Surgery: Prostate Cancer Surgery

Benchmarks sat down with Peter Pinto, M.D., director of the Urologic Oncology Fellowship Program in the Urologic Oncology Branch, part of NCI’s Center for Cancer Research, to discuss the details of a robotic prostatectomy.

Benchmarks – Briefly describe what a robotic prostatectomy is?

Dr. Peter Pinto: When you perform prostate surgery, the goal is to remove the cancerous prostate and ensure that none of the cancer is left behind. In addition, the surgeon aims to keep intact the nerves that maintain a man’s potency while reattaching the bladder to the urethra to maintain urinary continence. A robotic radical prostatectomy is a surgeon-directed robotic procedure where a machine called the da Vinci® robot is used to assist in removing the cancerous prostate and surrounding lymph nodes. This process is a minimally invasive approach to prostate cancer surgery.

Benchmarks - What is the difference between robotic surgery, regular open surgery and laparoscopic surgery?

Dr. Peter Pinto: Robotic surgery is done in the same fashion as open surgical removal. The difference is that what originally required a large incision (from the belly button down to the pubic bone), now only requires 4 to 6 small incisions, each about 5 mm-12 mm in length. These incisions allow instruments to pass through ports (a hollow cylinder through which instruments can pass), keeping the surgeon’s hands outside the patient.

Prior to the advent of this machine, surgeons like myself were performing these procedures laparoscopically. Laparoscopic radical prostatectomy is a less invasive approach to open surgery and uses the same ports to pass instruments as the robotic platform. During laparoscopy, the surgeon’s hands are physically attached to the instruments that go through the ports and the instruments themselves are limited in their range of motion. In addition, the laparoscopic camera that is placed inside the abdomen to visualize the prostate displays the image onto a screen that is two dimensional, so the surgeon has to overcome the lack of depth in the operation.

In the robotic platform, which has become so popular, the surgeon who would normally have his hands either inside the patient or attached to the instruments, is now moved back to a console which is most often in the operating room next to the patient. This console has two controls or masters for both hands that allows me to manipulate the instruments that are inside the patient through a robotic interface. Moreover, the instruments that go through the ports are wristed, meaning more degrees of freedom and allowing the movement of the instrument to be similar to that of the human wrist, creating better angles for surgery. Also, when you look through the console at the surgical field it gives you a magnified three dimensional image, therefore you can get the same depth as if you were seeing the image with your own eyes.

The type of instruments used in robotic surgery are the same ones I use in open surgery. We can use scissors, pick up or forceps, apply clips, suture and tie knots. The robotic platform emulates the open technique, but also removes surgical tremor and can scale down motion. In the open and laparoscopic platforms, if a surgeon’s hands shake slightly, movement of the instruments can be effected. However, with the surgical robot, those extremely small movements are not translated into the instruments.

Benchmarks – Are surgeries more successful using this technique, compared to open or laparoscopic surgery?

Dr. Peter Pinto: I would say the answer to that is no, even though it is still debatable. There are some papers that support the stance that the robotic platform makes the operation more successful and then there are other papers that conclude that this method is equivalent or actually makes things worse. This completely depends on who is using the machine, their comfort level doing robotic surgery and also their knowledge of the anatomy of the prostate and its surrounding structures. At our institution we have had great success using the robotic platform to perform prostate cancer surgery. Using this machine I am able to preserve a man’s sexual function and urinary control while removing his cancer. Since I started performing robotic surgery in 2002, I now recommend this platform to my patients over open or laparoscopic methods.

Benchmarks – Are there any safety issues concerning this technique?

Dr. Peter Pinto: There are. If the robotic platform is arguably no different than open surgery, then why has it become so popular and is safety one of the reasons? First of all, the robotic platform itself is an alternative to open surgery and because it is less invasive many patients have chosen this as an option for their treatment. Additionally, robotic surgery, like laparoscopic surgery, uses pneumoperitoneum; a method which uses gas ( like carbon dioxide) to create space that allows us to access to the abdominal cavity. That extra pressure permits us to operate in a less bloody field–so our patients lose less blood with the robotic procedure. This, along with this being a less invasive method, has made robotic prostatectomy a more popular alternative to open surgery.

There have been some safety concerns that the robot would go ‘out of control,’ meaning that the machine itself would act independently of the surgeon and that is incorrect. The da Vinci® system is a surgeon directed robot, so all movements are initiated by the surgeon. There is no automation or semi-automation, so the sci-fi images of machines working independently of a human interface are not the case. The only injuries that can occur using this technique would be if the surgeon incorrectly applies the instruments to a certain part of the body. Like any piece of equipment, if the machine were to break down, the robotic platform can mechanically come to a halt. The safety features of the machine then allow it to stop so it cannot be used any further. In those cases most hospitals have additional machines available, or the case can be completed laparoscopically or open, if the surgeon has those skill sets.

Benchmarks – Does this technique reduce recovery time, surgery time, or time in the hospital?

Dr. Peter Pinto: Since it is less invasive, the robotic technique allows the patient to recover faster, meaning that the time it takes to heal from a large open incision is longer than it is to heal small 5-8 mm incisions in the abdomen.

In regard to the surgery itself, part of the operation is removing the prostate, the surrounding lymph nodes where cancer can spread, sparing the nerves that allow a man to maintain his potency and reestablishing continuity of the bladder to the urethra to allow return of full urinary control . This means taking out the prostate and suturing the bladder back to the urethra so the man can stay dry. The surgery requires a catheter to be placed across the suture line between the urethra and the bladder, which allows that area to heal. Many institutions allow that healing phase to occur over 7-14 days, meaning the catheter stays in that long. In our institution, because suturing with the robot is very accurate and the bladder to the urethra is closed in a water tight fashion, we can remove the catheter in 3-5 days.

Regarding hospital stay, men who have open surgery can leave the hospital within a day or two after their procedure. Most men stay two days, but regardless, they do well with the open incision. In robotic surgery most men go home after a day. There are some individuals who go home the same day after a robotic prostatectomy but the time for hospital discharge, if anything, is only slightly shorter with the robotic platform. There is no significant difference here. One can argue that the benefits to the patient are long term, such as getting back to work and physical activities that the patient deems important. Even though there is still a debate, the perception [by our patients ] is that with the robotic platform you can get back to your normal, daily activities a few days to weeks earlier compared to the open approach.

Benchmarks – Is every patient a candidate for robotic surgery?

Just like the criteria for open surgery and radiation, there are set criteria for robotic surgery. These depend on the surgeon’s skill set-their comfort with doing the procedure. Almost every candidate has the opportunity to undergo surgery, whether it be open, laparoscopic or robotic. Body size, prostate size, previous surgeries all weigh as important factors in both open or robotic–neither one more important than the other. At our institution all men who are healthy enough to undergo open surgery can have a robotic procedure.

Benchmarks – Are patients ever intimidated by the robot?

I had the good fortune of taking care of an active military person with prostate cancer, whose former training was in the air force. He used to fly F-14′s and F-18′s. He said that in the older airplanes, you could actually have your hand on the throttle and, by moving it, feel the plane move, and you could control it directly. But, the new versions that he flies are interfaced through buttons and electronics, and you don’t have that same hands-on feel. I was explaining to him the difference between laparoscopic prostate surgery and robotic prostate surgery–I was operating on him many years ago when I was still doing both – and his first response to me was “I prefer not to have the robot, because I want to have your hands directly on the instruments, through the ports – I want you to do this laparoscopically”. Because of his experience, he felt uneasy having something between the surgeon and his body. After I explained to him that, with the robotic platform, a lot of the maneuvering that I perform laparoscopically is arguably better, he agreed to the robotic procedure and actually had that done. His robotic surgery went well and he had full return of urinary control and sexual function while remaining cancer free today.

Benchmarks – What is the training required to operate the da Vinci® Robot?

Dr. Peter Pinto: Most academic centers and hospitals where residents and fellows are currently working have robotic surgery as part of their training. We have about four fellows a year that train with us (they stay with us for two or three years) and they are learning to use the robot. Therefore when these physicians leave their fellowship they are often at least familiar with the robotic platform and can use the machine. Urologic surgeons who were never exposed to laparoscopic or robotic techniques have to take courses, many of which I help teach, and go on to proctored animal training sessions to become proficient with the system. They are usually weekend or four to five day courses. Additionally, these surgeons have mentors when they perform their first few robotic surgeries to allow them to get comfortable with the techniques and have someone to oversee the procedure. I think as time goes by, this will become less of a concern, since more and more of our trainees are becoming familiar with this platform. For me personally, I had the fortune of learning how to use laparoscopic and robotic machines in my training when I was at Johns Hopkins, so it was natural that I used it when I came to NCI.

Benchmarks – Do you think robotic surgery will eventually replace open surgery?

Dr. Peter Pinto: I think that the number of robotic surgical cases will continue to increase and we will see more urologic surgeons feel comfortable doing prostate surgery robotically instead of open, but keeping in mind the points mentioned earlier , such as machine breakdown, patient factors, etc; it may take a long time for us to completely replace open surgery. I think there will always be a role for open surgery but more and more cases, as the years go on, will be performed robotically.

Benchmarks – Technology has come a long way–from open to laparoscopic and now on to robotic surgery; do you think there will be more advances or a new and improved version of the da Vinci® robot?

Dr. Peter Pinto: I agree–technology continues to advance. In our everyday lives we see great strides made in computers and technology that assists us in the workplace. I imagine that has to happen in the field of surgery as well. The original robotic da Vinci® system was replaced by another more advanced system. The new robotic system is similar to the old, with a few minor modifications. Just as we have seen our computers go from very large desktops to notebooks and now handheld devices, I am sure we will see robotic surgery continue to get smaller and better. We may even see other companies get involved and provide platforms for robot assisted surgeries.

Benchmarks – The field of telesurgery is also continually advancing. Do you think eventually you will be able to do surgeries across the country or the world?

Dr. Peter Pinto: There have been reported cases of using robotic surgery where the surgeon is on the console in one room and the patient is elsewhere. That has been done for gallbladder surgery where the surgeon was in New York and the patient was actually in France. Telesurgery is a little bit different than robotic surgery in that you have to overcome the delay between what the surgeon sees [as in the instrument moving in the patient] vs. the time it actually happens in the remote location. Also, it is important to make sure the communication line between the surgeon and the patient is secure, especially if the patient is cross country. But telemedicine for diagnostic purposes, such as viewing CT scans and MRIs, where surgeons are in different locations, is continuing to expand and I can imagine with natural progression that platform will move on to surgical applications like telesurgery.

Animation/Video

Doctors performing a radical prostatcetomy

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Close-up of surgical robot assisting with radical prostatecomy

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Close-up of surgical robot assisting with radical prostatecomy

Photos/Stills

Peter Pinto, M.D., Staff Clinician at the Urologic Oncology Branch, National Cancer Institute, NCI.Wide angle view of the surgical suite where doctors are using a surgical robot called the "da Vinci" to help remove the prostate and lymphnodes.This surgical technique, robot assisted surgery and laparoscopic prostatectomy therapies has the potential for fewer side effects.

Schematic layout of operating room robotic prostate surgery/ Layout drawing of surgery suite from a bird's-eye perspective with positions of robot, screens, surgery table, instrument console, noted

Surgery: Prostate Cancer Surgery

Laparoscopic surgeries, in which a surgeon performs procedures through small incisions in the abdomen wall, have led to less invasive cancer surgeries with decreased pain and faster recovery times for patients. Because of the reduced size of the incisions, hospital stays are often shorter, with some patients even able to go home the same day.

During laparoscopic surgery, several slim, cylindrical ports, called trocars, are inserted into the patient’s abdomen through small incisions. Long thin instruments, including a lighted camera called a laparoscope, are passed through the trocars and into the abdomen. These instruments include scissors, graspers, and other instruments modeled after the typical instruments used in traditional open procedures.

However, because the surgeon does not have direct contact with the patient’s organs, and instead relies on a camera and monitor to view inside the body, there are certain limitations to laparoscopic surgery. For one, the surgeon is limited by the range of motion of the instruments. Unlike the human hand and wrist, the laparoscopic tools can only move in certain directions, limiting the types of actions that can be performed. In addition, because the surgeons are relying upon a two-dimensional screen displaying a mirror image of the instruments and the patient’s anatomy, there is a loss of depth perception, and an impact on hand-eye coordination. A new alternative to laparoscopic surgery, which is increasing in popularity, is robot-assisted surgery.

Surgery robots, which have been around in one form or another since the mid-1980s, can help surgeons overcome many of the challenges presented by the open or laparoscopic surgical styles, or platforms. Currently, the most successful and widely used surgical robot is the da Vinci system, developed by Intuitive Surgical in Sunnyvale, CA. The da Vinci system is similar to the laparoscopic surgical platform in that long, thin instruments resembling traditional surgical instruments (Figure 1) are inserted into the patient through trocars, allowing for smaller incisions, less pain, shorter hospital stays, and faster healing times. However, the style of the instruments and the way in which they are controlled are very different.

As shown in Figure 2, the da Vinci system has three main parts: the console, where the surgeon sits to operate the robot; the patient side cart, which is positioned over the operating table and contains the arms that hold the instruments; and a third cart which provides a view of the surgery for the other doctors and nurses in the room. When the surgeon looks into the console, he sees a three-dimensional view of the patients internal organs and the surgical instruments, similar to what he would see when operating in an open platform. Unlike when operating in the open platform, however, the viewer can magnify the image, using a high-resolution endoscopic camera. The console gives the surgeon more control over his own field of vision than is normally available using a laparoscopic platform, and there is no mirroring. In addition, because of its ergonomic design, the surgeon is not required to stand in awkward positions, for long hours, while using the long instruments required for laparoscopic surgery.

The arms of the robot on the patient cart and the individual instruments are operated by hand controls on the surgeon’s console (Figure 3) and foot pedals. Along with the magnification, the surgeon has the option of changing the scale of motion, so that the robot will reduce the amount of movement by a certain percentage. For example, if the surgeon moves his hand two inches, the robot can be set so that it will only move one inch. This is particularly useful for procedures needing extremely fine movements. The surgical robot also removes surgical tremor. In the open and laparoscopic platforms, if a surgeon’s hands shake slightly, that tremor will affect the instruments. However, with the surgical robot, those extremely small movements are not translated into the instruments.

Perhaps the largest advantage of the robot is in the design of the instruments. Unlike most laparoscopic instruments which can only move in certain directions, the da Vinci’s instruments are wristed. The surgeon can manipulate the instruments in multiple directions, giving the surgeon freedom similar to that of an open platform.

Students, as well as experienced surgeons who are new to the robotic platform, often learn on training machines that use models and inanimate objects to familiarize the trainee with the console and the use of the hand controls and foot pedals. Students can perform procedures, such as suturing and grasping, on foam circles and cones in order to become accustomed to the interface. This, of course, does not truly prepare the student for viewing anatomy through the console, so there are companies working to develop virtual reality models for the robot, to bridge the gap between operating on inanimate objects and operating on patients.

Robotic surgery and the da Vinci system are not without disadvantages. The largest disadvantage of robotic surgery is its cost. Currently, systems cost over $1 million and maintenance costs can be substantial. In addition, unlike operating in an open platform, the surgeon cannot feel the organs. When using the instruments to touch the organs, there is no tactile feedback, so surgeons must be extra vigilant about where each instrument is, in order to avoid damage to the organs. Finally, the da Vinci requires use of instruments that are manufactured only by Intuitive Surgical, Inc. If a procedure requires an instrument that is not currently available through the manufacturer, that part of the procedure must be completed by an assistant.

Surgical robots have been used in treating several cancers, including cancers of the lung, breast, gastrointestinal tract, kidneys, colon, rectum, bladder, prostate, testis, cervix, uterus, ovary, and tongue. The ability of this platform to blend benefits of both open and laparoscopic platforms has shown particular potential in the area of kidney cancer.

Application to Kidney Cancer

Peter A. Pinto, M.D., fellowship program director in the NCI’s Urologic Oncology branch, and colleagues, are pioneers in the use of robotic surgery for minimally invasive, nephron-sparing surgery, also called partial nephrectomy. While Dr. Pinto has been using the robot for radical prostatectomy (removal of the prostate) for quite some time, the use of the robot for partial nephrectomy is a new area of research.

The NCI Physician’s Data Query System lists several surgical treatment options for stage I renal cancer, including simple nephrectomy (removal of the kidney), radical nephrectomy (removal of kidney and surrounding tissues, glands and lymph nodes) and partial nephrectomy (removal of the tumor within the kidney and surrounding tissues, leaving the rest of the kidney intact). “Renal tumors that are less than or equal to 4 cm in size can be removed without removing the whole kidney – and you get the same cancer outcomes from a partial nephrectomy as you would if you took out the whole kidney,” explained Pinto. “But by leaving the healthy kidney behind, you decrease the risk of the patient going into renal insufficiency or renal failure… [which] can lead to heart problems… and shorten a person’s life.” However, in 2006, a study from the University of Michigan Medical Center reported that the use of partial nephrectomy to treat small, newly diagnosed kidney tumors was a vastly underutilized option across the country. In addition, at a meeting of the American Society of Clinical Oncology in 2008, researchers at the New York University School of Medicine reported that partial nephrectomy was offered as an option to only one out of every five patients who may have been eligible.

According to Pinto, one reason for this may be the difficulty of the procedure:

“In kidney surgery, the incision is… in the upper abdomen, often above the umbilicus [belly button]. It usually cuts through muscle, and occasionally cuts into the rib cage and you may have to remove part of the eleventh or twelfth rib, to get to the kidney. Those incisions are quite painful; and, unlike prostate surgery – which utilizes an open midline incision below the belly button and patients can go home in one or two days – open flank incisions, or kidney operations, often require a hospital stay of 3- 5 days or even a week. Laparoscopic kidney surgery has really improved, for the betterment of our patients, the recovery and pain and suffering from surgery, to the extent that laparoscopic renal surgery is now probably replacing open surgery for many of the smaller lesions.”

Pinto, along with his colleagues, W. Marston Linehan, M.D., Gennady Bratslavasky, M.D., and Craig Rodgers, M.D., in NCI’s Urologic Oncology Branch set out to apply the robotic platform to this issue – to overcome the difficulties involved in trying to complete a partial nephrectomy through a laparoscopic platform and to develop a way to educate other surgeons on this new found technique. In a 2007 paper, they demonstrated that, because of the wristed instruments, it was possible to complete all of the complex suturing and manipulation needed to achieve a minimally invasive partial nephrectomy using a robotic platform. “What we found was, in these patients who may have undergone a complete nephrectomy laparoscopically, or an open partial nephrectomy, we were able to successfully perform a robotic-assisted partial nephrectomy,” said Pinto. “They had their tumors removed, we were able to spare the kidney, we did it through minimally invasive small incisions, and they were able to go home very quickly.” They subsequently created an educational video for surgeons on this technique, and have been invited to several urological conferences to discuss these issues and train other surgeons.

While prostate surgery remains the most common cancer-related application of the robotic platform, many other fields within oncology have begun to explore its use, including gynecologic oncology. As robotic-assisted surgery rapidly develops and increases in popularity in the field of surgical oncology, Pinto stresses the importance of educating the next generation of surgeons in all three surgical platforms:

“I believe that most residency and fellowship programs do an excellent job in providing cases to our trainees that require they learn an open surgery skill set, a laparoscopic skill set, and a robotic skill set because when you are depending on technology, if it is not clear that it is going to work during the entire case you may have to move on to a different platform, whether it’s a laparoscopic platform or an open surgical platform…
“But I can see a time in the future when robotic assisted instruments become so common in the hospital, and there is more than one instrument available, that if the machine broke, you could just bring another one in during that procedure. But that day hasn’t come yet. Therefore, as a fellowship director here at NCI, I feel it necessary to train my fellows in all three aspects of surgery, which includes open, laparoscopic, and robotic.”

Works Cited

Miller, David C, John M Hollingsworth, Khaled S Hafez, Stephanie Daignault, and Brent K Hollenbeck. “Partial Nephrectomy for Small Renal Masses: an Emerging Quality of Care Concern?” The Journal of Urology, 2006: 853-858.

National Cancer Institute. “Partial Nephrectomy to Treat Small Renal Tumors Underused.” NCI Cancer Bulletin, February 19, 2008: 3-4.

National Cancer Institute. Renal Cell Cancer Treatment (PDQ®). May 22, 2008. http://www.cancer.gov/cancertopics/pdq/treatment/renalcell/ (accessed March 14, 2009).

Novakovic, Kristian R, and Peter A Pinto. “Robotic Surgery.” In DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology, Eighth Edition, by Vincent T DeVita, Theodore S Lawrence and Steven A Rosenberg, 3021-3030. Philadelphia: Lippincott Williams & Wilkins, 2008.

Rogers, Craig G, Amar Singh, Adam M Blatt, W Marston Linehan, and Peter A Pinto. “Robotic Partial Nephrectomy for Complex Renal Tumors: Surgical Technique.” European Urology 53, no. 3 (Oct 2007): 514-21.