Robotic radical prostatectomy Technique and results of nerve sparing approach EAU 2009 March 19 th 2009

Transcription

1 Robotic radical prostatectomy Technique and results of nerve sparing approach EAU 2009 March 19 th 2009 J.H. Witt Department of Urology and Pediatric Urology Prostate Center Northwest St. Antonius-Hospital Gronau

2 davinci S HD system

3 Prostate cancer surgical approches bladder prostate and SV pelvic floor and external sphincter Retropubic Perineal Laparoscopic Robot-assisted

4 Procedure in an anatomical region where a lot of different structures are close together Why robotic radical prostatectomy? Possible consequences: Incontinence Impotence

5 intuitive movements

6 radical prostatectomy Consequence: The optimal exposition both of the prostate and the surrounding structures is essential The more precise the preparation the better the oncological and the functional outcome

7 Robot 4-arm Robot Surgeon controlled motion of instruments and lens 7 degrees of freedom and possibility of 90 flexion of the "wristetd" instruments motion scaling and tremor reduction 5 cm 1 cm

8 better vision 3-D vision Orientation like in open surgery ergonomic comfort for the surgeon with less fatigue

9 robotic surgery = Combination of the advantages of open surgery and laparoscopy

10 USA Q2/2009 0,50% 0% 23,50% 23% Robotic prostatectomy cpen prostatectomy 77% classic endoskopic prostatectomy 77%

11 The last retropubic prostate surgeon

12 Robotic-assisted operations WW City of Hope National Medical Center Henry Ford Hospital Florida Hospital Celebration Health Karolinska Sjukhus University of North Carolina Hospitals St Antonius Hospital Gronau Lund Universite Hospital Henry Ford Hospital Menon Onze Lieve Vrouw Clinic Clinique Saint Augustin Universitätsklinikum des Saarlandes U i it f I b k

13 NVB preservation total interfascial high laterally standard

14 standard NVB preservation right, TIRARP left

15 RARP Gronau results (March 06 February 09, n = 850) age 63.2 (41-78) ipsa mean 10.2 ( ) ipsa median 6.9 ( ) pt % pt % pt % pt % R1 in T % R1 in T % Gleason < % Gleason % Gleason > % Regression (after LHRH/Radiatio) %

16 RARP Gronau results (March 06 February 09, n = 850) n % Conversion 4 0.5% 0 Revision 7 0.8% 3 Thrombosis 4 0.5% 0 Transfusion 5 0.6% 2 Bowel lesion (intraop. repair) 6 0.7% 1 Port infection/hematoma (subcutaneous) 6 0.7% 2 symptomatic lymphocele 3 0.4% 1 Bladdertamponade (partial) 1 0,1% 0 intra-/postop. apoplexy (without residua) 1 0.1% 0 Hernia (cameraport, early/late) 6 0.7% 3 Ostitis (os pubis) 3 0.4% 1 Stricture (anastomosis) 4 0.5% 2

17 Results best in class "Best in Class" in pt2 Positive margins (R1) in percent standard laparoscopy 1 7,7% open surgery 2 5,9% da Vinci 3 3,8% da Vinci 4 2-4% da Vinci Gronau 3,6% 1. Touijer K, Kuroiwa K, Saranchuk JW, Hassen WA, Trabulsi EJ, Reuter VE, Guillonneau B. Quality improvement in laparoscopic radical prostatectomy for pt2 prostate cancer: impact of video documentation review on positive surgical margin. J Urol Mar;173(3): p. 766 (Results) 2. Scardino PT. Open Radical Retropubic Prostatectomy. Presented at the American Urological Association s Carcinoma of the Prostate Course, San Francisco, California, Sept. 30 Oct T Ahlering. J. Urol. 175(4):217A, pg VR Patel. Urology Centers, Vestavia Hills, USA. Histopathologic Outcomes and Short Term PSA Data after Robotic Radical Prostatectomy. 500 Patients. Moderated Poster Session MP27, Wednesday, August 24, rd World Congress on Endourology and SWL 21 st Basic Research Symposium August 23-26, 2005, Amsterdam, The Netherlands. J Endourol Aug.; 19, Supplement 1: A135.

18 better oncological results?

19 Robotic surgery has a faster recovery

20 RARP Medical complications

21 docking time

22 blood loss

23 skin-skin time

24 skin-skin time surgeon 1 & 2 (after 350 RARP's)

25 pos. SM in pt2

26 early continence (n = 400) day 1 after removal of the catheter no of pads at day 1 after removing of the catheter

27 potency nerve sparing on both sides IPSS preoperative >20 n=61 sexual intercourse after six month: 65%

28 CaP Robotic Prostatectomy (AUA 2007)

29 Learning curves standardization : R1/blood loss expert: function surgical technique: skin-skin-time handling of technique: docking time

30 modular learning concept RARP surgical steps difficulty port-placement 2 preparation of cavum rezii 1 endopelvic fascia/aberrant vessels/dvc 2 bladder neck preparation 4 pedicels 3 neurovascular structures (NVB) 4 bladder neck/ dorsal reconstruction 3 anastomosis 3 lymphadenectomy 2

31 follow-up schedule follow-up after 3, 6, 12, 24, 36, 48, 60 month IPSS IIEF 5 ICSmaleSF QLQ-C30

32 RARP in Gronau at pznw

33 Patients are the driving force in spreading of robotic surgery

34 April 2008 Dear Dr. Witt, Since the operation, exactly one year ago, I can tell you, that everything turned out to be perfectly OK! No complications what so ever. I just want to thank you, and your staff again for doing a good job. Also was I very pleased with the medical care and nursing of the Urology ward. I wish you success and good health for yourself (take a break now and then). Kind regards, Frank B. (patient april 2007)

35 Summary RARP is state of the art in US and Sweden oncological results are excellent functional results are promising still much room for development

36 Summary robotic-assisted procedures will gain more relevance in the future "logic" development from standard laparoscopy advantage in case of procedures with high complexity and need for good functional results very high potential for development picture in picture 3-D picture overlay fluorescence- and microscope technology

37 outlook clinical use in different complex procedures: Urology kidney pylon bladder adrenal glands Gynecology ENT general surgery

38 More Information? Andreas Koch Head of Public Affairs European Robotic Institute Möllenweg Gronau Cell Tel Fax