Surgery: Prostate Cancer Surgery
Benchmarks sat down with Peter Pinto, M.D., director of the Urologic Oncology Fellowship Program in the Urologic Oncology Branch, part of NCI’s Center for Cancer Research, to discuss the details of a robotic prostatectomy.
Benchmarks – Briefly describe what a robotic prostatectomy is?
Dr. Peter Pinto: When you perform prostate surgery, the goal is to remove the cancerous prostate and ensure that none of the cancer is left behind. In addition, the surgeon aims to keep intact the nerves that maintain a man’s potency while reattaching the bladder to the urethra to maintain urinary continence. A robotic radical prostatectomy is a surgeon-directed robotic procedure where a machine called the da Vinci® robot is used to assist in removing the cancerous prostate and surrounding lymph nodes. This process is a minimally invasive approach to prostate cancer surgery.
Benchmarks - What is the difference between robotic surgery, regular open surgery and laparoscopic surgery?
Dr. Peter Pinto: Robotic surgery is done in the same fashion as open surgical removal. The difference is that what originally required a large incision (from the belly button down to the pubic bone), now only requires 4 to 6 small incisions, each about 5 mm-12 mm in length. These incisions allow instruments to pass through ports (a hollow cylinder through which instruments can pass), keeping the surgeon’s hands outside the patient.
Prior to the advent of this machine, surgeons like myself were performing these procedures laparoscopically. Laparoscopic radical prostatectomy is a less invasive approach to open surgery and uses the same ports to pass instruments as the robotic platform. During laparoscopy, the surgeon’s hands are physically attached to the instruments that go through the ports and the instruments themselves are limited in their range of motion. In addition, the laparoscopic camera that is placed inside the abdomen to visualize the prostate displays the image onto a screen that is two dimensional, so the surgeon has to overcome the lack of depth in the operation.
In the robotic platform, which has become so popular, the surgeon who would normally have his hands either inside the patient or attached to the instruments, is now moved back to a console which is most often in the operating room next to the patient. This console has two controls or masters for both hands that allows me to manipulate the instruments that are inside the patient through a robotic interface. Moreover, the instruments that go through the ports are wristed, meaning more degrees of freedom and allowing the movement of the instrument to be similar to that of the human wrist, creating better angles for surgery. Also, when you look through the console at the surgical field it gives you a magnified three dimensional image, therefore you can get the same depth as if you were seeing the image with your own eyes.
The type of instruments used in robotic surgery are the same ones I use in open surgery. We can use scissors, pick up or forceps, apply clips, suture and tie knots. The robotic platform emulates the open technique, but also removes surgical tremor and can scale down motion. In the open and laparoscopic platforms, if a surgeon’s hands shake slightly, movement of the instruments can be effected. However, with the surgical robot, those extremely small movements are not translated into the instruments.
Benchmarks – Are surgeries more successful using this technique, compared to open or laparoscopic surgery?
Dr. Peter Pinto: I would say the answer to that is no, even though it is still debatable. There are some papers that support the stance that the robotic platform makes the operation more successful and then there are other papers that conclude that this method is equivalent or actually makes things worse. This completely depends on who is using the machine, their comfort level doing robotic surgery and also their knowledge of the anatomy of the prostate and its surrounding structures. At our institution we have had great success using the robotic platform to perform prostate cancer surgery. Using this machine I am able to preserve a man’s sexual function and urinary control while removing his cancer. Since I started performing robotic surgery in 2002, I now recommend this platform to my patients over open or laparoscopic methods.
Benchmarks – Are there any safety issues concerning this technique?
Dr. Peter Pinto: There are. If the robotic platform is arguably no different than open surgery, then why has it become so popular and is safety one of the reasons? First of all, the robotic platform itself is an alternative to open surgery and because it is less invasive many patients have chosen this as an option for their treatment. Additionally, robotic surgery, like laparoscopic surgery, uses pneumoperitoneum; a method which uses gas ( like carbon dioxide) to create space that allows us to access to the abdominal cavity. That extra pressure permits us to operate in a less bloody field–so our patients lose less blood with the robotic procedure. This, along with this being a less invasive method, has made robotic prostatectomy a more popular alternative to open surgery.
There have been some safety concerns that the robot would go ‘out of control,’ meaning that the machine itself would act independently of the surgeon and that is incorrect. The da Vinci® system is a surgeon directed robot, so all movements are initiated by the surgeon. There is no automation or semi-automation, so the sci-fi images of machines working independently of a human interface are not the case. The only injuries that can occur using this technique would be if the surgeon incorrectly applies the instruments to a certain part of the body. Like any piece of equipment, if the machine were to break down, the robotic platform can mechanically come to a halt. The safety features of the machine then allow it to stop so it cannot be used any further. In those cases most hospitals have additional machines available, or the case can be completed laparoscopically or open, if the surgeon has those skill sets.
Benchmarks – Does this technique reduce recovery time, surgery time, or time in the hospital?
Dr. Peter Pinto: Since it is less invasive, the robotic technique allows the patient to recover faster, meaning that the time it takes to heal from a large open incision is longer than it is to heal small 5-8 mm incisions in the abdomen.
In regard to the surgery itself, part of the operation is removing the prostate, the surrounding lymph nodes where cancer can spread, sparing the nerves that allow a man to maintain his potency and reestablishing continuity of the bladder to the urethra to allow return of full urinary control . This means taking out the prostate and suturing the bladder back to the urethra so the man can stay dry. The surgery requires a catheter to be placed across the suture line between the urethra and the bladder, which allows that area to heal. Many institutions allow that healing phase to occur over 7-14 days, meaning the catheter stays in that long. In our institution, because suturing with the robot is very accurate and the bladder to the urethra is closed in a water tight fashion, we can remove the catheter in 3-5 days.
Regarding hospital stay, men who have open surgery can leave the hospital within a day or two after their procedure. Most men stay two days, but regardless, they do well with the open incision. In robotic surgery most men go home after a day. There are some individuals who go home the same day after a robotic prostatectomy but the time for hospital discharge, if anything, is only slightly shorter with the robotic platform. There is no significant difference here. One can argue that the benefits to the patient are long term, such as getting back to work and physical activities that the patient deems important. Even though there is still a debate, the perception [by our patients ] is that with the robotic platform you can get back to your normal, daily activities a few days to weeks earlier compared to the open approach.
Benchmarks – Is every patient a candidate for robotic surgery?
Just like the criteria for open surgery and radiation, there are set criteria for robotic surgery. These depend on the surgeon’s skill set-their comfort with doing the procedure. Almost every candidate has the opportunity to undergo surgery, whether it be open, laparoscopic or robotic. Body size, prostate size, previous surgeries all weigh as important factors in both open or robotic–neither one more important than the other. At our institution all men who are healthy enough to undergo open surgery can have a robotic procedure.
Benchmarks – Are patients ever intimidated by the robot?
I had the good fortune of taking care of an active military person with prostate cancer, whose former training was in the air force. He used to fly F-14′s and F-18′s. He said that in the older airplanes, you could actually have your hand on the throttle and, by moving it, feel the plane move, and you could control it directly. But, the new versions that he flies are interfaced through buttons and electronics, and you don’t have that same hands-on feel. I was explaining to him the difference between laparoscopic prostate surgery and robotic prostate surgery–I was operating on him many years ago when I was still doing both – and his first response to me was “I prefer not to have the robot, because I want to have your hands directly on the instruments, through the ports – I want you to do this laparoscopically”. Because of his experience, he felt uneasy having something between the surgeon and his body. After I explained to him that, with the robotic platform, a lot of the maneuvering that I perform laparoscopically is arguably better, he agreed to the robotic procedure and actually had that done. His robotic surgery went well and he had full return of urinary control and sexual function while remaining cancer free today.
Benchmarks – What is the training required to operate the da Vinci® Robot?
Dr. Peter Pinto: Most academic centers and hospitals where residents and fellows are currently working have robotic surgery as part of their training. We have about four fellows a year that train with us (they stay with us for two or three years) and they are learning to use the robot. Therefore when these physicians leave their fellowship they are often at least familiar with the robotic platform and can use the machine. Urologic surgeons who were never exposed to laparoscopic or robotic techniques have to take courses, many of which I help teach, and go on to proctored animal training sessions to become proficient with the system. They are usually weekend or four to five day courses. Additionally, these surgeons have mentors when they perform their first few robotic surgeries to allow them to get comfortable with the techniques and have someone to oversee the procedure. I think as time goes by, this will become less of a concern, since more and more of our trainees are becoming familiar with this platform. For me personally, I had the fortune of learning how to use laparoscopic and robotic machines in my training when I was at Johns Hopkins, so it was natural that I used it when I came to NCI.
Benchmarks – Do you think robotic surgery will eventually replace open surgery?
Dr. Peter Pinto: I think that the number of robotic surgical cases will continue to increase and we will see more urologic surgeons feel comfortable doing prostate surgery robotically instead of open, but keeping in mind the points mentioned earlier , such as machine breakdown, patient factors, etc; it may take a long time for us to completely replace open surgery. I think there will always be a role for open surgery but more and more cases, as the years go on, will be performed robotically.
Benchmarks – Technology has come a long way–from open to laparoscopic and now on to robotic surgery; do you think there will be more advances or a new and improved version of the da Vinci® robot?
Dr. Peter Pinto: I agree–technology continues to advance. In our everyday lives we see great strides made in computers and technology that assists us in the workplace. I imagine that has to happen in the field of surgery as well. The original robotic da Vinci® system was replaced by another more advanced system. The new robotic system is similar to the old, with a few minor modifications. Just as we have seen our computers go from very large desktops to notebooks and now handheld devices, I am sure we will see robotic surgery continue to get smaller and better. We may even see other companies get involved and provide platforms for robot assisted surgeries.
Benchmarks – The field of telesurgery is also continually advancing. Do you think eventually you will be able to do surgeries across the country or the world?
Dr. Peter Pinto: There have been reported cases of using robotic surgery where the surgeon is on the console in one room and the patient is elsewhere. That has been done for gallbladder surgery where the surgeon was in New York and the patient was actually in France. Telesurgery is a little bit different than robotic surgery in that you have to overcome the delay between what the surgeon sees [as in the instrument moving in the patient] vs. the time it actually happens in the remote location. Also, it is important to make sure the communication line between the surgeon and the patient is secure, especially if the patient is cross country. But telemedicine for diagnostic purposes, such as viewing CT scans and MRIs, where surgeons are in different locations, is continuing to expand and I can imagine with natural progression that platform will move on to surgical applications like telesurgery.
Animation/Video
Doctors performing a radical prostatcetomy
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Close-up of surgical robot assisting with radical prostatecomy
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Close-up of surgical robot assisting with radical prostatecomy
Photos/Stills
Peter Pinto, M.D., Staff Clinician at the Urologic Oncology Branch, National Cancer Institute, NCI.Wide angle view of the surgical suite where doctors are using a surgical robot called the "da Vinci" to help remove the prostate and lymphnodes.This surgical technique, robot assisted surgery and laparoscopic prostatectomy therapies has the potential for fewer side effects.
Schematic layout of operating room robotic prostate surgery/ Layout drawing of surgery suite from a bird's-eye perspective with positions of robot, screens, surgery table, instrument console, noted
