A traditional laparoscopic approach for procedures within the pelvis is difficult because of the confined space in which the surgeon must work, which makes complex reconstructions and knot tying challenging. That is why the advent of the da Vinci robotic surgical system (Intuitive Surgical, Inc.), originally designed for beating-heart surgery, was quickly adopted by urologists. Today, robotic radical prostatectomy is more common than all other prostate surgeries combined.
The original da Vinci system was approved by the FDA in 2001; a second-generation system was introduced in 2006. The robot does not work autonomously; the device is a master-slave system that can only do what its surgeon-master tells it to do. The new da Vinci system includes high-definition optics and the capacity to manipulate 3 separate instruments, up from the original 2.
"The da Vinci system is a laparoscopic tool," explained Ketan K. Badani, MD, the Director of the Division of Robotic Surgery at NewYork-Presbyterian/Columbia University Medical Center. "Instead of using traditional laparoscopic instruments that have 4 degrees of freedom of motion, the robot-assisted instrumentation has all 7 degrees of freedom, just like your hand." Dr. Badani is an Assistant Professor of Urology at Columbia University College of Physicians and Surgeons.
Ashutosh K. Tewari, MD, the Director of the Robotic Prostatectomy Program at NewYork-Presbyterian/Weill Cornell Medical Center, was equally as enthusiastic about the use of robotics in urology, noting that he performs about 600 robotic prostatectomies each year. "In addition, my associates do partial nephrectomies and radical cystectomies," he added. "We have a team of people who are very accomplished in different aspects of robotic surgery." Dr. Tewari is the Ronald P. Lynch Associate Professor of Urologic Oncology at Weill Cornell Medical College.
Physicians interested in learning the latest advances in urologic procedures should view this important webcast featuring Drs. Badani and Tewari, both of whom are leaders in the robotic approach to urologic disorders.
The advantages to be gained from the precision obtained by use of robotics include well-documented benefits for patients. Dr. Badani and colleagues recently reported robotic radical prostatectomy outcomes data with followup as far out as 5 years (Cancer. 2007;110(9):1951-8), finding that the cancer recurrence rates are as low as they have been historically for open surgery. Quality of life (QoL) measures were also reviewed, and urinary continence rates at just 3 months after surgery were nearly 80%, a figure that continued to trend upward into the high-90s after one year. "Much of this improvement over open surgery is the reconstructive capability that one has when using the robot," he said. "We have to reconnect the bladder back to the urethra after we remove the prostate. We can get deep into the pelvis and put the stitches in more precisely, and reconnect the supporting structures that improve continence."
Another QoL measure is sexual function, since the nerves that control penile erection wrap around the prostate and are by necessity damaged during prostatectomy. "The goal is to damage the least amount possible," Dr. Badani said. "And here's where the power of the robot comes into play, because you have the ability to precisely dissect the tissue under magnified vision and to perform nerve-sparing surgery. Men with less aggressive types of cancer are candidates for this surgery." In men who had good sexual function before the surgery and who had the enhanced nerve-sparing operation, upwards of 85% are able to have sexual intercourse one year later.
Dr. Tewari and colleagues have detailed the neural architecture around the prostate gland, which includes the proximal neurovascular tissue, the neurovascular bundle, and accessory neural pathways. The study of this neural anatomy has led him to devise nerve-sparing methods, including the ‘athermal trizonal nerve-sparing technique of robotic radical prostatectomy' (BJU Int 2008;101:1-5), whose purpose is to address the divergent goals of cancer control and maintenance of sexual function. "Most people use electrocautery in this surgery, but our surgical methods use small clamps to control bleeders," Dr. Tewari said. "Our group has found that there is more than one set of nerves that controls sexual function, and we try to save them." Indeed, Dr. Tewari and colleagues have gone beyond looking at the mechanics of penile erections by presenting findings on postoperative orgasm at the American Urological Association annual meeting.
Dr. Tewari has also championed total vesico-urethral reconstruction as a means of returning radical prostatectomy patients to continence earlier than rates found following standard methods (BJU Int 2008;101:871-877). The total reconstruction procedure, which includes both anterior and posterior reconstruction, allowed return to continence at rates much faster (at 24 weeks, 97%) than seen in patients receiving standard anastomoses (62%) or anterior reconstruction (87%).
Robotics are also employed in partial nephrectomies, in which the cancerous part of the kidney is excised while the normal part remains in the body. The robotic approach is helpful in partial nephrectomies because the kidney has to be reconstructed, requiring a large amount of knot tying. "The use of robotics is the biggest advancement in this area right now," Dr. Badani noted.
A third robotic urological operation is radical cystectomy, a response to invasive bladder cancer, in which the entire bladder is removed together with surrounding lymph nodes. An orthotopic neobladder or stoma is then created. The da Vinci surgical system performs well in this procedure because of the necessity of working with high precision amid a confined space.