American College of Surgeons 90th Annual Clinical Congress

NEW ORLEANS—According to the first report of outcomes following radical prostatectomy performed by surgeons using a surgical robot, male patients had equivalent surgical outcomes to the open approach with less blood loss, shorter hospital stay, faster recovery, and minimal use of narcotic medication during the recovery period. The study was presented at the 2004 Clinical Congress of the American College of Surgeons.

According to a preliminary study of the first 300 men who underwent robotic-assisted radical prostatectomy at Urology Centers of Alabama, Birmingham, the average blood loss was less than 50 mL, which is 300 to 2000 mL less than the typical amount of blood lost during standard open surgery. Also, blood products are not collected from the patient prior to or during surgery for retransfusion. The men were hospitalized for only one day following the operation, compared with a two- to three-day hospital stay after conventional open surgery. Recovery time was assessed by validated quality of life questionnaires, and return to independent activity of daily living (IADL) was 7-10 days versus the four to six weeks for traditional open surgery.

In addition, up to 80 percent of the men did not consume any narcotic medication during their perioperative period. "It is extremely rare for a patient to have almost any type of surgery these days without the use of some form of narcotic agent. That is why its amazing that patients are able to undergo major prostate cancer surgery without the use of any postoperative narcotics. The minimally invasive nature of the robotic surgery along with the use of anti-inflammatories and the ON-Q subcutaneous pump [I-flow Corporation, Newport Beach, CA] have allowed us to achieve non-narcotic radical prostatectomy in 80 percent of patients. Of that number, 20 percent do require narcotics, but the use is extremely limited—usually one or two pills maximum," Vipul Patel, MD, director of minimally invasive surgery at Urology Centers of Alabama, reported.

For many years, radical prostatectomy for prostate cancer has been done by means of an operation that requires a six- to eight-inch incision in the lower abdomen and blunt dissection, meaning surgeons use their fingers to locate and manipulate the prostate gland before excising and removing cancerous tissue. In the last few years, many surgeons have switched to the laparoscopic approach, which involves making a series of small incisions in the abdomen and introducing instruments that allow surgeons to see inside the abdominal area in order to dissect and remove prostate tissue. The surgical robot is called daVinci ® [Intuitive Surgical, Sunnyvale, CA] and provides the surgeon with magnified 3D vision and miniature articulating robotic writed instrumentation.

The addition of the surgical robot as an assistive device to perform laparoscopic radical prostatectomy increases precision. "Using traditional laparoscopic instrumentation is challenging, it's like operating with chopsticks. The vision is two-dimensional and the movements are counter-intuitive also. There's articulation of the ends of surgical instruments. Whereas with the robot, you have a "wrist" that can turn 360 degrees, which makes it easier to suture," Dr. Patel explained.

The robot improves magnification of the laparoscopic surgical field by a factor of 10 and provides three-dimensional vision, which allows surgeons to see small vessels and close them with sutures. Consequently, there is less loss of blood and a 0-1 percent need for trans-fusions. "Robotic prostatectomy makes a good surgeon even better because it enhances what you can do. It improves your ability to see the surgical field and allows increased surgical precision. This is important when attempting to remove the prostate while preserving the delicate nerves necessary for continence and potency," Dr. Patel said.

The study included men who had undergone robotic radical prostatectomy in the past two years. Oncologic outcomes were very favorable with a low positive margin rate. The clinical literature indicates that laparoscopic and open radical prostatectomy produce the same degree of cancer control as measured by postoperative levels of prostate specific antigen (PSA), an enzyme produced by the prostate gland that is elevated in the presence of cancer, and survival rates. "A small number of series of clinical investigations have indicated that PSA levels and survival rates after laparoscopic prostatectomy are equivalent to the rates achieved with open operation," Dr. Patel explained Robotic-assisted radical prostatectomy is not yet widely available. The daVinci ® Surgical System [Intuitive Surgical, Sunnyvale, CA] is frequently used by surgeons to perform heart surgery and general laparoscopic procedures, such as gallbladder removal, treatment of gastroesophageal reflux disease, and gynecologic treatment. However, only about 100 centers in the United States and Europe offer robotic-assisted prostate surgery, according to Dr. Patel. The surgical robot also is expensive; the device costs approximately $1.3 million.

Furthermore, surgeons must be trained in the use of the robot, which usually involves attending a two-day course, observing about four surgical operations, and performing two procedures under supervision. "There's a great deal of adaptation in using robotics to perform surgery," Dr. Patel said. "For the first time, surgeons are not standing next to or actually touching the patient. They're sitting at a console and are connected to the robot by wires. They're not even scrubbed or in a surgical gown. That approach takes a bit of getting used to," he added.

The demand for robotic-assisted radical prostatectomy is growing. Dr. Patel and his colleagues perform eight to 10 robotic procedures a week, largely as a result of word of mouth by patients, he said. Men are flying in for the procedure from as far away as India and parts of Europe. "We thought we would maybe perform 50 cases a year with the robot, but now we're estimating over 300 a year, and all because patients come in and say they want it. I think the addition of robotic assistance to prostate cancer surgery has really helped to decrease patient morbidity without sacrificing functional or oncologic outcomes. As larger series with long term data are published, we will begin to see the true efficacy. It definitely has the potential to become a standard of care in the future," Dr. Patel concluded.

News from the 2004 Clinical Congress