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Author: Brant R Fulmer, MD, Consulting Staff, Department of Urology, Geisinger Medical Center Urology
Coauthor(s): Daniel B Rukstalis, MD, Director of Urological Services, Geisinger Medical Center, Geisinger
Medical Group; Sanjeev Kaul, MD, MCh (Urol), Clinical Fellow in Laparoscopic Urology and Robotics,
Department of Urology, Henry Ford Hospital
Introduction
In 2007, prostate cancer was the most common newly diagnosed cancer among men in the United States. Although the incidence rates and mortality rates associated with prostate cancer have shown an overall declining trend, widespread screening and early diagnosis makes the management of clinically localized prostate cancer an ongoing challenge. After Walsh et al popularized the technique of anatomic nerve-sparing radical prostatectomy, open radical prostate surgery became a more desirable treatment for organ-confined prostate cancer.
The first successful laparoscopic radical prostatectomies were performed by Schuessler in 1992 and 1997.1 Unfortunately, this technique did not gain widespread acceptance because of its extreme technical difficulty and because it offered no advantage over the criterion standard of open radical retropubic prostatectomy. The initial series reported operative times that ranged from 8-11 hours and a mean hospital stay of 7.3 days.
The laparoscopic approach gained new attention when two French groups published their experience with laparoscopic radical prostatectomy in 1999 and 2000.2,3 They reported modifications to the original technique, resulting in operative times that ranged from 4-5 hours and a mean blood loss of 402 mL. The authors also reported a decreased mean hospital stay, due predominantly to earlier removal of the Foley catheter.
Even in the hands of these skilled laparoscopists, nerve-sparing dissection and construction of the urethrovesical anastomosis were demanding. With advances in medical technology, improved optics, and the widespread use of new laparoscopic instrumentation such as ultrasonic cutting and coagulating devices (eg, Harmonic scalpel; Ethicon Endo-Surgery, Inc; Cincinnati, Ohio), laparoscopic radical prostatectomy began to gain acceptance and was performed increasingly in several high-volume centers worldwide. However, the technical demands of laparoscopic radical prostatectomy prevented its widespread use by the average urologist and thus limited penetration.
The next significant advance in the surgical treatment of localized prostate cancer was the development of robotic surgical technology. Initially developed by the United States Department of Defense for use in military battlefield applications, robotic technology was adapted for civilian use through the entrepreneurial efforts of two rival corporations, Intuitive Surgical, Inc, and Computer Motion, Inc. These companies simultaneously developed robotic interfaces for use in human surgical applications. Computer Motion, Inc, introduced the Zeus Surgical System at approximately the same time that Intuitive Surgical, Inc, developed its da Vinci Surgical System.
Both technologies relied heavily on a laparoscopic patient-robot interface in which instruments were placed through small trocars implanted in the patient’s skin. The working field was maintained predominantly by insufflation of the peritoneal cavity with carbon dioxide. Subsequently, Intuitive Surgical, Inc, acquired Computer Motion, Inc, consolidating the robotic surgical technology and making Intuitive Surgical, Inc, the sole provider of advanced robotic technology for use in human surgical procedures.
Currently, several other companies develop and manufacture robotic surgical technology, including single robotic arms for laparoscopic cameras or as part of integrated minimally invasive operating-room systems, but none of these rival technologies can compete with the advanced robotic engineering by Intuitive Surgical, Inc.
The da Vinci Surgical System consists of a 3- or 4-armed robot connected to a remote console. The surgeon operates the system while seated at the console. Foot pedals are used for control, and 3-dimensional displays provide a unique and novel depiction of the surgical field not previously incorporated in other systems. Typically, 8- to 10-mm ports are used for the instruments, which have 7° of freedom, including rotation capabilities (ie, mimicking the movements of the human wrist), and a special robotic EndoWrist. The first reported robot-assisted laparoscopic prostatectomy using the da Vinci system was described by Abbou et al in 2001.4 Several other groups have also published their experience with the technique.5,6
Menon et al from the Vattikuti Urology Institute at Henry Ford Hospital in Detroit, Michigan, are responsible for the development and popularization of robotic radical prostatectomy.7,8,9,10 This technique has been gaining widespread acceptance in the United States and Europe and is increasing in penetration worldwide. Robotic radical prostatectomy offers the advantages of the minimally invasive laparoscopic approach but shortens the learning curve, facilitating and hastening mastery of the procedure.
Although solid basic laparoscopic skills are required for access and assistance, the console surgeon role requires less laparoscopic skill. Therefore, the procedure is accessible to experienced open surgeons with minimal or no laparoscopic experience. In the most recent published report, Badani et al have performed more than 2700 robotic prostatectomies and have reported a mean operative time of 154 minutes, a mean blood loss of 100 mL, and hospital stays of less than 24 hours in 96.7% of patients.11
For excellent patient education resources, visit eMedicine's Prostate Health Center, Cancer and Tumors Center, and Men's Health Center. Also, see eMedicine's patient education articles Prostate Cancer, Prostate Infections, Enlarged Prostate, and Causes of Erectile Dysfunction.
Surgical Techniques
The basic technique for performing minimally invasive radical prostatectomy is the same regardless of the technology used. Candidates for this approach include patients in whom the diagnosis and staging support organ-confined prostate cancer and in whom the appropriate metastatic workup results are negative. The goal of minimally invasive radical prostatectomy is to laparoscopically resect the prostate and its capsule, along with the seminal vesicles. The procedure can be performed either extraperitoneally or, more commonly, transperitoneally. The two most reported techniques for performing minimally invasive radical prostatectomy are robotic (robotic radical prostatectomy) and laparoscopic (laparoscopic radical prostatectomy).
Laparoscopic radical prostatectomy
The laparoscopic approach involves 2-dimensional monitors and conventional laparoscopic instruments (5 or 10 mm) with a 10-mm 0° and/or 30° telescope. The camera may be operated by a one-armed camera holder or by an assistant. The use of a single voice-operated robotic arm has also been described as an adjunct to the laparoscopic approach. A camera-holding device provides stability and prevents camera shake that can result from holding it by hand (ie, by an assistant).
Robotic radical prostatectomy
Currently, the only available integrated robotic surgical system is the da Vinci Surgical System (Intuitive Surgical, Inc; Sunnyvale, California). This computer-aided system has a basic master-slave design. A second generation of this system is currently available (da Vinci S HD System). The basic design is as follows:
- Surgeon console: This is the user interface of the robot for the surgeon. It consists of the following:
- Display system: The system is a 3-dimensional stereoscopic display for the console surgeon and is generally available for view in 2-dimensional form by assistants and observers.
- Master arms: These are the controls the surgeon uses for making surgical movements. Movements of the master arms translate to real-time movements of the instrument tips and may be scaled for fine movements. The master arms also provide basic force feedback to the surgeon but are limited in their ability to discriminate complex haptic feedback. Camera movements are controlled with a clutch mechanism. In the 4-arm systems, the surgeon can toggle between instruments.
- Control panel: The control panel is used to adjust the surgeon console display and control options. The control panel allows toggling between 2- and 3-dimensional display, adjusting various levels of scaling, and choosing the camera perspectives (0° vs 30° lens).
- Central processing unit: This is the computer that controls the system and integrates and translates robot control inputs from the surgeon.
- Robotic arms: Two or 3 arms are provided for mounting surgical instruments and one camera arm is provided for camera manipulation. The robotic arms are mounted on a surgical cart that is sterilely draped and moved into position over the patient. The arms are then mounted to 8-mm trocars placed through the patient's abdominal wall. The surgeon console is connected to the surgical cart via cables. Although the surgeon console and the surgical cart are typically in close proximity in the operating room, a longer interface has the potential to be used for long-distance surgery or telementoring.
Surgical Approaches
Patient preparation and positioning for minimally invasive radical prostatectomy
Once the patient is confirmed as an appropriate candidate for a complex laparoscopic procedure, he must undergo an appropriate preoperative preparation to minimize complications and to facilitate operative success. The authors’ standard preoperative regimen consists of an extended office visit with the patient to explain the risks, benefits, and potential alternatives of the procedure. The patient receives details of the robotic technology in the form of patient-centered brochures. The patient is also directed to the institution’s Web site, which contains extensive information on what the patient should expect before, during, and after the procedure.
The authors’ standard surgical consent form emphasizes the complications that are inherent to laparoscopic techniques. The priorities of the procedure are also emphasized, including patient safety, preservation of the oncologic integrity of the surgical procedure, and an attempt at performing the procedure laparoscopically. The risk of conversion to an open procedure is explained thoroughly in the framework of this group of priorities. Specifically, if the patient’s safety or the oncologic integrity of the operation is jeopardized, the attending surgeon may decide to convert the procedure to the open surgical technique.
The preoperative and preanesthesia screening to determine suitability for a complex laparoscopic procedure is identical to that performed prior to open surgery. The authors generally perform a preoperative bowel preparation, including both antibiotic and mechanical bowel cleansing. This not only reduces bowel distention and adds visualization but also reduces the potential for infection due to the spillage of bowel contents in the uncommon event of a bowel perforation. On the day of surgery, a preoperative enema is performed, sequential compression stockings are placed, and a large-bore intravenous line is begun with preoperative antibiotics that cover both genitourinary and skin flora.
Regardless of the technique used, the patient is placed in the supine position with his head down. This head-down position allows for gravity to facilitate the natural retraction of the pelvic tissues. If the procedure is to be performed transperitoneally, a periumbilical incision is made to provide access for the initial laparoscopic port. A Veress needle or Hasson-type trocar is used to establish pneumoperitoneum and to facilitate the laparoscopic survey of the abdomen. The Veress needle is an ideal access device when the patient has no history of abdominal surgery. In patients who have undergone previous abdominal surgery, particularly involving infraumbilical incisions, the Hassan trocar is ideal for direct visualization and confirmation of entrance into the peritoneal cavity.
Carbon dioxide is then insufflated into the abdomen to achieve pneumoperitoneum. If a Veress needle was used for initial access, it is replaced by a 12-mm radially dilating laparoscopic trocar. The 3-dimensional robotic laparoscope is then inserted through the infraumbilical trocar site, and a laparoscopic survey of the abdomen and pelvis is performed. If the procedure is to be performed extraperitoneally, the first steps for access consist of a small incision and development of the extraperitoneal space.
Robotic Transperitoneal Approach
The transperitoneal approach to robotic radical prostatectomy was developed and popularized by Menon et al at the Vattikuti Urology Institute at Henry Ford Hospital in Detroit, Michigan. In this technique, the dissection proceeds in an antegrade manner and releases the prostate from the bladder neck early in the procedure, allowing the prostate to be manipulated with traction to aid in visualization for nerve sparing. The seminal vesicles and all subsequent dissection proceed in the direction of telescope vision (ie, antegrade), facilitating visualization.
The patient is placed in the supine position, secured to the table, and placed in steep Trendelenburg position (45°). The legs can be placed in stirrups or positioned apart. The robot is then brought between the patient’s feet. The total number of ports and port configurations depends on several factors. Three-armed robots have a total of 6 ports in an inverted V-shaped configuration. The Veress needle is used to establish the pneumoperitoneum, and a 12-mm port is placed just to the left of the umbilicus (camera port). A 30° upward-looking lens is then used to place the remaining ports; two 8-mm ports are placed as mirror images of each other, 10-12 cm from the camera port and 2 fingerbreadths below it. The ideal port position is approximately 15 cm above the pubic symphysis to afford the instrument adequate length of excursion.
Two ports are placed in the right lower quadrant—(1) a lateral 10-mm port just above the right anterior superior iliac spine for retraction and passage of sutures and (2) a medial 5-mm port for suction and irrigation midway and slightly inferior to the umbilicus and right robotic port. Finally, a 5-mm left lateral port is placed as a mirror image of its right-sided counterpart. Initially, this procedure called for two bedside assistants, but the evolution and application of the fourth robotic arm eliminated the need for one of the assistants, in turn obviating the need for the most lateral left 5-mm port.
The port placement of a da Vinci system with a 4-arm configuration is similar except the assistant is usually relegated to the left side and two right lateral ports are 8-mm robotic trocars. The assistant can then use either one or two of the ports on the left side. At least one 10-mm trocar is necessary for suture passage. The authors use a single 10-mm trocar with the port placed about 2 fingerbreadths above the umbilicus on the left. Although this trocar position necessitates the use of a extended-length (bariatric) suction irrigator, the more cephalad positioning of the trocar discourages movement conflicts with the left robotic arms. Careful trocar positioning is more important with the first-generation 3-arm and 4-arm systems. The newer da Vinci S was designed to have a smaller profile for camera and instrument arm movement, thereby making precise trocar placement less vital.
The robot is then docked, and the robotic instrument ports and the camera port are fixed to the arms of the robot. This portion of the procedure is initially time-consuming but becomes much shorter with experience. This step routinely takes 10-15 minutes at the authors’ institution.
A stepwise approach to robotic transperitoneal prostatectomy is discussed below. Instruments used include a bipolar cautery on the left robotic arm (left hand) and a monopolar cautery scissors or hook/spatula on the right robotic arm (right hand). If a fourth robotic arm is used, large grasping forceps (Cadiere or Prograsp) are also used.
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