Robotic-Assisted Surgery Improves Outcomes for Radical Prostatectomy Patients

October 18, 2004 /New Orleans/ Robotic surgery for prostate cancer has equivalent surgical outcomes to the open approach with less blood loss, shorter hospital stay, faster recovery, and minimal use of narcotic medication during the recovery period, according to a study presented Oct 11 at the 2004 Clinical Congress of the American College of Surgeons.

In the first 300 men who underwent robotic-assisted radical prostatectomy at Urology Centers of Alabama, Birmingham, the average blood loss was less than 50 mL, which is 300 to 2000 mL less than the typical amount of blood lost during standard open surgery.

The patients did not have to undergo blood donation procedure prior to or during surgery for retransfusion.

The men were hospitalized for only one day following the operation, compared with a two- to three-day hospital stay after conventional open surgery.

Quality of life questionnaires showed that men returned to independent activity of daily living (IADL) in 7-10 days versus the four to six weeks for traditional open surgery.

In addition, up to 80 percent of the men did not take any narcotic medication during their perioperative period.

"It is extremely rare for a patient to have almost any type of surgery these days without the use of some form of narcotic agent," Vipul Patel, MD, director of minimally invasive surgery at Urology Centers of Alabama, said. "That is why its amazing that patients are able to undergo major prostate cancer surgery without the use of any postoperative narcotics."

"The minimally invasive nature of the robotic surgery along with the use of anti-inflammatories and the ON-Q subcutaneous pump [I-flow Corporation, Newport Beach, CA]," Patel reported, "have allowed us to achieve non-narcotic radical prostatectomy in 80 percent of patients. Of that number, 20 percent do require narcotics, but the use is extremely limited - usually one or two pills maximum."

Contrast with traditional surgery

For many years, radical prostatectomy for prostate cancer has been done by means of an operation that requires a six- to eight-inch incision in the lower abdomen and blunt dissection, meaning surgeons use their fingers to locate and manipulate the prostate gland before excising and removing cancerous tissue.

In the last few years, many surgeons have switched to the laparoscopic approach, which involves making a series of small incisions in the abdomen and introducing instruments that allow surgeons to see inside the abdominal area in order to dissect and remove prostate tissue. The surgical robot is called daVinci ® [Intuitive Surgical, Sunnyvale, CA] and provides the surgeon with magnified 3D vision and miniature articulating robotic writed instrumentation.

The addition of the surgical robot as an assistive device to perform laparoscopic radical prostatectomy increases precision. "Using traditional laparoscopic instrumentation is challenging, it's like operating with chopsticks. The vision is two-dimensional and the movements are counter-intuitive also. There's articulation of the ends of surgical instruments. Whereas with the robot, you have a 'wrist' that can turn 360 degrees, which makes it easier to suture," Dr. Patel said.

The robot improves magnification of the laparoscopic surgical field by a factor of 10 and provides three-dimensional vision, which allows surgeons to see small vessels and close them with sutures. Consequently, there is less loss of blood and a 0-1 percent need for trans-fusions.

"Robotic prostatectomy makes a good surgeon even better because it enhances what you can do. It improves your ability to see the surgical field and allows increased surgical precision. This is important when attempting to remove the prostate while preserving the delicate nerves necessary for continence and potency," Dr. Patel said.

The study included men who had undergone robotic radical prostatectomy in the past two years. Oncologic outcomes were very favorable with a low positive margin rate. The clinical literature indicates that laparoscopic and open radical prostatectomy produce the same degree of cancer control as measured by postoperative levels of prostate specific antigen (PSA), an enzyme produced by the prostate gland that is elevated in the presence of cancer, and survival rates.

"A small number of series of clinical investigations have indicated that PSA levels and survival rates after laparoscopic prostatectomy are equivalent to the rates achieved with open operation," Dr. Patel explained.

Robotic-assisted radical prostatectomy is not yet widely available. The daVinci ® Surgical System is frequently used by surgeons to perform heart surgery and general laparoscopic procedures, such as gallbladder removal, treatment of gastroesophageal reflux disease, and gynecologic treatment. However, only about 100 centers in the United States and Europe offer robotic-assisted prostate surgery, according to Dr. Patel. The surgical robot also is expensive; the device costs approximately $1.3 million.

How many robotic operations has a doctor done?

Surgeons must be trained in the use of the robot. The training sounds quite minimal -- it usually involves attending a two-day course, observing about four surgical operations, and performing two procedures under supervision.

The newness of robotic surgery and this short period of training clashes with one of the main rules of cancer patient self-care -- choose a doctor (whatever the procedure) who has a lot of experience and a good, long track record.

"There's a great deal of adaptation in using robotics to perform surgery," Dr. Patel said. "For the first time, surgeons are not standing next to or actually touching the patient. They're sitting at a console and are connected to the robot by wires. They're not even scrubbed or in a surgical gown. That approach takes a bit of getting used to," he added.

The demand for robotic-assisted radical prostatectomy is growing. Dr. Patel and his colleagues perform eight to 10 robotic procedures a week, largely as a result of word of mouth by patients, he said. Men are flying in for the procedure from as far away as India and parts of Europe.

"We thought we would maybe perform 50 cases a year with the robot, but now we're estimating over 300 a year, and all because patients come in and say they want it. I think the addition of robotic assistance to prostate cancer surgery has really helped to decrease patient morbidity without sacrificing functional or oncologic outcomes. As larger series with long term data are published, we will begin to see the true efficacy. It definitely has the potential to become a standard of care in the future," Dr. Patel concluded.

More information about Dr. Vipul Patel

Update January 2006

If you are considering minimally invasive prostate cancer treatment, make sure you take these steps:

1. make sure you are actually a good candidate for this type of treatment. This means, at minimum, know your cancer stage and your Gleason score (reviewed by an expert pathologist), then consult doctors in different fields of prostate cancer treatment (e.g. a urological surgeon, a radiation oncologist and a medical oncologist).

2. In view of your desire for a minimally invasive procedure, be realistic about the advantages and disadvantages and compare laparoscopic surgery with brachytherapy and external beam radiation.

Are reliable doctors advising you that you will be better served by surgical removal of the prostate (by any method) than by seeding or external beam radiation or more advanced treatments?

Or are you just looking for a type of surgical removal that involves shorter hospital stay, less blood loss, and so on?

It is widely agreed that LRP greatly reduces "the physical and emotional toll of radical prostate surgery and reduces blood loss, hospital time, and cost." (Krongrad A, 2000). Reduction of blood loss is a real advantage for men whose only other good option is traditional, open radical prostatectomy.

But if you happen to be a good candidate for radiotherapy (either external or implant type), this advantage is irrelevant.

Be aware that some patients report bad results from laparoscopic prostate surgery (just as some patients do from other procedures). For example some men have reported total loss of urinary control. The surgeon's training, skill, and experience (number of surgeries done per year and per month) all matter. A surgeon who can show you peer-reviewed published results may be superior.

Given the relative newness of LRP, published reports so far cover immediate and short term results. For continence and potency, results appear to be as good as for open radical prostatectomy. In a pooled analysis of published literature on robotic laparoscopic prostate surgery published in Expert Rev Anticancer Ther. 2006 Jan;6(1):11-20, doctors from the Robotic program at Weill-Cornell, New York write:

Pathological outcomes are comparable to RRP and LP with acceptable positive margin rate. At short-term follow-up, continence and potency results appear to be equivalent to RRP and LP.

You would need to compare these results with those from radiotherapy.

Other recent results from robotic prostate surgery

Robotically assisted laparoscopic prostatectomy: An assessment of its contemporary role in the surgical management of localized prostate cancer. Am J Surg. 2004 Oct;188(4 Suppl 1):63-7, J. A. Smith Jr., Vanderbilt University Medical Center, Nashville, Tennessee. Found no difference in immediate side effects: " no difference was seen in postoperative pain, length of stay, or requirement for blood replacement. However, the most important outcome measures are tumor control, continence, and sexual potency. The outstanding visibility and precision afforded by the robotic approach may offer advantages in each of these areas."

Robotics in urology. Curr Opin Urol. 2004 Mar;14(2):89-93. A. K. Hemal and M. Menon, Vattikuti Urology Institute K-9, Henry Ford Health System, Detroit, MI. "The impact of robotics is ... very promising. However, controlled clinical trials and comparisons from various centers are needed. Other important concerns are the cost and training implications. Future application may also allow integration of pre- and intraoperative imaging in the management of urological diseases."

The technique of apical dissection of the prostate and urethrovesical anastomosis in robotic radical prostatectomy. BJU Int. 2004 Apr;93(6):715-9 Menon M, Hemal AK, Tewari A, Shrivastava A, Bhandari A. Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI

"Over 550 robot-assisted radical prostatectomies have been undertaken using Vattikuti Institute Prostatectomy (VIP) technique in patients with localized carcinoma of the prostate. We present a critical analysis of the first 120 procedures by one surgeon (M.M.) at our institution using this newly developed technique of urethrovesical anastomosis preceded by dissecting the apex of the prostate.... " All but 24 patients had their catheter removed 4 days after surgery, as indicated by a cystogram. The catheter was removed successfully at 7 days in the remaining 24 patients who had a mild leak on cystography. Two patients had urinary retention within a week of removing the catheter and had to be re-catheterized. Continence was evaluated using standardized criteria before and after the procedure. The patients also replied to a mailed validated questionnaire survey; 96% were continent at 3 months and the remaining 4% used a thin pad for security."


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