Just as humans have evolved over time and adopted technology into their day-to-day lives,so has the art of surgery. We have moved from primitive and simple instruments, such as the scalpel, to highly advanced pieces of technology to make our operations more effective and precise. Looking at the current penetration of minimally invasive surgery by specialty, we note that laparoscopic cholecystectomy is a routine procedure that enjoys a high penetration rate within most hospitals.
Conversely, penetration of minimally invasive techniques into gynecology, urology and cardiac surgery have been limited traditionally in the past because of the inherent complexity associated with those procedures. So, as the complexity of the procedure increases, the penetration with the minimally invasive approach decreases. This is where the da Vinci system has bridged the gap. The robotic surgical system was specifically developed to address these more complex specialties and procedures and for the sake of this discussion, we will focus on urology with da Vinci prostatectomy. The adoption curve of robotic prostatectomy follows the same predictable adoption curve that we have seen in the adoption of laparoscopic cholecystectomy as the minimally invasive surgical option in general surgery.
Robotic prostatectomy, also known as daVinci prostatectomy, has been the fastest growing treatment option for men diagnosed with clinically localized prostate cancer. As the rate of adoption for da Vinci prostatectomy has increased, the number of open prostatectomies has clearly declined at the same rate. With the advent of any new surgical technique, we have to remember that open radical prostatectomy originally set the bar for outcomes after surgery, and whatever treatment the patient chooses, it is really about three different types of outcomes:
1. Cancer control as it relates to pathological results and margin status and subsequently PSA recurrence down the line.
2. The immediate surgical outcomes as it relates to bleeding, the length of stay of the hospitalization, complications such as wound infections/bleeding/transfusion, etc., and the extent of time that the catheter is left in place
3. From a postoperative recovery standpoint, the time the patient has take off of work and/or bladder and sexual function. When we switch to talk about minimally invasive surgery, we have to remember what has influenced our drive to adopt newer technology, such as laparoscopy or robotic surgery.
The minimally invasive approaches use smaller incisions, and therefore there is less pain. With the use of the gasor pneumoperitoneum to establish the surgical field, there is less blood loss because of pre-emptive control of blood vessels and some pressure on venous bleeding. In turn, there should be quicker recovery and shorter length of stay. With three-dimensional visualization afforded with the robotic interface and magnified view of visualization, there is also improved reconstruction of the anastamosis leading to shorter catheterization time.
What we have achieved is the same cancer surgery as the open approach and all o fthese variables have lead us to also have quicker return of continence and sexual function. In contrary to what people may think or have been told, there are not many contraindications for laparoscopy and robotics. We can do minimally invasive surgery inpatients who: have had previous abdominal surgery, prostate sizes that are large than 80 gm, have advanced disease, who are morbidly obese, those with previous open or laparoscopic hernia repair, or even those having undergone previous therapy with radiation or brachytherapy. Starting from the exterior and aesthetically speaking these are the incision sizes associated with open and robotic surgery.
As we all know, this is probably the least important difference between the two but this is what the patient perceives and believes translates to what has also been carried out inside their body. Open prostatectomy incisions are clearly bigger and more painful than the incisions associated with laparoscopy. So, why have not all surgeons adopted minimally invasive approaches into their practices? There is obviously a very steep learning curve for use of a pure laparoscopic approach.
Data from a memorial Sloan-Kettering study comparing pure laparoscopy and open prostatectomy as it relates to positive margin status shows that only after the first 200 cases had been operated on did the margin status seem to stabilize. This was a study that looked at the results of a single surgeon. From our own pooled experience with the learning curve for a pure laparoscopic radical prostatectomy the operative times with the procedures seem to have plateaued after approximately 200 cases, similar to the number of cases in the Memorial study above. So, there is a very steep learning curve for laparoscopy that most surgeons do not have the time, training, patience, or resources to endure. Contrary to pure laparoscopy, robotics is an improved technological platform based on an ergonomic interface that allows the surgeon to perform the operation in a very precise fashion. It gives you binocular vision with three-dimensional visualization, along with greatly enhanced dexterity, precision and control from an endowrist technology that provides 7 degrees of motion not achievable with standard laparoscopic instruments. All of these factors in turn have helped shorten the learning curve for the application of minimally invasive surgery in the field of prostatectomy.
As a result, both patients and surgeons recognize the impact this can have on their procedures, and over the past decade, the number of installed surgical systems has exploded almost like a robotic epidemic. As a result, the market share for robotics has increased while the use of open prostatectomy has clearly decreased with pure laparoscopic radical prostatectomy being almost non-existent in the current arena of prostatectomy This is a picture of a robotic system: The device is docked or positioned over the patient, who is placed in steep position with their head down, and the arms numbered 1, 2, and 3, are interactive parts, which execute movements of the laparoscopic instruments based on the surgeon’s commands, who is seated at a separate nearby surgical console. So why has there been such growth. Well, there is a growing body of clinical evidence supporting the advantages of robotically assisted minimally invasive surgery in urology, general and cardiac surgery,as well as in a number of gynecological procedures. In addition,with the use of the Internet, patients today are better informed and have taken more responsibility for their healthcare decisions. So,one has to ask, is robotic prostatectomy the new goal standard? The technical aspects of the operation involve detaching the prostate from the bladder and the neurovascular bundles, which are draped over the prostate from a posterolateral fashion.
The bundles are delicately dissected off to detach the prostate from the urethra, and then the urethra and bladder are reconstructed with the use of needle drivers to make a watertight anastamosis. One of the most technically challenging parts of the operation is the dissection of the neurovascular bundles. They clearly have a role in postoperative potency in addition to urine control. Therefore peeling off the neurovascular bundles in a way as to limit their injury is considered to be one of the most important goals of prostatectomy. When you have a chance to see a video showing the neurovascular bundle esection, one can immediately appreciate that the amount of bleeding, and any shaking or tremor is clearly less than was seen in the open approach.But does this really translate to better outcomes for the patient? I will be the first admit that studying outcomes in radical prostatectomy is not very easy because most of the data that is published is not reliable. Most results are non-randomized series, physician-collected, or sequential series using non-standardized collection methods, and a lot of negative studies have not been published. However a very comprehensive and excellent review of both open and laparoscopic and robotic approaches for doing prostatectomy was recently reported in Current Opinion in Urology. In order to limit differences due to surgeon experience or institutional experience, the results reported were from high-volume, single institution, single surgeon series.
Average blood loss for robotic prostatectomy is anywhere from 150-300 cc, compared to500-800 cc for open prostatectomy. Transfusion rates are clearly less for robotic compared to open, and complication rates seem to be comparable. In terms of pathological outcomes, again,these are side-by-side studies in the same institutions. Positive margin rates seem to be comparable, if not less with the use of robotics, and when it comes to functional outcomes, continence rates at the one year mark after robotics compared to open prostatectomy are clearly in favor of the robotic approach.
Continence rates with robotic show that anywhere from 92-97% of patients are pad free,compared to 88-94% of patients being pad free in the open approach. Similarly, the potency rates with the robotic approach show that 60-80% have the ability to engage in intercourse with or without the use of medications, compared to 40-60% of patients in the open approach. In our own experience of over 2100 patients to date, average blood loss is less than 300 cc, transfusion rate is below 1%,overall positive margin rates are 14%, continence rates at the one year mark 97%, and 85% of pre-operative potent patients are able to engage in sexual activity post-op. Although the data reported with robotic surgery to date has been limited due to the variables mentioned above, we do think robotic surgery and laparoscopy is the perfect surgical modality for the scientific study of surgery. Our techniques can be standardized and viewed by others in order to duplicate and allow them to validate the results. In our opinion(and this is shared by many other highly specialized surgeons who have had the chance to utilize all available techniques) robotic prostatectomy is definitely here to stay, and although a randomized control trial comparing the techniques would be ideal, it is clear that this is unlikely occur in the near future. In the meantime, patients have voted with their feet and are opting to have robotic surgery where available. With time, the use of open surgery for clinically localized prostate cancer will likely be limited to those with certain risk factors precluding them from having laparoscopic/robotic surgery, and one can argue that maybe surgery in that case may not be the best choice after all.