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.

Precision Robotic Tools Facilitate Minimally Invasive Prostatectomy

By Zach Bohannan

Because critical nerve bundles and blood vessels surround the prostate, prostatectomy can carry high risks of erectile dysfunction and urinary incontinence.

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 prostatectomy.

Robotic advantages

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.

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.

Patient selection

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 obstructive element.”

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.

Future directions

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.

For more information, contact Dr. John Davis at 713-792-3250.

Other articles in OncoLog, March 2012 issue:

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