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Robot Aids In Prostate Cancer Surgery

Klint Lowry/SUNCOAST NEWS

These small robotic hands of the da Vinci Surgical System allow surgeons to perform prostate surgery with great precision.

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By KLINT LOWRY | The Suncoast News

Published: August 13, 2008

NEW PORT RICHEY - For men of a certain age, just the word "prostate" can provoke involuntary cringing, let alone phrases like "prostate cancer" or "prostate surgery."

For many men the possibility of a prostate cancer diagnosis is only slightly more frightening than the prospect of what they might hear next, the suggestion that the best course of action would be to have the prostate removed.

It's just not an area of the body we like to imagine being carved up, even if our lives depend on it.
But should that diagnosis be in your future, guys, prostate removal surgery is not what it once was, and the latest in minimally invasive surgical technology is available in New Port Richey.

Community Hospital of New Port Richey is the first and, for now, only hospital in Pasco, Hernando and Citrus counties to offer state-of-the-art robotic surgical technology to patients with prostate cancer with the da Vinci Surgical System.

Best of both worlds
"Now we have a robot here in Pasco," Dr. David DiPiazza said tongue-in-cheek, referring to the misconception some people have when they hear the phrase "robot-assisted laparoscopic prostatectomy."

There are no Star Wars-type robots involved, no independent-minded mechanical beings who might run amok halfway through an operation. Rather, the da Vinci system takes all the advantages of laparoscopic surgery and gives surgeons like DiPiazza and fellow urologists Drs. Yaser Bassel, Lonnie Klein, Martin Richman and Michael Szostak much-improved tools for removing a diseased prostate.

"You're not really reinventing the wheel," Bassel said. "You're doing a standard prostatectomy. The principles are the same; the anatomy is the same, but it's a new technology."

It's still the surgeon who is doing the work, still making every move as it happens. The robotic instruments, however, give the surgeon a better view of and access to the prostate than either conventional or laparoscopic surgery.

So far, and yet so near
Removing a prostate is not easy. It is located under the pubic bone, crowded by and connected to other organs, nerves and blood vessels. With conventional, or "open," surgery, just getting a surgeon's hands to the prostate can be difficult.

Traditional laparoscopic techniques make getting there easier, but the tools lack dexterity and there is a lack of a sense of touch. Surgeons have to learn to compensate by depending more on sight, which is not easy watching themselves move "backward" on the viewing monitor.

Robotic surgery is essentially laparoscopic surgery with advanced tools that overcome most of these shortcomings.

"It's essentially almost like miniaturizing yourself, you getting in there and operating with your hands," Szostak said.

As with other forms of laparoscopic surgery, instead of a large incision, small incisions are made – six of them for a prostatectomy – through which a camera and "arms" with surgical tools are inserted through ports.

With the da Vinci Surgical System, the surgeon sits a few feet away from the patient at a console, watching through a view screen while operating three of the surgical arms and the camera. The camera produces a binocular image, so the surgeon has a three-dimensional view of the operative field and thus the advantage of depth perception.

The camera can also be adjusted to magnify up to 10 times, meaning the surgeon has even better visual access than with the naked eye.

"With the robot, since you have binocular, three-dimensional vision, you have a better sense of where your instrument 'hands' are," Richman said. "You use the magnification combined with the spatial relationship that you can see to make up for the tactile sensation you would have with open surgery."

Along with superior visual range, the da Vinci system also gives surgeons their hands back, so to speak, another shortcoming of standard laparoscopic surgery.

"Standard laparoscopy, it's like operating with chopsticks," Szostak said.

The robotic hands have "wrists" that can move just as a human wrist does. As the surgeon moves the hand controls at the console, the robotic "hands" inside the patient move in exactly the same manner.

The machine can adjusted so the movement the robot's hands make will be larger or smaller in relation to the amount of movement the surgeon makes. It also is designed to compensate if the surgeon's hand shakes.

All the surgeons agreed, between the improved vision and mobility, the da Vinci system makes it much easier to cut, sew, dissect and all the other tasks needed to remove a prostate efficiently.
If a man is getting a prostatectomy, it is for one reason, the removal of prostate cancer, DiPiazza said.

The most important aspect of the operation is to make sure the entire prostate is removed, that there are no traces of prostate tissue left behind. But along with that, there are other aspects that make for a successful prostatectomy. The nerves that cause erection surround the prostate; the surgeon must be careful not to damage them.

Once the prostate is removed, the pathway through which urine makes its way out of the body has been cut off. To renew the pathway, the bladder and distal urethra have to be sewn together. These aspects of the operation require precision and dexterity for the patient to enjoy a full recovery as quickly as possible.

Feeling like a new man
Laparoscopy is minimally invasive, meaning less blood loss, less visible scarring, less chance of post-operative hernias and in many cases less pain. But like the old saying goes, it's what's inside that counts.

With prostate removal, there is a whole checklist of postoperative guideposts on the road to recovery – catheter removal, return of continence, a return to normal physical activity and the return of the ability to get an erection. By all of these benchmarks, robotic laparoscopy seems to lead to a quicker, less painful recovery than by standard laparoscopy and certainly by open surgery.

With robotic surgery, patients are up and moving around by the next day, in fact they are encouraged to get ambulatory. They usually go home from the hospital the next day.

Catheters used to stay in about two and a half weeks with conventional prostatectomy surgery. With laparoscopic surgery, the catheter can usually be removed in about 10 days.

"For guys every day, every minute is too long, so if you can tell them I can take this out a week or week and half earlier, they are very appreciative about that" Szostak said.

On average, continence and erectile function also return more quickly. Statistical data and anecdotal evidence seem to show the robotic procedure offers advantages in just about every way. In fact, Richman added, some patients maybe get a little overconfident.

"There are reports of patients going out and playing golf a week after their surgery – I wouldn't recommend that," Richman said.

Even though there are fewer visible scars and the recovery doesn't seem as arduous as patients thought it would be, Richman said, he reminds them not to underestimate what they have gone through.

"I tell them, you still had a big surgery through a small incision," Richman said.

A positive prognosis
"There are very few urological procedures that aren't done laparoscopically today," DiPiazza said.
Similarly, he and his colleagues concurred that in a few years robotic laparoscopic surgery will become the norm as the technology becomes more commonplace and more doctors become acquainted with it and see the advantages it offers them and their patients. The transition is already happening in the northeastern part of the country, DiPiazza said.

There are several things to be remembered, as well, the doctors mentioned. First, the procedure being talked about here is prostatectomy, the removal of a cancerous prostate. Prostate cancer is often confused with Benign Prostatic Hyperplasia, better known as BPH or simply enlarged prostate. Same organ, different condition, different treatment options.

Also, there is more than one way to attack prostate cancer.

"If someone is not a good surgical candidate, radiation treatment is almost just as good an option, statistically speaking," Richman said.

Some patients who have had multiple previous abdominal surgeries are not good candidates for any kind of laparoscopy, robotic or otherwise. Also, if a patient has already undergone radiation therapy for prostate cancer, the complication risks are much higher trying to perform a laparoscopic prostatectomy.

To find out more about the da Vinci robotic laparoscopic prostatectomy offered at Community Hospital, as well gynecological and urologic procedures, visit the hospital's href=http://www.communityhospitalnpr.com> Web site.
Klint Lowry can be reached at 727-815-1067 or klowry@suncoastnews.com.

Klint Lowry can be reached at 727-815-1067 or klowry@suncoastnews.com.

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