Laparoscopic Robotic Assisted Prostatectomy

The goal of radical prostatectomy is to: 1) excise the cancer completely; 2) provide good urinary continence post-operatively; and 3) maintain ability to have erections after the surgery (if present before the surgery). Once these goals can be met reliably, then efforts can be made to minimize post-operative discomfort.

Laparoscopic robotic assisted prostatectomy is performed with the assistance of a surgical robot (UMHS uses the da Vinci system), this procedure duplicates the standard open surgical radical retropubic prostatectomy (RRP) but with smaller incisions.

Instead of the midline incision extending up from the pubic bone towards the umbilicus (as for the open surgical procedure), 5 small incisions (one-quarter to one-half inch each) are made in the lower abdomen.

Through these incisions are passed the robot-controlled videocamera, 2 robotic manipulating arms, and 2 assisting instruments. The surgeon sits at a console and manipulates the robot arms and directs the camera with hand-controls, while looking at the operative field with an immersive 3-dimensional view. The ends of the robotic arms are like miniature wrists that allow very fine movements.

  The advantages of laparoscopic roboticradical prostatectomies are due to the lack of large surgical incision and the excellent magnified vision. These advantages include improved cosmetic result, less blood loss, and briefer and less intense post-operative convalescence. This procedure provides cancer control, urinary continence and erectile function that is equivalent to that associated with the standard open surgical prostatectomy.

Below is a comparison between open and robotic prostatectomy. All data below is from the time of surgery. Patients undergoing a Robotic prostatectomy had less blood loss and less narcotic use in the hospital.

Two videos demonstrate the robot arms performing surgery. These arms are directly controlled by the surgeon at a remote console, "automated" maneuvers are not possible with the robot. In video #1, the prostate is seen with a yellow catheter protruding through the middle of the prostate and entering the bladder. The suture is being placed in the dorsal vein complex that drains a large amount of blood from the pelvis. Control of this vein is critical. With the robot, we are able to place to suture in the exact position needed to control bleeding. In video #2, the neurovascular bundle on the right that controls the ability for a man to have erections is being separated from the prostate. The nerve bundle is in the bright yellow tissue at the bottom right of the video and the prostate is the whitish round organ in the middle. With he robot arms we are able to gently separate the nerves from the prostate.

1. Dorsal venous complex stitch placed. Foley catheter seen between prostate and bladder.
2. Right Lateral Prostate Fascia

The benefits of high volume institutions with high volume surgeons:

In the June 2005 issue of the Journal of Urology, two articles and an accompanying editorial highlight the benefits of having a radical prostatectomy at high volume institutions (more than 61 procedures per year) , and performed by high volume surgeons (more than 5 procedures per year) . UMHS is such an institution. At UMHS there is a high volume of radical prostatectomies performed, by individual surgeons whom each perform a high volume of these operations. From June 2004 through May 2005, 260 radical prostatectomies were performed at UMHS. Drs. Montie and Wood have performed over 1500 radical prostatectomies, each averaging about 100 per year. Dr. Hollenbeck, a recent addition to the Urologic Oncology faculty who specializes in laparoscopic and open oncologic procedures, performs approximately 50 radical prostatectomies per year. This concentration of experience by individual surgeons, in a hospital with a very large instutitional experience, contributes to excellent outcomes at UMHS.

In the study by Ellison and associates (Journal of Urology, Volume 176, pages 2093 - 2098, 2005), which studied a database of more than 12,000 men, the cancer was less likely to recur when the initial prostatectomy was performed in a hospital with a high volume of prostatectomies (more than 61 procedures per year). At hospitals with a lower volume the prostate cancer were less severe (lower grade and stage) but still there were more recurrences. In the study by Bianco and coworkers (Journal of Urology, Volume 176, pages 2099 - , 2005), also using a large database of procedures performed nationwide, urologists who did many prostatectomies (more than 5 procedures per year) tended to have lower complication rates than those who did fewer procedures.