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.