Robotic Surgery for Prostate Cancer

Dr. Michael Stifelman provides an overview of robotic surgery for prostate cancer in this video interview.

Robotic Surgery for Prostate Cancer

Robot-assisted radical prostatectomy involves the surgical removal of the entire prostate and seminal vesicles in men with prostate cancer. The procedure is done primarily when there is a good likelihood the disease is confined to the prostate, with the intent of curing the cancer. Thanks to recent advances in robotic surgical technology, robotic prostatectomy is emerging as an increasingly desirable alternative to traditional open prostate surgery. The outcomes of robotic prostatectomyappear comparable to open surgery in terms of both tumor removal and minimizing the likelihood of post-operative side effects, including impotence or incontinence. Robot-assisted prostatectomy also offers the potential for improved vision and dexterity on the surgeon’s part, and reduced blood loss and rapid recovery for the patient.

How is Robotic Prostatectomy Performed?

After the patent is anesthesized, five small incisions (about an inch wide) are made across the abdomen and ports are placed in them, four forthe robot’s camera and instrument arms and a fifth for passing needles in and out during surgery. An additional, smaller incision is made for the passing of instruments.

Since the prostate sits outside the abdominal cavity in the pelvis, the surgeon must reach it by cutting through the abdominal cavity’s lining (the peritoneum) from the inside. In the process, the bladder is released from its abdominal attachments to allow access to the prostate.Once the prostate is exposed, the surgeon frees the attachments surrounding the prostate, and the dorsal vein complex (a large vein network running over the prostate) is tied to avoid bleeding. The bladder neck is then cut and the bladder rolled away, after which the vas deferens (the tubes carrying sperm from the testicles) are cut, and the adjacent seminal vesicles (the sacs that hold the semen expelled during ejaculation) are freed along with the prostate.

Next, the surgeon develops a separation between the rectum and the prostate, and the blood supply to the prostate is then cut. The surgeon must be very careful at this point not to injure the nerve bundles that allow erections, which lie in a groove between the prostate and the rectum and resemble a fine spider web. The surgeon protects them by rolling the web of nerves away from the prostate, taking care not to damage its structures.

Finally, the dorsal vein complex and the urethra are cut, completely freeing the prostate, which is placed in a plastic bag for removal. In most cases, the lymph nodes are then removed for sampling, in order to guide future treatment. Robotics is ideally suited to this important staging procedure, since it allows the delicate dissection of the lymph nodes from important nerves and blood vessels with minimal blood loss and high accuracy.  Finally, the bladder neck is reattached to the urethra. Multiple steps are taken in this part of the operation to ensure a tension-free, water-tight closure between the bladder and the urethra.

Advantages of Robotic Prostatectomy

Less scarring with robotic prostatectomy.

Much smaller incisions are utilized for the robotic approach than with the traditional open approach. Also, these incisions are located across the abdomen, rather than vertically on the lower abdomen as with open surgery.

Less post-operative pain with robotic prostatectomy.

In general, patients undergoing roboticprostatectomy utilize less pain medication during recovery than those undergoing open surgery. While they are usually discharged on oral pain medications, many men don’t need to use such medications for more than afew days.

Less blood loss with robotic prostatectomy.

While the percentage of patients needing transfusions with open radical prostatectomy at the Smilow Center has historically been very low (3 to 5%), nationally the transfusion rate has been as high as 20 to 30%. For robot-assisted radical prostatectomy, however, transfusion rates nationwide have been quite low (2 to 3%), with less blood loss per case also reported. This means there is generally no need for pre-operative blood donation by thepatient or administration of drugs to increase the blood count prior to surgery. Additionally, while it’s hard to measure, patients discharged after surgery with higher blood counts may feel stronger and recover more easily than those with low blood counts. This may contribute to the rapid convalescence observed with robot-assisted prostatectomy.

The visual approach of robotic prostatectomy offers certain potential advantages.

1. The magnification of the da Vinci Si's 3-D, high-definition camera offers enhanced visualization of small blood vessels, nerves, and other structures around the prostate gland during dissection.
2. When approaching the prostate from the abdomen, the mobile camera view allows the surgeon to easily look behind the prostate, where nerve fibers are located, and to visualize specific structures from various vantage points.
3. The dexterity and visualization of the robot allow the surgeon to perform a tension-free, water-tight closure of the bladder and the urethra.  Finally, the ability of the surgeon to control the camera personally (unlike laparoscopic surgery) allows the instrument movement to be synchronized with the camera.

Robotic Prostatectomy at the Smilow Center

The urologic surgeons at the Smilow Center in New York City are among the most experienced in the world at performing both robotic and open prostatectomies. Our surgical team performed over 1,000 open procedures prior to taking up the robotic approach. The successful treatment of prostate cancer is our overriding goal at Smilow, and our utilization of robotic prostatectomy reflects our firm conviction that robotic technology and surgical techniques have advanced to the point where the outcomes of robotic prostatectomy are equivalent to those of open prostatectomy.

In addition, having now performed robotic prostatectomies for a number of years, we believe the robotic approach, with its magnified, 3-D visualization and general absence of blood loss, allows for a better view of the structures being dissected than open surgery, and also appears to result in an easier convalescence for patients. As established leaders in this surgical area, we also know that the techniques utilized in this procedure will become increasingly refined in the years ahead, as our own experience grows and as robot-assisted surgical technology continues to improve.

Avoiding Exposure in Pregnancy

No law or professional standard requires that radiologists determine in advance whether a patient of childbearing-age is pregnant [1]. However, it is clearly good practice to implement the following guidelines:

Signs should be prominently displayed in all radiology departments asking each patient to notify a technologist or physician if she is, or thinks she could be, pregnant.
All technologists should ask women of childbearing-age if they might be pregnant prior to performing a radiologic procedure.
Radiology requisition forms filled out by referring physicians should include a section dealing with the possibility of pregnancy.
No radiological procedure involving exposure to the pelvis should be undertaken in a patient who declares she may be pregnant without consultation with a radiologist. The radiologist should discuss risks and benefits with the patient, and determine if it is appropriate to proceed, perform an alternative procedure, or delay the study to allow performance of a pregnancy test.

It should be noted that current recommendations do not recognize a safe period during the menstrual cycle, and so the concept of the "ten day rule" is obsolete. A patient who thinks she may be pregnant should be discussed with the referring physician, in order to determine the appropriate course of action (e.g., rescheduling after pregnancy testing, proceeding with the test after counseling, or changing to another modality).

Key point: It is the responsibility of the patient to disclose any possibility of pregnancy, although appropriate signage and questioning of all women of reproductive age is also critical. The supervising radiologist should discuss any cases of possible pregnancy with the referring physician.

Scanner for security an radiation

In our frightening new world, x-rays and CTs have become as important for airports as for hospitals.  Hand luggage is put through x-ray scanners; because one pass exposes your items to only a tiny fraction of the energy used in a chest x-ray, these scanners are safe for photographic film — and for the security personnel who use them all day long.  But checked baggage is passed through CT scanners that are far more powerful; they will damage your film but not your medications.

The new full-body scanners have raised concerns about privacy and safety.  The privacy issue is personal, but the safety issue is a scientific matter — and scientists agree that scanners are safe.  Two types are in use.  Millimeter wave scanners use radio waves to generate images, and they don’t expose travelers to any ionizing radiation.  Backscatter scanners do use low-intensity x-rays, but they bounce off the skin without penetrating the body.  They deliver only a tiny amount of radiation, about the same amount as you get in three to nine minutes of daily living, or about 1/1000 as much as an ordinary chest x-ray.  A person would need to have 2,500 to 5,000 backscatter scans a year to reach the established annual safety limit.

KIDNEY STONE TREATMENT

Treatment of a kidney stone that is causing obstruction depends upon the size and location of the stone, as well as your pain and ability to keep down fluids. If your stone is likely to pass, your pain is tolerable, and you are able to eat and drink, then you can be treated at home.

If you have severe pain or nausea, you will need to be treated with stronger pain medications and IV fluids, which are often given in the hospital. In addition, patients with stones and who also have a fever should be treated in the hospital as soon as possible to avoid a life-threatening infection. (See "Options in the management of renal and ureteral stones in adults".)

Home treatment — You can take non-prescription pain medication until the stone passes. This includes nonsteroidal anti-inflammatory drugs such as ibuprofen (Advil, Motrin) or naproxen (Aleve), but it is important to check with your doctor first.

Other medications, such as tamsulosin, may also be recommended to speed the passage of stones.

You will probably be asked to strain your urine to recover the stone; after you retrieve it, you should bring it to your doctor so it can then be analyzed in a laboratory to determine the composition of the stone (eg, calcium oxalate, uric acid, etc). Knowing what type of kidney stone you have is important in planning treatments to prevent future stones. (See 'Kidney stone prevention' below.)

If the stone does not pass — Stones larger than 9 or 10 millimeters rarely pass on their own and generally require a procedure to break up or remove the stone. Some smaller stones also do not pass. Several procedures are available.

Shock wave lithotripsy (SWL) — Lithotripsy is a reasonable treatment option in many patients who need help passing a stone. Lithotripsy is particularly good for stones 1 cm or less in the kidney and upper ureter. Lithotripsy is not effective for treating large or hard stones. You may require medication to make you sleepy and reduce pain during lithotripsy treatment, although this depends upon the type of lithotripsy equipment used.

Lithotripsy is performed by directing high-energy shock waves toward the stone. These sound waves pass through the skin and bodily tissues and release energy at the stone surface. This energy causes the stone to break into fragments that can be more easily passed in the urine.

Percutaneous nephrolithotomy (PNL) — Extremely large or complex stones, or large stones resistant to shock wave lithotripsy, may require a minimally invasive surgical procedure to remove the stone. In this procedure, a small endoscopic instrument is passed through the skin (percutaneously) of the back into the kidney to remove the stone.

Ureteroscopy — Ureteroscopy is a common endoscopic procedure that uses a thin scope, which is passed through the urethra and bladder, into the ureter and kidney. This endoscope allows the urologist to see the stone and remove it, or to break up the stone into smaller pieces that can pass more easily. Ureteroscopy is often used to remove stones blocking the ureter, and sometimes for small stones in the kidney.

Treatment of asymptomatic stones — If you have a kidney stone that is causing no symptoms, you may or may not need to remove the stone. The decision is based upon the size and location of your stone, as well as your ability to be treated quickly if symptoms were to develop. If there is a chance that you would not be able to get treatment quickly (eg, if you travel frequently), you are more likely to be advised to have the stone removed.

Regardless of the decision to treat or not, you should be evaluated for underlying health conditions that can increase the risk of kidney stones