Robotic Prostatectomy

Robotic Radical Prostatectomy

Figure 1

The first robotic prostatectomy in the world was performed in 2000 in Germany. Since then, tens of thousands of robotic prostatectomies have been performed around the world from USA, to Europe, and now, Asia. By 2004, robotic assistance was used in 8000 prostate cancer patients, or nearly 10% of all radical prostatectomies performed in the United States. By 2007, this number reached 50000, or nearly 70% of all surgeries. 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 operate 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, with the limitation of the narrow male pelvis, resulting in less precise anastamotic suturing of the bladder to the transected urethra. On the other hand, the Da Vinci system is ideal in such a confined space; it controls up to three robotic arms, which wield various 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 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 his hand motions. The only technical disadvantage is the lack of tactile feedback, something that the surgeon has to get used to when performing the surgery. However, with the help of a regular team, the assistants can provide the tactile feedback to guide the surgeon.

Fig 2. Click on the image to watch video on Robotic Radical Prostatectomy

Figure 3 shows the conventional lower midline incision used in open surgery, compared to the five small incisions that for robotic laparoscopic surgery. Figure 4 shows the robotic arms in place. The surgery takes 4 to 5 hours to do.

Prostatectomy Incision

Figure 3

robotic arms

Figure 4

In terms of clinical outcome, clear benefits of robotic surgery are reduction in postoperative pain and length of hospitalization because of the minimally invasive nature of the procedure. Generally most patients can be discharged by the second post-operative day. Decreased blood loss is the other advantage, the blood loss being less than 200 ml on average, resulting in negligible transfusion rates compared to open prostatectomy. The other concerns that patients have is 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 to the penis. Data from various centres show faster return to continence and potency.

Not surprising, there is a trend for patients to routinely travel 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. In Singapore, the Da Vinci robot made its debut in 2002 at the Singapore General Hospital. This was the first version and had 3 arms. In 2004, Mt Elizabeth Hospital acquired the newer version which has 4 arms.

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

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