1. 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

3. Is The Disease Important?

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

5. 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: % chance of death b.) Gleason 6: % chance of death c.) Gleason 8-10: % chance of death**
Frankel et al. Lancet, 361: 1122, March 2003
**Albertsen et al., JAMA, 280: 975, 1998

6. 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

7. 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:

8. 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 (

9. 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 (

10. 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 (

11. 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 May;151(5):1326-9

12. Improved Treatment Strategies
Endorectal MRI
Nomograms
Nerve Grafting

13. 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

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

16. 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.

17. 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

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

19. Robotic Prostatectomy

20. Da Vinci Instrumentation

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

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

23. 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

24. 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)

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

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

27. Robotic Assisted Laparoscopic Urology
Extirpative Reconstructive
Pyeloplasty
Prostatectomy
Partial Nephrectomy
RPLND

28. Ureteral spatulation

29. Anastomosis

30. Ureteral stent

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

32. Comparison to the Gold Standard

33. The European Experience
Cathelineau et al. Urol Clin NA, 31: , 2004

34. Further Comparison

35. The Robotic Experience Worldwide

36. Patient Positioning

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

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

39. 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

40. 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

41. 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

42. 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

43. Anastamosis
Running suture with 2.0 monocryl

44. Video Footage

45. 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

46. 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”

47. 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%

48. 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

49. 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