Robotic Prostatectomy Questions and Answers
	What is Robotic Laparoscopic Prostatectomy? This is a minimally invasive laparoscopic procedure performed for early stage (clinically confined) prostate cancer, done by placing pencil thin instruments and a camera through small incisions with the aid of surgeon controlled robot.  A large abdominal incision is avoided and open surgery is avoided.  In this procedure the prostate gland and seminal vesicles are removed intact (in one piece), and in proper candidates, the nerves for sexual function are preserved.  In selected patients, the pelvic lymph nodes that may contain spread of prostate cancer are also removed. A small telescope is placed into the abdomen through the umbilicus and pencil thin instruments are introduced via small incisions in the abdomen.   The operation is performed by the surgeon controlling these microscopic instruments, gently freeing the prostate and seminal vesicles and avoiding trauma to the surrounding tissue. The prostate and seminal vesicles are removed intact (in one piece) and delivered outside the body through the umbilicus. Lymph nodes are similarly removed. The bladder is then attached back to the urethra.  Nerve Sparing Prostatectomy is accurately accomplished to maintain the patient’s pre-surgical level of sexual function and erections. In the hands of experienced surgeons, the state-of-the-art Da-Vinci surgical system has made this procedure extremely precise.  This computer enhanced surgical system is comprised of two components, robotic arms that hold the pencil thin surgical instruments, and a surgeon’s console that controls the robotic arms.  The robot’s surgical instruments move to the direction of the surgeon’s hands, while the surgeon views the operative field through a 3-D TV screen.  The tips of these tiny instruments have six degrees of freedom, allowing for movements like a tiny wrist around the prostate.  Non-robotic surgical instruments (open or laparoscopic) cannot move in this manner and do not have this degree of range of motion and flexibility.  The highly magnified 3-D viewing screen allows the surgeon to feel “immersed” within the patient, allowing for better visualization of the surgical field than open or standard laparoscopic surgery.  There is more precise differentiation between healthy and diseased tissue, thereby making this surgery highly effective in curing prostate cancer.  In effect the surgeon accurately removes the prostate and pelvic lymph nodes, while preserving the vital structures such as the neurovascular bundles responsible for erections and pelvic floor muscles responsible for quick recovery of bladder control. Is Robotic Laparoscopic Prostatectomy experimental? No. This procedure is FDA approved.  Over 50,000 Robotic Prostatecotmies have been performed in the United States in the past 5 yrs.  RLP is the fastest growing field in prostate cancer treatment.  In 2005 340,000 Robotic Prostatectomies were performed.  More and More surgeons are learning how to do this procedure.   Is Robotic Laparsocopic Prostatectomy is proven safe and effective? Yes. Over 120 research articles have been written on Robotic Prostatectomies.  This minimally invasive procedure has been shown to be extremely safe and effective.  Chances of operative complications or side effects have been shown to be minimal.  Robotic Prostatectomy has been shown to be highly effective in removal of prostate cancer. How effective is Robotic Laparoscopic Prostatectomy in removal of cancer? The efficacy of any prostate cancer surgery has to do with positive and negative margins.  Positive margins mean that at least one of the boarders of the prostate, where the surgeon made the cuts to remove the prostate have prostate cancer at the cut edge under microscopic exam.  A positive margin indicates that cancer was possibly left behind in the area or surgery.   Conversely, negative margins mean that all the boarders of the prostate, where the surgeon made the cuts are fee of cancer under microscopic exam. Research has shown that Robotic Prostatectomy has a low positive margin rate and high negative margin rate, meaning that this procedure is highly effective in removal of all the prostate cancer.  Furthermore, the rates of positive and negative margins are the same between open and robotic prostate surgery.  Therefore, Robotic Prostatectomy is highly effective in removal and treatment of prostate cancer. Why is it necessary to be able to feel the prostate in open surgery but not in robotic surgery? In open surgery, the surgeon relies on feeling the prostate and surrounding tissues, because of difficulty in visualizing the vital structures deep in the pelvis.  Since the prostate is located underneath and deep to the pubic bone, the prostate and tissues surrounding it are difficult to see.  Therefore, surgeon has to rely on “feeling” his/her way around the prostate for a successful surgery. In Robotic surgery, the camera can be placed underneath the pubic bone or any other location deep in the pelvis and near the vital structures.  The field of vision is 3-Dimensional and magnified 15 times.  The robotic viewing screen allows for the surgeon to be virtually placed inside the patient’s body.  Since the surgeon’s visualization is far superior in robotic surgery than in open surgery, the need for “feeling the tissues” is a mute point. Do all Urologists perform Robotic Laparoscopic Prostatectomy? No.  Since laparoscopic robotic prostatectomy is only about 7 years old, most urologists have not been trained in this advanced type of surgery.   Consequently, they are unable to offer robotic surgery as a treatment option. What qualifications are important in a surgeon who performs Robotic Laparoscopic Prosatectomy? Qualifications of the surgeon should include experience, excellent results, and a desire to mend a personal relationship filled with compassion and personal attention towards the patient.  It takes a large number of Robotic Prostatectomies before a surgeon would be considered highly experienced and skilled in performing such operations.  A highly qualified surgeon must have done at least 150 Robotic Prostatectomies.  He or She must be willing to share his/her personal results.  Furthermore, as a physician, the surgeon must make a personal relationship with the patient, and not view the patient as another opportunity to do surgery.  A patient with prostate cancer deserves respect, compassion, and personal attention by his doctor.                                                                               Dr. Ramin’s Results                                                                               (Over 500 procedures) Must have excellent oncologic results Negative margin rate           Greater than 85%                 88% Positive margin rate             Less than 15%                     12% Must have excellent reconstructive results Nerve sparing rate:              Greater than 75%                 85% Continence rate:                  Greater than 92%                 97% Must have a low complications rate Transfusion:                         Less than 1%                        ½% Deep Vein Thrombosis:        Less than 1%                        ½% Pulmonary Embolism:           Less than 1%                        ½%         Recto-urethral fistula:           Less than 1%                        0% Bowel injury                          Less than 1%                        ¼% Bladder Neck Contracture    Less than 1%                        ¼% Wound Infection                   Less than 1%                        0% Having performed and taught over 500 robotic prostatectomies, Dr. Ramin’s rates of complications are among the lowest of published and reported series.  His rates of continence, nerve sparing and potency are among the highest.  His oncologic results (negative/positive margins) are among the best results. Is it true that the surgeon can see better with robotic surgery than open surgery for prostate cancer? Yes.  The field of visualization is better with robotic surgery for three reasons. 1.        The location of the prostate makes it difficult to visualize in open surgery.  The prostate is located deep in the pelvis, underneath the arch of the pubic bone, which is very wide.  In open surgery, a long incision is made to ease the field of visualization.  However, the surgeon is still forced to rotate his/her head in order to see underneath the arch of the pubic bone.   The urethra and the muscles that wrap around the urethra are even deeper under the arch of pubic bone and not seen very well.  This increases the chances of injury to these structures and causing post operative incontinence.  On the other hand, the robotic telescope which is placed in the abdomen can be moved anywhere within the vicinity of the prostate and the pelvis.  Therefore, one can see the prostate and other vital organs much better.  In fact one can even see underneath the prostate, which is not a possibility with open surgery.  The muscles that wrap around the urethra, the urethra itself, and the nerves that control erection are visualized much better, making this method a more accurate surgery.  It is important to note that an experienced surgeon in robotic prostatectomy can better understand the anatomy and the vital structures under vision than a surgeon that has recently started to perform robotic surgery. 2.        There is less blood loss in robotic laparoscopic prostatectomy as compared to open surgery.  The average blood loss in open surgery is around 500 to 1000 cc’s (16 to 32 ounces).  The average blood loss in robotic laparoscopic surgery is 150 to 250 cc (3 to 8 ounces).  The chance of needing a blood transfusion with robotic prostatectomy is less than 1%, while it is about 10% -15% in open surgery.  Since less blood accumulates around the prostate in robotic laparoscopic surgery, the field of vision is cleaner and better visualized. 3.        Field of surgery is highly magnified in robotic surgery.  The 3- dimensional robotic telescope (laparoscope) magnifies the field of surgery 15 times greater than open surgery.  This makes the field of surgery even more accurate and better seen than open surgery.  To compensate for this difference, some open surgeons use “surgical loops” or magnifying lenses during open radical prostatectomy.  These loops usually magnify the field by two to five times, still not as high as robotic surgery.  Field magnification can help the surgeon dissect the vital structures such as neurovascular bundles (for erection) more accurately. Can nerve sparing surgery be done with Robotic Laparoscopic Prostatectomy? Yes.  Nerve sparing surgery can be done with a high degree of accuracy using the Da-Vinci Robotic Surgery system.  This system allows for accurate nerve dissection for many reasons.  The field of surgery is magnified 15 times, making it easier to recognize the small, delicate neurovascular bundles.  Also, the tips of the microscopic instrument can turn, swivel, bend, and rotate, just like the human wrist. This is known as the “Endowrist Technology”.  The ability to have wrist like movement around the prostate gland allows the surgeon to dissect the neurovascular bundles more accurately.  In experienced hands, nerve sparing surgery can be successful in as much as 90% of men. What are the advantages of Robotic Laparoscopic Surgery? 1.  Faster recovery 2.  Very little pain         Patient can walk the same day         Patient may exercise such as playing golf or tennis within one week         Patient may drive in 2 days         Faster return to bladder control         Less incontinence         Excellent chances for return of erections         Earlier removal of urinary catheter:         5 days after surgery versus 2 – 3 weeks with open surgery 3.  Very little bleeding: less than 1% chance of transfusion         Not Disfiguring: incisions are very smal         Excellent chance of prostate cancer cure         Very small rates of positive margins What are important factors in choosing a doctor? 1.        Must be a Board Certified Urologist 2.        Fellowship trained in minimally invasive surgery 3.        Fellowship trained in Oncologic (cancer) surgery for the urinary tract 4.        Must have done at least 200 cases 5.        Must be willing to provide patients with personal results on               a.        Rates of continence               b.        Rates of potency               c.        Rates of negative margins               d.        Complication rates 6.        Must work at a center of excellence and robotic surgical team 7.        Must have a skilled assistant surgeon 8.        Must be able to provide personalized attention to patients