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ORIGINAL ARTICLE
Year : 2005  |  Volume : 21  |  Issue : 2  |  Page : 93-96
 

Robotic radical prostatectomy-a minimally invasive therapy for prostate cancer: results of initial 530 cases


Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA

Correspondence Address:
A Tewari
Vattikuti Urology Institute,Henry Ford Health System,Detroit, MI - 48202
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-1591.19628

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   Abstract 

Context: In 2000, the number of new cases of prostate cancer was estimated at 5 13 000 worldwide [Eur J Cancer 2001; 37 (Suppl 8): S4]. In next 15 years, prostate cancer is predicted to be the most common cancer in men [Eur J Cancer 2001; 37 (Suppl 8): S4]. Radical prostatectomy is one of the most common surgical treatments for clinically localized prostate cancer. In spite of its excellent oncological results, due to the fear of pain, risk for side effects, and inconvenience (Semin Urol Oncol 2002; 20: 55), many patients seek alternative treatments for their prostate cancer. At Vattikuti Urology institute, we have developed a minimally invasive technique for treating prostate cancer, which achieves oncological results of surgical treatment without causing significant pain, large surgical incision, and side effects (BJU Int, 2003; 92: 205). This technique involves a da Vinci™ (Intuitive Surgical®, Sunnyvale, CA) surgical robot with 3-D stereoscopic visualization and ergonomic multijointed instruments. Presented herein are our results after treating 750 patients. Methods: We prospectively collected baseline demographic data such as age, race, body mass index (BMI), serum prostate specific antigen, prostate volume, Gleason score, percentage cancer, TNM clinical staging, and comorbidities. Urinary symptoms were measured with the international prostate symptom score (IPSS), and sexual health with the sexual health inventory of males (SHIM). In addition, the patients were mailed the expanded prostate inventory composite at baseline and at 1, 3, 6, 12 and 18 months after the procedure. Results: Gleason seven or more cancer grade was noted in 33.5% of patients. The average BMI was high (27.7) and 87% patients had pathological stage PT2a-b. The mean operative time was 160 min and the mean blood loss was 153 cm3. No patient required blood transfusion. At 6 months 82% of the men who were younger and 75% of those older than 60 years had return of sexual function and 64 and 38%, respectively, had sexual intercourse. At 6 months, 96% patients were continent. Where next?: This procedure is safe and effective in managing patients with clinically localized prostate cancer. However, the surgical robot has a significant prize tag attached and not every center has access to the technology. In future, hopefully, the robot will become smaller, and cheaper to allow wide acceptance of this procedure.


Keywords: Laparoscopy; Prostate cancer; Radical prostatectomy; Robotics


How to cite this article:
Tewari A, Bhandari A, Hemal A, Menon M. Robotic radical prostatectomy-a minimally invasive therapy for prostate cancer: results of initial 530 cases. Indian J Urol 2005;21:93-6

How to cite this URL:
Tewari A, Bhandari A, Hemal A, Menon M. Robotic radical prostatectomy-a minimally invasive therapy for prostate cancer: results of initial 530 cases. Indian J Urol [serial online] 2005 [cited 2019 Oct 17];21:93-6. Available from: http://www.indianjurol.com/text.asp?2005/21/2/93/19628


Surgical treatment of prostate cancer is currently undergoing major refinements. While several urological giants founded the efficacy and safety of radical prostatectomy, patients were still concerned with the fear of an open surgical procedure and impact of this procedure on the quality of life. These concerns have encouraged urologist's world wide to explore minimally invasive surgical alternatives for the treatment of prostate cancer. The search for such a minimally invasive treatment got major boost due to the development of laparoscopic prostatectomy in the Europe. Several acclaimed laparoscopic urologists embraced this procedure and today several thousand such procedures are being performed worldwide. While laparoscopy appears as a viable tool for handful of trained laparoscopic surgeons, mainstream surgeons find this procedure challenging, and difficult to master. This challenge becomes even more frustrating when we consider that nonlaparoscopic surgeons perform most of the approximately 50 000 radical prostatectomies in the USA. However, recent developments in robotic manipulations techniques and stereoscopic 3-D vision allows conventional open surgeons, who are familiar with principles of anatomic radical prostatectomy, to attempt minimally invasive anatomic surgery with minimal morbidity, excellent functional, and oncological outcomes.

Robotic assistance offers an open surgeon sophisticated tools to perform complex laparoscopic surgery. Three-dimensional visualization, wristed instrumentation, intuitive, finger controlled movements, a comfortable seated position for the surgeon - all make for a technologically advanced ergonomic operation. We started performing robotic prostatectomy in November 2000[1],[2],[3],[4] and have done 530 such operations as of August 2003. Our current approach - Vattikuti Institute Prostatectomy (VIP) is based on the palimpsest of conventional anatomical 'open' prostatectomy, overwritten by technical nuances that are derived from robotic technology as elaborated by the da Vinci surgical systemδ (Intuitive Surgical® Sunnyvale, CA). The experiment presented herein is based on the integration of several technological, medical, and surgical marvels by a team of motivated surgeons who encompassed a difficult challenge and have developed an easily learnable, safe, and effective minimally invasive surgery for prostate cancer. These conclusions are drawn on the basis of treating 750 patients with prostate cancer using robotic technology.


   Patients and methods Top


Men with Gleason more than five prostate cancers with a Charlson comorbidity score of less than three are candidates for this procedure. We prospectively collected baseline demographic data such as age, race, body mass index (BMI), serum prostate specific antigen (PSA), prostate volume, Gleason score, percentage cancer, 1992 TNM clinical staging, comorbidities, and previous abdominal surgery. Urinary symptoms were measured with the international prostate symptom score (IPSS), and sexual health with the sexual health inventory of males score (SHIM). In addition, the patients were interviewed on phone by third party and were also mailed the expanded prostate inventory composite (EPIC) (a quality of life instrument).[5],[6],[7] The quality of life instruments have been validated previously in the patients with prostate cancer. [5],[6],[7] Questionnaires were collected at baseline and at 1, 3, 6, 12 and 18 months after the procedure.

Data collection

Details of each surgical procedure were entered on a comprehensive data collection sheet, which was filled up by a third party. This included the times of entry into the operative room, induction of anesthesia, and for the various steps of the operation-port placement, development of retroperitonal space, lymph node dissection, ligation of the dorsal venous complex, retroapical release, bladder neck transection, exposure of vas and seminal vesicles, control of pedicles, incision of posterior layer of Denonviller's fascia, neurovascular bundle release, urethral transection, apical biopsies, and anastomosis.

Additional data elements that were measured were blood loss (determined by the anesthesiologist), the postoperative pain score (using a visual analogue score), days of hospitalization, hemoglobin at discharge, and duration of catheterization. Any untoward event within 30 days of surgery was recorded as a perioperative complications.[8]

Histopathological analysis

The surgical specimen was inked and processed for histopathological analysis.[9] Margins were considered positive if there was tumor present at ink. For the apex, margins were considered positive if the margins of the apical biopsies (see Result section), which represent the actual margin of the apical dissection, had cancer. Positive margins were either focal (1 mm or less cancer) or extensive (>1 mm cancer).

Data analysis

Data were entered in a custom-made access database and analyzed using SAS data analysis software.[10] Between-group comparison of nominal variables were done using Fisher exact test and chi square analysis while continuous variables were compared using analysis of variance (anova). The days to continence, erection, and intercourse were recorded and used in the time dependent-survival-analysis using the Kaplan-Meier method.


   Results Top


Data collection is completed on 530 of the first 750 patients. [Table - 1] summarizes some of the variables. Gleason seven or more cancer grade is noted in 35% of patients. The average BMI is high (27.7) and 86% patients have pathological stage PT2a-b and remaining PT3. The mean operative time is 160 min and the mean blood loss is 153 cm[3]. No patient requires blood transfusion and mean hematocrit at discharge is 39%. Patients do not feel as fatigued as when they have postoperative anemia. The duration of catheterization is shorter and patients feel much less pain.

[Table - 1] also lists the perioperative complications. The port site hernias and ileus were seen in our earlier cases. We have had one ileus and no hernias in the last 150 cases. The return of sexual function is summarized in the last section of [Table - 1]. We noted that at 6 months 82% men who were younger than 60 years had return of sexual function and 64% had sexual intercourse. The return of continence is summarized in [Figure - 1]. At 6 months, 96% patients were either pad free or were using a liner for security reasons and 4% were using one or more pads. Patients who were dry, or using a liner were 'mostly satisfied' to 'delighted' with the quality of life due to urinary symptoms, whereas those wearing pads were 'mostly dissatisfied' or 'unhappy' with the quality of life. About 4% of patients undergoing VIP had a 4-point decrease in IPSS score and 33% had a 4-point decrease in IPSS score?

Comments

We have summarized the results of the initial 530 vip operations. Currently we are performing four procedures a day. Vip is a promising approach to the treatment of localized prostate cancer and it compares favorably with published series of laparoscopic[8],[11],[12],[13],[14],[15],[16] and conventional radical prostatectomies. [17],[18],[19],[20],[21],[22]

 
   References Top

1.Menon M, Shrivastava A, Tewari A. Laparoscopic and robot assisted radical prostatectomy: establishment of a structured program and preliminary analysis of outcomes. J Urol 2002;168 : 945.   Back to cited text no. 1    
2.Menon M, Shrivastava A, Tewari A . Interim analysis of Robotic Prostatectomy. Journal of Endourology : in press, 2003  Back to cited text no. 2    
3.Menon M, Tewari A. Robotic radical prostatectomy and the vattikuti urology institute technique: an interim analysis of resultsand technical points. Urology 2003;61:15.  Back to cited text no. 3    
4.Menon M, Tewari A, Baize B, Guillonneau B, Vallancien G. Prospective comparison of radical retropubic prostatectomy and robot-assisted anatomic prostatectomy: the Vattikuti Urology Institute experience. Urology 2002;60:864.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Day D, Ambegaonkar A, Harriot K, McDaniel A. A new tool for predicting erectile dysfunction. Adv Ther 2001;18 : 131.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Wei JT, Dunn RL, Litwin MS, Sanda MG. Development and validation of the expanded prostate cancer index composite (EPIC) for comprehensive assessment of health-related quality of life in men with prostate cancer. Urology 2000;56 : 899-905.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Wei JT, Dunn RL, Sandler HM, McLaughlin PW, Montie JE, Litwin MS et al. Comprehensive comparison of health-related quality of life after contemporary therapies for localized prostate cancer. J Clin Oncol 2002;20:557-66.  Back to cited text no. 7    
8.Guillonneau B, Rozet F, Cathelineau X, Lay F, Barret E, Doublet JD et al.: Perioperative complications of laparoscopic radical prostatectomy: the Montsouris 3-year experience. J Urol 2002;167:51-6.  Back to cited text no. 8    
9.Ohori M, Wheeler TM, Kattan MW, Goto Y, Scardino PT., Baumert H et al. Prognostic significance of positive surgical margins in radical prostatectomy specimens. J Urol 1995;154:1818-24.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.SAS/STAT(R), S. I. I.: Users Guide, Version 8 ed. Cary, NC: SAS Institute, 1999  Back to cited text no. 10    
11.Abbou CC, Salomon L, Hoznek A, Antiphon P, Cicco A, Saint F et al. Laparoscopic radical prostatectomy: preliminary results. Urology 2000;55 : 630-4.  Back to cited text no. 11    
12.Abbou CC, Hoznek A, Salomon L. Laparoscopic radical prostatectomy with a remote controlled robot. J Urol 2001;165:1964.  Back to cited text no. 12    
13.Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: initial experience and preliminary assessment after 65 operations. Prostate 1999;39 : 71.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]
14.Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: the Montsouris experience. J Urol 2000;163 : 418.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]
15.Guillonneau B, Cathelineau X, Doublet JD, Baumert H, Vallancien G. Laparoscopic radical prostatectomy: assessment after 550 procedures. Crit Rev Oncol Hematol 2002;43 : 123-33.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]
16.Guillonneau B, el-Fettouh H, Baumert H. Laparoscopic radical prostatectomy: oncological evaluation after 1,000 cases a Montsouris Institute. J Urol 2003;169 : 1261.  Back to cited text no. 16    
17.Lepor H. Radical retropubic prostatectomy. Urol Clin North Am 2001;28 : 509.  Back to cited text no. 17    
18.Lepor H, Nieder AM, Ferrandino MN. Intraoperative and postoperative complications of radical retropubic prostatectomy in a consecutive series of 1,000 cases. J Urol 2001;166 : 1729.  Back to cited text no. 18    
19.Lepor H, Walsh PC. Long-term results of radical prostatectomy in clinically localized prostate cancer: experience at the Johns Hopkins Hospital. NCI Monogr 1988;117.  Back to cited text no. 19    
20.Walsh PC, Marschke P, Ricker D, Burnett AL. Patient-reported urinary continence and sexual function after anatomic radical prostatectomy. Urology 2000; 55: 58-61.  Back to cited text no. 20    
21.Walsh PC, Lepor H, Eggleston JC. Radical prostatectomy with preservation of sexual function: anatomical and pathological considerations. Prostate 1983;4:473.  Back to cited text no. 21    
22.Hull GW, Rabbani F, Abbas F. Cancer control with radical prostatectomy alone in 1,000 consecutive patients. J Urol 2002;167:528.  Back to cited text no. 22    


    Figures

  [Figure - 1]
 
 
    Tables

  [Table - 1]

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