CLOSE-UP VIEW OF ROBOTIC SURGERY FOR PROSTATE CANCER THOMAS JEFFERSON UNIVERSITY HOSPITAL, PHILADELPHIA, PENNSYLVANIA Broadcast January 19, 2006

Transcription

1 CLOSE-UP VIEW OF ROBOTIC SURGERY FOR PROSTATE CANCER THOMAS JEFFERSON UNIVERSITY HOSPITAL, PHILADELPHIA, PENNSYLVANIA Broadcast January 19, :00: NARRATOR: The American Cancer Society reports that 1 in 6 men will develop prostate cancer in his lifetime. One treatment option is a laparoscopic radical prostatectomy to remove the entire prostate gland and surrounding tissue through small incisions. During the next hour in this live interactive webcast from Philadelphia, Thomas Jefferson University Hospital surgeons will demonstrate the procedure using a futuristic state of the art robotic technology. You may ask the surgeons questions at any time by clicking the MDirectAccess button on your computer screen. This webcast represents the hospital s ongoing efforts to bring the latest medical education to both patients and the health care community. 00:01: LEONARD GOMELLA MD: Hello and welcome to Room 4 at Thomas Jefferson University Hospital here in Philadelphia, one of our minimally invasive surgery suites. It is my great pleasure to welcome you today to our live webcast of a robotically-assisted laparoscopic radical prostatectomy. We re very happy to have you with us today and hope you find this to be a very educational experience. Working with us today will be two surgeons actually performing the procedure. First I d like to introduce Dr. Costas Lallas, Assistant Professor of Urology here at Thomas Jefferson University. Dr. Lallas has trained in robotic and laparoscopic surgery at the Mayo Clinic in Scottsdale, Arizona. Working with DR. Lallas today is Dr. Ed Trabulsi, also Assistant Professor of Urology here at Thomas Jefferson University. Dr. Trabulsi completed his oncology fellowship at Memorial Sloan-Kettering in New York and did additional work there in laparoscopic radical prostatectomy. Again, welcome, Dr. Lallas and Dr. Trabulsi, to our audience here today. 00:01: This procedure, using robotically-assisted laparoscopic prostatectomy, normally takes around minutes, so in preparation for this webcast today, the live surgical procedure here in the operating room has been underway for approximately the last hour to hour and a half. What I d like to do is take a couple of minutes to update our viewing audience on exactly what steps have been completed so far here in our minimally invasive surgery suite. Today we re working with the davinci robotic system, made by Intuitive Surgical. It s the main robot that we have to work with during laparoscopic prostatectomy. A series of steps are necessary when you re performing laparoscopic prostatectomy using robotic assistance. The first thing that s done, as you can see in the video, is the placement of working trocars. This is similar to standard laparoscopy. Under a pneumoperitoneum, after the patient has had general anesthesia and has been positioned and draped, using the pneumoperitoneum, the trocars are placed. For the robotically assisted prostatectomy, three 8 mm trocars which are specifically mated to the robot are used, along with two working ports, one for the camera and an additional 5 mm assistant port. After these ports are placed, the next procedure involves what s known as docking the robot. Here you see the robot being brought into position and Dr. Lallas on the left and Dr. Trabulsi on the right are demonstrating how the robot is docked to the patient. You can see that the trocars have to be connected to the robotic arms in order for the surgeon to be able to control the movements of the robot from the console. The robot has also been prepared in advance. It s sterilely draped by the nursing staff before this part of the procedure. You can also see here the special dual lens laparoscopic camera that allows for a stereo and threedimensional view of the console is now in position. All these instruments must be very carefully placed in order to allow the surgeon to have very precise and accurate control. 00:04: Next, the instruments which are actually used for the surgery need to be connected to the robotic arms, to the actuators. Here you see the instruments being clicked into place. They mate with the actuators and again it s

2 very important for the surgeon standing at the bedside, under sterile conditions, to make sure that these arms are in proper position so that when the procedure is performed, all of the surgeon s motions are very precisely communicated to these robotic instruments at the patient. 00:04: Next, the operation of the robot actually takes place at a console. Here you can see some of the control elements of the console. You can see the binocular view that gives wonderful 3D stereoscopic view to the surgeon as he s seated at the console. Dr. Lallas will be at the console, performing the working part of the case today. There are a variety of foot pedals that are used to control various functions of the robotic arms and the robotic instruments. These are the actuators, the actual hand controls that the surgeon uses at the remote console, which is in the room but away, physically, from the patient. We re showing you the underside view of these actuators and these control toggles that the surgeon uses to very precisely control the robotic arms, which are connected by wires to the robot. 00:05: So we ve now gone ahead and done these mechanical parts of the operation. The patient, again, has been in the operating room for about 150 minutes now, or so, as a prelude to this. We d like to show you now the specific surgical steps that have been accomplished to get us to this point in the operation. These steps are actually collected from other patients who have had this procedure performed, because obviously we re doing live surgery right now and it s not possible to capture all the steps, edit them, and show them, so what we d like to do now is show you procedural steps that are involved, where we get to this point with the radical prostatectomy. This technique is done transperitoneally. The first step, after the surgeon enters the abdomen and assures that there s no injury, is taking down the bladder. Here you see an example of how the coagulation and the precision of the davinci robotic system is used in order to mobilize the bladder. To those that are familiar with radical prostatectomy, this is done transperitoneally, not done extraperitoneally today, although some surgeons do that. The next part of the procedure is incising the endopelvic fascia. Here you can see that the prostate is being retracted and that, using coagulation at the end of the davinci surgical instrument, the endopelvic fascia is being opened in order to allow exposure of the prostate. You can also see the white bands, the puboprostatic ligaments, here in the distal portion of the prostate. 00:07: The next part of the procedure is that the surgeon passes a 2-0 Vicryl on an SH needle behind the dorsal vein complex. This operation requires an assistant to be standing next to the table. Dr. Trabulsi passes the suture in for Dr. Lallas and then Dr. Lallas uses the remote control arms to go ahead and complete the knot. Again, this secures the dorsal vein complex, which helps minimize bleeding. Next, something known as a bunching suture is placed. To those surgeons who are familiar with open radical prostatectomy, the bunching suture is generally the back bleeding stitch, again performed with a 2-0 Vicryl on an SH needle. The needle is passed into the midprostate to bunch up the superior aspect of the prostate and allow for additional hemostasis. 00:08: Next, in an antegrade fashion, as opposed to a retrograde fashion with a standard radical retropubic prostatectomy, the prostate is disconnected from the bladder here anteriorly using primarily electrocautery. You can see in this view the Foley catheter in the 12:00 position has been pulled superiorly by the assistant and that the cautery is used to complete the dissection of the posterior aspect of the prostate. 00:08: Next, after the prostate has been disconnected from the bladder, we go behind the prostate and the prostatovesicle junction and dissect the seminal vesicles and the vas so that they can be ligated as part of the radical prostatectomy. You can see that electrocautery is very effective in minimizing bleeding. You can also understand that we have less blood loss with laparoscopic and robotically-assisted laparoscopic prostatectomy because we are working under a pneumoperitoneum and the pneumoperitoneum tends to cause tamponade of vessels and minimize bleeding. 00:09: The next part of the procedure is to carefully dissect the pedicles. You can see now electrocautery is not used and dissecting the pedicles and the neurovascular bundles is done only with sharp dissection. This is an important point. This is similar to what a lot of surgeons do in open surgical procedures in that the dissection along the neurovascular bundle with the scissor is done sharply in order to minimize the injury to the lateral bundles. In that particular video shot, you saw the cautery being used, not on the lateral bundles, but on the pedicles, in

3 order to ensure hemostasis. Again, all the lateral nerves are freed up using sharp dissection in order to minimize damage to the nerves. When you see the suction enter the field, the suction is being brought in by the surgeon s assistant, standing at the bedside, who can also provide retraction as needed to the operating physician. 00:10: At this point, the previously ligated dorsal vein complex can be sharply incised. You can see that there is some back bleeding from this area, but the bleeding is quite minimal compared to what it might be with an open technique. Now that we ve moved away from the neurovascular bundles, a little more cautery may be used. Here you see coming down on the prostatic urethral junction and you see the urethra being sharply incised. Coming into view is the Foley catheter. At this point, the prostate has been dissected. Here you see Dr. Trabulsi. Now we re back, live, in the operating room, so we ve gotten to this point. Dr. Trabulsi, can you explain to us what you re doing in this shot right now? 00:11: EDOUARD TRABULSI MD: We ve dissected the prostate completely free and we re about to start the anastomosis between the urethra and the bladder. We re about to capture the prostate in the bag right now and Dr. Lallas is going to use the fourth arm on the robot to grab the prostate. I m going to grab it in the bag right here. 00:11: LEONARD GOMELLA MD: Tell us a little bit about the bag, Dr. Trabulsi, and how you place it into the abdomen. 00:12: EDOUARD TRABULSI MD: This is a 10 mm instrument that goes through one of the assistant ports on my side. It has a bag that opens with the instrument and then it has a drawstring to close the bag and keeps everything inside the bag so we don t have anything falling out or getting dislodged. 00:12: LEONARD GOMELLA MD: Again, you re watching a live laparoscopic robotically-assisted radical prostatectomy from Thomas Jefferson University Hospital here in Philadelphia. 00:12: EDOUARD TRABULSI MD: We re going to leave the prostate in the bag now while we start the anastomosis and finish the procedure. Right here, while we were waiting, we started on the anastomosis and we have, using my sucker to show the opening in the bladder, Dr. Lallas is raising upöthis is our bladder opening right here and then we have a metal sound through the penis, into the urethra, which I m going to show to you right here. That helps show us where we need to sew to. 00:13: LEONARD GOMELLA MD: Ed, can you tell us a little bit about this patient, who has kindly agreed to undergo this live procedure today? 00:13: EDOUARD TRABULSI MD: Sure. He s a 68-year-old white gentleman who has had an elevated PSA in the past. He s never had a previous biopsy before, but his serum PSA was running in the 8 range and then recently rose to 9 and, on repeat, rose to That prompted his local urologist to recommend a transrectal ultrasound and prostate biopsy. That was done in November and showedöthey took 10 biopsies randomly through the prostate, 5 on each side, and the left-sided biopsies, fortunately, were all negative, but 3 of the 5 biopsies on the right side did show cancer. The cancer was evaluated to be a Gleason 3+4 or Gleason 7 cancer in 3 out of the 5 cores. The longest core that was positive was 90% of the biopsy. The specific locations of the biopsy were not recorded in terms of whether it was in the base of the prostate or the middle of the prostate or the apex, near the rectum. These biopsies were reviewed here, at Jefferson, by our pathologists and confirmed to be Gleason 3+4=7 cancer. When I met the gentleman on my examination, on digital rectal exam, I thought his prostate was slightly enlarged, but normal, without any definite nodularity or firmness, giving him a clinical T1C exam, so his tumor parameters are clinical T1C with a PSA of 10.4 and Gleason 3+4=7 in 3 out of 10 cores. He had a staging bone scan and CT scan of the abdomen and pelvis which were negative for metastatic disease. So we talked about the treatment options and he elected for a robotically assisted laparoscopic prostatectomy. Using the Katan nomograms, which we apply to all patients to give us an idea of surgical risk, his chances of lymph node involvement were 8%, which is higher than we d like to see. Therefore, I recommended that we also perform pelvic lymphadenectomy for both staging and possibly therapeutic benefit, so we ve already done that as well. We ve removed lymph nodes from the right and left side and removed them already. 00:16:31.000

4 LEONARD GOMELLA MD: I d like to remind our viewers that you can submit a question anytime during this live webcast by clicking on the MDirectAccess button on your computer screen. We will answer as many of your questions as we can during this broadcast. You can also make an appointment to refer a patient at any time during this broadcast by clicking on the appropriate button on your computer screen. Costas, can you tell us a little bit about the suture material that you re using for the anastomosis? 00:16: COSTAS LALLAS MD: Yeah. We like to use a Monocryl suture for our anastomosis. The reason we like to use that is, as you can see, it slides very easily through the tissues. What we do is we take 2 Monocryl sutures and actually tie them together and we make them different colors. This one in my left hand is blue. This one in my right hand is clear. That s so we don t get confused. What I m going to do throughout the course of the next hour is actually run the clear one up around from 12:00 to 6:00 on the right side and run the blue one from 12:00 to 6:00 on the left side and meet them in the middle here on the bladder and then go ahead and tie them down to complete my anastomosis. 00:17: LEONARD GOMELLA MD: Now, was there a stay suture that you put on the posterior bladder neck? 00:17: COSTAS LALLAS MD: No. I had placed that suture beforehand, actually, but with a nice stump of urethra, you should not need a stay suture for this case. 00:18: LEONARD GOMELLA MD: There you see a shot of Dr. Lallas, who is at the remote control console, actually working the arms. You can see his hands in the actuators on the robot itself. We already have our first question coming in off the web. The first question is is the robot doing the surgery? Dr. Trabulsi, would you like to answer that question? 00:18: EDOUARD TRABULSI MD: We obviously get asked that question all the time. It s a little bit intimidating to think about. This truly is not a robot operating independently. That s why we call the procedure a robotically-assisted laparoscopic prostatectomy. The robot comes in because it is translating Dr. Lallas movements to these two surgical instruments here in front of us. It has wrists with much more degrees of freedom of motion than you see with standard laparoscopic instrumentation, so it s more of a sort of master-slave device than an independent, autonomous robot. It s much more of an assistant, but that being said, Dr. Lallas is not here, next to the patient, like I am. He is away from the patient and that s a little bit different than we normally think of for surgery. 00:19: LEONARD GOMELLA MD: Another question that we ve already received from a physician, and maybe, Ed, you d be a good one to discuss this one, since you trained with Dr. Gillinov, who is one of the pioneers in the pure laparoscopic prostatectomy, can you tell us specifically what you consider to be the differences between this procedure and the pure laparoscopic prostatectomy? 00:20: EDOUARD TRABULSI MD: There are several differences. Like I said, the instruments have wrists, so we have a little more access of motion, especially in a tight spot like we sometimes are in here with the prostate down in the pelvis. It definitely can be helpful having extra degrees of motion. The vision is improved as well. The camera that we use is a specific camera designed for this robot that has actually two cameras within it to give a left and right eye and stereoscopic vision to the surgeon at the console, so that gives a 3-dimensional view and the magnification is excellent, so the vision really is amazing. The other important difference is ergonomically it s much easier for the surgeon. As you probably saw, Dr. Lallas is sitting down and looking pretty comfortable, so it makes things a little bit more efficient for the surgeon and it really speeds things up. It really helps with the learning curve. This is one of the most difficult laparoscopic procedures being done in urology and arguably in any field, so anything that helps you with that is a big assistance. It speeds things up. It makes surgeons who don t have a lot of laparoscopic experience more comfortable with the procedure to allow better results and quicker results so that way we can help more patients. 00:21: LEONARD GOMELLA MD: What are you doing now, Ed? Costas is suturing with the robot. What are you doing, as his assistant? 00:22:02.000

5 EDOUARD TRABULSI MD: Peeking in here from the corner, I have a regular standard laparoscopic needle holder, holding the right or clear suture taut so it does not loosen up or unravel while he s working on the left side. I m also periodically sticking my suction device in to try to help out, show the bladder, if needed. I m also, as you probably noticed in the urethra, sneaking the sound in and out to help show the urethra and make sure he gets a good bite of the urethra on every throw. 00:22: LEONARD GOMELLA MD: So again, it s important to understand that the assistant is really critical in performing this procedure. Also helping is, obviously, our anesthesiologist. We also have a scrub nurse and a circulating nurse, who are all involved with caring for this patient in the operating room at the present time. To recap for those of you who may just be joining us here for our live laparoscopic robotically-assisted radical prostatectomy for prostate cancer here at Thomas Jefferson University Hospital in Philadelphia, the patient s been anesthetized. The laparoscopic portion was initially performed, placing the ports in the abdomen. The robot has been docked. The instruments have been connected to the inside of the patient and Dr. Lallas has gone to the console. A bilateral lymph node dissection we completed in this patient because he had a slightly increased risk of having positive nodes, around 8%. The bladder and the prostate were disconnected from each other. The nerve-sparing portion has been completed. The prostate has been removed off the field and placed in a bag. It s still in the abdomen. Now, at this point, what we re seeing is Dr. Lallas at the console and Dr. Trabulsi is his assistant, completing the urethral vesicle anastomosis, re-establishing the continuity of the urinary tract, connecting the urethra to the bladder. Costas and Ed, if you get to one point here, if you maybe could just take a second to show people the anatomy so those people that are not used to looking at pelvic procedures, such as radical prostatectomy, can actually understand exactly where we re working at this point. 00:24: COSTAS LALLAS MD: Okay, Lenny, I can help out with that a little bit. The wonderful thing about the robot is that I am looking into the pelvis in an area that is almost humanly impossible without using the laparoscopic template that we re using. I m actually under the pubic symphysis, looking up into the urethra, so the patient s penis is actually through this way. His head is coming back toward you. His feet are actually down this way. This is his urethra, this is his bladder, and that s what I m putting back together again. The prostate was located in the space between the urethra and the bladder, and that s why we have to reconstruct what we re doing here. Coming back a little bit, unfortunately, the space is very tight, as you can see, but you can actually see where we performed our lymph node dissections. This is the nerve over here and that space over there is actually, and you can see the artery in the foreground. That space was one of our lymph node dissections, which we performed right after removing the prostate. Then, the nerve on the other side is actually located right there. You can see the empty fossa right here, which is where we performed our lymph node dissection. 00:26: LEONARD GOMELLA MD: Can you guys address a little bit about the technical aspects of the pneumoperitoneum and what your parameters are for the pneumoperitoneum for this procedure? 00:26: COSTAS LALLAS MD: Yeah. Pneumoperitoneum is not something that s a foreign concept, especially to surgery. I mean, it s pretty standard in all laparoscopic surgery. The nice thing about pneumoperitoneum is that, first of all, it blows the patient up so that it gives us more working space inside a patient, but in addition, the pressures that it creates inside the patient actually help to tamponade or stop small blood vessels from bleeding. What that means, essentially, is that these patients experience less blood loss and I think that s a huge benefit. 00:27: LEONARD GOMELLA MD: Okay. What I think we ll do is a little bit of the slides right now and talk about robotically-assisted and laparoscopic prostatectomy. Robotically-assisted laparoscopic prostatectomy really continues to gain popularity. Both patients and practitioners alike are interested in exploring the possibility of robotically-assisted laparoscopic prostatectomy as a minimally invasive procedure for the treatment of clinically localized prostate cancer. Basically, when you treat a patient with localized prostate cancer, we have other therapeutic options and it s important for patients, in particular, or physicians who are not used to dealing with prostate cancer, to really understand that there is not one way to treat prostate cancer. We have many different options available. Surgical removal of the prostate, either through the standard radical retropubic prostatectomy, where the incision is made in the lower abdomen; the radical perineal prostatectomy, where the incision is made between the rectum and the scrotum; and the pure laparoscopic prostatectomy, where the surgeon controls all of

6 the laparoscopic instruments and the laparoscope and manually moves the instruments by hand. Other options for localized prostate cancer, which are employed, include some type of radiation therapy, most commonly brachytherapy or seed therapy or external beam radiation therapy. Lastly, some patients are also able to undergo hormonal ablation for localized prostate cancer, not commonly done in a younger man, and also treatment such as watchful waiting. We have to stress that not all patients with prostate cancer require an aggressive surgery, such as radical prostatectomy. From an understanding standpoint, for patients in general, sometimes the concepts of robotic prostatectomy, laparoscopic prostatectomy, and radical retropubic prostatectomy all sometimes become a little bit intermeshed, but the reality is that they are all accomplishing the same goal; that is, complete removal of the prostate and reconstruction of the urinary tract, so all men who have surgical treatment for prostate cancer, in general, have what s known as a radical prostatectomy, but the reality is that the way the prostate is taken out and how the incisions are made can be somewhat different. 00:29: To talk about the benefits to the surgeon for the laparoscopic robotically assisted prostatectomy are as follows. The so-called Endowrist technology gives a lot of freedom of movement for the surgeon performing the procedure. The robot directly translates movements from the surgeons to the instruments. Clearly the 3- dimensional visualization of the technique is enhanced. The ergonomic design, you saw Dr. Lallas is very comfortably sitting behind the console, holding the hand pieces of the davinci robotic system, working things very, very easily. You can see the movements, how precise they are and how that Endowrist technology allows many different ways for that needle driver that s currently being used to place these Monocryl sutures is enhanced. 00:30: Now, a comment. There s a couple of different robotic systems currently available. There are 3-arms and a 4-arm system. Currently here at Thomas Jefferson University in Philadelphia we re using the 4-arm system. Costas, do you want to comment a little bit about the 3-arm versus the 4-arm system? 00:31: COSTAS LALLAS MD: Yeah. Where I trained, actually, out in Scottsdale, we had a 3-arm system and it actually works quite well. What the fourth arm does for the surgeon is that it actually makes him a little bit less dependent on the assistant, which can be nice. I m actually very lucky because I have Ed and Ed s a very qualified assistant because he does pure laparoscopy himself. However, there are some surgeons out there who do not have assistants who can help them as well and that s where the fourth arm really benefits the surgeon. But that really is the big advantage of having the fourth arm. 00:31: LEONARD GOMELLA MD: Ed, is that a special sound that s in there? It seems to have a hole in the end of it. What type of sound is that? 00:31: EDOUARD TRABULSI MD: It s actually a custom made sound. I brought this here with me from New York. We used to use it up there. It s got a special curve at the end that really helps guide the suture into the right spot and that hole is actually custom drilled in there so it can help give us a target for the end of the needle and then helps us roll our wrists to get it into a good spot. A lot of people here will just use a regular catheter, but I ve been adopting some of the things I use from straight laparoscopic prostatectomy. I don t think Dr. Lallas really complains too much about using this sound. It seems to help out a little bit. 00:32: LEONARD GOMELLA MD: But it is a custom sound. It s not something that s readily available. 00:32: EDOUARD TRABULSI MD: Yes, it s a custom sound. 00:32: LEONARD GOMELLA MD: I want to remind all our viewers that you can submit a question to us anytime during the broadcast by clicking on the MDirectAccess button on your computer screen. Again, we ll get to as many questions as possible. We have a question here that I ll refer to Dr. Lallas. Dr. Lallas, from a consumer in the audience, how does the recovery from this surgery compare with the standard surgery and, in general, what s the pain level? 00:33:13.000

7 COSTAS LALLAS MD: Actually, the recovery from this surgery is quite good, which is really one of the beauties of the surgery. You know, there s those buzzwords of minimally invasive surgery, in which the patient has better cosmesis, meaning that there s a smaller incision; here is less intraoperative bleeding, which means less chance of a blood transfusion; there is less pain associated with the operation; and there s a quicker convalescence. Really, what I ve noticed with these procedures is that patients benefit from most all of these. Again, that is just one of the benefits of minimally invasive surgery and we are seeing that in the robotic prostatectomy as well as our pure prostatectomy population. 00:34: LEONARD GOMELLA MD: And here s a good roll-in to our next slide on the screen, where we talk about the benefits to the patient for the robotically-assisted laparoscopic prostatectomy. Cosmetically, there s improved cosmesis on the abdomen. Instead of having a longer incision, you can have a shorter incision. You have multiple small incisions compared to about 8-9 incisions for a standard retropubic prostatectomy. To some men, these cosmetic issues are very important. There is clearly a benefit of decreased blood loss with these laparoscopic techniques, as we mentioned earlier, due to the pneumoperitoneum. We believe that there is improved perioperative quality of life through quicker convalescence. Right now we re not clear if we have dramatically better functional results with regard to continence and potency, but certainly the potential for this is there. At least from the short-term standpoint right now, the oncologic efficacy or the ability to control cancer, at least in the short-term, appears to be equivalent to the open technique. Now, the published series of robotic laparoscopic prostatectomy are actually relatively sparse compared to much larger series from published laparoscopic techniques. We have to remind ourselves always that this is a laparoscopic prostatectomy. The difference is that we re using the robot I order to enhance some of the surgeon s maneuvers and ability to perform the procedure in a more efficient fashion. Certainly blood loss with the laparoscopic radical prostatectomy, in this review we can see that there s a tremendous reduction in the blood loss associated with laparoscopic radical prostatectomy from these multiple series reported in the United States and in Europe. The other issues concern laparoscopic prostatectomy. Here again we re talking about the laparoscopic use, not necessarily about the robotically-assisted laparoscopy, but here we see that for the radical retropubic prostatectomy, which is the RRP, versus the LRP, the laparoscopic radical prostatectomy, you do see improvements, to answer that last consumer s question, in pain. For example, the standard radical retropubic prostatectomy patient takes around 17 pain pills at home. The person who has the laparoscopic technique took about 9. Full recovery, those who have a radical prostatectomy before they re totally functional and all back and work and doing activities of daily living completely as before surgery takes about 47 days. In the published laparoscopic radical prostatectomy series, it s about 30 days. This from a paper by Dr. Bayoni that was published in Urology in March There has been studies of convalescence over the long term. We know there s a lot of benefit in the short term with the laparoscopic prostatectomy in terms of convalescence, based on the published literature. The prospective comparison of laparoscopic versus open radical prostatectomy revealed that they both did suffer from some decrease in quality of life of patients due to incontinence and impotence. This long term quality of life issue appears to be the same, regardless of the technique. If we look at improvement in voiding symptoms between laparoscopy and open surgery, based on published series, the improvement in the voiding symptoms appears to be the same. In about 6 months, the quality of life appears to be virtually identical. However, when you question patients in different groups, based on a study by Dr. Harrah and associates, more patients in the laparoscopic group would choose the same treatment again. I think that brings up an interesting point that we should make. Dr. Trabulsi, when you counsel patients about the treatment for prostate cancer and you sit and specifically talk about localized treatment for prostate cancer, something that we do every week in the Kimmel Cancer Center, Multidisciplinary GU Center here at Jefferson, how do you direct patients toward a standard open, a straight laparoscopic, or a robotically-assisted prostatectomy in your weekly encounters in the Cancer Center here? 00:38: EDOUARD TRABULSI MD: That s a difficult question to answer quickly. A lot of it depends on the individual patient. Things that would make a laparoscopic or a robotically-assisted prostatectomy more difficult are obesity. Obviously the thicker the level of fat between the skin and the belly makes our maneuverability more difficult. Another big one is if they ve had a lot of previous surgery or previous radiation, things that make me think we could encounter a lot of scar tissue on the inside and make the procedure more difficult. Then a lot of it depends on whether I think they re a surgical candidate in the first place. You know, if they re on the older side, where I m worried about their surgical risk or I think that they have unacceptably high risk from surgery, then I might steer

8 them away from surgical treatment. That s something that we talk about with the radiation oncologists that we see patients with jointly. So that s a good 45 minutes or an hour discussion, trying to help the patient decide on the best treatment. 00:40: LEONARD GOMELLA MD: We ve been doing laparoscopic prostatectomy here at the Thomas Jefferson University Hospital and the Kimmel Cancer Center since around The future of a straight laparoscopic prostatectomy, Ed, compared to the robotically assisted prostatectomy, what do you think? 00:40: EDOUARD TRABULSI MD: I think in terms of the quality of the operation, they re comparable. I think technically the laparoscopic procedure is harder without using the robot. I think probably they ll coexist. I think there are surgeons that are very good at straight laparoscopic surgery and are going to continue to keep doing it, and there are training centers that are teaching it. I think for urologists out in practice that cannot do a fellowship, I think using the robotic assistance that the davinci machine offersö 00:41: LEONARD GOMELLA MD: Wait a minute. You and Costas are moving at breakneck speed here. You guys just did a couple of key maneuvers there. Can you go back and tell us what you guys just did? You re moving so quickly, we lost what you just did. 00:41: EDOUARD TRABULSI MD: I m sorry. We ve sewn the urethra and the bladder together and we re ready to tie the suture down. While we were talking, I ve cut one of the needles off and removed it from the body. We ve also placed a catheter in through the penis, into the bladder. Maybe Costas can show us the catheter there. 00:41: LEONARD GOMELLA MD: Costas, why don t you show us what you re doing there? Can we maybe get a peek at the catheter or is it too late? 00:41: COSTAS LALLAS MD: No, I haven t tied it down yet. I can certainly show it to you. See the yellow right in there? That s the catheter. One thing I d like to comment on is, I don t know how much you were paying attention, but one of the big benefits of this visualization is that I m able to get a nice mucosal to mucosal apposition for my anastomosis, meaning that I take the inside of the urethra and I put it to the inside of the bladder, which are both mucosal surfaces. That really helps with the healing in these patients and with these anastomoses, and the visualization is so nice that it s actually very easy for me to accomplish that. 00:42: LEONARD GOMELLA MD: We have a question from one of our viewers right now about complications and risks of the procedure, and that brings me very naturally here to our next slide, where we talk about what some of the complications are of laparoscopic prostatectomy because surely any operative procedure, unfortunately, has its risks and benefits. The big issues that we have with robotically-assisted laparoscopic prostatectomy involve open conversion, taking the patient and going ahead and making the standard incision and completing the operation. The chance for hemorrhage, the chance for blood clots any time you perform prostate surgery is a possibility. Urinary tract complications and bowel complications appear to be fairly similar to those of standard open prostatectomy. If you compare the laparoscopic prostatectomy, again, remember, this is all laparoscopic prostatectomies, not specifically referring to robotic prostatectomy, you have overall complication rates of the open and laparoscopic techniques reported here. Again, overall complications fairly similar. Again, this is an operation that does have some risks with it and there can be complications. Hopefully through skilled surgeons and adequate perioperative counseling and decision-making by the patient and the team who cares for the patient, these complications can be significantly reduced. So across the board, if we look at the complications, they re generally similar to open radical prostatectomy. The key thing is the technique and knowing the potential for complications and attempting to minimize them. What s very important, and maybe Dr. Lallas, I ll ask you to comment on this, if you re not too busy sewing there with your finest friend, the robot, there, can you talk a little bit about experience and how experience helps with robotic or robotically-assisted radical prostatectomy? 00:44: COSTAS LALLAS MD: When you say experience, Len, what do you mean? 00:44: LEONARD GOMELLA MD: As in the learning curve, numbers of cases, and things like that.

9 00:45: COSTAS LALLAS MD: The way I look at that question is I think every surgeon out there would agree that repetition is very important. This concept of the learning curve has come up with minimally invasive surgery because it s just so new and there are a lot of series out there who publish what the learning curve is of different procedures. What that means is how many numbers do you have to accomplish before you re competent with the procedure? That number gets batted around a lot. I ve seen anywhere from 20 to 100 cases. One thing that I will mention about the robot is that if you are comfortable with either an open or a laparoscopic prostatectomy, from my own experience and from people who I ve talked to, the robot will come much easier to you because you re comfortable with the anatomy and you re comfortable with the procedure, so it s really hard to answer how many cases it s going to take for you to become good at the procedure because, inherently, what you have to take into mind is not only what your personal experience is with open surgery and your familiarity with the anatomy, but you also have to keep in mind how many you have accomplished. 00:46: LEONARD GOMELLA MD: Maybe you can show us, Ed, a close-up of the abdomen so our viewers can get an understanding of where the different trocars are positioned relative to the connection of the robot? 00:46: EDOUARD TRABULSI MD: Sure. The patient s head is over here, where my hand is, and the patient s legs are going that way. We have him in Trendelenberg position. Basically, the head is down and the feet are up. We have his feet up in stirrups to get them out of the way to allow room for the robot to come in. This right here is the port holding the camera. It s right above his belly button. Then the yellow and the green are the two main instruments that the robot controls and that s off to the side, approximately 10 cm from the middle. We also measure where his pubic is, which I m sneaking my hand in through here. We mark on the skin and we try to measure approximately 15 cm from that mark, where his pelvic bone is, to the instrument. That s based on the length of the instrument, the working length that we have, to try to standardize it so we re not too short or too long. Over here, on the patient s left side, in red, is the fourth arm. That s usually used the least amongst the different robotic arms. We use that to hold things, to pull things out of the way, to help us retract. On this side ñ it may be difficult to see ñ is my two hands. I have two ports right in here that are standard ports. These are the laparoscopic ports that we use all the time, where I can pass instruments in and out of, I can pass sutures in ands out of. This port in the middle here, I have my sucker in basically the whole time. 00:48: LEONARD GOMELLA MD: Maybe we can get your colleague with the camera in for a closer view of that, Ed. 00:48: EDOUARD TRABULSI MD: This port right here is the suction port and then my assistant port here. 00:48: LEONARD GOMELLA MD: And that string coming out of that one port isö 00:48: EDOUARD TRABULSI MD: This string is the string that the end of the bag in which the prostate has been captured in, so I don t want to lose the string, so I just put a little instrument on there so it doesn t get swallowed up inside. 00:48: LEONARD GOMELLA MD: Maybe we can go back for an inside view and, Costas, you can show us what you re up to in there. 00:49: COSTAS LALLAS MD: Okay. Well, we ve just tied our anastomosis together. Again, this is my blue string and this is my clear string. The needles come off the clear string. I still have the needle on the blue string. Ed s going to go ahead and cut that off now. 00:49:19.000

10 LEONARD GOMELLA MD: Is it a problem getting that needle back out? Does that needle ever get stuck or cause any problems to you? 00:49: COSTAS LALLAS MD: Usually this size needle does not have a problem going out of the port. If there are any concerns about it, one of the nice things is that I also control the camera from where I am, so I can actually follow the needle out and make sure that Ed doesn t drop it. That s the trocar he actually just took it out of. 00:49: LEONARD GOMELLA MD: Why don t you go back, Costas, and show us that you have the prostate bagged. The prostate is sitting in a bag right now. It s not been extracted. 00:50: COSTAS LALLAS MD: The prostate is located right there. We will extract that at the end of the case and we ll actually extract it through the incision that the camera is coming through. In all, it s going to be maybe a 4-5 cm incision. 00:50: LEONARD GOMELLA MD: A couple of questions. Ed, do you want to comment about potency? Is it more preserved with the robot compared to the open radical prostatectomy? Can you say anything definitive about that? 00:50: EDOUARD TRABULSI MD: Well, it s very controversial. The jury is still out on that. That s the types of things that we talk about at our meetings all the time. The vision that we have here and our ability to see where the nerves lie and our ability to try to save them, we think may, definitely in the future, be better than the open surgery, but I don t know if we re quite ready yet to say right now that it s better. The vision is definitely better than you get open, so it would make sense that in the future, as more of these procedures get done and we have more followup to see how the guys are doing in terms of potency, that it may prove to be the case. I don t mean to hedge. I may sound like I m hedging, but it s really, the jury s still out on that. 00:51: LEONARD GOMELLA MD: I don t think you re hedging. I think you re being honest that we still really have challenges with all potency preservation in the treatment of prostate cancer. I don t think you re hedging; I think that s a fair comment. 00:51: EDOUARD TRABULSI MD: Len, I m just filling the catheter up. 00:51: LEONARD GOMELLA MD: Maybe we can go back to the inside laparoscopic view at this point and show him filling the catheter and showing how Dr. Lallas has skillfully completed a watertight anastomosis. 00:51: EDOUARD TRABULSI MD: I just took a syringe full of saline and connected it to the catheter and I ve just filled his bladder up. Now I m withdrawing it out. While I did that, I really didn t see anything leak out and I got every cc of irrigation that I put in came back out, so that tells us that we have a pretty good connection here. It does not look like there s any leakage at all. 00:52: LEONARD GOMELLA MD: In case we run out of time here, because it s hard to believe the hour is almost up, can we talk about the next couple of steps that our audience probably won t have the opportunity to see concerning this laparoscopic, robotically-assisted prostatectomy procedure? Costas, do you want to talk about what will be done next? 00:52:34.000

11 COSTAS LALLAS MD: Our next part of the procedure is actually to put in a drain. We put in a drain with everybody. That drain stays in the patient throughout their hospitalization, which is typically between 1 and 2 days. After that, we ll go ahead and de-dock the robot, so in other words, pull the robot away from the patient and then we ll go ahead and extract the specimen. Again, we extract the specimen through the midline incision, which is where the camera is coming out of. Then we go ahead and close that incision at the fascial level and then close the skin and that usually is the end of the procedure. 00:53: EDOUARD TRABULSI MD: We normally will do the lymph node dissection on patients that we think need it at the end. We would be starting that right now. We have a little extra time, so we did that first. Maybe we can give you a little tour of that area here. I m going to suck this out here. Right here is the patient s obturator nerve. That s a nerve going out to his leg. Then we have his external iliac vein. 00:53: COSTAS LALLAS MD: And there is an accessory vein. You see how well you can see that coming across right here. 00:53: EDOUARD TRABULSI MD: So all of the lymph nodes that used to live right in here we ve already removed. The same thing on the other side. We have the veinöwe re sword-fighting here a little bit. We have the vein out here and we have the obturator nerve right there, which I m pointing out with my sucker. This is his pelvic bone and all of the lymph nodes that used to live in here we ve removed already. 00:54: LEONARD GOMELLA MD: Post-op for this patient, what is his post-op care going to look like? 00:54: EDOUARD TRABULSI MD: I tell patients to expect to stay in the hospital a day or two. Right now it s running about 50/50, men that are ready to go home the next day or men that stay a little longer. 00:54: LEONARD GOMELLA MD: I think everyone has been able to appreciate, again, the precision and the many different ways that the davinci robotic prostatectomy system allows the surgeon to move the needles and the instruments in order to more smoothly and efficiently complete the procedure. Just a couple of comments about oncologic efficiency. We have to remember that this is a cancer operation. Our goal is to care for the patient in the best way possible. We believe that the early convalescence and reduced blood loss is of benefit to the patient s recovery. We have to recognize the fact that these laparoscopic minimally invasive surgical techniques have really only been around for about 6 years or so and only really being done in high volumes over the last 2-3 years, so time will tell if the disease control of this operation is as good as the well-studied, radical, standard incision prostatectomy, but clearly right now the surgical margin data that we re starting to see as surgeons gain experience with the laparoscopic and robotically-assisted laparoscopic prostatectomies are certainly improving and certainly getting better. Ed, do you want to say anything as we get ready to wrap up our webcast here from Thomas Jefferson University Hospital on the robotically-assisted radical prostatectomy? 00:56: EDOUARD TRABULSI MD: No. I just want to thank everyone for watching. I hope this helped patients and physicians alike understand what s involved. There s a lot of press lately about the robot and this, hopefully, demonstrated how it s helping us for men with prostate cancer. 00:56: LEONARD GOMELLA MD: Costas, any closing comments in the last few minutes here? 00:56: COSTAS LALLAS MD: I appreciate everyone tuning in and, again, I hope this cleared up what the robot can do for us and do for patients as well.

12 00:56: EDOUARD TRABULSI MD: We can show the drain going in. 00:56: LEONARD GOMELLA MD: They re going to show the drain going in. The drain has been placed in through one of the trocar sites, Ed? 00:56: EDOUARD TRABULSI MD: Right. It s through one of the holes we already have and it s going to go right above the bladder, so if there s any little leak of urine, it should come out through this drain and we ll know about it. 00:56: LEONARD GOMELLA MD: Typically, Ed, how long does that drain stay in these patients? 00:57: EDOUARD TRABULSI MD: Usually we pull it out the next day. They ll go home with the catheter in place and we usually pull it out in 7-10 days and then we ll tell them to take it easy in terms of strenuous physical activity or exercise or lifting for 6-8 weeks, just to let everything heal, but short of that, I ve had several patients that have desk jobs or that really are not too worried about exertion that go back to work within a week or so. 00:57: LEONARD GOMELLA MD: I want to remind our CME viewers that they can receive CME credit by completing the evaluation at the end of the broadcast today. You can also make an appointment or refer a patient to the Kimmel Cancer Center multidisciplinary clinic, where we have a team of physicians, including surgeons, radiation oncologists, medical oncologists, nutritional support, social support, who all see the patient in consultation and recommend the best treatment for a patient with localized or advanced prostate cancer. For those of you who are interested in seeing a replay of this live laparoscopic robotically-assisted prostatectomy from Thomas Jefferson University Hospital, a replay of the webcast will be available beginning January 20 at You ll be able to see a replay of this live webcast from Jefferson starting tomorrow, January :58: EDOUARD TRABULSI MD: Now we re just taking the robot out of the way. 00:58: LEONARD GOMELLA MD: Can we show the de-docking of the robot on the open camera view? The surgical procedure has been completed. We still have to extract the prostate, but Dr. Lallas and Dr. Trabulsi are performing the procedure known as de-docking the robot, where the robot is being disconnected from the trocars and being backed out of position so that the surgeons can complete the extraction of the prostate and the closure. 00:59: I d like to thank all of you for being with us today for this live laparoscopic robotically-assisted prostatectomy from Thomas Jefferson University Hospital in Philadelphia. I d certainly like to thank a lot of people, certainly Dr. Lallas and Dr. Trabulsi, who were under a lot of pressure today, with the world watching them perform this laparoscopic robotically-assisted procedure. I d like to thank our operating room staff, our technical folks at slp3d, who made this webcast possible, and very most importantly thank the patient and his family for allowing us to perform this pioneering surgery that s been with us now for the last couple of years in the field of urologic oncology, live, today. I m Dr. Leonard Gomella here at Room 4 at Thomas Jefferson University Hospital in Philadelphia and we bid you all good night. 01:00: NARRATOR: This has been a live internet broadcast of a minimally invasive robotic-assisted radical prostatectomy for prostate cancer from Thomas Jefferson University Hospital in Philadelphia. To make an appointment with a