Surgical experience key to successful robotic prostatectomy

By Ross Tomlin

Given their history of embracing technological advancement, one would expect urologic surgeons to accept robotic prostatectomy more rapidly.

True to form, in 2004, 10 percent of all prostate cancer surgeries were performed using this state-of-the-art robotic technology. Last year, close to 25 percent of these operations were performed robotically, a rate of growth driven by a number of factors. Not surprisingly, robotic prostate surgery pioneers at Baylor College of Medicine say the rate of acceptance of the machine has nowhere to go but up.

Robotic technology enhances precision

"Time is against anyone who bets against computers, which only become better, faster, and cheaper," said Kevin Slawin, M.D., professor of urology at BCM and director of the Baylor Prostate Center. "The arrival of robotic technology has dramatically enhanced a surgeon's abilities to perform minimally invasive surgery with precision and speed. From a scientific standpoint and judging from the medical literature, there is a huge sea change moving towards this technology."

Although the use of robotic devices is on the rise, physicians at most of the hospitals and institutions that currently perform robotic prostatectomy are relatively inexperienced with the procedure. Meanwhile, BCM urologists have performed hundreds of the procedures at The Methodist Hospital and St. Luke's Episcopal Hospital since the technology was introduced five years ago. Slawin, who holds the Dan L. Duncan Family Chair in Prostate Disease, and Brian Miles, M.D., professor of urology at BCM, have successfully treated more prostate cancer patients using the robotic-assisted laparoscopic approach than anyone else in Houston, and more than most other surgeons in Texas.

"You want this done by people who do a lot of them," said Miles, who holds the Distinguished Cullen Chair in Urology. "If I'm more comfortable and doing a better job, the patient gets a better procedure."

Getting a 3-D perspective

Compared to traditional laparoscopic procedures, which provide a relatively limited range of vision and motion, its robotic counterpart offers many advantages. Since its inception, robotic technology has increased the prostate surgeon's abilities to perform minimally invasive surgery quickly and accurately. With the da Vinci Surgical System, which is made by Intuitive Surgical, the surgeon performs the operation seated a few feet away from the patient at a control console with assistants near the operative table. Advanced optics allow the surgeon to view the operative field at high magnification while maintaining a 3-D perspective of the surgical area (versus 2-D with standard laparoscopic surgery).

The technology translates the surgeon's hand, wrist, and finger motions into precise, real-time robotic movements. A wide range of instruments endows surgeons with maximal maneuverability for clamping, suturing and manipulating tissue, permitting seven degrees of movement versus just three with standard laparoscopic surgery. Scaling motion allows microsurgical motion unequaled by other surgical approaches. The robotic device can even dampen tremors of less dexterous surgeons.

"The robot faithfully recreates an open atmosphere, and what I see looks as it would if I were at the patient's side," said Miles. "With a robot, I can twist my wrist, and the robotic arm will twist in the same way. You can't do that with a regular laparoscope. The robot makes suturing much easier."

Advantages of robotic technique

Outcomes of prostate surgery are measured by the rate and rapidity of return of continence and potency as well as by surgical margin and cancer cure rates. These parameters, currently under study at the Baylor Prostate Center, compare favorably to results with other standard techniques. Furthermore, robotic-assisted prostatectomy surgery is associated with less postoperative blood loss, less postoperative pain and a more rapid overall recovery. Patients are often walking and eating on the evening of the day of surgery and are routinely discharged the next morning.

Case in point: Slawin and former Scott Department of Urology chair Peter Scardino, M.D., treated five brothers with prostate cancer over a six-year span. The first four were treated successfully using a standard open radical prostatectomy procedure. The fifth brother, however, was treated by Slawin in 2003 with the robotic procedure. While all five of them emerged from their operations cancer-free, the last surprised his brothers by the rapidity of his recovery compared to theirs, returning quickly to the same quality of life he enjoyed before the surgery.

"Our outcomes are unparalleled because we've been able to bring to this operation years of experience doing prostate cancer surgery and then marrying to it our skill in using robotic technology to do the operation," said Slawin.

Debunking misinformation

Despite the body of evidence endorsing robotic prostatectomies, misinformation about the procedure permeates some corners of the healthcare world.

• Myth #1: Robotic prostatectomies are dangerous. In the hands of a capable surgeon, the robotic device is safe and enables a more efficient procedure than preexisting measures. Robotic prostatectomies are sometimes discouraged by physicians simply because of relative ignorance and lack of personal experience with the procedure.
  
  "There is an aversion among some urologists to learning how to use the robot," said Miles. "It can take a long time and a lot of effort, and a lot of older urologists don't want to get into that."
• Myth #2: Every prostate cancer patient qualifies for a robotic prostatectomy. While most prostate cancer patients – roughly 80 percent – are good candidates for the robotic procedure, some are better off with an alternative approach. Patients should be leery of healthcare professionals that are quick to "sell" them the robotic procedure without a thorough examination.
  
  "Each patient needs a tailored approach," said Slawin. "Some places try to market robotic prostatectomies to everybody that walks in the door. Since BCM has such an extensive experience doing these surgeries a number of different ways, we don't have a stake in any one of them. Our goal is to provide the best possible care."
• Myth #3: The robot makes the physician. A surgeon must be skilled, robot or no, to give quality care. Furthermore, practice makes perfect in urology as in any other trade – it takes roughly, at the very least, 50 cases to fully master the robotic procedure – and an advanced skill level is a prerequisite to harnessing the technology's full spectrum of tools.
  
  "A moderately skilled surgeon is not suddenly going to become a 'maestro' once he starts using the da Vinci robot to perform surgery," said Slawin. "A robot is just a tool. It doesn't turn you from someone who doesn't understand how to do the operation into somebody who does. The learning curve required to understand the complex anatomy and the principles underlying successful prostate cancer surgery is universal and applies to any tool, including the da Vinci system. The learning curve with the robot is difficult, and true mastery of its use requires hundreds of surgeries."

Despite its successful track record spearheading cutting-edge treatment for prostate cancer, BCM's urology department is not content with the status quo. Using post-operative evaluations of patients, Miles and Slawin continue to modify the way they perform what has become trademark robotic surgery. Meanwhile, ongoing translational research at BCM virtually guarantees that technological enhancements of surgical techniques, improved perioperative care, and more effective medications are always in the pipeline. Fortunately for present and future prostate cancer patients, time is on their side.