Improving outcomes with surgical precision

GP talks to Mr Amrith Rao and Mr Omer Karim about a robotic surgical procedure to treat prostate cancer.

Why is there a need for robotic surgery?
Prostate cancer is the most common cancer affecting men in developed countries and is also the biggest killer among cancers in men in the western world.

Dr Karim and rhe da Vinci robot

Treatment for prostate cancer depends upon the patient's life expectancy, medical co-morbidities and the stage of the disease. Other than active surveillance (in highly selected patients) and radiotherapy, radical prostatectomy appears to be the most effective way of curing the disease.

Radical prostatectomy was, in the past, an operation with significant morbidity as it involved making a large incision in the abdomen. It was also associated with adverse outcomes such as incontinence and impotence.

However, with the improvement in anatomical knowledge and surgical techniques together with the introduction of minimally invasive surgery (keyhole), the morbidity associated with radical prostatectomy has significantly decreased.

Robotic radical prostatec-tomy has the significant advantage of delivering a highly magnified 3D image of the operative field. This directly translates into better preservation of the neurovascular bundles that supply the nerves for erections.

It also provides precise suturing of the bladder to the urethra providing excellent control of urinary continence.

Operating with precision allows good haemostatic control and studies have clearly shown that using the da Vinci robot has virtually eliminated the need for blood transfusion.

From a practical point of view, surgeons find that the minimally invasive robotic approach is technically superior to traditional laparoscopic or 'keyhole' surgery where the surgeon has to stand by the operating table with long, difficult to manipulate, wand-like instruments.

The average hospital stay in the UK is around five days for an open operation compared with around two days for robotic surgery. There are emerging data that return to work is faster for patients undergoing robotic surgery compared with open surgery.

Which patients may benefit? What types of problem are best treated with this method?
Most patients who are suitable for an open operation or laparoscopic operation are suitable for surgery using the robot.

The patients who benefit the most by operating using the robot are young men who are sexually active and older men who wish to retain their potency.

Prostate cancer that has not spread beyond the capsule (localised prostate cancer) can be treated by removing the entire prostate gland and the accompanying seminal vesicles (radical prostatectomy), sparing the neurovascular bundle supplying the penis.

Robotic surgery is also used for kidney operations such as nephrectomy and pyeloplasty. Radical cystectomy for bladder cancer is also being carried out successfully using the robot.

It has been used by other specialties such as cardiac surgeons (for bypass), general surgeons, plastic surgeons and gynaecologists, where precision is the key to success in delicate surgery.

Summary of benefits

Robotic radical prostatectomy offers

  • Small incisions
  • Better preservation of the neurovascular bundle = better sexual function
  • Less blood loss
  • Less post-operative pain
  • Early return of continence and potency
  • Early recovery
  • Good oncological outcome

What does it involve and how is it performed?
Patients diagnosed with prostate cancer are discussed in the multidisciplinary team meeting and those deemed to be fit to undergo radical surgery are referred to the urologist.

The patient is counselled thoroughly by the cancer nurse specialist about the benefits and the risks associated with the operation. The patient is provided with an information leaflet regarding robotic radical prostatectomy.

Patients are also put in contact with those who have undergone a similar operation and wish to share their experience.

The procedure involves a general anaesthetic. The peritoneum is approached using four or, if needed, five ports. One port at the level of the umbilicus is for the camera. Other ports are used for the robotic arms.

Once all the instruments are docked to the robot, the urologist sits at the console, where the image of the interior of the abdomen is displayed in 3D.

The urologist then performs the operation, which takes about two hours. Once the operation is complete, the specimen containing the cancerous prostate and the accompanying seminal vesicle is removed. The wounds are closed with absorbable stitches.

In how many patients has this been performed?
In the US, approximately 70 per cent of all radical prostatectomies are performed using the robot. In the UK, it is estimated to be less than 5 per cent.

Are there any problems with this technique?
There are no specific problems with the use of a robot compared with other techniques. There is a learning curve for the urologist who is performing the procedure. However, studies have shown that the learning curve is much quicker with the robot as compared with the laparo-scopic technique due to the ease of handling the instruments.

One of the advantages of the robotic surgery compared with the open or laparoscopic techniques is that it virtually eliminates the surgeon's tremor, which can be crucial when handling sensitive and delicate structures such as the nerves, blood vessels and sphincters.

How long do patients take to recover?
At Wexham Park, patients are usually discharged 24-48 hours following surgery with a urethral catheter, which is removed after seven to 10 days. Patients can resume most physical activity within two weeks of surgery.

Are there any outcome statistics available?
Although robotic prostatectomy is a fairly new technology, because of the improved results, it has become the most popular treatment in the US.

The table below compares the outcome of robotic, open and laparoscopic radical prostatectomy. Robotic radical prostatectomy has a definite advantage in decreasing the length of hospital stay. There is also an early return to urinary function and also sexual function.

What is the cost?
As the technology is new, the cost of robotic radical prosta- tectomy is about £6,500. It is thought that there will be a new HRG code to uplift the tariff for hospitals treating patients with robotic technology, which should help off-set the large capital outlay.

However, the hospital stay is shorter and hence there is less risk of hospital-acquired infections and morbidity associated with prolonged convalescence from an open operation.

The quality of life indicators such as early return of continence and resumption of sexual activity cannot be quantified. However, quality of life questionnaires have shown a significant satisfaction among men undergoing robotic prostatectomy.

How did you get involved in this work?
Mr Karim has performed more than 500 open radical prostat-ectomies and trained under Professor Patrick Walsh, a world authority on radical prostatectomy.

When the research data from the US showed that robotic radical prostatectomy had better outcomes than open radical prostatectomy on many parameters, Mr Karim was keen to offer it to NHS patients.

He was one of four urologists who started the first robotic radical prostatectomy programme in the UK. He was involved in the first modular training in robotic prostatectomy in the UK and has performed more than 250 robotic radical prostatectomies with very good results.

The installation of the da Vinci robot at Wexham Park Hospital in August 2008 was the first in a UK district general hospital.

Mr Karim is a recognised trainer in robotic surgery and is now mentoring other consultant urologists.

Where is it available?
There are only 10 NHS hospitals in the UK with a da Vinci robot. Wexham Park has the most experience, with more than 50 robotic operations. Recently, due to increased demand from patients and the successes seen in these centres, more urologists are being mentored.

  • Mr Rao is an SpR in urology and Mr Karim is a consultant urological surgeon at St Mary's Hospital, London as well as Wexham Park Hospital, Slough, Berkshire.
DA VINCI SURGERY VERSUS TRADITIONAL SURGERY
Outcome da Vinci surgery Open surgeryLaparoscopic
surgery
Cancer control
T2 margin status2.55.97.7
Complications
Length of hospital stay1.2 days3 days2.5 days
Major1.7%6.7%3.7%
Minor3.7%12.6%14.6%
Urinary function
3 month92.9%54%62%
6 month94.9%80%77%
9 month97.4%93%83%
Sexual function
12 month86% 71% 76%7176%

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