Robotic Surgery for Prostate Cancer: A Realistic Approach in … · 2018. 1. 31. · Robotic Surgery for Prostate Cancer: A Realistic Approach to Getting Started “The Evolution

Robotic Surgery for Prostate

Cancer:

A Realistic Approach to

Getting Started “The Evolution of a Robotic Surgeon”

Douglas S. Scherr, M.D.

Clinical Director, Urologic Oncology

Weill Medical College of Cornell University

Is The Disease Important?

PROSTATE CANCERHighest in Incidence and Second in Cause of Death

from Cancer in American Males

Incidence Cause of DeathMelanoma of Skin 5%

Lung & Bronchus 14%

Oral Cavity & Pharynx 3%

Pancreas 2%

Colon & Rectum 11%

Kidney 3%

Prostate 30%

Urinary Bladder 7%

Leukemia 3%

Non-Hodgkin’s Lymphoma 4%

All Sites 637,500All Sites 637,500

189,000 New Cases

3% Esophagus

31% Lung & Bronchus

5% Pancreas

3% Kidney

3% Liver

10% Colon & Rectum

11% Prostate

3% Urinary Bladder

4% Leukemia

5% Non-Hodgkin’s Lymphoma

288,200 All Sites 288,200 All Sites

30,200 Death2002 Estimates

U.S. Incidence and Mortality of

Prostate Cancer

Surveillance, Epidemiology and End Results (SEER) Data

Natural History

• Natural history understood: -To die of prostate cancer or die with prostate cancer? -Conservative Treatment: a.) Gleason 2-4: 4-7% chance of death b.) Gleason 6: 18-30% chance of death c.) Gleason 8-10: 60-80% chance of death**

Frankel et al. Lancet, 361: 1122, March 2003

**Albertsen et al., JAMA, 280: 975, 1998

The Disorder

“Prostate Cancer”

Progression-free probability

by risk group

Low risk

High risk

Intermediate risk

D’Amico et al JAMA 280:969-74, 1998

Swedish randomized trial: Surgery v. Watchful waiting

Surgical excision alters the natural history of prostate cancer,

reducing metastases and cancer-specific mortality by 50% at 8 years.

From: Holmberg L, Bill-Axelson A, Helgesen F, et al. A randomized

trial comparing radical prostatectomy with watchful waiting in early

prostate cancer. N Engl J Med, 2002;347:781-789.

Distant metastases Cancer-specific mortality

WW 27.3%

RP 13.4%

WW 13.6%

RP 7.1%

DEMOGRAPHICS OF AGING

• More and more doctors will be faced with how to treat our aging population

• the older population will burgeon between the years 2010 and 2030 when the "baby boom"

generation reaches age 65.

• This will more than double the 65+ population by the year 2030 compared to 2000 numbers

Source: Administration on Aging (www.aoa.gov)

DEMOGRAPHICS OF AGING

• Over 2.0 million persons celebrated their 65th birthday in 2000 (5,574 per day).

• In the same year, about 1.8 million persons 65 or older died, resulting in an annual net increase of approximately 238,000 (650 per day).

Source: Administration on Aging (www.aoa.gov)

DEMOGRAPHICS OF AGING

Source: Administration on Aging (www.aoa.gov)

• By 2030, there will be over 70 million older persons, more than twice their number in 2000.

• People 65+ were 12.4% of the pop. in 2000 but are expected to grow to be 20% of the pop. by 2030.

Corral DA and Bahnson RR. J Urol. 1994 May;151(5):1326-9

A. Life expectancy by age for all men. At age 70 life expectancy is 11 yrs

B. Ten year survival by patient age. At 70 52% of men will survive 10 years

Life Expectancy and Ten Year Survival

Improved Treatment Strategies

• Endorectal MRI

• Nomograms

• Nerve Grafting

Improved Cancer Detection

Through Imaging Endorectal MRI/Spectroscopy

• Potential improvement over ultrasound

• Biochemical gradients to decipher cancer

from benign

• Remains investigational

• Possible role in high risk patients

Image 8 I 54.44 mm Image 9 I 57.56 mm

H

H H

H H H

H H H H

H H H

H H

H H

H H H H

H H H H H

* * *

sc vc vc

Treatment Stratifications

• Allow for improvement in patient

understanding

• More objective in guiding treatment

decisions

• Less physician bias

Palm Pilot Nomogram Software

• Includes pretreatment and postoperative

predictions.

• Uses published nomograms in prostate cancer.

Technical Improvements in Surgery

Nerve Grafts

• Cavernosal nerves necessary for post-

operative erectile functions

• In advanced disease, nerves may need to

be resected to obtain a negative margin

• Sural nerve or genitofemoral nerve serve

as sources of nerve grafts in this setting

What’s Next

• Improvements in Surgical Technique have

Stagnated

• Re-birth in Perineal Prostatectomy

Robotic Prostatectomy

Da Vinci Instrumentation

• Stereoscopic design with two 3-chip cameras

• 75% better resolution than any imaging system

da Vinci System: 3-D vision

‘Open’ surgery orientation

• 6 Degrees of freedom

• Surgical hand movements are transposed to the instrument tips

• Ability to scale motion

da Vinci System: Endowrist Technology

History Of Laparoscopic Surgery

• Guillonneau and Vallancien – Montsouris

Technique

“If this laparoscopic procedure is

shown to be equivalent or better, it may

replace open retropubic radical

prostatectomy.”

June 2000

Guillonneau and Vallancien, J Urol, 163: 1643, 2000

Eliminates

• Counter-intuitive motion

• Instrument tremor

Provides

• Improved ergonomics

• Hand / eye alignment

Transforms

• 2-D vision to true 3-D

• 4 DOF instruments to 6 DOF (greater endoscopic dexterity)

Enhances Laparoscopy

Disadvantages

• Loss of tactile feedback

• Set-up time

• Surgeon away from OR table

– Conversion

– Communication

• Limitation of instrumentation

• Cost

Robotic Assisted

Laparoscopic Urology

• Nephrectomy

• Partial Nephrectomy

• Prostatectomy

• Adrenalectomy

• Intra-abdominal

orchiectomy

• RPLND/PLND

• Pyeloplasty

• Birch Procedure

• Colposuspension

• Cyst Marsupilization

• Varicocelectomy

Extirpative Reconstructive

• Prostatectomy

• Partial Nephrectomy

• RPLND

• Pyeloplasty

Extirpative Reconstructive

Robotic Assisted

Laparoscopic Urology

Ureteral spatulation

Anastomosis

Ureteral stent

Tewari et al. BJU Int. 92, 205-210, 2003

Functional Outcome: Robotic Prostatectomy vs. Radical

Retropubic Prostatectomy

Continence Erections

Intercourse

Comparison to the Gold Standard

The European Experience

Cathelineau et al. Urol Clin NA, 31: 693-699, 2004

Further Comparison

The Robotic Experience Worldwide

Patient Positioning

8cm 9cm

12mm

12mm

5mm

5mm

Davinci Davjnci

U

Port Placement

Entering the Space of Retzius

• Incise median umbilical ligaments

• Drop bladder

• Expose endopelvic fascia

• Adequate exposure/mobilization facilitates dissection of prostate base/node dissection

Endopelvic Fascia/Dorsal Vein

• Begin lateral to puboprostatic ligament and medial to levator ani

• Critical in facilitating apical dissection

• 80% of prostate cancer comes within 8mm of prostatic apex

• Place DVC stitch distal to prostatic apex

Bladder Neck/Seminal Vesicles

• Biologic significance of + BN margin well documented

• Wide excision necessary

• Send frozen section to confirm absence of any prostatic tissue

• Guide to intraoperative decisions: a.) site specific biopsy labeling b.) DRE c.) endorectal MRI

• Inspect for median lobe

• Compete removal of SV necessary

• Judicious use of electrocautery at SV tip

• Proper dissection of SV sets up posterior plane

Pedicles/Nerve Sparing

• Begin posterior dissection beneath the

posterior layer of Denonviller’s Fascia

• 25% of men with palpable nodule on DRE

will have ECE posteriorly

• Pedicles taken with clips

• Antegrade nerve sparing

Urethral Incision/Apical

Dissection

• Incise DVC distal to prostatic apex

• Place 2nd stitch into DVC if necessary

• Avoid distal urethral dissection – maintain

maximal functional urethral length

Anastamosis

• Running suture with 2.0 monocryl

Video Footage

Results of First 50

• Oncologic: Pos. Margin Rate: 6/50 (12%)

• Continence: -97% of catheters removed at 7 days -3 patients with high JP output -86% of patients with <1 pad at 6 weeks -0% patients with bladder neck contracture

• Potency: Too early to characterize

• Post operative Complications: -one patient required take back for incarcerated hernia -no blood transfusions -mean operative time at 238 minutes -72% of patients discharged < 24 hours

“Robotic assistance offers an open surgeon sophisticated tools to perform complex

laparoscopic surgery. A technologically advanced ergonomic operation is achieved

because of 3-dimensional visualization; wristed instrumentation; intuitive, finger-

controlled movements; and a comfortable seated position for the surgeon”

Urology Gold Journal, 4/03

Robotic Radical Prostatectomy

And The Vattikuti Urology

Institute Technique p.15-20

ff Title

Avg. Operative Time:

160 min.

Avg. Hospital Stay:

1.2 days

Blood Transfusions:

0

Patients

discharged

Within 24 hours:

93%

Avg. Blood Loss:

153 ml.

Positive Margins:

6%

Avg. Catheterization time:

7 days

Continence at 6 mos.:

96%

Potency (men 60 yr) at 6 mos:

82% Had Return of Sexual Function

64% Had Sexual Intercourse

Urology Gold Journal, 4/03

Robotic Radical Prostatectomy

And The Vattikuti Urology

Institute Technique p.15-20

Data Collection:

First 200 patients

da Vinci Benefits:

The Patient

• Shorter hospital stay

• Less post operative pain

• Less risk of infection

• Less blood loss and transfusions

• Less scarring & improved cosmesis

• Faster recovery and return to normal

daily activities

Dave Kinsey, Robotic

Prostatectomy Patient

Is It Any Better?

• Comparable results can be achieved

• Learning curve reasonable

• Long term results await

• Robotic surgery will have a role as long as

prostatectomies exist