Robot Assisted Laparoscopic Radical Prostatectomy

Mimimally Invasive Removal of the Prostate

        The Department of Urology is pleased to offer Laparoscopic Prostatectomy assisted by the da Vinci Robotic Slave Interface. Now in his 2nd year of robotic-assisted surgery, Dr. Thomas Ahlering of UC, Irvine Urology has perfomed minimally invasive robotic prostatectomies on more than 100 patients in addition to his previous 400+ open surgeries. The robot-assisted surgery offers many advantages for the surgeon: True 3-dimensional high magnification vision, greatly lowered blood loss, and normal 'intuitive' manipulation of surgical instruments. Table 1 highlights the methods and results between open, laparoscopic and robot-assisted laparoscopic prostatectomy.

Table 1. Comparison of Prostatectomy Surgical Options: Open, Laparoscopic, and Robot-Assisted Laparoscopic

*Data is supplied from UC, Irvine single surgeon, Dr. Ahlering. Laparoscopic data is derived from published literature.

       The da Vinci Robot gives the surgeon new tools for minimally invasive (laparoscopic) surgery. The robotic system was originally developed by the Department of Defense for use as a robotic surgeon for the battlefield and is approved by the FDA.

The Da Vinci 3-D Camera. Standard laparascopic viewing utilizes one single camera and limits surgeon's vision to a 2-D view similar to watching your television.The da Vinci robotic camera consists of TWO high resolution fiber optic cameras. Like your eyes they produce a true 3 dimensional color picture available to the surgeon seated at the da Vinci console by viewing the twin eyepieces. Magnification of up to 10-12x can be achieved with these cameras. A central robotic arm positions the camera and lighting exactlly where the surgeon wishes it, because it is operated by the surgeon by foot pedals as he/she is comfortably seated at the console. Also note the camera can be placed within 2 inches of the prostate during surgery. Two different cameras are also available: straight, and 30 degree oblique. The oblique camera can allow the surgeon to peek around the corners and to partially see underneath the prostate.

The Da Vinci Surgical Intruments. Although visually similar to standard laparascopic instruments, the robotic instruments have the additional advantage of being articulated. The allows the instruments not only to open and close but to fully turn and twist, allowing more natural mimicry of the human hand and wrist. Unlike your hand these intruments are much smaller. Many of the jaws of the tools are similar or shorter in length than your fingernail. This allows very small and precise incisions to carefully dissect out the prostate.

The Manipulation of the Da Vinci Surgical Intruments. Standard laparascopic instruments are manipulated counter-intuitively or 'backwards'. The surgeon operates one end of the instrument which acts like a lever-push one end down and the other end goes up. Push right to make the instrument go left. This is similar to a teeter-totter, where the center is the port or entrance to the body cavity. Thus for standard laparoscopic procedure, the surgeon has learned to operate essentially backwards. Although difficult, a highly qualified surgeon can master this process. The Da Vinci robot does NOT have these limitiations. The robot-slave technology translates a surgeons hand movements exactly as he/she does them. Turn your wrist right and the articulated robotic wrist turns right; go up, the robot wrist move up, etc. in three dimensions. The robot also allows the surgeon to 'scale' their hand movements. A large hand movemement at the console can be translated into a micro precise dissection or exposure. The robot can also filter out hand tremors, enhancing precision.

Minimizing Blood Loss with the Da Vinci Robot. Similar to standard laparascopic procedures, patients are insufflated in the lower abdomen. This gas pressure acts like an invisible hand to suppress blood loss and it also gently sweeps bowel away from the surgical target site. The gas is exhaled away after surgery. The enhanced visibility and magnification of the robotic cameras aid the surgeons in finding small 'bleeders', which translates into lower blood loss. Now surgeons can keep blood loss to a minimum, which means an increased clarity of vision to more carefully identify essential anatomy of the prostate: the edges of prostate (margins), the urethra (continence), and nerves and blood vessels which may aid potency.

The Results of the Da Vinci Robotic Assisted Surgery.

How do these advances in technology translate into beneficial results for the patient?

Cancer Control. The true color 3-D high magnification vision, 'intuitive' manipulation of technological advanced precise articulated surgical instruments, control of blood loss allowing clearer visibility significantly impacts the surgeon to more carefully identify, expose, and dissect out cancerous prostate. The overall rate of margin positivity of robotic prostatectomy is <19%. More importantly in men whose cancer is confined to within the prostate, the apical region was correctly visualized and dissected, resulting in very low 4% positive margins in the last 40 cases of organ confined disease. Prior to the Da Vinci robot, it was very difficult to make such a clean and refined excision of the apical region of the prostate.

Hospital Length of Stay. The average hospital stay for patients is slightly more than 24 hours after surgery, regardless of age.

Estimated Blood Loss. The average estimated blood loss per patient averages 116 cc. This volume is roughly the 1/3 of the volume of a 12 oz. soda can. Estimated Blood loss has ranged for robotic patients from 25cc to a maximum of 400 cc in the 1st 100 patients. Because of these low blood losses, none of these men required a blood transfusion, nor were they asked to donate autologous blood prior to surgery.

Urinary Continence After Surgery. Robotic prostatectomy sets an excellent record of continence. Using the definition of zero pads used per day means men will use no pads, not even security pad, although they may have a few drops of leakage during the day. The percentage of men at this zero pad/day standard is 50% at 1 month, and 75% at 3 months after surgery. The remaining men use either a security pad or some number of pads per day at 3 months.