da Vinci Prostatectomy My Greek personal experience

Transcription

1 da Vinci Prostatectomy My Greek personal experience Vassilis Poulakis MD, PhD, FEBU Ass. Prof. of Urology Director of Urologic Clinic Doctors Hospital Athens

2 Laparoscopy - golden standard in Urology - PROVED: Pyeloplasty Partial nephrectomy Simple or donor nephrectomy Radical nephrectomy for localized tumors Adrenalectomy NOT PROVED, BUT IS GOING TO BE: Radical prostatectomy Radical cystectomy

3 I used to be laparoscopic surgeon My wide and advance laparoscopic spectrum: Radical prostatectomy Simple / radical nephrectomy Partial nephrectomy Nephroureterectomy Pyeloplasty Adrenalectomy Sacropexy

4 I used to be laparoscopic surgeon Over 600 laparoscopic operations Over 400 laparoscopic radical prostatectomies Over 10 papers about laparoscopic urology in MEDLINE Acting as mentor and proctor of laparoscopic urology in Germany and in Greece

5 Restrictions of open RP Insufficient lighting & magnification Difficult anatomic preparation Hospital stay Blood loss Pain

6 Restrictions of laparoscopic RP Long, rigid instruments Insufficient freedom of movements Non-Intuitive motion Non-Ergonomic 2-D Vision

7 Image the laparoscopic surgeon

8 Potentials of robotic RP - advantages combination of open & laparoscopic technique - Bloodless & painless 3-D & magnified vision Freedom & precision of movements Improved continence & potency Disease cure Lower morbidity Faster recovery

9 Indication for robotic RP Localized Prostate cancer without metastases ct2 and/or ct3, cn0, cm0 Identical with the open RP Life expectancy longer than the physical progress of cancer disease at least 10 years None remarkable surgical risks

10 Indication for nerve-sparing RP Independent of pre-op sexual function Nerve-sparing improved continence! DRE none tumor in the apex Partin s tables low risk for extracapsular extension During surgery None adhesions at neurovascular bundle Walsh 2007

11 Indication for lymphadenectomy Risk of lymph node metastasis >10% at least one of the following: PSA >20ng/ml Local stage > ct2a Gleason grade 4 as primary or Gleason grade 4 as secondary in >3 biopsy cores Heidenreich A. et al. EAU Guidelines on prostate cancer 2009

12 Technique of lymphadenectomy If a pelvic lymphadenectomy is indicated, this must be always extended despite all its possible complications and not restricted in the obturatory fossa 50% of lymph node metastases outside the obturatory fossa! The transperitoneal laparoscopic or robotic lymphadenectomy are equivalent with the open! Heidenreich A. et al. EAU Guidelines on prostate cancer 2009

13 Limits of pelvic lymphadenectomy - range I + II = extended field -

14 Extended robotic pelvic lymphadenectomy

15 Aims of prostate cancer therapy - trifecta - Potency Cure Continence Scardino P et al. Urology 2005; 66: 83

16 Aims of robotic RP - multi-fecta - Minimal complications Shorter recovery Trifecta Quality of life Positive relationship of cost-morbidity

17 End results: nerve-sparing

18 Anastomosis

19 Robotic urethrovesical anastomosis - single vs continuous - Single Continuous

20 Anatomy of prostatic fascia Intra-fascial Inter-fascial Walsh, 2004 Extra-fascial

21 Basic principles of nerve-sparing open vs robotic Open Robotic Menon M. et al; Eur Urol (2009)

22 Techniques of nerve-sparing retrograde antegrade

23 Ahlering s nerve-sparing technique antegrade interfascial athermal clipless bulldog at prostatic pedicle

24 Menon s nerve-sparing technique antegrade intrafascial opening endopyelic fascia veil of Aphrodite

25 Patel s nerve-sparing technique antegrade interfascial athermal early retrograde release of neurovascular bundle

26 Conventional nerve-sparing technique antegrade interfascial athermal clip early dissection of prostatic pedicle

27 Veil of Aphrodite Schematic difference Veil of Aphrodite vs Conventional nerve-sparing Conventional Nerve-sparing

28 Improved early continence - periurethral suspension stitch -

29 Improved early continence - restoration of posterior aspect of sphincter -

30 Robotic RP - extraperitoneal vs transperitoneal - Extra- Trans-

31 Meta-Analysis of comparative studies open vs laparoscopic vs robotic 3 meta-analyses Comparative study of 2 at least RP approaches > 40 comparative studies > 5,000 patients Equivalent results Continence & potency in 1 year Positive surgical margins & recurrence Advantage of laparoscopic & robotic RP Less bleeding Less transfusions Ficcarra V et al, Eur Urol 2009, 55: 1037 Parsons JK et al, Urology 2008, 72: 412 Tooher R et al, J Urol 2006, 175: 2011

32 Personal experience first 350 robotic RP Patients data Age (median, rage) Prostate volume 64 (41 82) years 58 (10 285) ml Body Mass Index 29.5 (19 45) kg/m 2 PSA 7 ( ) ng/ml Biopsy Gleason score 7 (5 9) Clinical stage 60% ct1c Prior surgery 62% lower abdomen ASA 2-3

33 Personal experience first 350 robotic RP Access extra/transperitoneal Transfusion 1.4% Mean OR time 121 (82-367) min Complications 7% Second operation 0.6% Conversions 0% Death 0% Positive surgical margins 6% Hospital stay 97% in 3 days Early continence (0 pads) 60% (1 month) Catheter removal 98% in 8 days

34 Potency after da Vinci Prostatectomy bilateral nerve-sparing 100% 87% 75% 50% 25% 43% 25% 56% age <60years age >60years 0% 6 months 12 months

35 Why move to the Robot? Robotic Assisted laparoscopic RP is: Safe Reproducible At least theoretical benefits for more favorable & completed results

36 Using robotic technology I expand my operative spectrum Robotic radical cystectomy with intracorporeal neobladder Simple prostatectomy for BPH Bilateral varicelectomy Ureteral new implantation in the bladder

37 Wrong marketing promotion! This is the same for both laparoscopic and robotic as minimal invasive procedures

38 The real advantages of robotic urology Improved accuracy of manipulation Better and precise visualization Less bleeding Better cancer control Improved functional results (i.e. continence and potency)

39 Robotic Urology - personal perception - Robotic surgery is the translation of traditional surgery in a minimal invasive fashion, but with : - better vision - more meticulous handling - miniaturisation of instruments Result : - surgeon relaxed & comfortable > better job - fine instruments with articulations at their tips > less tissue damage & more precision > better oncological & functional outcome - of course... learning curve, but acceptable!