There are many forms of therapy for BPH (benign prostatic hyperplasia). Prostates that are very large respond poorly long term to minimally invasive therapies. Robotic simple prostatectomy is the newest therapy for large prostates.

BPH involves growth of the middle part of the prostate. The treatment involves removal of this part called the adenoma.

I performed my first robotic simple prostatectomy this past week using the da Vinci surgical system, from Intuitive surgical. I performed the procedure in a retropubic fashion similarly to the open procedure with some robotic modifications that I made from my experience with the cancer operation, da Vinci prostatectomy. The procedure took about 2 1/2 hours and the patient went to the regular surgical floor without bladder irrigation. The blood loss and pain were very similar. The patient developed a small amount of constipation that kept him in the hospital for 2 days, but a 24 hour stay should be adequate in general.

The important point from this is that this robotic approach was far superior to the open version that has a high blood loss and a 3-7 day hospital stay. I feel it is also much easier than the laparoscopic approach which will never be implemented in a widespread fashion.

The largest series of the laparoscopic, non robotic series I found was from a multicenter study including Dr. Gill.

Their key findings were:
RESULTS: Mean operative time was 156 minutes (range 85 to 380), blood loss was 516 ml (range 100 to 2,500), hospital stay was 48 hours (range 15 to 110), and Foley catheter duration was 6.3 days (range 3 to 7). Mean specimen weight on pathological examination was 72 gm (range 32 to 120). Five patients (29%) required blood transfusion.

My first patient had a TRUS volume of 82 cc, lost about 50 ccs of blood, and went home at 42 hours. I have not performed any laparoscopic simple prostatectomies, but I have performed about 30-35 open ones. My first robotic one went as well as could be expected. I think my robotic experience of over 100 cases, along with my open experience, and experience with HOLEP (Laser enucleation of the prostate) all contributed to our success.

I think this can be easily replicated by a surgeon with moderate robotic experience and familiarity with the open approach.

The only prior experience I know of with robotic simple prostatetcomies was from Dr. Kawachi, at the City of Hope hospital in California. I discussed his approach prior to my first case and he pointed out that he opens the endopelvic fascia prior to opening the capsule. I found this approach beneficial as well and will be writing a paper on my approach.

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Dr. Menon gave a presentation at the Pacific Rim Robotics Conference on nerve preservation and the anatomical concept that he has named the veil of Aphrodite. After first reviewing the history of impotence after radical prostatectomy he described the latest modification of his techniques, which he claims further improves the preservation of potency. Originally, of course, radicals were associated with nearly 100% impotence until Dr. Walsh introduced the concept of "nerve sparing". While Walsh has at times claimed very high rates of preservation, many others felt that preservation in perhaps 50-60% of patients having a nerve sparing represented excellent results. In the introductory remarks to his talk Dr. Menon cited several papers that quoted rates of "normal" erections of only 4-33% after nerve sparing. There is clearly room for improvement.

The veil of Aphrodite is simply the superficial membrane on the anterolateral surface of the prostate, as best I understand it. Dr. Menon feels that this is important because he has identified nerves on the surface of the prostate in that area. To perform a veil of Aphrodite dissection he makes his lateral incision from base to apex much higher on the prostate closer to the midline anteriorly.

To prove that this gave superior outcomes he designed a study that took 76 patients in 2003 who were potent not requiring a PDE-5 inhibitor for erections and who were diagnosed with prostate cancer. They were randomized to two groups, one getting a "classical" VIP and the other getting a veil procedure. Only 48 participated in the complete follow up evaluation. 17% of those receiving a classical VIP were having normal erections without PDE-5, 26% with, and 51% receiving a veil procedure were having normal erections and 86% with.

Several things struck me about the presentation. First was the low rate of potency among the patients getting a VIP which I thought Menon had been promoting as already superior to a standard open prostatectomy. A 17% potency rate is nothing to brag about. Second was that, after describing how the patients were randomized to the two groups, he went on to say that he felt uncomfortable putting patients with higher risk disease by pre-op parameters in the veil group because of concern about getting a positive margin. So he put those in the "classical" group. Unless I misunderstood, that decision made this no longer a randomized controlled study. Third was that, while he has identified nerves on the surface of the prostate, no one knows where they are going or what they are innervate.

Posted by Dale Russell M.D. | Permalink | Comments (0) | TrackBacks (0)

This is a monthly update on the growth of Robotic Surgery in my practice.

Original blog entry about robotic surgery growth was in November of 2005 and is updated monthly.

For January, I performed 14 robotic operations including 9 prostate removals for cancer, 3 kidney removals for tumor, one ureteral reimplant, and a bladder and prostate removal in an elderly gentleman.

The highlights for January were:

Prostates: All 9 patients went home the following day making it 25 straight patients discharged the day following surgery.
I performed our most obese patient by BMI in 3 hours and 45 minutes and he was also discharged home within 24 hours.

Kidneys: We removed our largest tumor through a bikini cut incision- it was 10 cm or 4 inches plus the kidney.

Reimplant: We performed our first ureteral reimplant for scar tissue from a prior stone.

I unfortunately had complications this month as well, although neither of the 2 were related to robotics or surgery, but surgeons consider complications that happen in the postoperative period as surgical complications even if they are medical in nature.

One of our kidney patients also had her ureter and a piece if bladder removed open. She was anemic to start with and was our first robotic patient to receive a blood transfusion, about 2 days after surgery. She also had other medical complications.

Our bladder cancer patient had medical problems after going home.

I have completed 95 robotic operations so far including 70 robotic prostatectomies and have 15 operations (14 dvp) scheduled for February.

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At the Pacific Rim Robotics Conference last month there was a session on robotic pyeloplasty. It was held on Saturday afternoon, the last day of the conference, and featured a lecture by Dr. Elspeth McDougall and a live broadcast of the operation from UC Irvine performed by Dr. Ralph Clayman. Dr. McDougall described the operation as they perform it at UCI and then showed their results in about a half dozen cases, including a bilateral pyeloplasty in a horseshoe kidney. The outcomes were at least as good as with open, laparoscopic or endoscopic pyeloplasty techniques. The steps that she described in her lecture were those that we would see Dr. Clayman follow in the live demo that was presented imediately after her talk. I was interested because I have done about a half dozen or more myself and my partner has done several as well.

What struck me about their technique was that both Dr. McDougall and Dr. Clayman still do almost the entire operation with straight, handheld instruments and only bring in the robot for the purpose of sewing the pyeloplasty once the pelvis has been completely dissected. I simply could not understand the logic, especially when during the live demo a crossing vein and artery were encountered. We could hear Dr. Clayman, as he struggled to deal with the vessels, complaining several times that if he only had a decent right angle laparoscopic dissector he could get under the vessels and proceed with the operation. All I could think of was that any one of a number of the Endowrist instruments would make excellent right angle dissectors. In fact, I thought the entire operation could have been done quicker with the da Vinci than with the laparoscopic instruments. But when I asked Dr. McDougall, who continued to add to the commentary from the podium during the case, why they did it that way instead of using the da Vinci I was told that that was just the way they felt was best. I didn't find that a very satisfying answer.

Now I am not in a position to question two university professors and leaders in the field with far more laparoscopic experience than me, but I think it is that grounding in laparoscopy that is preventing them from making a break and going to a fully robotic procedure. There was nothing in the presentation that would cause me to change back to laparoscopic dissection.

For a urologist starting robotics, a dismembered pyeloplasty is an excellent first or at least early case. The anatomy is in most cases straightforward enough that it shouldn't pose any major problems and the dissection gives the surgeon a chance to get a good feel for the instrument. But I would do the whole thing robotically, start to finish.

Posted by Dale Russell M.D. | Permalink | Comments (1) | TrackBacks (0)

In my opinion most patients with prostate cancer are candidates for robotic prostate cancer surgery, or the daVinci Prostatectomy.

The ideal patient would be one with early prostate cancer that is likely confined to the prostate. The patient also needs a good chance of living at least 10 years.

Certain surgeries and medical conditions can make a patient less than ideal, but probably still a candidate.

Read on to find out my take on certain conditions and please comment if you can think of any others.

Medical Problems-

I have successfully completed robotic prostate surgery on patients with recent heart surgery, heart attacks, lung disease (COPD, asthma), insulin dependent diabetes, sleep apnea, prior strokes, prior blood clotting disorders, anemia, GI problems (inflammatory bowel disease), and multiple sclerosis (MS), and HIV.

By itself I haven't had to turn down anyone for robotic prostatectomy based on medical issues. It is important to make sure the patient has a life expectancy that warrants surgery however.

The advantages of robotics for some of the above include:
Less chance of infection, especially in diabetics.
Less trouble breathing postoperatively for the lung patients since there is less pain.
Less trouble getting around for patients with MS.
Less chance of getting a blood transfusion with the anemic patients. Several patients with anemia are included in my first 70 dvPs without a transfusion.
Less chance of a surgeon contracting HIV with robotics than open.

Past Surgeries
Prior TURP- prostate surgery- makes the surgery more challenging, but in my hands only adds about 15 minutes to the operation.
Prior Appendix removal- need to remove scar tissue, adds 5-20 minutes and a very small risk of intestinal injury (<1%).
Prior colon surgery for infection or cancer, adds a variable amount of time and a small risk of injuring the intestines (<5%) and a small risk of needing to convert (5%). One patient of mine had a colon surgery and a hernia left over from that surgery.
Prior hernia repair- no big deal unless it was done laparoscopically (in that case adds 20-30 minutes to expose the prostate.

Hernias
If a patient has an umbilical hernia this will be fixed at the same time and only adds 5 minutes.
If a patient has an inguinal hernia or if I find one, I fix it at the same time.

Obesity
This is an important point. Some surgeons do not feel comfortable operating on obese patients, but in my opinion these are the patients that are helped the most by this kind of surgery. The incisions would be larger, the risk of wound infections would be larger, and the overall complication rate would be larger.
My last 7 guys weighing between 230 and 290 pounds all went home the next day. The connection is much harder to make for the heavier patients and there is a greater chance they will need the catheter for more than 1 week. Most of my early guys have the catheters in for more than 1 week, but only 2 of the last 7 needed to for more than 1 week.
My philosophy is to offer these patients surgery and if they can loose weight, I think its much easier on me to do their surgery, but I have never refused to operate on someone for weight alone.

Age
The oldest patient I have done a dvP on is 74, but I think it woudl be reasonable to go to 80 years old if the patient has a 10 year life expectancy.

Prior Prostate Cancer Therapy
Hormonal Therapy- Makes the surgery a little more difficult.
Radiation or Cryosurgery- See previous blog entry.

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