Dr. Bahjat Abbas
2007 / 6 / 20
After the specialist in laparoscopy for radical prostate surgery in a university hospital in Toronto told Tom (not his name) that the procedure will take between 4 and 5 hours and, if he, the surgeon, finds it is going to take longer time, he would have no choice but to perform an open surgery. Tom started to think not twice but ten times, since he knows that a permanent incontinence and other complications might be a possibility. Tom contacted his family physician telling him about his concern. The family physician told Tom that he read about the robot radical prostatectomy and was impressed by its accuracy and precision, but he had little information about it, except that a surgeon in Texas is conducting it, and the surgical operation is very expensive. By going to Internet for more information, Tom found that many hospitals in the States, and not only that surgeon in Texas, are using it.
After researching the Internet extensively to know more about the prostate cancer and robot – assisted prostatectomy, Tom reached the conclusion that this type of surgery might be the surgery of the future. Then he decided without hesitation to undergo such a surgery. He did and found the result fantastic. The operation took about 2 and ½ hours and he was able to walk 100 metres several hours after the operation. And after he was released from the hospital next day, he walked from the hospital to the apartment, which is located on the campus of the hospital without major problems. After 2 days from the catheter removal, 9 days after the surgery, he was driving his car coming to his home. What is the type of this surgery, when it started, its benefits and difference from other forms of surgery, I would like to give an idea using my knowledge as a pharmacist, who holds a MSc degree in Experimental Pathology and PhD in Biochemistry with the information collected from different websites of Internet and from the surgeons involved and had expertise in this field. I would like here to present the data briefly and in a simple way, which might be useful for the people suffering from the problems of the prostate, to let them know and understand their problems, and have an idea about this disease and the right decision to be taken to act in time and not later.
What is the prostate ?
The prostate is the gland of man, which is located below the bladder, close to the rectum, surrounding the urethra and surrounded itself by many tissues, nerve fibres and blood vessels. It is essential in the early stage of life for reproduction, but becomes a burden and even dangerous in the late stage of the man’s life.
Prostate Cancer and Surgery
The prostate, as any other organ, is vulnerable to diseases. The main diseases associated with the prostate are the enlargement of its size, a walnut- size, inflammation and the worst of all is the cancer. It is estimated that about 22,000 men in Canada get prostate cancer every year and 8,000 of them are advised to undergo prostatectomy (removal of prostate). The traditional way in doing that is by open surgery, which is performed by making a 6-8 inch incision under the naval to let the surgeon observe the prostate. However, this method of surgery may be traumatic to the patient causing severe pain and complications with a long recovery period. It can result in side effects such as incontinence and impotence. However an alternative to this operation is available, and it is the laparoscopic radical prostatectomy (LRP). The procedure entails producing small opening ports in the body and inserting small cameras. The result is a shorter stay in hospital, less pain and suffering. However, this procedure does have its drawbacks. “ With regular laparoscopy you only have one camera, which gives you a two-dimensional view. You lose one dimension –depth perception.” said Dr. David Samadi, director of Robotic Laparoscopic Surgery at Columbia Presbyterian Medical Centre in New York City. In addition to the flattened field of surgery, the fixed-wrist instruments have limitations on surgeon’s dexterity.
The Robot da Vinci
To overcome the above mentioned obstacles, and to improve the surgical operation, researchers developed a surgical robotic system entitled, Da Vinci in 1999. It was approved by the FDA in July 2000 for surgical procedures, such as heart bypass, kidney transplants, hysterectomy etc. It was then used for prostatectomy procedures in May 2001.
Da Vinci consists of a surgeon console, a patient’s side cart with four interactive robotic arms, high performance In Site vision system and EndoWrists instruments. The surgeon’s hand movements are scaled and translated into precise movements of the EndoWrists movements. The surgeon at his console operates comfortably viewing a 3-D image of surgical field without touching the patient’s body, and the arms on the side cart enter the patient’s body through small ports, whereas the tiny forceps is holding the tissues and the small knife is cutting while the assistant (helper) is rinsing the field and sucking the debris. The only big incision is about 2 inches long under the naval, through which the prostate is pulled out after it has been put in a small plastic pouch attached to a string, lest to spill some cancerous cells, at the end of operation i.e after its separation from the surrounding tissues. It is an effective, accurate and precise procedure.
Robotic- surgery Patients have a 14% higher rate of cancer removal than other kinds of surgery, and regain urinary function in 44 days ( 4 times as fast as open –surgery patients.) and the sexual intercourse regained in about 11 months, while in open surgery half of the patients didn’t regain full sexual function even two years later, as reported by Vattikuti Urology Institute in Henry Ford Hospital, Detroit, in comparison of both types of surgery performed in Henry Ford Hospital.
LRP is used as an alternative to robot to perform the surgery in Ontario, Edmonton and some cities in Canada because it is cheaper, but Dr. Michael Hogart, head of urology at the Edmonton hospital said : It is difficult for surgeons to learn how to do the less invasive laparoscopic procedure with their own hands." CBC News, December 8, 2006 – Internet." However, Dr. Laurence Klotz, the chief urologist at Sunnybrook Hospital in Toronto says “ So far, the data has not shown any really substantial difference in term of patient outcome.” (Ibid.)
But the advantages of robot – assisted prostatectomy are summarized by Dr. Stephen Pautler, surgical oncologist at St. Joseph’s Health Centre in London, Ontario, who is using the robot, “ We are able to see with 10 to 12 times magnifications using the robot, so it allows us to be more precise than we are in open surgery.” –Ibid. And also by Dr. Thomas E. Ahlering, director of Urological Oncology , University of California Irvine Med. School saying “ As a trained oncologist, da Vinci has allowed me a better cancer operation with improved clinical outcome.”
The robot da Vinci, the only robot used in USA and the world, is used extensively by Vattikutti Urology Institute in Henry Ford Hospital, where this hospital has performed about 3000 robotic prostatectomy, more than any hospital in the world, and Dr. Mani Menon, the director of the institute, has improved the magnification to 35 times identifying areas where the cancer has spread, particularly under the prostate, bed of prostate, and to the bladder. Dr. Menon developed a technique to preserve the prostatic fascia (veil of Aphrodite) that appears to enhance the quality of nerve preservation during robotic prostatectomy. “ The potency outcome with our robotic surgery are the highest reported to date.” said Dr. Menon. “ Of the patient undergoing the procedure, 97 percent achieved erections strong enough and half not requiring medications to do so.” In comparison between the robot system used by Vattikuti Urology Institute in Henry Ford Hospital and the open surgery in the same hospital, Dr. Menon summarized the differences as follows:
- Less trauma to the tissues.
- Less blood and need to transfusion.
- Short hospital stay.
- Faster recovery and return to normal daily activities.
(With robotic surgery two weeks against 2 months with open
- less scarring.
- The patient has better chance of being cancer-free
(91% with da Vinci against 76% with Open surgery.)
- Nerve-saving and muscles which control bladder and erection.
( Henry Ford Hospital’s website)
There are 300 robots in USA, several in UK, France, Holland, Belgium and other European countries, while 2 only in Canada, one in London, Ont. and one in Montreal.
Are we going to see in the near future the robot in Canadian hospitals performing the safe and efficient prostatectomy with less pain and suffering and short recovery to patients?
Who underwent such a surgery, like Tom, understands the value of the wonderful benefits of robot.