RADICAL PROSTATECTOMY

1-In 2007, prostate cancer was the most common newly diagnosed cancer among men in the United States. Although the incidence rates and mortality rates associated with prostate cancer have shown an overall declining trend, widespread screening and early diagnosis makes the management of clinically localized prostate cancer an ongoing challenge. After Walsh et al popularized the technique of anatomic nerve-sparing radical prostatectomy, open radical prostate surgery became a more desirable treatment for organ-confined prostate cancer.

2-The image below depicts a portion of a minimally invasive radical prostatectomy. Laparoscopic and robotic radical prostatectomy. In Laparoscopic and robotic radical prostatectomy. Incision of the endopelvic fascia. Courtesy of Vattikuti Urology Institute - Henry Ford Health Systems.

3- Diagnosis and Staging, a Critical Images slideshow, to help determine the best diagnostic approach for this potentially deadly disease.

4-Also, see the Advanced Prostate Cancer: Signs of Metastatic Disease slideshow for help identifying the signs of metastatic disease.

5-The first successful laparoscopic radical prostatectomies were performed by Schuessler in 1992 and 1997.[1] Unfortunately, the technique did not gain widespread acceptance because of its extreme technical difficulty and because it offered no advantage over the criterion standard of open radical retropubic prostatectomy. The initial series reported operative times that ranged from 8 to 11 hours and a mean hospital stay of 7.3 days.

6-The laparoscopic approach gained new attention when 2 French groups published their experience with laparoscopic radical prostatectomy in 1999 and 2000.[2, 3] They reported modifications to the original technique, resulting in operative times that ranged from 4 to 5 hours and had a mean blood loss of 402 mL. The authors also reported a decreased mean hospital stay, due predominantly to earlier removal of the Foley catheter.

7-Even in the hands of these skilled laparoscopists, nerve-sparing dissection and construction of the urethrovesical anastomosis were demanding. With advances in medical technology, improved optics, and the widespread use of new laparoscopic instrumentation such as ultrasonic cutting and coagulating devices (eg, Harmonic scalpel), laparoscopic radical prostatectomy began to gain acceptance and was increasingly performed in several high-volume centers worldwide. However, the technical demands of laparoscopic radical prostatectomy prevented its widespread use by the average urologist and thus limited penetration.

8-The next significant advance in the surgical treatment of localized prostate cancer was the development of robotic surgical technology. Initially developed by the United States Department of Defense for use in military battlefield applications, robotic technology was adapted for civilian use through the entrepreneurial efforts of 2 rival corporations, Intuitive Surgical, Inc, and Computer Motion, Inc. These companies simultaneously developed robotic interfaces for use in human surgical applications. Computer Motion, Inc, introduced the Zeus Surgical System at approximately the same time that Intuitive Surgical, Inc, developed its da Vinci Surgical System.

9-Both technologies relied heavily on a laparoscopic patient-robot interface in which instruments were placed through small trocars implanted in the patient’s skin. The working field was maintained predominantly by insufflation of the peritoneal cavity with carbon dioxide. Subsequently, Intuitive Surgical, Inc, acquired Computer Motion, Inc, consolidating the robotic surgical technology and making Intuitive Surgical, Inc, the sole provider of advanced robotic technology for use in human surgical procedures.

10Several other companies also develop and manufacture robotic surgical technology, including single robotic arms for laparoscopic cameras or as part of integrated minimally invasive operating-room systems, but none of these rival technologies can compete with the advanced robotic engineering by Intuitive Surgical, Inc.

11-The da Vinci Surgical System consists of a 3- or 4-armed robot connected to a remote console. The surgeon operates the system while seated at the console. Foot pedals are used for control, and 3-dimensional displays provide a unique and novel depiction of the surgical field not previously incorporated in other systems. Typically, 8- to 10-mm ports are used for the instruments, which have 7° of freedom, including rotation capabilities (ie, mimicking the movements of the human wrist), and a special robotic EndoWrist. The first reported robot-assisted laparoscopic prostatectomy using the da Vinci system was described by Abbou et al in 2001.[4] Several other groups have also published their experience with the technique.[5, 6] Rise of robotic radical prostatectomy

12- Menon et al from the Vattikuti Urology Institute at Henry Ford Hospital in Detroit, Michigan, are responsible for the development and popularization of robotic radical prostatectomy.[7, 8, 9, 10] This technique has been gaining widespread acceptance in the United States and Europe and is increasing in penetration worldwide.[11] Robotic radical prostatectomy offers the advantages of the minimally invasive laparoscopic approach but shortens the learning curve, facilitating and hastening mastery of the procedure.

13- Although solid basic laparoscopic skills are required for access and assistance, the console surgeon role requires less laparoscopic skill. Therefore, the procedure is accessible to experienced open-procedure surgeons with minimal or no laparoscopic experience. In a published report, Badani et al have performed more than 2700 robotic prostatectomies and have reported a mean operative time of 154 minutes, a mean blood loss of 100 mL, and hospital stays of less than 24 hours in 96.7% of patients.

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