In the United Kingdom prostate cancer is the 2nd most common cause of cancer death after lung cancer.
As per the “Cancer Research UK”, every year 35,000 new cases are diagnosed in the UK, of which 84% will survive for 10+ years.
Prostatectomy is the curative surgical treatment of prostate cancer. The surgical procedure can be performed by wide opening of the abdomen or by a mini-invasive approach (laparoscopy). Laparoscopy is performed through small incisions in the abdominal wall through which laparoscopic instruments are inserted to reach the area of surgery. The removal of the prostate and seminal vesicles is achieved during this operation.
The prostate is an organ located in the hardly accessible depths of the pelvis, in close contact with many nerves and vessels whose preservation is essential for the recovery of urinary and sexual functions.
Laparoscopic prostatectomy assisted by Da Vinci robotic system allows the surgeon maximum accuracy by providing him a magnified view of the operative field.
Rapidly growing in the UK, the Da Vinci prostatectomy became the first choice treatment.
Laparoscopic prostatectomy and Da Vinci robot usage
The reasons prostatectomy is the most common surgical treatment against prostate cancer are:
- Local recurrences are less frequent with this treatment,
- If illness is back in spite of prostate ablation, it is more easily and earlier detectable,
- In case of local relapse, it is curable by a salvage radiotherapy in opposite to scenario where a relapse would occur after radiotherapy / brachytherapy, surgery wouldn’t be realizable (or very difficult),
- Surgery provides the most accurate assessment of the disease evolutionary stage, thus its prognosis.
The Da Vinci robot, first used for prostatectomy in 2003 in Chicago, provides ultra-precise response using remote handling with 3D vision, recreating from a console the conventional surgery conditions. However this robot is not working alone, and is neither autonomous nor programmable; the urologist keeps a tight control on the robot actions throughout all stages of the surgery.
Da Vinci Robot Description
The robot is run by a surgeon with one or eventually two assistants. Instead of widely opening the abdomen, the surgeon performs short incisions (5 to 12 mm.) to position the trocars through which surgical instruments are inserted.
The Da Vinci robotic system consists of 3 elements:
- A remote imaging system with a logistics column containing the computer system, the cold light source, the CO2 regulator and the control monitor for the assistant;
- The patient carriage carrying 4 interactive robotic arm articulated in 3 dimensions, equipped with surgical instruments (scissors, pincers, needle holder …);
- A control and display console managed by the surgeon, responsible for activating the robot arm joysticks.
The arms of the robot are docked to the corresponding trocars.
One of the arms carries the HD camera introduced into the patient’s body providing a three-dimensional view of the operating field.
The other 3 arms operate the instruments through which the surgeon performs basic operating techniques, i.e cutting and dissecting tissues, expose and tow, electro-coagulate and suture. Surgeon can inter-change the instruments during the operation according to his needs.
The actions of Da Vinci robot arm merely reproduces the movements made by the surgeon’s hands via his control console.
In order to guide the robot arm movements, the surgeon, sitting in front of the console, screens images broadcasted live in 3D high definition from the in-progress operation. The system provides two major technological innovations:
- 3D vision, not achievable with classic laparoscopy,
- Robotic arms dexterity, at levels virtually unfeasible for human hand gestures, for instance the 360 degree rotation.
Benefits of Da Vinci robotic System
In comparison to conventional laparoscopy, robot-assisted laparoscopic advantages are:
- A more precise tissue dissection thanks to its instruments fineness
- The instruments articulation, possible 360°, conferring 7 degrees of freedom reproducing the movements of human hand against 2 degrees of freedom for conventional laparoscopic instruments
- The three-dimensional vision in relief and the quality of high definition optical ventilated by an anti-fogging system against a two-dimensional vision for classic laparoscopy
- The robot eliminates possible surgeon’s hand tremor and more generally any parasite movement
- The operating field vision stability since the robot arm carrying the camera remains stable beside movements initiated by the surgeon while in conventional laparoscopic, the camera is activated by the assistant hand which could be exhaustible.
- The comfort of the surgeon: seated in an ergonomic position at the console, arms and head supported, the robot is minimizing fatigue risks, contributing to operation success, especially when the intervention is long and difficult. It is important to keep in mind that in prostatectomy, most delicate phase takes place once surgeon sutures the bladder and the urethra at the very end of the intervention.
The advantages of Da Vinci robot-assisted laparoscopic prostatectomy VS conventional open surgery are:
- Reducing intraoperative bleeding
- Reducing post-operative pain
- Reducing hospital stay
- Reducing infection risk intraoperative
- Limiting scarring and postoperative risk of incisional hernia through the abdominal wall
- An earlier resumption of personal and professional activities, and more generally a faster recovery of prior-treatment quality of life;
- A faster recovery of continence and sexual function.
Additionally, positive margins percentages are similar for both approaches and early control of the cancer disease as well.
Da Vinci robot drawbacks
The only serious drawbacks of Da Vinci robots are related to its financial cost but also the longer intervention time caused by learning curve during the familiarization phase.
Da Vinci’s price (nearly €2.000.000 for robotic system purchase and the annual maintenance fee of €150,000) is the main obstacle to its deployment. Extra cost of Da Vinci prostatecomies versus traditional surgery is of € 2,000 representing a real handicap.
No drawback is reported on the quality of the intervention itself, if only marginally: surgeons might be bothered by the loss of tactile sensation (ability to “feel” the patient tissue), such feeling will disappear completely after operator training.
Generalization of Da Vinci robotic system in laparoscopic prostatectomy
The many teams that acquired the Da Vinci robotic system are using it systematically, to the detriment of open prostatectomy or traditional laparoscopy.
The number of Da Vinci robot installations has experienced significant growth in recent years. In the US, approximately 80 per cent of all radical prostatectomies are now carried out by robotic-assisted surgery. In the UK, Intuitive Surgical quoted the proportion of Da Vinci prostatectomies to be more than 50 per cent in 2012.
It should however be borne in mind that the experience and competence of the urologist surgeon remains THE key element leading to surgery success. It is also important to note that the risks specific to each surgery and each patient remains, regardless to Da Vinci robot’s trustworthiness.
However, Da vinci robot is a new landmark in the evolution of the surgical gesture. Nonetheless, traditional ways that deliver excellent results remain topical. A step that will need to be scientifically evaluated, pending a decrease in costs that will democratize patient’ access to the robotic system.
Dr. DAVODY speaks in his own name and receives no sponsorship from the INTUITIVE SURGICAL company.
Some bibliographic elements related to the Da Vinci robot in laparoscopic prostatectomy:
Description and use in the USA and Canada (French)
Da Vinci robot Benefits (French)