|Dr. Huong Truong, a senior resident,
assists at the bedside during a robotic
prostatectomy. The bedside surgeon
assists the surgeon operating the
robotic instruments and changes or
adjusts the instruments as needed.
Robotic Tools Facilitate Minimally Invasive Prostatectomy
critical nerve bundles and blood vessels surround the prostate,
prostatectomy can carry high risks of erectile dysfunction and urinary
Today, minimally invasive robotic prostatectomies are preferred in
facilities that have the necessary equipment, and these procedures
often reduce the recovery times and surgeon fatigue associated with
Robotic prostatectomy has become the gold standard for prostate surgery
in recent years. Although it has similar overall outcomes to open
prostatectomy, robotic surgery limits bleeding and reduces recovery
times. The size and precision of the instruments can also make it
easier for surgeons to avoid sensitive structures like nerve bundles.
Because robotic surgery does not require the surgeon to remain at the
operating table, performing the surgery is much less fatiguing. Adding
to the comfort is the customizable nature of the control booth, which
can be adjusted for the surgeon’s height and personal preferences, thus
reducing awkward angles and body positions. The current (third
generation) robot has expanded ergonomic capabilities to accommodate
surgeons of all sizes and preferences.
John W. Davis, M.D., an assistant professor in the Department of
Urology at The University of Texas MD Anderson Cancer Center, said,
“Because of the position of the patient, open surgery can involve a lot
of reaching and leaning for the surgeon to access the area. Robotic
surgery makes difficult cases easier because you don’t have to reach
deep into the pelvis with your arms, and you have a set vantage point.”
|Dr. John Davis performs a robotic prostatectomy. The robotic system’s three-dimensional monitor and maneuverable tools make complex tasks easier to perform compared with laparoscopic surgery. Left: Close-up of the surgeon’s hands on the controls.
Superficially, robotic surgery is similar to laparoscopic approaches,
but the tools are vastly different. The surgical robot looks something
like a spider with several arms that hover over the patient. Each arm
has an interface that can connect to a wide array of modular surgical
tools. Robotic surgical tools have four wheels that lock in to
corresponding gears in the robot arm. These wheels move the mechanical
“wrist,” which is the key difference between robotic and laparoscopic
tools and allows a far greater range of motion that essentially mirrors
the surgeon’s hand motions. Dr. Davis said, “Compared with laparoscopic
tools, the robotic tools offer extra degrees of freedom that make many
tasks, such as suturing, much less taxing.”
The surgeon sits several feet away from the patient in a booth that is
connected to the robot by several cables and contains a pair of
articulating arms that translate the surgeon’s hand movements through
the robot and into the tools. The interface also provides some tactile
feedback: any restriction to a tool’s mobility also restricts the
controls. For instance, if a tool comes in contact with bone, it will
prevent the tool from moving, which in turn prevents the controller arm
from moving. The surgeon uses a microphone to communicate with the rest
of the surgical team, who remain centered around the patient and can
view the progress of the surgery via monitors.
The robotic procedure
In a typical robotic prostatectomy, the patient is first placed
head-down on a slanted operating table and anesthetized. Next, the
patient’s abdomen is insufflated with carbon dioxide, and the surgeon
places surgical ports in the abdomen. The various tools needed for the
surgery are attached to the robotic arms and inserted into the ports.
Once that is accomplished, the surgeon removes his or her mask and
gloves and takes a seat in front of the robot control booth on the
other side of the room.
|“Robotic surgery makes difficult cases easier.”
|– Dr. John Davis
Using a scissor tool and a foot pedal–activated electrocautery clamp
tool, the surgeon is able to cauterize and then either cut or pull
apart tissue. As in other surgeries, before any larger blood vessels
are cut, surgical assistants apply clamps to the vessels using an
independent laparoscopic tool. They are aided by two-dimensional
monitors that project the surgeon’s view. The surgeon, who has a
three-dimensional monitor, helps them judge depth and gives guidance
via microphone. Because the camera is physically linked to all the
robotic tools, the perspective of both the surgeon’s and the surgical
assistants’ views remains constant. This direct perspective is
different than that of laparoscopy, which can involve cameras and tools
at many different angles.
According to Dr. Davis, patient selection criteria for robotic
prostatectomy are similar to those for open and laparoscopic
prostatectomies. Surgeons new to the system may want to avoid
complicated cases at first, but otherwise, robotic surgery can
effectively replace laparoscopy for minimally invasive prostatectomies.
Where robotic surgical suites are available, robotic surgery is
generally preferred over laparoscopic surgery because of the advantages
mentioned above. However, some surgeons still prefer to use open
surgery because of their level of experience with open surgery.
Other factors that affect whether a patient is a candidate for robotic
prostatectomy are similar to the considerations for open prostatectomy.
If the patient has already undergone radiation therapy, later surgery
may be more difficult because radiation damages the surrounding tissue
and can change the anatomy of the area around the prostate. Similarly,
patients treated with radiation or surgery for previous colorectal
disease may not be candidates for minimally invasive prostatectomy
because of scarring and anatomical changes.
There are, however, some indications that robotic surgery is
advantageous for prostatectomy after radiation therapy. Dr. Davis
hypothesized, “Perhaps the strength of the robotic scissors can
negotiate irradiated tissue as well as, if not better than, hand-held
scissors or blunt dissection. However, the surgeon will need to have a
high level of expertise in dealing with irradiated tissue.”
Patients who have not previously been treated with radiation must
consider the different risks related to bowel control, erectile
function, and other quality-of-life factors associated with radiation
therapy versus surgery. Other health issues must also be taken into
account. For instance, Dr. Davis said, “Some patients also have benign
prostate enlargement, so they may opt for surgery to remove that
|The monitors used by surgical staff during a robotic prostatectomy display in two dimensions what the surgeon sees on the three-dimensional monitor in the control booth.
Robotic surgical suites are very expensive, as are the disposables
associated with robotic surgery, and this expense limits the
technology’s adoption to large or high-volume facilities. It is unclear
whether the costs of robotic procedures will decrease in the near
future. Dr. Davis said, “Robotic instruments have a fixed 10-use life
span and then have to be replaced, which is expensive. However, many
basic instruments, such as needle drivers, could be safely used many
more times.” Although there is currently only one manufacturer of
instruments approved for patient care, the system is built to allow
novel instruments that may improve vessel sealing, suction, or staple
placement to be developed by other companies.
Robotic technology continues to advance. The third-generation robot has
an improved high-resolution camera setup and can accommodate two
surgeons working at their own consoles on the same patient. Another
exciting direction is the fusion of ultrasonography and fluorescence
imaging into the console such that the surgeon can view the operative
field and imaging at the same time, which may allow more accurate
identification of various tissue types.
Another attractive capability of the robotic surgical suite is its
utility for training new surgeons in a manner similar to pilots using a
flight simulator. The third-generation robot has a virtual reality
surgical simulator that allows trainees to practice various skills and
situations. The software also grades the trainee for time and accuracy.
Telemedicine using the robotic surgical suite is also possible, and
some grants have been awarded for the development of telemedicine
programs in which robotic surgery will play an important role. Dr.
Davis said that telemedicine could allow surgeons at MD Anderson’s main
campus to collaborate on difficult robotic cases with surgeons at its
regional care facilities or at other institutions, which would mean
better quality of care for more patients.
information, contact Dr. John Davis at
articles in OncoLog, March 2012 issue:
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