Robot-Assisted Prostate Surgery

November 28, 2018

Robot-Assisted Prostate Surgery Makes Compelling Case for  Patients and Surgeons

The world’s first known modern-day open prostatectomy to remove a man’s prostate gland was a major medical advance back in the late 1800s. Today, robotic-assisted laparoscopic radical prostatectomy surgery using the da Vinci system offers patients and surgeons a compelling alternative for one of the most common open surgery procedures. 

That’s because prostate cancer has become the most common type of cancer among men in the US and other westernized countries, and prostatectomy surgery is the most frequently-performed open surgery for men. 

“Around 25 years ago, keyhole surgery using laparoscopy was introduced as a minimally-invasive alternative to open prostate surgery,” says Dr. Teerapon Amornvesukit, a urologist at Bumrungrad International Hospital with many years’ experience treating patients with prostate cancer. “With laparoscopy, instruments and a camera are inserted through tiny tubes down to the prostate area. But there is a drawback: The instruments are fixed-wrist, so they have a limited range of movements. The function of the laparoscopic instruments is only ‘open’ and ‘close’. The instruments are a bit like chopsticks; they are straight, so fine movements are just not possible.”

Then the Robots Came

The first fully robotic-assisted laparoscopic radical prostatectomy using the da Vinci system (DVS) was carried out in 2000. Robots were still a novelty back then, but the new technology and its anticipated benefits quickly made it a compelling alternative to open and laparoscopic surgeries, both for surgeons and for patients. Within a few years, nearly 10% of US prostatectomies were DVS robot-assisted. This year, that number will be about 90%.

The rise of robot-assisted surgery stems from patient preferences as well as the experiences of the surgeons who have been trained to use the system. Dr. Poochong Timratana, a Bumrungrad physician specializing in laparoscopic, bariatric and esophageal surgery, has been performing robotic-assisted surgery since Bumrungrad put the da Vinci Si system into use in 2016. He says the system’s 3D imaging helps a surgeon’s precision and accuracy compared to open or standard keyhole (non-robotic) laparoscopic surgery. “The camera’s optical zoom enhances images up to 3x,” says Dr. Poochong, “so through high definition goggles I can see a very clear close-up view of the treatment area in much greater detail than I could with my own eyes.” 

Better Chance For a Cure

For a prostate cancer patient, the improved imaging is the first step toward greater surgical precision needed to achieve a cure by completely removing the cancerous tissue. Wrist movement is the second step.

The DVS system captures the natural, human-like wrist movements and range of motion that surgeons were looking for. “The normal wrist can move in six directions while holding normal surgical instruments,” explains Dr. Teerapon. “The da Vinci system robotic wrist instruments have seven directions of movement, so the system can translate my own motions precisely, and it enables me to reduce the size of incisions and cut less tissue.” 

Shorter Stays, Faster Recovery

The result for patients is fewer wound infections, less pain, reduced blood loss and shorter hospital stays after surgery. A typical patient stays one or two nights in the hospital and returns home for two to three weeks of recovery before fully resuming normal activities. With traditional open surgery, recovery time is typically about two months.

“Aside from curing the cancer,” Dr. Teerapon says, “patients judge the quality of surgery by two things: continence and sexual function.” Thanks to the range of motion capabilities and better imaging of the da Vinci system, patients typically see a quick return in bladder control, resolution of incontinence and erectile function. 

The Role of Training

As with any surgical technique, training is the key to mastering the DVS. Surgeons must take part in an extensive training program before they are certified to perform their first da Vinci surgery on a patient. “We start out training on a simulator first,” Dr. Teerapon explains. “As we get comfortable with the system, we move on to simulated surgeries, first with fruit and later we do operations on pigs. It is one of those techniques that you master through repetition — each time you use it, you notice some improvement.” 

Looking Ahead

While other parts of society may have justifiable concerns about the future impact of robotics and the broader artificial intelligence (AI) revolution that is taking shape, the medical community sees a lot of beneficial applications to come. “There are some advanced physical therapy robots being developed that look very promising,” Dr. Poochong notes. “They perform all the same movements as a human physical therapist does, but the robots can lift a lot more weight and would be placed in the patient’s home after surgery.” 

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