Surgical Robots Developed By Vanderbilt Researchers Could Make Radical Prostatectomy Safer And Less Invasive
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Researchers at the Vanderbilt Institute for Surgery and Engineering have developed a minuscule robot that could revolutionize surgical procedures for treating prostate cancer, which affects one in nine men in the United States. Using a lifelike model, the team demonstrated that the surgical robot could not only remove the prostate gland and tissues through the urethra, but also accomplish the difficult step of suturing the bladder to the urethra.
The article describing their research, Transurethral Anastomosis After Transurethral Radical Prostatectomy: A Phantom Study on Intraluminal Suturing With Concentric Tube Robots, was in the journal Institute of Electrical and Electronics Engineers on Oct. 29.
A typical radical prostatectomy, which is the standard treatment for prostate cancer, requires cutting through the abdomen to reach the prostate. This cutting and exposure of healthy tissue and nerves can cause incontinence and erectile dysfunction in some who undergo the procedure. There are no current alternative endoscopic removal techniques because there are no available instruments that allow surgical dexterity at such a small scale.
The research was funded by the NIH grant R01 EB026901.
Will I Retain The Function That I Have
Men tend to recover physically more quickly, allowing them to resume their normal activities in just a few weeks. They also tend to regain bladder control and sexual function more readily simply by staying physically active. This helps to improve recovery. Subtle modifications in the procedure are tailored to the individual patient depending on the details of their cancer. However, a robotic-assisted radical prostatectomy allows the surgeon to do a more accurate and reliable procedure which improves patient outcomes and quality of life.
Different Types Of Radical Prostatectomy
There are various types of radical prostatectomy.
- Radical prostatectomy with the retropubic approach
This is the most common type of radical surgery performed by most urologists. By means of this procedure, the surgeon can even remove the lymph nodes if they are also affected by prostate cancer.
If cancer has spread into the nervous area, there may be fewer chances to spare the nerves that are related to erection production. In this case, the surgeon may need to cut the nerves on both sides of the prostate, thus losing the erectile function. But if cancer has not spread to the nerves, then the erectile function may come back to normal in a short while.
- Radical prostatectomy with the perineal approach
Radical prostatectomy with the perineal approach is used less often than the prostatectomy with the retropubic approach. By using this surgical technique, the nerves can not be spared. Also, the lymph nodes can not be removed. However, the advantage of this procedure is that is less time-consuming. Also, it is recommended for men who may not benefit any more from nerve-sparing. Al factors need to be taken into account, as the perineal approach is more painful and esthetically not so good looking.
- Laparoscopic radical prostatectomy
Laparoscopic radical prostatectomy involves several small incisions through which small instruments are being introduced with a video camera inside.
- Robotic radical prostatectomy
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Control Of The Lateral Pedicles And The Veil Of Aphrodite
The lateral pedicles at the prostate vesical junction are controlled using Hem-o-lock clips and/or bipolar coagulation. The clips are applied close to the prostate, and the pedicle is divided between them . Once the dissection enters the plane between the prostatic fascia medially and the levator fascia laterally, electrocautery is avoided and the anterior nerve-sparing dissection proceeds using sharp cutting with scissors and blunt dissection using the grasper . This dissection proceeds distally to the puboprostatic ligaments.
Several authors have also advocated a completely cautery-free or athermal dissection of the lateral pedicles to avoid any inadvertent damage to the neurovascular bundle. This can be achieved with laparoscopic bulldog clamps and oversewing of the neurovascular bundle for hemostasis. Although results of this technique have not been validated in large series, minimizing the use of cautery or other thermal hemostatic instruments during dissection near the neurovascular bundle seems prudent.
Rocco And Van Velthoven Anastomosis
We utilized the Rocco stitch as we believe it simplifies anastomosis and significantly reduces postoperative hematuria and reduces bladder neck contractures . A 3-0V-lock begins at the bladder incorporating the cut edge of Denonvilliers and then the posterior bladder detrusor. The next suture is intended to incorporate as much of the muscular structural support behind the urethra as possible. We stress that only the bladder is pulled toward the urethra to avoid pulling and tearing out from the urethral side. The anastomosis is the standard single-knot Van Velthoven anastomosis . We start at 5 oâclock full thickness in the bladder neck throwing six consecutive sutures and then cinching the bladder down to the urethra. The suture continues up to 10 oâclock. The second suture runs up the other side.
Single-knot method for laparoscopic running urethrovesical anastomosis.
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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.
Rise Of Robotic Radical Prostatectomy
Menon et al from the Vattikuti Urology Institute at Henry Ford Hospital in Detroit, Michigan, are responsible for the development and popularization of robotic radical prostatectomy. This technique has been gaining widespread acceptance in the United States and Europe and is increasing in penetration worldwide. Robotic radical prostatectomy offers the advantages of the minimally invasive laparoscopic approach but shortens the learning curve, facilitating and hastening mastery of the procedure.
Although solid basic laparoscopic skills are required for access and assistance, the console surgeon role requires less laparoscopic skill. Therefore, the procedure is accessible to experienced open-procedure surgeons with minimal or no laparoscopic experience. In a published report, Badani et al have performed more than 2700 robotic prostatectomies and have reported a mean operative time of 154 minutes, a mean blood loss of 100 mL, and hospital stays of less than 24 hours in 96.7% of patients.
The following image provides a portion of a minimally invasive radical prostatectomy.
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Worth The Cost A Closer Look At The Da Vinci Robots Impact On Prostate Cancer Surgery
Urology fellow, Jeremy Fallot, and nurse, Shauna Harnedy, assist in robotic surgery by Ruban Thanigasalam in Sydney, Australia.Credit: Ken Leanfore for Nature
Loved by surgeons and patients alike for its ease of use and faster recovery times, the da Vinci surgical robot is less invasive than conventional procedures, and lacks the awkwardness of laparoscopic surgery. But the robots US$2-million price tag and negligible effect on cancer outcomes is sparking concern that its crowding out more affordable treatments.
There are more than 5,500 da Vinci robots globally, manufactured by California-based tech giant, Intuitive. The system is used in a range of surgical procedures, but its biggest impact has been in urology, where it has a market monopoly on robot-assisted radical prostatectomies , the removal of the prostate and surrounding tissues to treat localized cancer. Uptake in the United States, Europe, Australia, China and Japan for performing this procedure has been rapid. In 2003, less than 1% of surgeons in the US performed a RARP in preference to open or laparoscopic surgery. By 2014, RARP accounted for up to 90% of radical prostatectomies across the country. When it comes to prostate cancer surgery in the United States, says Benjamin Davies, surgeon and professor of urology at the University of Pittsburgh, the die is cast there is only robotic surgery.
Nature Index Cancer 2020
What Happens After Robotic Prostate Surgery
- Robotic prostate surgery operative time is typically 2-4 hours
- Hospital stay is typically 1-2 days
- Our team will be seeing you on a daily basis during your stay in the hospital and will give you detailed after-surgery instructions prior to your discharge home.
- Foley Catheter typically comes out on day 5 after a cystogram
- Jackson Pratt drain comes out around the time of Foley catheter removal depending on your individual circumstances
- No driving for 7 days after prostate surgery
- No other restrictions in physically activities after surgery – just do what you can tolerate
- Aspirin can be restarted when you are back to eating regular meals
- The first PSA check after prostate surgery is at 1 month and then 3-6 months thereafter.
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Advantages And Disadvantages Of Laparoscopic Transperitoneal Approach
The advantages of the transperitoneal approach include familiarity with anatomy, adequate space for dissection, and the presence of several reference points to aid the surgeon in orientation. Maximum mobility of the bladder is achieved in this approach, which helps provide a tension-free urethrovesical anastomosis.
Disadvantages of the transperitoneal approach include communication of the anastomotic site to the peritoneal cavity with the potential for peritoneal urine leak and ascites. The transperitoneal approach also increases the risk of bowel injury, ileus, and adhesions.
What Are The Benefits Of Robotic Prostate Surgery
Since robotic prostate surgery uses tiny incisions, there is very little blood loss to obscure the surgical field. That clarity, plus the 3D magnification, provides superior visualization of the prostate. The dexterity and size of the robotic instruments enable Dr. Samadi to operate on the walnut-size prostate, densely surrounded by nerve bundles.
After a radical prostatectomy, men experience a quicker recovery and a shorter hospital stay. There is also a reduced risk of complications, the possibility of infections being minimized. The size of the incisions is smaller than in traditional, open surgeries. The robotic prostate surgery system requires 4-5 small incisions, each less than 2 inches. Also, the small size of the incisions ensures minimal scarring after robotic prostatectomy. This fact is not only beneficial for aesthetic reasons, but it also promotes better and faster healing.
Another critical benefit of surgery is prostate cancer staging. While this may seem backward, the truth is that current prostate cancer diagnostics are somewhat limited in their ability to precisely stage the disease. Research shows that, in as many as 40% of prostate cancer cases, post-surgery tumor analysis revealed a more advanced disease than shown by pre-surgery testing.
Robotic prostate surgery is the only prostate cancer treatment that removes the cancerous prostate and gives men the lifelong assurance of a nearly undetectable PSA level.
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The Steps Of The Robotic Prostatectomy
Robotic prostatectomy requires 5 small incisions, each about one-quarter of an inch in the lower abdomen, through which instruments are inserted. A sophisticated video camera is one of the instruments, which gives Dr. Samadi a three-dimensional, 10x magnified field of vision. The keyhole incisions drastically reduce blood loss and the camera provides unprecedented visual clarity. The result is a clear surgical field during the prostatectomy with nothing to obstruct Dr. Samadis view of the prostate and surrounding tissue.
Cameras are also used in laparoscopic prostatectomy, but they provide only a two-dimensional image and no magnification.
The prostate surgery follows these specific steps:
Indications And Contraindications For Minimally Invasive Radical Prostatectomy
Candidates for either laparoscopic or robotic radical prostatectomy include patients in whom the diagnosis and staging support organ-confined prostate cancer and in whom the appropriate metastatic workup results are negative. However, both approaches are contraindicated in individuals who have undergone previous pelvic surgery. Prior benign prostatic hyperplasia surgery, along with large prostate size, pose technical challenges and increase operative times and blood loss during robotic radical prostatectomy.
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What Is A Robotic Or Laparoscopic Radical Prostatectomy
Now routine procedures at Cleveland Clinic, laparoscopic or robotic prostatectomy are minimally invasive surgery procedures used to remove the prostate. Both forms of surgery are now routinely offered at the Cleveland Clinic to patients with prostate cancer. Our single-institution experience now exceeds 1000 cases of laparoscopic and robotic prostate surgery performed.
How Many Robotic Prostate Surgeries Has Dr Samadi Performed
Dr. Samadi has unparalleled experience in robotic prostate removal surgery. He has successfully removed over 7000 cancerous prostates with his novel SMART Surgery for robotic prostate removal. He conducts every surgery himself from start to finish. Preservation of sexual function, urinary control, and quality of life after prostate cancer are his top priorities.
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How Is A Robotic Prostatectomy Performed
The abdomen is inflated using carbon dioxide gas, which provides the surgeon with “working room”. Five or six small incisions, ¼ to ½ inch in length, are made in the lower abdomen and ports are placed to keep the incisions open to permit passage of laparoscopic instruments. The robotic arms are attached to the working instruments, and the surgeon sits at the video console to control the movement of the various scissors, graspers, and cautery used to dissect around the prostate gland. The enhanced vision and precision of the robot improves the ability to identify the delicate nerves and tiny blood vessels surrounding the prostate.
Whats Unique About Dr Samadis Smart Surgery
The Samadi Modified Advanced Robotic Technique Surgery is an innovative, robotic-assisted laparoscopic prostatectomy technique. It was expressly designed to spare the neurovascular bundles responsible for erectile function and better manage the urethra for optimal continence after surgery.
To further enhance the minimally invasive nature of the procedure, Dr. Samadi approaches the prostate from the inside out, rather than the outside in. During surgery, he preserves the three delicate areas most important to sexual function and urinary control:
- The urinary sphincter
- The endopelvic fascia
- The neurovascular bundles
Urinary control is further preserved by leaving the dorsal vein complex unstitched until the close of surgery, allowing Dr. Samadi to control urethra length and reduce urinary leaking. He uses only cold scissors and clips during surgery, never cautery, to further protect nerves.
SMART Surgery in Dr. Samadis hands takes less than 90 minutes, and since the procedure is minimally invasive, men typically return home less than 24 hours after the procedure. No blood transfusions are needed and recovery is much faster than with traditional surgery.
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Why Is There Less Blood Loss With Robotic
The use of the robotic equipment in surgery means a more precise and less disruptive dissection, which helps control potential sources of bleeding. Blood loss is also reduced because of the pressure generated by the gas used in inflate the abdomen during surgery, which provides surgeons with a better and more expansive view of the operating area around the prostate.
Smart Surgery Advanced Robotic Prostatectomy For Prostate Cancer
SMART Prostate Surgery
SMART is a revolutionary and advanced prostate cancer surgery and prostate cancer treatment method, which drastically reduces blood loss, pain, hospital stay, recovery time, and the side effects of other types of prostate cancer treatments. The SMART Technique is also known as bloodless prostate surgery. The SMART Technique does not require opening the endopelvic fascia or cutting the dorsal vein complex. This results in no sutures and less damage to the neurovascular bundle.
Dr. Samadi is able to enter into the patient through a few small keyhole entrances and handle the SMART robotic surgery with very tiny and precise instruments that allow him to perform the surgery with great precision and remove the patients prostate gland without doing any harm to surrounding tissue. The patient is left with only a few small marks on his abdomen none of the scars normally associated with prostate cancer treatment and surgery.
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Comprehensive Care And Rapid Recovery
At Miami Cancer Institute, we take a team approach to robotic prostatectomy treatment. Medical and surgical assistants, nurses and rehabilitation experts work closely with the surgeons to make sure you experience the best possible outcome.
As part of this team approach, we use an enhanced recovery after surgery system to help you get up and move soon after the procedure. The ERAS system can reduce pain and recovery time, which also improves your surgery results.
Miami Cancer Institute also provides complete rehabilitation services for our robotic prostatectomy patients. You’ll have access to a range of mens health services, including physical and sexual rehabilitation.
What Is Robotic Prostate Surgery
A surgical treatment for prostate cancer, the radical prostatectomy procedure removes the entire prostate gland. Radical prostatectomy can now be done by laparoscopic or robotic techniques. In open prostate surgery, the prostate gland is removed through a larger incision in the lower abdomen. Laparoscopic prostate surgery involves key-hole incisions which used for inserting a lighted viewing instrument into the pelvic region and allows examination and removal of the prostate without a large abdominal incision.
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