Laparoscopic and robotic surgery: Into the 21st Century

Why is a robotic prostatectomy better than open or laparoscopic?

To understand why things have evolved such that nearly 80% of prostatectomies in America today are done robotically, one must be given a brief history lesson of radical prostatectomy. In the 1980's, Urologists knew only one way to operate on the prostate, and that was through an incision made under the scrotum. This was and is called a perineal prostatectomy, and this approach was also used to biopsy the prostate before the advent of transrectal ultrasound. In the 1980's, PSA did not exist, and thus patients were rarely found with prostate cancer in its early, curable stage. Thus, a perineal prostatectomy was a rare operation, and most surgeons were not highly experienced in doing it. This approach did not provide a good access to spare the erectile nerves. Because of this, most patients opted for external beam radiation. Unfortunately, back then radiation caused very significant side effects, causing the dose to be too low and therefore the cure rates also to be low.

When PSA was popularized in the late 1980's and early 1990's, there was a sudden flood of patients presenting to Urologists with early prostate cancer. During this time, since a better surgery was necessary that gave a chance to spare the erectile nerves and to increase the poor cure rates radiation provided, a new approach to the radical prostatectomy evolved. This was and is called a radical retropubic prostatectomy. This is performed through an incision between the umbilicus and the pubic bone. The great disadvantages of this approach are that visualization of the anatomy and particularly of the erectile nerves is poor, and that blood loss is very high. However, this approach does offer a chance to spare the erectile nerves, and this advantage outweighed the disadvantages and eventually led to this modality becoming the standard modality. By the mid to late 1990's, despite high impotence and incontinence rates, radical retropubic prostatectomy had exploded in popularity.

At the same time, brachytherapy or implantation of radioactive seeds promised a means by which to deliver higher doses of radiation with hopefully fewer side effects. By the late 1990's, before long term data on "seeds" could come out, this technique was so popular that approximately 50% of patients chose this and 50% chose radical retropubic prostatectomy. However, eventually long term data showed that the long term impotence rates are actually no better and even worse with radiation than surgery, and that "seed"s was quite inferior to surgery in terms of cure rate for all Gleason scores higher than 6. This caused seeds to significantly drop in popularity. Now, the trend is towards combining "seeds" with external beam radiotherapy and hormone therapy in the hope of equaling the cure rate surgery provides. Such a radiotherapy program is morbid, however, and this causes it to be less popular than surgery today.

As surgery provides significant emotional closure, and high cure rates, it has remained popular throughout this evolution. However, the major problems of poor visualization, high blood loss and thus 4-6 week recovery time, have continued. The other major ergonomic problem with open radical prostatectomy is the need to use very long instruments, and to operate on the prostate at a tangent since the prostate sits at the bottom of the pelvis. This means that the operation requires a lot of manual tugging, and blind, blunt dissection.

The first attempt to address these disadvantages was to apply standard laparoscopy to this operation. Standard laparoscopy does increase visualization, but its camera is only 2D which makes depth perception very difficult. Standard laparoscopy uses instruments that are very similar to the long instruments that are used in the open procedure. Thus, the problem of operating on the prostate at a tangent is not addressed. Blood loss is much less with all laparoscopic procedures because the abdomen is inflated with gas at a pressure just high enough to stop any venous bleeding. Comparative studies between open and laparoscopic prostatectomy never really showed any true advantage. Any improvements found in blood loss or post-operative paid were countered by operating times that are nearly five hours even in experienced hands, and no true other outcome advantages.

Robotic prostatectomy represents the application of engineering to all failings of the both the laparoscopic and open approaches. Visualization is perfect with a 3D camera. Now, the surgeon can actually see the nerves as he/she is dissecting them. There is no more blind dissection, or guessing. This allows us to nearly always perform at least a partial nerve sparing operation on both sides. Blood loss is still low due to the laparoscopic platform robotic surgery is built on, and this keeps hospital stay to less than a day, and shortens recovery from 4-6 weeks to 2 weeks. And most importantly, the instruments completely mimic the human hand. This allows for a much better reconstruction that is always water tight. This is why catheterization time has been reduced from 10-14 days to 5-7 days. Complications have also been minimized in Dr. Engel's series so as to be equal or less than what would be seen in an open series. In experienced hands, we believe that robotic surgery provides advantages in nearly every way, and should be applied any time surgery for localized prostate cancer is considered.

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