robotic surgery for prostate cancer: a realistic approach in … · 2018. 1. 31. · robotic...
TRANSCRIPT
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Robotic Surgery for Prostate
Cancer:
A Realistic Approach to
Getting Started “The Evolution of a Robotic Surgeon”
Douglas S. Scherr, M.D.
Clinical Director, Urologic Oncology
Weill Medical College of Cornell University
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Is The Disease Important?
PROSTATE CANCERHighest in Incidence and Second in Cause of Death
from Cancer in American Males
Incidence Cause of DeathMelanoma of Skin 5%
Lung & Bronchus 14%
Oral Cavity & Pharynx 3%
Pancreas 2%
Colon & Rectum 11%
Kidney 3%
Prostate 30%
Urinary Bladder 7%
Leukemia 3%
Non-Hodgkin’s Lymphoma 4%
All Sites 637,500All Sites 637,500
189,000 New Cases
3% Esophagus
31% Lung & Bronchus
5% Pancreas
3% Kidney
3% Liver
10% Colon & Rectum
11% Prostate
3% Urinary Bladder
4% Leukemia
5% Non-Hodgkin’s Lymphoma
288,200 All Sites 288,200 All Sites
30,200 Death2002 Estimates
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U.S. Incidence and Mortality of
Prostate Cancer
Surveillance, Epidemiology and End Results (SEER) Data
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Natural History
• Natural history understood: -To die of prostate cancer or die with prostate cancer? -Conservative Treatment: a.) Gleason 2-4: 4-7% chance of death b.) Gleason 6: 18-30% chance of death c.) Gleason 8-10: 60-80% chance of death**
Frankel et al. Lancet, 361: 1122, March 2003
**Albertsen et al., JAMA, 280: 975, 1998
The Disorder
“Prostate Cancer”
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Progression-free probability
by risk group
Low risk
High risk
Intermediate risk
D’Amico et al JAMA 280:969-74, 1998
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Swedish randomized trial: Surgery v. Watchful waiting
Surgical excision alters the natural history of prostate cancer,
reducing metastases and cancer-specific mortality by 50% at 8 years.
From: Holmberg L, Bill-Axelson A, Helgesen F, et al. A randomized
trial comparing radical prostatectomy with watchful waiting in early
prostate cancer. N Engl J Med, 2002;347:781-789.
Distant metastases Cancer-specific mortality
WW 27.3%
RP 13.4%
WW 13.6%
RP 7.1%
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DEMOGRAPHICS OF AGING
• More and more doctors will be faced with how to treat our aging population
• the older population will burgeon between the years 2010 and 2030 when the "baby boom"
generation reaches age 65.
• This will more than double the 65+ population by the year 2030 compared to 2000 numbers
Source: Administration on Aging (www.aoa.gov)
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DEMOGRAPHICS OF AGING
• Over 2.0 million persons celebrated their 65th birthday in 2000 (5,574 per day).
• In the same year, about 1.8 million persons 65 or older died, resulting in an annual net increase of approximately 238,000 (650 per day).
Source: Administration on Aging (www.aoa.gov)
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DEMOGRAPHICS OF AGING
Source: Administration on Aging (www.aoa.gov)
• By 2030, there will be over 70 million older persons, more than twice their number in 2000.
• People 65+ were 12.4% of the pop. in 2000 but are expected to grow to be 20% of the pop. by 2030.
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Corral DA and Bahnson RR. J Urol. 1994 May;151(5):1326-9
A. Life expectancy by age for all men. At age 70 life expectancy is 11 yrs
B. Ten year survival by patient age. At 70 52% of men will survive 10 years
Life Expectancy and Ten Year Survival
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Improved Treatment Strategies
• Endorectal MRI
• Nomograms
• Nerve Grafting
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Improved Cancer Detection
Through Imaging Endorectal MRI/Spectroscopy
• Potential improvement over ultrasound
• Biochemical gradients to decipher cancer
from benign
• Remains investigational
• Possible role in high risk patients
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Image 8 I 54.44 mm Image 9 I 57.56 mm
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Treatment Stratifications
• Allow for improvement in patient
understanding
• More objective in guiding treatment
decisions
• Less physician bias
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Palm Pilot Nomogram Software
• Includes pretreatment and postoperative
predictions.
• Uses published nomograms in prostate cancer.
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Technical Improvements in Surgery
Nerve Grafts
• Cavernosal nerves necessary for post-
operative erectile functions
• In advanced disease, nerves may need to
be resected to obtain a negative margin
• Sural nerve or genitofemoral nerve serve
as sources of nerve grafts in this setting
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What’s Next
• Improvements in Surgical Technique have
Stagnated
• Re-birth in Perineal Prostatectomy
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Robotic Prostatectomy
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Da Vinci Instrumentation
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• Stereoscopic design with two 3-chip cameras
• 75% better resolution than any imaging system
da Vinci System: 3-D vision
‘Open’ surgery orientation
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• 6 Degrees of freedom
• Surgical hand movements are transposed to the instrument tips
• Ability to scale motion
da Vinci System: Endowrist Technology
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History Of Laparoscopic Surgery
• Guillonneau and Vallancien – Montsouris
Technique
“If this laparoscopic procedure is
shown to be equivalent or better, it may
replace open retropubic radical
prostatectomy.”
June 2000
Guillonneau and Vallancien, J Urol, 163: 1643, 2000
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Eliminates
• Counter-intuitive motion
• Instrument tremor
Provides
• Improved ergonomics
• Hand / eye alignment
Transforms
• 2-D vision to true 3-D
• 4 DOF instruments to 6 DOF (greater endoscopic dexterity)
Enhances Laparoscopy
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Disadvantages
• Loss of tactile feedback
• Set-up time
• Surgeon away from OR table
– Conversion
– Communication
• Limitation of instrumentation
• Cost
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Robotic Assisted
Laparoscopic Urology
• Nephrectomy
• Partial Nephrectomy
• Prostatectomy
• Adrenalectomy
• Intra-abdominal
orchiectomy
• RPLND/PLND
• Pyeloplasty
• Birch Procedure
• Colposuspension
• Cyst Marsupilization
• Varicocelectomy
Extirpative Reconstructive
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• Prostatectomy
• Partial Nephrectomy
• RPLND
• Pyeloplasty
Extirpative Reconstructive
Robotic Assisted
Laparoscopic Urology
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Ureteral spatulation
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Anastomosis
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Ureteral stent
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Tewari et al. BJU Int. 92, 205-210, 2003
Functional Outcome: Robotic Prostatectomy vs. Radical
Retropubic Prostatectomy
Continence Erections
Intercourse
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Comparison to the Gold Standard
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The European Experience
Cathelineau et al. Urol Clin NA, 31: 693-699, 2004
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Further Comparison
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The Robotic Experience Worldwide
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Patient Positioning
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8cm 9cm
12mm
12mm
5mm
5mm
Davinci Davjnci
U
Port Placement
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Entering the Space of Retzius
• Incise median umbilical ligaments
• Drop bladder
• Expose endopelvic fascia
• Adequate exposure/mobilization facilitates dissection of prostate base/node dissection
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Endopelvic Fascia/Dorsal Vein
• Begin lateral to puboprostatic ligament and medial to levator ani
• Critical in facilitating apical dissection
• 80% of prostate cancer comes within 8mm of prostatic apex
• Place DVC stitch distal to prostatic apex
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Bladder Neck/Seminal Vesicles
• Biologic significance of + BN margin well documented
• Wide excision necessary
• Send frozen section to confirm absence of any prostatic tissue
• Guide to intraoperative decisions: a.) site specific biopsy labeling b.) DRE c.) endorectal MRI
• Inspect for median lobe
• Compete removal of SV necessary
• Judicious use of electrocautery at SV tip
• Proper dissection of SV sets up posterior plane
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Pedicles/Nerve Sparing
• Begin posterior dissection beneath the
posterior layer of Denonviller’s Fascia
• 25% of men with palpable nodule on DRE
will have ECE posteriorly
• Pedicles taken with clips
• Antegrade nerve sparing
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Urethral Incision/Apical
Dissection
• Incise DVC distal to prostatic apex
• Place 2nd stitch into DVC if necessary
• Avoid distal urethral dissection – maintain
maximal functional urethral length
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Anastamosis
• Running suture with 2.0 monocryl
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Results of First 50
• Oncologic: Pos. Margin Rate: 6/50 (12%)
• Continence: -97% of catheters removed at 7 days -3 patients with high JP output -86% of patients with <1 pad at 6 weeks -0% patients with bladder neck contracture
• Potency: Too early to characterize
• Post operative Complications: -one patient required take back for incarcerated hernia -no blood transfusions -mean operative time at 238 minutes -72% of patients discharged < 24 hours
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“Robotic assistance offers an open surgeon sophisticated tools to perform complex
laparoscopic surgery. A technologically advanced ergonomic operation is achieved
because of 3-dimensional visualization; wristed instrumentation; intuitive, finger-
controlled movements; and a comfortable seated position for the surgeon”
Urology Gold Journal, 4/03
Robotic Radical Prostatectomy
And The Vattikuti Urology
Institute Technique p.15-20
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ff Title
Avg. Operative Time:
160 min.
Avg. Hospital Stay:
1.2 days
Blood Transfusions:
0
Patients
discharged
Within 24 hours:
93%
Avg. Blood Loss:
153 ml.
Positive Margins:
6%
Avg. Catheterization time:
7 days
Continence at 6 mos.:
96%
Potency (men 60 yr) at 6 mos:
82% Had Return of Sexual Function
64% Had Sexual Intercourse
Urology Gold Journal, 4/03
Robotic Radical Prostatectomy
And The Vattikuti Urology
Institute Technique p.15-20
Data Collection:
First 200 patients
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da Vinci Benefits:
The Patient
• Shorter hospital stay
• Less post operative pain
• Less risk of infection
• Less blood loss and transfusions
• Less scarring & improved cosmesis
• Faster recovery and return to normal
daily activities
Dave Kinsey, Robotic
Prostatectomy Patient
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Is It Any Better?
• Comparable results can be achieved
• Learning curve reasonable
• Long term results await
• Robotic surgery will have a role as long as
prostatectomies exist