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Urology Resources
Robotic Radical Prostatectomy
Dr Chin Chong Min, Consultant Urologist, Mt Elizabeth Medical Centre
The first robotic prostatectomy in the world was performed in 2000 in Germany. Since then, thousands of robotic prostatectomies have been performed around the world from USA, to Europe, and now, Asia.
By 2006, nearly 40% of all radical prostatectomies in the USA were performed robotically. The exponential growth is due to the advantages provided by the Da Vinci robotic system (Intuitive Surgical, Inc., CA, USA) which allow surgeons to sit comfortably at a console and immerse themselves in a 10-fold magnified, 3-dimensional view of the pelvis and prostate. (Figure 1). The conventional method of open radical prostatectomy does not confer such a stereoscopic, magnified view, hampered by the limitation of the narrow male pelvis and less precise anastamotic suturing of the bladder and transected urethra.
Fig 1.
The Da Vinci system is ideal in such a confined space; it controls up to three robotic arms, which wield various and interchangeable small instruments. The instruments articulate with wrist-like movements that allow six degrees of motion compared to four degrees with conventional laparoscopic instruments (Figure 2). Unlike the conventional laparoscopic method, the surgeon is also in direct control of the camera and is further aided by computer-filtration which eliminate hand tremor and fine-scales hand motions as much as 5:1 ratio. Because tactile feedback is limited, the surgeon has to rely on visual cues while dissecting and handling tissue. This is about the only technical disadvantage that the surgeon has to get used to when performing the surgery. However, with the help of a regular team, the assistants can provide tactile feedback besides paving the way during dissection.
Fig 2.
Figure 3 shows the conventional lower midline incision needed for open surgery, compared to the five small incisions for robotic laparoscopic surgery. The surgery itself takes an average of 4 - 5 hours.
Fig 3.
In terms of clinical outcome, the clear benefits of robotic surgery are the reduction in postoperative pain and length of hospitalization because of the minimally invasive nature of the procedure. Generally most patients are ready for discharge by the second post-operative day.
Decreased blood loss associated with laparoscopic and robotic-assisted surgery is the other advantage. The blood loss is usually less than 200 ml, resulting in negligible transfusion rates compared to open prostatectomy.
The other concerns that patients have is the incontinence and impotence following radical prostatectomy. Here again, robotics give better preservation of urethral length, and reconstruction of a watertight anastomosis. As for potency preservation, the magnified visualization allows precise dissection and in suitable cases, preservation of the nerve bundle. Data from various centres are now showing a faster return to continence and potency because these attributes contribute to better preservation of sphincter and sexual function.
Not surprising, there is a trend for patients to routinely travel out of their respective healthcare markets to leading hospitals that offer robotic surgical technology. This emerging trend can be attributed to the measurable clinical benefits that robotic-assisted radical prostatectomy offer despite its higher cost. Robotic prostatectomy is the fastest-growing treatment for prostate cancer in the United States. Asia is likely to follow suit with more Da Vinci systems being installed to match the rising number of men being diagnosed with early prostate cancer. The advantage to patients who opt to have their surgery done here is the relatively lower cost.
Dr Chin Chong Min at the console of the Da Vinci robot
Figs 1, 2 and 3 provided by kind courtesy of Intuitive Surgical, Inc., California, USA
