Robot in Prostate Cancer; Robotic Radical Prostatectomy, Robotic Lymph Node Dissection
What does the prostate do?
The prostate is a walnut-sized (15-20 grams) gland located just below the urinary bladder, where some of the semen content in men is produced. While the prostate plays a role in the fluidity of the semen with the fluids it secretes, on the other hand, it regulates the urine flow through the urinary canal. In addition, it is adjacent to important anatomical structures. Nerves that pass right next to the prostate capsule make the penis hard. In the same way, the muscle structures that we call the sphincter, which enable urinary retention, are in close neighborhood with the prostate tissue. Prostate cancer occurs with the abnormal development of these secretory cells in the prostate.
What is the purpose of the surgical treatment of prostate cancer?
It is the removal of prostate tissue in a way that does not leave cancerous tissue behind, protecting the nerves that provide sexual functions and not damaging the structures that control urine.
What is the difference between robotic prostate cancer surgery and open method?
Classical surgery has many difficulties for both the patient and the surgeon. In the classical open surgery method, a large incision (10-12 cm) is made below the umbilicus of the patient (figure 1). This causes the patient to recover late after surgery, to stay in the hospital longer, to be exposed to a greater risk of wound infection, and to cause large scarring in the patient. The narrowness of the surgical field, on the other hand, causes insufficient hand movements, a good field of view and a long operation time, which can be considered difficulties for the surgeon.
Figure 1: Incision made in open radical prostatectomy technique
How is robotic prostate cancer surgery performed?
In robotic surgery, this operation has become possible from very small incisions. Robotic surgery is performed with robot arms and cameras and instruments placed on them. The robot has 4 working arms. One of these arms is equipped with a camera to view the operating field, and the other three arms are equipped with robotic instruments that allow the surgeon to operate. Three incisions with dimensions of 0.8 cm and one incision of 1.2 cm are made at the level of the patient's navel region, and these instruments are placed in the abdomen. In addition, an additional 1.2 cm incision is made for use by the bedside assistant, and an assistant trocar is placed here to give the surgeon the material needed during the operation. As a result, 5 incisions with dimensions of 0.8-1.2 cm are made in the abdomen of the patient in robotic surgeries of prostate cancer (figure 2).
Figure 2: Placement of working channels (trocars) in robotic radical prostatectomy technique
In this procedure, the prostate, seminal vesicles, the prostatic ends of the vas deferens are removed (robotic radical prostatectomy). The bladder neck and the external urinary tract, which we call the urethra, are anastomosed end-to-end (figure 3). In necessary cases, the lymph nodes of the prostate are also removed in the same session (robotic lymph node dissection). After robotic prostate cancer surgery, the cancerous prostate tissue is placed in a special package. At the end of the surgery, one of these incisions is slightly enlarged and the prostate is removed from here (figure 4).
Figure 3: Schematic view of the robotic radical prostatectomy technique
Figure 4:Prostate (star), seminal vesicles (blue arrows) and ends of vas deferens (red arrows) that I removed after robotic radical prostatectomy
Who is suitable for robotic prostate cancer surgery?It is applied to patients whose disease is limited to the prostate, that is, there is no spread (metastasis) outside the prostate. The general condition of the patient and co-morbidities are also factors to be considered when deciding on robotic prostate cancer surgery.
What are the advantages of robotic surgery?
- Less blood loss: Thanks to the special cameras used in robotic surgery, which provide 3D vision, have high image quality, and can enlarge the operation field 12 times, bleeding vessels are more easily noticed during the operation and can be stopped by sealing. In addition, the fact that the abdomen is inflated with gas during the operation in robotic surgery and the gas pressure associated with this helps to prevent bleeding by pressing on the veins.
- Less pain: Patients undergoing robotic surgery have smaller incisions than open surgery. Therefore, these patients feel less pain in the postoperative period and need less pain medication.
- Faster hospital discharge: Because of the smaller surgical incisions, less blood loss, and less postoperative pain in robotic surgery, these patients stay in the hospital less often than other patients who underwent open surgery and are discharged earlier.
- Bettercancer control: Robotic surgery provides better cancer control. Due to the ability of the camera and robot arms with three-dimensional and high-resolution images to move in different planes, cancerous tissue is more clearly recognized and removed during surgery.
- Rapid catheter withdrawal: The catheters of patients who have undergone radical prostatectomy with robotic surgery are withdrawn earlier. That is, the probe residence times are shorter. The probe residence time usually ranges from 5 to 7 days. The reason for this is that in robotic prostatectomy surgery, the urinary bladder, and the external urinary tract, called the urethra, can be sewn to each other in a better and waterproof way.
- Quicker urine control:After prostate cancer surgeries performed with robotic surgery, urine control becomes better and faster. Urinary control is quicker in the postoperative period due to better visualization, less bleeding, better suturing of the bladder and urinary canal, better protection of the bladder neck (figure 5).
Figure 5: Bladder neck (blue star prostate, blue arrow bladder neck) that I protected in one of my patients during the robotic radical prostatectomy operation.
- A quicker return to sexual life: The neurovascular bundle that provides hardening in the male organ passes right next to the prostate. These structures are better recognized and therefore better preserved in robotic surgery. Therefore, returning to sexual life after robotic prostate cancer surgery is earlier (figure 6).
Figure 6: After prostate removal in a patient who underwent nerve-sparing robotic radical prostatectomy, preserved neurovascular bundle is observed on both sides (white arrows)
How long and how many hours does robotic prostate cancer surgery take?
The most important factor determining the duration of robotic prostate cancer surgery is the experience of the surgeon. In addition, factors such as the patient's weight, the size and location of the tumor, the necessity of removing the lymph nodes and previous surgery determine the duration of the operation. Depending on these factors, the duration of this operation varies between 2 and 4 hours.
What are the risks of robotic prostate cancer surgery? Like all other surgeries, robotic prostate cancer surgery has some risks related to anesthesia. To evaluate and minimize these risks, all patients are evaluated by the anesthesiologist before surgery. However, it is also possible to return to open surgery during surgery due to possible adhesions, bleeding, or disruption of the robot device. However, these are rare complications. Does the doctor have an importance in robotic prostate cancer surgery? As in all urological surgeries, it is very important that the surgeon performing the surgery is experienced. After all, the one who controls the robot is a surgeon. For a successful and smoother operation, it is necessary to have an operation with a doctor who is specialized in robotic surgery.