Robotic Radical Prostatectomy for Localized Prostate Cancer
Radical prostatectomy is the term used to describe the operation to remove the prostate for prostate cancer. The word “radical”, when used in a medical context means “total”; so, radical prostatectomy means total, surgical removal of the prostate and its adjacent structures.
The surgery requires general anesthesia, with an overnight hospital stay. On the day following surgery, patients are sent home with a urinary drainage tube (a catheter), which remains in place for about a week.
When evaluating treatment choices, physicians and patients weigh the benefits and hazards associated with the treatment. The main benefit of this operation is that it has the potential to remove all of the cancer, provided that the cancer is confined within the prostate. Radical prostatectomy offers the man, whose cancer has not spread outside the prostate, the possibility of freedom from the disease for the rest of his life.
The disadvantages of radical prostatectomy are the hazards associated with the operation, the most notable of which are erectile dysfunction and urinary incontinence. Erectile dysfunction, which means the inability to get a normal erection, develops in a subset of men after radical prostatectomy. The chance of having erectile dysfunction depends on a man’s age and health, his sexual function before treatment, the stage of the cancer, and the ability to save the nerves that control erection during the surgery. Younger men (under 60 years of age) are less likely to have problems with their erections than are older men. If erectile dysfunction does occur after surgery, erections may return to normal over time. There are also medications and devices that can help restore erection.
Urinary incontinence (accidental loss of urine) may occur after radical prostatectomy in some men. Fortunately, if incontinence does develop it usually lessens or stops with time. Other hazards associated with radical prostatectomy may include: alteration of bladder function, bowel symptoms, bladder infection, and blockage of the urine flow from the bladder. Sometimes scar tissue may form at the junction of the bladder and urinary pathway, which may interfere with the flow of urine and require a further outpatient-based procedure to clear the blockage.
In the late 1990s, robotic surgery became available. Rather than the surgeon holding the tools on long thin instruments themselves, the tools are connected to robotic arms and the robot is controlled by the surgeon. The robotic platform available today is called the Da Vinci Surgical System by Intuitive Medical.
The Robotic Team
The surgeon sits in the “console” which is a specialized control center where one can control the camera, robotic arms and application of different types of electricity to stop bleeding. An assistant sits at the patient’s bedside using laparoscopic tools through ports to introduce stitches, provide suction, change robotic tools and make adjustments to the robotic arms as needed. A scrub technician sits at the other side of the patient to provide tools and sutures and make adjustments to the robotic arms. The anesthesiologist remains at the patient’s head, providing anesthesia and monitoring the patient’s heart and lungs.
The Robotic Interface
Using a robotic interface offers a number of important advantages. The robotic camera provides tenfold magnification and three dimensional vision rather than two dimensional vision used during laparoscopy. The robotic arms can not only move in and out and control the instrument, but also introduce a “wrist” type motion for the surgeon, a whole other dimension of movement. In fact, the robotic wrist can twist over 360 degrees, more than a human wrist! The robotic interface provides motion scaling to make each of the surgeon’s movements more precise. The robot also makes fine adjustments to filter out human tremor, inherent in laparoscopy. Finally, robot surgery is more ergonomic (comfortable) for the surgeon and surgical team, resulting in less surgeon fatigue during long complex cases.
Introduction of the da Vinci robot has provided the surgeon with a number of advantages including increased precision, 3D visualization, increased surgical maneuverability, tremor filtering and advanced instrumentation. Compared to traditional open surgery, laparoscopic surgery results in less blood loss, decreased risk of blood transfusion, shorter hospital stay and quicker return to normal function.
Traditionally, prostatectomy was performed through an open abdominal incision. The da Vinci robot laparoscopic technique results in a smaller incision.
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