals and flexibility of the instruments more than compensates for this.

"You are working in 3-D with a perception of depth not afforded in laparoscopic surgery," says Mr Laniado. "The magnification provides a degree of precision which more than makes up for any lack of visual feedback."

The whole procedure usually takes two to three hours under general anaesthesia. Most patients experience only a small blood loss and blood transfusions are needed in less than one percent of patients, Mr. Laniado says.

Mr. Laniado is Consultant Urologist, Prostate specialist, at Harley Street Urology, London, UK.

Last edited by Jacquie Strax on February 15, 2011 at 5:09 pm