Prostate removal surgery, like all surgeries, has gone through evolutionary advances. State-of-the-art prostatectomies are robotic, but the first surgical method for prostate cancer was open or traditional surgery, which led to laparoscopic and finally robotic techniques. The volume of robotic procedures has increased dramatically since 2002, when laparoscopic surgeries outnumbered robotic.
The evolutionary leap afforded by robotic technology essentially boils down to vision. Open surgery requires a large incision running midline from pubic bone to navel and retractors to pull tissue and muscles away from the surgical field. When a cut of this magnitude is made, blood loss is significant, as are pain and recovery time. Blood pools at the site, making it difficult to see tissue, so an open surgeon relies heavily on feel.
A robotic prostatectomy requires 5 small incisions, each about one-quarter of an inch in the lower abdomen, through which instruments are inserted. A sophisticated video camera is one of the instruments, which gives surgeons a three-dimensional, 10x magnified field of vision. This makes the operation far more exact. In addition to the visual clarity provided by the camera, there’s virtually no blood clouding the surgical site and obstructing vision. Cameras are also used in laparoscopic surgeries, but they provide only a two-dimensional image and no magnification.
Prostatectomy – Incontinence
Loss of bladder control, or urinary incontinence, is a potential side effect of radical prostatectomies (complete removal of the prostate gland). Because the prostate sits just below the bladder and encircles the urethra, the urinary tract may be damaged during a radical prostatectomy. In the hands of an experienced robotic surgeon, who preserves the urinary sphincter and competently rebuilds the urinary tract, there may be no resulting incontinence. Because open prostatectomies are less precise than robotic, and the surgical site is visually more restricted, urinary incontinence is more common after open prostate surgery. The increased definition available from the robotic camera compared to the laparoscopic, means a corresponding increase in an unharmed urinary tract, and little or no incontinence from a radical robotic prostatectomy after several weeks of healing.
Prostatectomy – Impotence
One of the great advancements made possible by robotic prostatectomies is nerve sparing. Nerve sparing is crucial for retaining sexual function since severing or damaging the cavernous nerves causes erectile dysfunction. These nerves course laterally along the prostate and rectum and provide nerve connections to the proximal penis deep in the pelvis. If they are damaged, erectile function is, too. Put simply, preserving the cavernous nerves preserves sexual potency. There are treatments for erectile dysfunction resulting from radical prostatectomies, but every patient, of course, wants to retain natural sexual function. Often, but not always, the open surgery technique inadvertently results in damage to one or both of the cavernous nerves.
Prostatectomy – Recovery
Recovery time is substantially improved for robotic prostatectomies in comparison to open prostate surgery. As mentioned earlier, the much larger incision required in open surgery means pain is greater and recovery longer. More than 90% of patients are released within 24 hours of having a robotic prostatectomy, whereas around 80% of open prostatectomy patients leave the hospital within the first day.
Eradicating prostate cancer is the true measure of a surgery’s success, be it open, laparoscopic or robotic. Nowhere is the evolutionary progression more pronounced than with this marker. The positive surgical margin is the measurement used to determine whether any cancer remains or is likely to recur. A physician always seeks low positive margins. In a recent study, there was a steep drop-off in positive margins from open, to laparoscopic to robotic. Open prostatectomies received a positive surgical margin of 23%, laparoscopic one of 19% and robotic prostatectomies got a positive margin of 12%. Mt. Sinai’s positive margin rate for radical robotic prostatectomies was even better at just a little over 6%.
A prostate cancer patient may now expect to have his cancer cured, remain continent and retain sexual function. This was unthinkable not too long ago.Oncology