Performing The Robotic Prostatectomy: A Prostate Cancer Surgery General Overview For Patients
The essence of minimally invasive prostate cancer surgery is to gain access to the involved anatomy via the smallest entry points possible. Traditional open prostatectomies involved cutting open the lower abdomen with a large incision. Predictably, large incisions in traditional surgery for prostate cancer run a higher risk of infection and require significantly more time for the patient to heal, not to mention they tend to leave a large scar. Laparoscopic techniques however, using the da Vinci Robot, bypass this large incision and gain the same access through a few small holes in the skin, each roughly the size of a dime. A small plastic tube known as a port is inserted in each hole to keep a channel open for laparoscopic Port Placement image tools to reach through. To allow room inside for the surgeon to work, the abdomen is inflated slightly with carbon dioxide like a balloon. In this working space, the surgeon can perform the same surgeries as if the abdomen had actually been cut open, but without the large incision.
What Are The Advantages Of Laparoscopy
As is the case with other minimally invasive procedures, laparoscopic prostate removal has significant advantages over traditional surgery:
- Laparoscopy can shorten your hospital stay to 1 or 2 days. About 50% of men are discharged one day after surgery.
- There is much less bleeding during the operation.
- You are less likely to need prescription painkillers after you leave the hospital. Patients often need nothing more than Tylenol.
- At your follow-up appointment 1 week after surgery, the tube, or catheter, draining your bladder will be removed if there are no signs of other problems. Occasionally, the catheter remains in place for another week, as with conventional surgery.
- About 90% of patients can return to work or resume full activity in only 2 to 3 weeks.
What Are The Risks Of Robotic
As with any major surgery done under general anesthesia, there is a certain amount of risk, including heart attack, stroke and death. Preoperative assessment of a patients overall health is part of the surgical workup at UC Davis. Prostatectomies, including those done with a robotic-assisted surgery system, are also associated with the risks of impotence and incontinence.
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How Does The Robotic
It is similar to the conventional, minimally invasive laparoscopic prostatectomy. However, working from a special console in the operating room, the surgeon operates four precision-guided robotic arms to cut and remove the prostate. The procedure uses a small video camera, inserted through a keyhole-sized incision to provide surgeons with magnified, 3-D images of the prostate site. This expansive view allows doctors to see the nerve bundles and muscles surrounding the prostate. The robotic arms, with full 360-degree rotation capabilities, are placed through several other keyhole incisions allowing surgical instruments to move with greater precision, flexibility and range of motion than in a standard laparoscopy.
The procedure usually takes 2 to 3 hours under general anesthesia. Most patients experience only a small blood loss and blood transfusions are needed in less than one percent of patients. Prostatectomy patients typically spend one night in the hospital and are usually discharged as soon as their laboratory tests are acceptable, pain is controlled and they are able to retain liquids. Patients are discharged with special catheter, which is removed during an outpatient visit 5-7 days after the operation.
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Lefrak Center For Robotic Surgery And Institute Of Prostate Cancer
The Lefrak Center for Robotic Surgery is dedicated to the care of patients with prostate cancer using innovative MRI based diagnostic and staging approach and provides comprehensive care involving active surveillance, focal therapy, robotic prostatectomy, radiation and medical therapy. The Center has performed over 3500 robotic procedures and its faculty have published extensively about their outcomes in peer reviewed literature. For more information visit .
What Is The Procedure
The robotic surgery procedure and approach is very similar to conventional laparoscopy.
However, robotic surgery aids operations. It helps the surgeon, for example, in one of the most difficult and complex steps in laparoscopic radical prostatectomy: urethrovesical anastomosis using stitches .
Before the operation, and in addition to the patients physical examination, a series of blood, urine and other tests are run. This assessment is complemented by radiology tests such as MRI scans, CT scans and possibly others .
The procedure involves general anaesthetic and lasts around 2 hours.
In practice, the patient needs to know the following:
- The surgeon can access the prostate via small incisions at strategic points
- The technique uses a video camera, which takes very high quality 3D images, that guides the surgeons work
- During surgery, the doctor sits at a console beside the patient and performs the operation using tiny instruments
- The surgeons movements are replicated by the robot.
Treatment is usually followed by a hospital stay of a few days.
When discharged, the patient must refrain from movements at home that entail physical exertion in the first few weeks.
Surgeons Experience Trumps Technology
The equality of the two operative techniques did not surprise Dr. Falcone. An experienced endometriosis surgeon, he has co-edited multiple textbooks on robotic and laparoscopic technique. He feels the surgical approach does not matter as much as how well the disease is understood.
Due to the complex nature of pain in endometriosis, knowledge of the disease process and what the disease looks like in a patient plus familiarity with the anatomy are more important to outcomes than the surgical technique or technology used, he says.
He admits that robotic surgery has a certain cachet. However, he emphasizes that the technology itself does not improve outcomes.
If you are a good driver, its unlikely that a more expensive car like a Ferrari will make you drive better. Its the same with surgery, he says. The robot isnt magical.
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The Radical Prostatectomy Procedure
A radical prostatectomy is used to surgically remove the prostate. Surgeons typically access and remove the prostate gland via an incision made in the lower abdomen. Laparoscopic prostatectomies which incorporate robotic, keyhole surgery are also available, although opinions are divided as to which method provides the greatest accuracy and optimal results.
Adverse Reactions To The Anesthesia
If a person has a history of swelling of the face or generalized itching, it is important to inform the anesthetist before the procedure because, although allergic reactions to anesthesia can be mild, involving only wheezing or some skin irritation, it is also possible to experience an anaphylactic response which can be life-threatening.
Somebody suffering from an allergic reaction to an anesthetic may display signs like breathing difficulties, low blood pressure, rashes, hives and swollen skin around the eyes or mouth and throat. It is possible to perform tests prior to the surgery to identify which chemicals trigger an allergic reaction and if necessary an appropriate alternative anesthetic solution can then be chosen.
Other adverse reactions, such a muscle soreness, a sore throat from the breathing tube or nausea and vomiting after the surgery are a lot more common than allergic reactions. Around 10 percent of people will experience some kind of adverse reaction to anesthetic drugs, and anesthetists are trained to recognise and treat reactions as and when they occur during or after surgery.
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Patient Positioning And Abdominal Access
Regardless of the technique used, the patient is placed in the supine position with the head down. This head-down position allows for gravity to facilitate the natural retraction of the pelvic tissues. If the procedure is to be performed transperitoneally, a periumbilical incision is made to provide access for the initial laparoscopic port. A Veress needle or Hasson-type trocar is used to establish pneumoperitoneum and to facilitate the laparoscopic survey of the abdomen. The Veress needle is an ideal access device when the patient has no history of abdominal surgery. In patients who have undergone previous abdominal surgery, particularly involving infraumbilical incisions, the Hassan trocar is ideal for direct visualization and confirmation of entrance into the peritoneal cavity.
Carbon dioxide is then insufflated into the abdomen to achieve pneumoperitoneum. If a Veress needle was used for initial access, it is replaced by a 12-mm radially dilating laparoscopic trocar. The 3-dimensional robotic laparoscope is then inserted through the infraumbilical trocar site, and a laparoscopic survey of the abdomen and pelvis is performed. If the procedure is to be performed extraperitoneally, the first steps for access consist of a small incision and development of the extraperitoneal space.
What Is Robotic Prostate Cancer Surgery
Of the available comprehensive treatment options, UCA is proud to offer robotic prostate cancer surgery to patients with prostate cancer. As a surgical treatment option, the radical prostatectomy procedure removes the entire prostate gland. This can be performed by laparoscopic or robotic techniques. When open prostate surgery is performed, the prostate gland is removed through a larger incision in the lower portion of the abdomen. Laparoscopic prostate surgery involves small incisions, around the size of a keyhole, which are used for inserting a lighted viewing instrument into the pelvic region and allows the surgeon to examine and remove the prostate without a large, cumbersome abdominal incision.
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What Happens During Surgery
Your surgeon will put a small needle just below your belly button, into your abdominal cavity. The needle is connected to a small tube that passes carbon dioxide into the belly. This lifts the abdominal wall to give the surgeon a better view once the laparoscope is in place.
Next, a small cut will be made near your belly button. The laparoscope is placed through this incision and is connected to a video camera. The image your surgeon sees in the laparoscope is projected onto video monitors placed near the operating table.
Before the surgery, the surgeon will take a thorough look at your abdominal cavity to make sure the laparoscopy procedure will be safe for you. If the surgeon sees scar tissue, infection, or abdominal disease, the procedure will not be continued.
If the surgeon decides the surgery can be safely performed, more small cuts will be made, giving them access to the abdominal cavity. If necessary, one of these small incisions may be enlarged to remove the pelvic lymph nodes.
How Long Has Cleveland Clinic Been Performing Laparoscopic Prostatectomies
Cleveland Clinic has the most experience of any health care center in the United States related to laparoscopic prostatectomy. Our specialists have been performing laparoscopic prostatectomy procedures for the past three years.
We are investigating the long-term effects of the procedure versus the open radical prostatectomy. Preliminary results suggest that return to continence and potency is comparable to that of the open procedure.
Our staff will provide a comprehensive evaluation and refer you to the appropriate physicians for your specific condition.
Difficulty Getting An Erection
Impotence is more likely to happen if you are older. Nerve sparing surgery and robotic surgery may reduce the risk for some men. Speak to your doctor before you have surgery to get an idea of your risk of problems afterwards.
How Long Does This Surgery Take
Although this surgery takes approximately 3 hours to perform, patients generally feel much better and have significantly fewer pain requirements in the early operative period. Unlike open surgery where the catheter stays in for two to three weeks, most laparoscopic prostatectomy patients have their Foley catheters removed on the third day after surgery.
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What Can I Expect Before And After Robotic Prostatectomy
If after consulting with Dr. Engel, becoming educated on the topic of prostate cancer, potentially seeking other opinions, and being presented all options, a patient opts for robotic prostatectomy, he will then be taken extensively through what to expect. Dr. Engel currently performs robotic surgery exclusively at George Washington University Hospital, and a date and time will be scheduled for surgery there. The patient will generally be urged to see his internist for a pre-operative physical, although this can also be accomplished at the hospital itself. Tests to rule out spread of cancer such as a bone scan and CT scan, looking for spread to bones and lymph nodes, may be performed in higher risk cases. The patient will be given detailed instructions regarding a bowel preparation regimen and the patient must follow this strictly. The purpose of the bowel prep is not only to create more space in the abdomen, but also for safety in the very unlikely event that there is an inadvertent injury to the intestine or rectum during the surgery. If this occurs, a bowel prep will likely keep this from being a life threatening problem.
What Are The Patient Criteria For Robotic
The decision to surgically treat prostate cancer involves many considerations. UC Davis urologic surgeons will discuss your treatment options and help you decide the best course of action. Nearly all patients diagnosed with localized prostate cancer will have the option of choosing robotic-assisted surgery. It is the now most commonly selected prostatectomy approach in the United States. Patients with significant abdominal adhesions or obesity, however, may not be appropriate candidates for the this procedure.
Outcome Measurements And Statistical Analysis
Costs per surgical technique were assessed based on resource variable data from the LAPPRO database. The calculation of average costs was based on mean values Swedish currency was converted to purchasing power parity US dollar . All tests were two-tailed and conducted at = 0.05 significance level.
Robotic Radical Prostatectomy Versus Laparoscopic Or Open Surgery
Robotic radical prostatectomy offers significantly lower operative times and blood loss than laparoscopic or open surgery. Catheterization times and hospital stay are also superior to those associated with open and laparoscopic approaches. The learning curve is less with robotic assistance compared with laparoscopy. The one significant question that remains unanswered pertains to the cost-effectiveness of robotic prostatectomy compared with open and laparoscopic radical prostatectomy.
A randomized controlled phase 3 study by Yaxley et al that compared robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy reported that both techniques had similar functional outcomes at 12 weeks. Urinary function scores and sexual function scores were not significantly different between these two groups at 6- and 12-weeks post-surgery.
Early functional results are are summarized in Table 4 below.
Table 4. Outcomes of Functional Parameters Using Robotic Radical Prostatectomy
Badani et al
Ahlering et al
96% at 6 mo
IIEF = International Index of Erectile Function.
Preliminary results from the above series show that oncologic and functional results following robotic prostatectomy compare very favorably with those of either open or laparoscopic radical prostatectomy. The margin rates and rates of prostate-specific antigen recurrence are similar, but potency and continence rates are better than those of open and laparoscopic approaches.
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The Most Effective Form Of Treatment For Prostate Cancer Is Surgery However Open Surgery Carries With It The Potential For Complication
In India, prostate cancer is one of the most common types of cancer in men. Like the majority of other cancers, prostate cancer is difficult to diagnose in its early stages, as individuals dont show any symptoms until the cancer has progressed to an advanced stage. The prevalence of prostate cancer is massive and is estimated to be the second most common type of cancer in India, especially among older men in metropolitan cities such as Kolkata, Bangalore, and Pune. Statistics have shown it to be one of the top ten leading cancers that occur in men in cities other than the metros.
Often times, the symptoms of prostate cancer are painful and frequent urination, bloody urine, and the frequent occurrence of UTIs, which are neglected as they are thought to be a natural by-product of aging. This leads to untimely detection and reduced chances of efficient treatment, which is why it is important to get regular screening and blood tests done, especially if one is in a high-risk zone.
The minimally invasive method for the management of prostate cancer
Most common post-surgery complications like urine incontinence or erectile dysfunction be managed by advanced tech
Equipment For Robotic Radical Prostatectomy
Currently, the only available integrated robotic surgical system is the da Vinci Surgical System . This computer-aided system has a basic master-slave design. A second generation of this system is currently available .
The surgeon console
This is the user interface of the robot for the surgeon and consists of the following:
Display system: The system is a 3-D stereoscopic display for the console surgeon and is generally available for view in 2-D form by assistants and observers.
Master arms: These are the controls the surgeon uses for making surgical movements. Movements of the master arms translate to real-time movements of the instrument tips and may be scaled for fine movements. The master arms also provide basic force feedback to the surgeon but are limited in their ability to discriminate complex haptic feedback. Camera movements are controlled with a clutch mechanism. In the 4-arm systems, the surgeon can toggle between instruments.
Control panel: The control panel is used to adjust the surgeon console display and control options. The control panel allows toggling between 2- and 3-D display, adjusting various levels of scaling, and choosing the camera perspectives .
Central processing unit: This is the computer that controls the system and integrates and translates robot control inputs from the surgeon.
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