1. Robotic-assisted Laparoscopic Prostatectomy
Blake W. Moore, MD
Virginia Urology

2. Prostate Cancer
Prostate cancer (PCa) is the most frequently diagnosed cancer in American men
Lifetime risk of PCa diagnosis is ~16%
Screening has profoundly affected the diagnosis and treatment of PCa and enabled physicians to detect prostate tumors while they are still potentially curable.
Why is screening important?
Lifetime risk of having prostate cancer is around 1 in 6 men and closer to 1 in 4 for african american men
Screening has definitely led to earlier diagnosis and treatment with improved outcomes

3. Prostate Cancer
Screening led to a significant increase in diagnosis of prostate cancer in the 90’s with improvement in deaths thereafter

4. Surgical Treatment
Prostatectomy overall is a safe operation with very low risk of major operative complications
It is the gold standard of treatment for PCa
The downside of surgical treatment for PCa is the potential post-operative side effects
The two most bothersome potential side effects of prostatectomy are incontinence and erectile dysfunction
Despite advances in surgical technique, rates of incontinence following prostatectomy still range from 5-10% and rates of erectile dysfunction range from %

5. Prostate Anatomy
The prostate is located next to the bladder with the urethra running through it

6. Prostate Anatomy
During surgery, we remove the prostate and reconnect the plumming to allow the bladder to drain

7. Prostate Anatomy

8. Prostate Anatomy

9. Robotic vs. Open Surgery
Majority of cases now performed robotically rather than open (>85%)
Potential benefits include improved visualization, more precise movements, loss of tremor, improved ergonomics for the surgeon, decreased blood loss, faster recovery compared to open surgery (less pain)
Based on multiple studies, may have faster recovery of continence and overall improved ED and continence
Potential disadvantages include lack of tactile sensation, limitation of movements, and cost (increases cost by $1-5K)
? Prior surgery, increased patient weight, high grade cancer

10. Open Procedure

11. Robotic Procedure

13. Surgeon’s Console
The surgeon sits at the console and controls the robot from across the room

14. The Patient-side Cart
There are two ways to do this operations, open approach and robotically. I am a robotic surgeon so I’ll talk a little more about that option.

15. Endowristed Instruments
The console has hand grips that give you a full range of motion while you operate for more precise movements

16. Robotic Prostatectomy
Steps:
Drop bladder from anterior abdomen
Divide prostate from bladder neck
Divide vascular pedicles of prostate using clips
Detach seminal vesicles
Depending on disease: Laterally separate prostate from neurovascular bundle (nerve sparing) Vs. wide resection [athermal technique]
Separate the dorsal venous complex from above the prostate & suture closure DVC
Divide urethra from prostate
[Optional] Pelvic lymphadenectomy
Urethro-vesical anastamosis
Bag and extract specimen

17. Robotic Prostatectomy
Basics
Complete removal of prostate and seminal vesicles
Minimize use of electrocautery (thermal energy) posterio-laterally near NVB
Minimize trauma to the urethra and pelvic floor
Maximize urethral length
Watertight urethro-vesical anastamosis (short catheterization period)
Continues to be one of the most technically demanding urologic operations
Patient functional and oncologic outcomes, complications are closely tied to surgeon technical abilities and experience

18. What to expect post-op
Majority of patients (>90%) leave after one night
5-7 days with a foley catheter
No heavy lifting for 4 weeks
Discuss pathology at 1 week follow-up when catheter is removed
First PSA check at 4-6 weeks after surgery

20. Thank you
I typically see it during inspiration.