Robotic Surgery for Prostate Cancer: A Realistic Approach to Getting Started The Evolution of a Robotic Surgeon

Transcription

1 Robotic Surgery for Prostate Cancer: A Realistic Approach to Getting Started The Evolution of a Robotic Surgeon Douglas S. Scherr, M.D. Clinical Director, Urologic Oncology Weill Medical College of Cornell University

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3 Is The Disease Important? PROSTATE CANCER Highest in Incidence and Second in Cause of Death from Cancer in American Males Incidence Melanoma of Skin 5% Oral Cavity & Pharynx 3% Lung & Bronchus 14% Pancreas 2% Colon & Rectum 11% Kidney 3% Prostate 30% Urinary Bladder 7% Leukemia 3% Non-Hodgkin s Lymphoma 4% All Sites 637, ,000 New Cases 2002 Estimates Cause of Death 3% Esophagus 31% Lung & Bronchus 5% Pancreas 3% Kidney 3% Liver 10% Colon & Rectum 11% Prostate 3% Urinary Bladder 4% Leukemia 5% Non-Hodgkin s Lymphoma 288,200 All Sites 30,200 Death

4 U.S. Incidence and Mortality of Prostate Cancer

5 Natural History The Disorder Prostate Cancer Natural history understood: -To die of prostate cancer or die with prostate cancer? -Conservative Treatment: a.) Gleason 2-4: 4-7% chance of death b.) Gleason 6: 18-30% chance of death c.) Gleason 8-10: 60-80% chance of death** Frankel et al. Lancet, 361: 1122, March 2003 **Albertsen et al., JAMA, 280: 975, 1998

6 Progression-free probability by risk group Intermediate risk Low risk High risk D Amico et al JAMA 280:969-74, 1998

7 Swedish randomized trial: Surgery v. Watchful waiting Surgical excision alters the natural history of prostate cancer, reducing metastases and cancer-specific mortality by 50% at 8 years. Distant metastases Cancer-specific mortality WW 27.3% WW 13.6% RP 13.4% RP 7.1% From: Holmberg L, Bill-Axelson A, Helgesen F, et al. A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer. N Engl J Med, 2002;347:

8 DEMOGRAPHICS OF AGING More and more doctors will be faced with how to treat our aging population the older population will burgeon between the years 2010 and 2030 when the "baby boom" generation reaches age 65. This will more than double the 65+ population by the year 2030 compared to 2000 numbers Source: Administration on Aging (

9 DEMOGRAPHICS OF AGING Over 2.0 million persons celebrated their 65th birthday in 2000 (5,574 per day). In the same year, about 1.8 million persons 65 or older died, resulting in an annual net increase of approximately 238,000 (650 per day). Source: Administration on Aging (

10 DEMOGRAPHICS OF AGING By 2030, there will be over 70 million older persons, more than twice their number in People 65+ were 12.4% of the pop. in 2000 but are expected to grow to be 20% of the pop. by Source: Administration on Aging (

11 Life Expectancy and Ten Year Survival A. Life expectancy by age for all men. At age 70 life expectancy is 11 yrs B. Ten year survival by patient age. At 70 52% of men will survive 10 years Corral DA and Bahnson RR. J Urol May;151(5):1326-9

12 Improved Treatment Strategies Endorectal MRI Nomograms Nerve Grafting

13 Improved Cancer Detection Through Imaging Endorectal MRI/Spectroscopy Potential improvement over ultrasound Biochemical gradients to decipher cancer from benign Remains investigational Possible role in high risk patients

14 * * * Image 8 I mm Image 9 I mm H H H H H H H H H H H H H H sc vc H H H H H H H vc H H H H H

15 Treatment Stratifications Allow for improvement in patient understanding More objective in guiding treatment decisions Less physician bias

16 Palm Pilot Nomogram Software Includes pretreatment and postoperative predictions. Uses published nomograms in prostate cancer.

17 Technical Improvements in Surgery Nerve Grafts Cavernosal nerves necessary for postoperative erectile functions In advanced disease, nerves may need to be resected to obtain a negative margin Sural nerve or genitofemoral nerve serve as sources of nerve grafts in this setting

18 What s Next Improvements in Surgical Technique have Stagnated Re-birth in Perineal Prostatectomy

19 Robotic Prostatectomy

20 Da Vinci Instrumentation

21 da Vinci System: 3-D vision Stereoscopic design with two 3-chip cameras 75% better resolution than any imaging system Open surgery orientation

22 da Vinci System: Endowrist Technology 6 Degrees of freedom Surgical hand movements are transposed to the instrument tips Ability to scale motion

23 History Of Laparoscopic Surgery Guillonneau and Vallancien Montsouris Technique If this laparoscopic procedure is shown to be equivalent or better, it may replace open retropubic radical prostatectomy. June 2000 Guillonneau and Vallancien, J Urol, 163: 1643, 2000

24 Enhances Laparoscopy Eliminates Counter-intuitive motion Instrument tremor Provides Improved ergonomics Hand / eye alignment Transforms 2-D vision to true 3-D 4 DOF instruments to 6 DOF (greater endoscopic dexterity)

25 Disadvantages Loss of tactile feedback Set-up time Surgeon away from OR table Conversion Communication Limitation of instrumentation Cost

26 Robotic Assisted Laparoscopic Urology Extirpative Nephrectomy Partial Nephrectomy Prostatectomy Adrenalectomy Intra-abdominal orchiectomy RPLND/PLND Reconstructive Pyeloplasty Birch Procedure Colposuspension Cyst Marsupilization Varicocelectomy

27 Robotic Assisted Laparoscopic Urology Extirpative Prostatectomy Partial Nephrectomy RPLND Reconstructive Pyeloplasty

28 Ureteral spatulation

29 Anastomosis

30 Ureteral stent

31 Functional Outcome: Robotic Prostatectomy vs. Radical Retropubic Prostatectomy Continence Erections Intercourse Tewari et al. BJU Int. 92, , 2003

32 Comparison to the Gold Standard

33 The European Experience Cathelineau et al. Urol Clin NA, 31: , 2004

34 Further Comparison

35 The Robotic Experience Worldwide

36 Patient Positioning

37 Port Placement 5mm 12mm 12mm 9cm U 8cm 5mm Davinci Davjnci

38 Entering the Space of Retzius Incise median umbilical ligaments Drop bladder Expose endopelvic fascia Adequate exposure/mobilization facilitates dissection of prostate base/node dissection

39 Endopelvic Fascia/Dorsal Vein Begin lateral to puboprostatic ligament and medial to levator ani Critical in facilitating apical dissection 80% of prostate cancer comes within 8mm of prostatic apex Place DVC stitch distal to prostatic apex

40 Bladder Neck/Seminal Vesicles Biologic significance of + BN margin well documented Wide excision necessary Send frozen section to confirm absence of any prostatic tissue Guide to intraoperative decisions: a.) site specific biopsy labeling b.) DRE c.) endorectal MRI Inspect for median lobe Compete removal of SV necessary Judicious use of electrocautery at SV tip Proper dissection of SV sets up posterior plane

41 Pedicles/Nerve Sparing Begin posterior dissection beneath the posterior layer of Denonviller s Fascia 25% of men with palpable nodule on DRE will have ECE posteriorly Pedicles taken with clips Antegrade nerve sparing

42 Urethral Incision/Apical Dissection Incise DVC distal to prostatic apex Place 2 nd stitch into DVC if necessary Avoid distal urethral dissection maintain maximal functional urethral length

43 Anastamosis Running suture with 2.0 monocryl

44 Video Footage

45 Results of First 50 Oncologic: Pos. Margin Rate: 6/50 (12%) Continence: -97% of catheters removed at 7 days -3 patients with high JP output -86% of patients with <1 pad at 6 weeks -0% patients with bladder neck contracture Potency: Too early to characterize Post operative Complications: -one patient required take back for incarcerated hernia -no blood transfusions -mean operative time at 238 minutes -72% of patients discharged < 24 hours

46 Urology Gold Journal, 4/03 Robotic Radical Prostatectomy And The Vattikuti Urology Institute Technique p Robotic assistance offers an open surgeon sophisticated tools to perform complex laparoscopic surgery. A technologically advanced ergonomic operation is achieved because of 3-dimensional visualization; wristed instrumentation; intuitive, fingercontrolled movements; and a comfortable seated position for the surgeon

47 Urology Gold Journal, 4/03 Robotic Radical Prostatectomy And The Vattikuti Urology Institute Technique p Data Collection: First 200 patients Title ff Blood Transfusions: 0 Avg. Operative Time: 160 min. Avg. Blood Loss: 153 ml. Avg. Catheterization time: 7 days Positive Margins: 6% Continence at 6 mos.: 96% Avg. Hospital Stay: 1.2 days Patients discharged Within 24 hours: 93% Potency (men 60 yr) at 6 mos: 82% Had Return of Sexual Function 64% Had Sexual Intercourse

48 da Vinci Benefits: The Patient Shorter hospital stay Less post operative pain Less risk of infection Less blood loss and transfusions Less scarring & improved cosmesis Faster recovery and return to normal daily activities Dave Kinsey, Robotic Prostatectomy Patient

49 Is It Any Better? Comparable results can be achieved Learning curve reasonable Long term results await Robotic surgery will have a role as long as prostatectomies exist