Robotic Surgery for Prostate Cancer: A Realistic Approach to Getting Started “The Evolution of a Robotic Surgeon” Douglas S. Scherr, M.D. Clinical Director, Urologic Oncology Weill Medical College of Cornell University

Is The Disease Important?

U.S. Incidence and Mortality of Prostate Cancer Surveillance, Epidemiology and End Results (SEER) Data

Natural History The Disorder “Prostate Cancer” Natural history understood: -To die of prostate cancer or die with prostate cancer? -Conservative Treatment: a.) Gleason 2-4: 4-7% chance of death b.) Gleason 6: 18-30% chance of death c.) Gleason 8-10: 60-80% chance of death** Frankel et al. Lancet, 361: 1122, March 2003 **Albertsen et al., JAMA, 280: 975, 1998

Progression-free probability by risk group Intermediate risk Progression-free probability by risk group Low risk High risk D’Amico et al JAMA 280:969-74, 1998

Cancer-specific mortality Swedish randomized trial: Surgery v. Watchful waiting Surgical excision alters the natural history of prostate cancer, reducing metastases and cancer-specific mortality by 50% at 8 years. Distant metastases Cancer-specific mortality WW 27.3% WW 13.6% RP 13.4% RP 7.1% From: Holmberg L, Bill-Axelson A, Helgesen F, et al. A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer. N Engl J Med, 2002;347:781-789.

DEMOGRAPHICS OF AGING More and more doctors will be faced with how to treat our aging population the older population will burgeon between the years 2010 and 2030 when the "baby boom" generation reaches age 65. This will more than double the 65+ population by the year 2030 compared to 2000 numbers Source: Administration on Aging (www.aoa.gov)

DEMOGRAPHICS OF AGING Over 2.0 million persons celebrated their 65th birthday in 2000 (5,574 per day). In the same year, about 1.8 million persons 65 or older died, resulting in an annual net increase of approximately 238,000 (650 per day). Source: Administration on Aging (www.aoa.gov)

DEMOGRAPHICS OF AGING By 2030, there will be over 70 million older persons, more than twice their number in 2000. People 65+ were 12.4% of the pop. in 2000 but are expected to grow to be 20% of the pop. by 2030. Source: Administration on Aging (www.aoa.gov)

Life Expectancy and Ten Year Survival A. Life expectancy by age for all men. At age 70 life expectancy is 11 yrs B. Ten year survival by patient age. At 70 52% of men will survive 10 years Corral DA and Bahnson RR. J Urol. 1994 May;151(5):1326-9

Improved Treatment Strategies Endorectal MRI Nomograms Nerve Grafting

Improved Cancer Detection Through Imaging Endorectal MRI/Spectroscopy Potential improvement over ultrasound Biochemical gradients to decipher cancer from benign Remains investigational Possible role in high risk patients

* * * Image 8 I 54.44 mm Image 9 I 57.56 mm vc sc vc H H H H H H H H * * * Image 8 I 54.44 mm Image 9 I 57.56 mm H H H H H H H H H H H H H H H H H H vc sc vc H H H H H H H H

Treatment Stratifications Allow for improvement in patient understanding More objective in guiding treatment decisions Less physician bias

Palm Pilot Nomogram Software WE DEVELOPED A TOOL FOR THE PALM PILOT. WRITTEN BY PAUL FEARN, A MEMBER OF OUR GROUP, THIS APPLICATION COMPUTES THE NOMOGRAM PREDICTIONS OF OUR PREOPERATIVE, POSTOPERATIVE, AND PATHOLOGIC STAGING TABLES. THE USER SELECTS OR WRITES IN VALUES AND PRESSES A BUTTOM TO COMPUTE THE PREDICTIONS, WHICH ARE RETURNED AS CONFIDENCE INTERVALS. THIS APPLICATION IS IN USE AT SEVERAL ACADEMIC UROLOGIC CENTERS THROUGHOUT THE COUNTRY. WE PLAN TO ADD OTHER TREATMENT MODALITIES TO IT SOON, SUCH AS BRACHYTHERAPY AND RADIATION THERAPY. Includes pretreatment and postoperative predictions. Uses published nomograms in prostate cancer.

Technical Improvements in Surgery Nerve Grafts Cavernosal nerves necessary for post-operative erectile functions In advanced disease, nerves may need to be resected to obtain a negative margin Sural nerve or genitofemoral nerve serve as sources of nerve grafts in this setting

What’s Next Improvements in Surgical Technique have Stagnated Re-birth in Perineal Prostatectomy

Robotic Prostatectomy

Da Vinci Instrumentation

da Vinci System: 3-D vision Stereoscopic design with two 3-chip cameras 75% better resolution than any imaging system ‘Open’ surgery orientation

da Vinci System: Endowrist Technology 6 Degrees of freedom Surgical hand movements are transposed to the instrument tips Ability to scale motion

History Of Laparoscopic Surgery Guillonneau and Vallancien – Montsouris Technique “If this laparoscopic procedure is shown to be equivalent or better, it may replace open retropubic radical prostatectomy.” June 2000 Guillonneau and Vallancien, J Urol, 163: 1643, 2000

Enhances Laparoscopy Eliminates Counter-intuitive motion Instrument tremor Provides Improved ergonomics Hand / eye alignment Transforms 2-D vision to true 3-D 4 DOF instruments to 6 DOF (greater endoscopic dexterity)

Disadvantages Loss of tactile feedback Set-up time Surgeon away from OR table Conversion Communication Limitation of instrumentation Cost

Robotic Assisted Laparoscopic Urology Extirpative Reconstructive Pyeloplasty Birch Procedure Colposuspension Cyst Marsupilization Varicocelectomy Nephrectomy Partial Nephrectomy Prostatectomy Adrenalectomy Intra-abdominal orchiectomy RPLND/PLND

Robotic Assisted Laparoscopic Urology Extirpative Reconstructive Pyeloplasty Prostatectomy Partial Nephrectomy RPLND

Ureteral spatulation

Anastomosis

Ureteral stent

Functional Outcome: Robotic Prostatectomy vs. Radical Retropubic Prostatectomy Continence Erections Intercourse Tewari et al. BJU Int. 92, 205-210, 2003

Comparison to the Gold Standard

The European Experience Cathelineau et al. Urol Clin NA, 31: 693-699, 2004

Further Comparison

The Robotic Experience Worldwide

Patient Positioning

Port Placement 12mm 5mm 8cm 9cm 12mm U 5mm Davinci Davjnci

Entering the Space of Retzius Incise median umbilical ligaments Drop bladder Expose endopelvic fascia Adequate exposure/mobilization facilitates dissection of prostate base/node dissection

Endopelvic Fascia/Dorsal Vein Begin lateral to puboprostatic ligament and medial to levator ani Critical in facilitating apical dissection 80% of prostate cancer comes within 8mm of prostatic apex Place DVC stitch distal to prostatic apex

Bladder Neck/Seminal Vesicles Biologic significance of + BN margin well documented Wide excision necessary Send frozen section to confirm absence of any prostatic tissue Guide to intraoperative decisions: a.) site specific biopsy labeling b.) DRE c.) endorectal MRI Inspect for median lobe Compete removal of SV necessary Judicious use of electrocautery at SV tip Proper dissection of SV sets up posterior plane

Pedicles/Nerve Sparing Begin posterior dissection beneath the posterior layer of Denonviller’s Fascia 25% of men with palpable nodule on DRE will have ECE posteriorly Pedicles taken with clips Antegrade nerve sparing

Urethral Incision/Apical Dissection Incise DVC distal to prostatic apex Place 2nd stitch into DVC if necessary Avoid distal urethral dissection – maintain maximal functional urethral length

Anastamosis Running suture with 2.0 monocryl

Video Footage

Results of First 50 Oncologic: Pos. Margin Rate: 6/50 (12%) Continence: -97% of catheters removed at 7 days -3 patients with high JP output -86% of patients with <1 pad at 6 weeks -0% patients with bladder neck contracture Potency: Too early to characterize Post operative Complications: -one patient required take back for incarcerated hernia -no blood transfusions -mean operative time at 238 minutes -72% of patients discharged < 24 hours

Urology Gold Journal, 4/03 Robotic Radical Prostatectomy And The Vattikuti Urology Institute Technique p.15-20 “Robotic assistance offers an open surgeon sophisticated tools to perform complex laparoscopic surgery. A technologically advanced ergonomic operation is achieved because of 3-dimensional visualization; wristed instrumentation; intuitive, finger- controlled movements; and a comfortable seated position for the surgeon”

82% Had Return of Sexual Function 64% Had Sexual Intercourse Title Urology Gold Journal, 4/03 Robotic Radical Prostatectomy And The Vattikuti Urology Institute Technique p.15-20 Data Collection: First 200 patients ff Blood Transfusions: Avg. Operative Time: 160 min. Positive Margins: 6% Avg. Blood Loss: 153 ml. Continence at 6 mos.: 96% Avg. Catheterization time: 7 days Avg. Hospital Stay: 1.2 days Potency (men  60 yr) at 6 mos: 82% Had Return of Sexual Function 64% Had Sexual Intercourse Patients discharged Within 24 hours: 93%

da Vinci Benefits: The Patient Shorter hospital stay Less post operative pain Less risk of infection Less blood loss and transfusions Less scarring & improved cosmesis Faster recovery and return to normal daily activities Dave Kinsey, Robotic Prostatectomy Patient

Is It Any Better? Comparable results can be achieved Learning curve reasonable Long term results await Robotic surgery will have a role as long as prostatectomies exist