Robotic Surgery

The prostate gland is a fibrous organ that surrounds the urinary urethra at the base of the bladder.  Located deep in the pelvis, the prostate sits behind the pubic bone, in front of the rectum and beneath the bladder.  The walnut-sized gland wraps around the urethra.  A large vein lies on top and tiny nerves that affect erectile function are positioned on either side of the prostate.

Traditional open radical prostatectomy requires a large incision to provide the surgeon access to and vision of the gland, organs, nerves, and blood vessels.  A robotic radical prostatectomy is the precise removal of a cancerous prostate gland, while sparing nerves for erection and significantly decreasing the chance of urinary incontinence.

The da Vinci Surgical System enables surgeons to perform a radical prostatectomy using minimally invasive techniques.  This robotic system enhances the surgeon’s range of motion, precision and dexterity, all crucial in the complex anatomy surrounding the prostate gland.  The operation is performed through five incisions no wider a dime.  A pencil-size binocular telescope held by one of the arms is inserted through an incision to provide magnified, 3-dimensional images of the surgical site, comparable to the view a surgeon has during open surgery.  The da Vinci technology translates the large hand movements of the surgeon into precise, minute movements inside the patient, which are critical skills during a radical prostatectomy.  Tiny, exact sutures can mean the difference between incontinence and normal urinary function.  Precise moves with scissors in hard-to-maneuver areas are able to spare nerves that preserve sexual function.

Comparing Robotic Vs. Open Prostate Surgery

Patients are most concerned about several factors when deciding what type of prostate cancer treatment to undergo:

• Cancer Removal
• Continence
• Potency
• Safety
• Pain
• Blood Loss

Cancer Removal

Surgeons measure their success in eliminating cancer from a patient’s body by looking at the surgical margins – or the edges of tissue on the removed prostate. A pathologist will look at the removed prostate under a microscope, and if he sees cancer cells on the edge of the prostate, this is called a positive margin. The reverse of a positive margin is a negative margin – indicating all the cancer in the prostate has been removed.

Whether a cancer can be removed completely depends on two factors, the skill of the surgeon and how bad the cancer is. Thus any surgeon, no matter how good he or she is, will not be successful in removing all the cancer if the cancer is aggressive or particularly bad. Pathologists relate the aggressiveness of prostate cancer to tumor volume (how much cancer there is) and to tumor grade (how abnormal the cancer looks under the microscope). At Henry Ford, surgeons tend to operate on more aggressive cancers than at other institutions. Yet, 76 percent of patients undergoing the open surgery had negative margins or the complete removal of cancer.

With the robotic prostatectomy, surgeons were able to completely remove the cancer in 91 percent of patients. robotic prostatectomy may be better at removing cancer completely because of the increased precision offered by the robotic surgical system.

If the cancer is removed completely, the PSA should be 0. At 20 months, less than 2 percent of patients have had detectable PSA in the blood. This is a very good sign, but the numbers are preliminary and further study is needed to confirm these observations.

Continence at Six Months

When the prostate is removed, one of two muscles that control urination is removed because this muscle lives in the prostate. The second muscle is able to control urination in most men, but it will take some time until this happens.

Until then, a patient will leak urine, or be incontinent. Incontinent patients can wear pads to contain their urinary leakage. For patients undergoing the open prostatectomy at Henry Ford, 60 percent are NOT wearing pads six months after their surgery, and 25 percent are dry at eight weeks.

For those patients having the robotic prostatectomy, 96 percent are NOT wearing pads at six months, and 90 percent are dry at eight weeks. In fact, the majority of the patients operated upon this year have had total urinary control within 24 h after removal of the catheter. In other words, patients undergoing robotic prostatectomy regain continence much faster than patients undergoing conventional surgery.

Potency at Six Months

One very common side effect of prostate cancer surgery (or radiation or hormone treatments) is impotence or the inability to have and sustain an adequate erection for sexual intercourse. While sexual desire, orgasm and sensation should be the same, most men notice a change in the quality of their erections. This is because the nerves and blood vessels required for erections often are pulled or cut during prostate surgery.

Over a period of two to three years, erections should return. The rate of return depends on emotional factors, age, the partner, the level of current sexual activity and whether the doctor was able to preserve the nerves during surgery.

In the year 2002, among patients having open surgery, 33 percent were able to have sexual intercourse six months after surgery. Among robotic prostatectomy patients, 66 percent had erections strong enough for sexual intercourse six months after surgery. As with continence, robotic prostatectomy patients appear to regain potency faster than patients undergoing open surgery, and it is likely that these results will improve with time. There also are many methods to improve sexual function, and we encourage using these.

Safety

No matter how routine, there are risks to every operation. Complications during surgery can include a hernia at the “port,” where the scopes are inserted into the body, post-operative bleeding, deep venous thrombosis (DVT) or blood clots that develop in the veins of the legs and pelvis, etc. For patients undergoing the open procedure at Henry Ford, 85 percent had NO complications whatsoever. Among robotic prostatectomy patients, 98 percent had NO complications. This means that the robotic prostatectomy has proven to be a safer operation than the open prostatectomy.

Pain

All patients are asked to complete a pain evaluation test upon completion of their surgery. A score of “1” indicates no pain at all, and a score of “10” indicates the worst pain imaginable. On average, patients undergoing the open procedure at Henry Ford indicate an average pain score of “7,” and robotic prostatectomy patients indicate an average pain score of “3.” Patients undergoing the robotic prostatectomy generally have less pain compared to patients having the open surgery.

Blood Loss

The prostate has multiple large blood vessels surrounding it. Therefore, bleeding during surgery is a common risk. Sometimes, blood loss is so significant that patients need a transfusion to replace what is lost. This has happened in 11 percent of patients having open prostate surgery at Henry Ford. However, no robotic prostatectomy patient ( of over 800) has had to undergo a transfusion due to excessive blood loss during surgery. Therefore, the risk of transfusion/blood loss with the robotic prostatectomy is much lower compared to open surgery.

Even though most patients undergoing open surgery do not require a blood transfusion, most of them are anemic when they go home. This results in a tired, washed out feeling. Most robotic prostatectomy patients (97 percent) are NOT anemic when they go home. Thus, they are able to resume normal activity in one to two weeks.