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Douglas S. Scherr, M.D. Clinical Director, Urologic Oncology

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. Is The Disease Important?.

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Douglas S. Scherr, M.D. Clinical Director, Urologic Oncology

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  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

  2. Is The Disease Important?

  3. U.S. Incidence and Mortality of Prostate Cancer Surveillance, Epidemiology and End Results (SEER) Data

  4. 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

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

  6. Swedish randomized trial: Surgery v. Watchful waitingSurgical excision alters the natural history of prostate cancer, reducing metastases and cancer-specific mortality by 50% at 8 years. Cancer-specific mortality Distant metastases 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;347:781-789.

  7. 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 (www.aoa.gov)

  8. 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 (www.aoa.gov)

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

  10. 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. 1994 May;151(5):1326-9

  11. Improved Treatment Strategies • Endorectal MRI • Nomograms • Nerve Grafting

  12. Improved Cancer Detection Through ImagingEndorectal MRI/Spectroscopy • Potential improvement over ultrasound • Biochemical gradients to decipher cancer from benign • Remains investigational • Possible role in high risk patients

  13. * * * Image 8 I 54.44 mm Image 9 I 57.56 mm H H H H H H H H H H H H H H H H H H vc sc vc H H H H H H H H

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

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

  16. Technical Improvements in SurgeryNerve Grafts • Cavernosal nerves necessary for post-operative 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

  17. What’s Next • Improvements in Surgical Technique have Stagnated • Re-birth in Perineal Prostatectomy

  18. Robotic Prostatectomy

  19. Da Vinci Instrumentation

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

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

  22. 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

  23. 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)

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

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

  26. Robotic Assisted Laparoscopic Urology Extirpative Reconstructive • Pyeloplasty • Prostatectomy • Partial Nephrectomy • RPLND

  27. Ureteral spatulation

  28. Anastomosis

  29. Ureteral stent

  30. Functional Outcome: Robotic Prostatectomy vs. Radical Retropubic Prostatectomy Continence Erections Intercourse Tewari et al. BJU Int. 92, 205-210, 2003

  31. Comparison to the Gold Standard

  32. The European Experience Cathelineau et al. Urol Clin NA, 31: 693-699, 2004

  33. Further Comparison

  34. The Robotic Experience Worldwide

  35. Patient Positioning

  36. Port Placement 12mm 5mm 8cm 9cm 12mm U 5mm Davinci Davjnci

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

  38. 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

  39. 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

  40. 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

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

  42. Anastamosis • Running suture with 2.0 monocryl

  43. Video Footage

  44. 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

  45. Urology Gold Journal, 4/03 Robotic Radical Prostatectomy And The Vattikuti Urology Institute Technique p.15-20 “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, finger- controlled movements; and a comfortable seated position for the surgeon”

  46. Title Urology Gold Journal, 4/03 Robotic Radical Prostatectomy And The Vattikuti Urology Institute Technique p.15-20 Data Collection: First 200 patients ff Blood Transfusions: 0 Avg. Operative Time: 160 min. Positive Margins: 6% Avg. Blood Loss: 153 ml. Continence at 6 mos.: 96% Avg. Catheterization time: 7 days Avg. Hospital Stay: 1.2 days Potency (men  60 yr) at 6 mos: 82% Had Return of Sexual Function 64% Had Sexual Intercourse Patients discharged Within 24 hours: 93%

  47. 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

  48. 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

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