The da Vinci unit at left is the robotic arms that go into the patient, and the one below is the console (like a video game console in an arcade).. where the surgeon sits to control the robotic arms.
Many are talking about the introduction of robotic surgery into urology. Robotic surgery is a variation on laparoscopic surgery, where surgeries are performed through very small incisions in the skin with instruments held outside the body. Visualization of the inside of the body is with a camera inserted through a skin incision. As opposed to standard laparoscopic surgery where hand-held instruments are introduced through small skin incisions, in robotic surgery the surgeon controls robotic arms which move surgical instruments inside the body.
Currently, “Intuitive Surgical” is the only manufacturer of robotic surgical instruments in the U.S. Their da Vinci surgical robot uses a 3-D camera and up to 3 surgical instruments to perform complicated surgeries using less than ½ inch incisions. A common misconception is that the robot performs the surgery. The robot is not performing surgery; the surgeon performs the surgery using the robot as an instrument. Why use a robot rather than traditional hand-held laparoscopic instruments? Robotic instruments can perform more complex movements than standard laparoscopic instruments, so more complex surgeries generally can be performed faster and with more precision.
da Vinci from the Start
The da Vinci surgical robot was originally developed to perform heart surgery, but its application has spread to many areas of surgery, including gy
necology, lung surgery, general surgery, and urology. Its use in urology began in 2000, when the robot was first used to perform radical prostatectomy.
Radical prostatectomy is the surgical removal of the prostate to treat localized prostate cancer. Prostate cancer is the most common cancer in men in the U.S., with more than 200,000 cases diagnosed in the U.S. yearly. Prior to the use of robotic surgery, roughly one third of prostate cancer patients yearly were treated with radical prostatectomy. In 2008 the vast majority of radical prostatectomies performed in the U.S. were performed with the da Vinci robot. Since its initial use with radical prostatectomy, urologists have expanded the use of the da Vinci robot. Now there are some urologists using the robot to perform many of the major surgeries in urology, including kidney, bladder, and ureteral.
Robotic urologic surgery has quickly become widespread because of both patient and physician preference. Patients tend to prefer new technologies and think they will get a better surgery if the urologist uses a robot. Is it true that robotic radical prostatectomy is better than radical prostatectomy using a traditional surgical incision? Many urologists believe that the robot helps them remove the prostate with less trauma to adjacent nerve and muscle resulting in a better surgical outcome.
Meeting the Challenge
The challenge of removing a prostate is not injuring the nerve tissue lying immediately beneath it which provides for erectile function. When nerve injury occurs, impotence results. The urologist must also reduce injury to the urinary sphincter that abuts the end of the prostate. When there is injury to the urinary sphincter, incontinence results. Estimates of impotence after radical prostatectomy using a traditional incision vary widely, but generally 50% is a good rule of thumb. Estimates of incontinence also vary, but most claim a less than 10% chance.
Recent published literature has demonstrated robotic radical prostatectomy to be at least as good at preventing impotence and incontinence as the traditional approach. And there is some evidence that the robotic approach causes an earlier return to continence and less risk of impotence after surgery. But there are skeptics, and preliminary published data has not definitively proven proponents or skeptics to be correct.
My own experience with robotic radical prostatectomy is that there is less nerve injury with a robotic approach because there is less tension on the nerves at the time of surgery and a better, more magnified view of the prostate and its surrounding structures. In my experience urologists perform a more exacting surgery with the aid of the robot. But despite the agreement of many urologists, there are eminent urologists who fervently disagree.
Where There Is Agreement
There are points of agreement, however. The routine hospital stay after radical prostatectomy is 1-2 days regardless of the approach used, and pain after surgery is not markedly different. But full recovery after robotic surgery is usually quicker, and using the robot there is less blood loss during the surgery. There usually are 6 individual small incisions after robotic radical prostatectomy versus 1 longer incision with the traditional approach. So incisions should probably play no role in preferring one approach over the other. The real question is what approach removes the cancer better and has fewer complications. Short term cancer control has proven equivalent for both approaches. While disagreement among urologists persists, there is some evidence that there is less impotence after robotic surgery.
Interest in robotic radical prostatectomy has resulted in more urologists using the robot, and for different types of surgeries. Some urologists are now using the robot routinely to remove kidney tumors, reimplant injured ureters, and remove entire bladders. Removal of the bladder is performed to treat certain bladder cancers. In my experience, the robot is a good tool for bladder removal and results in shorter hospital stays and quicker patient recovery after surgery. But this is a recent use of the robot, and published evidence of long term surgical outcome is lacking.
The recent incorporation of robotic surgery into urology is still in its infancy, despite its early successes and popularity in some circles. One is tempted to predict that over time there will be an even greater use of robots in urology. Robotic technology will improve, become more useful, and perhaps some time in the future the majority of all urologic surgery will be performed with the robots of the future. June, 2009.
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