Davinci
Prostate cancer is the most commonly diagnosed malignancy in men across Western Europe and the United States. Moreover, together with lung and colon cancer, it accounts for most cancer-related deaths in these populations.
Twenty thousand new cases are diagnosed annually. Undoubtedly, this number is expected to raise with population ageing, as increasing age is one of the risk factors of the disease.
One of the most efficient ways to treat prostate cancer is to perform a surgery aimed to remove the diseased organ from the organism, namely a radical prostatectomy. Unfortunately, this surgery may be associated with two significant complications: erectile dysfunction and urinary incontinence.
The location of the prostate is very inconvenient in terms of performing the procedure, as the surgical field has a very limited size. Moreover, the prostate lies deep inside the pelvis, neighboring tissues responsible for urinary continence (internal and external urethral sphincter) and for penile erections (neurovascular bundles). Damage to these structures may significantly impair the quality of life. Thus, sparing of them is vital.
The modern approach in surgical treatment is based either on classic, or robot-assisted laparoscopic surgery.
Robot-assisted surgeries using the da Vinci surgical system have been performed for decades around the world. In our Department of Urology of the European Health Center in Otwock, affiliated with the 2nd Urology Clinic of the Center of Postgraduate Medical Education, we have been using this superb device for one and a half years, having successfully treated dozens of patients with prostate cancer.
Robot-assisted surgery with assistance of the da Vinci surgical system is currently the most advanced minimally-invasive method of surgical treatment of many kinds of diseases. It allows for otherwise unavailable precision (thanks to processed elimination of natural hand tremor) and a perfect view of the surgical field, achieved with up to 10x optical zoom. Not to mention the availability of unique ergonomics to the operating surgeon.
The robot provides a significant opportunity to isolate and spare the abovementioned tissues essential for the postoperative quality of life, as well as allows for very good medical and oncological outcomes.
A robot-assisted surgery begins similarly to a classic laparoscopic surgery, i.e., with insufflation (or gas-filling) of the abdomen and installing trocars, which are small devices placed through the abdominal wall and used as ports for inserting or removing tools from inside the abdomen. And this is where the differences start, as during a robot-assisted surgery we do not insert traditional laparoscopic tools via the trocars but the arms of the robot instead. This may resemble inserting miniature hands of the surgeon to the inside of the abdomen. The operating surgeon sits in a console localized in close proximity to the operating table and steers the arms of the robot, and the surgical tools with special manipulators tied to the fingers, being aided with a high-zoom three-dimensional video camera system. I have to emphasize that it is the surgeon, not the robot, who is operating. The robot has no autonomy and will not carry out any movement without control and will of the surgeon. It is the surgeon steering the robot. Still, the surgeon is the most important contributor to the surgery. Many experienced urologic surgeons claim that while the robot allows for a good surgeon to become even more proficient, the robot will not make a less skillful surgeon operate at the same level of proficiency.
Thanks to advanced technology, an almost unlimited range of tool movement within a very small operating field, and highly magnified, three-dimensional view, we are allowed to dissect a tissue, tumor or an organ with high precision, with no or minimal damage to surrounding structures. In case of surgical treatment of prostate cancer, this is of tremendous significance for the quality of postoperative urinary continence and erectile function. In many cases, we are able to successfully dissect the neurovascular bundles that overlie the prostate, to preserve a long urethral stump, and to dissect the bladder neck in a way that allows both maximal cancer “purity” and a good or a very good postoperative quality of life (with regard to urinary continence and erectile function).
At the University of Chicago, where I had an opportunity to obtain training in the field of robotic surgery, the robot-assisted surgeries with the da Vinci surgical system are performed in almost every case of a disease that needs surgical management. In that institution, the da Vinci surgical system is employed for procedures associated with urology, gynecology, general surgery, cardiac surgery, pediatric surgery and otolaryngology. The robot-assisted surgeries in urology are associated predominately with uro-oncology, i.e., the management of prostate, kidney or bladder cancer.
At the Department of Urology of the European Health Center in Otwock, affiliated with the 2nd Urology Clinic of the Center of Postgraduate Medical Education, we use the da Vinci surgical system to operate patients with prostate cancer (radical prostatectomy with or without extended pelvic lymph node dissection) and bladder cancer (radical cystectomy). We undergo intense training to start using the robot for treatment of patients with renal tumors in the nearest future.
The advantages of a robot-assisted surgery with the da Vinci surgical system:
- minimally invasive surgery (just a few small cuts in the skin),
- an extraordinary precision during the operation (a significant impact on the oncologic and functional quality of the treatment),
- minimal blood loss – in our department, for a number of years we have not been routinely ordering blood products for prostate cancer surgeries (a perfect choice for patients unwilling to receive blood products),
- an excellent cosmetic effect,
- fast recovery and restoration of normal life activity – in our ward, the patient becomes ambulatory, eating light diet on the first postoperative day, and discharged home on the second day.
The process of preparing the patient to a robot-assisted procedure is not different from preparing them to any other kind of surgery. If no medical (i.e. cardiovascular or pulmonary) contraindications to surgical treatment exist and the patient needs urologic treatment, no other contraindications to a robot-assisted surgery can be seen by the urologist. The operating surgeon must take special care when insufflating the abdomen and inserting the robot arms in patients with a history of prior abdominal surgeries. In our department we have operated significant number of patients in whom various general surgery procedures (e.g. appendectomy, cholecystectomy or colon or intestinal surgeries) or urologic procedures (transurethral resection of bladder tumor, holmium laser enucleation of prostate – HoLEP, high intensity focused ultrasound – HIFU, open or laparoscopic adenomectomy) had been performed in the past.
We have observed that a robot-assisted surgery allows for safe and successful treatment in morbidly obese patients, in whom an open or traditional laparoscopic surgery could be considered impossible. The arms and tools of the robot have a much wider range and are significantly more precise. We operate overweight and morbidly obese patients on a regular basis (our most obese patient weighted 167 kg!)
Thanks to amazing precision, the almost unlimited range of tool movement, and perfect visualization of surgical field, more and more often we are using the robot in complex urological surgeries, including local recurrence of prostate cancer previously managed with radiotherapy or nodal prostate cancer recurrence, regardless of primary treatment type.
In most patients operated with the assistance of surgical robot, the postoperative recovery is rapid. One of very important considerations is minimizing the postoperative pain. The way in which the arms of the robot are built allows for atraumatic penetration of the abdominal walls, causing only minor tension of the skin and other tissues, which results in a reduction of postoperative pain. Most patients can drink and eat the next day after the surgery. In patients operated for prostate cancer we are able to safely remove the catheter from the bladder on the 2nd to 5th postoperative day, which may contribute to more rapid restoration of high-quality urinary continence.
