Robotic assisted laparoscopic radical prostatectomy is a type of keyhole surgery for prostate cancer. It is very similar to laparoscopic radical prostatectomy, however the instruments are held by mechanical arms that are controlled by the surgeon at a console, rather than holding the instruments directly. This has some advantages and disadvantages.
The procedure done today has evolved over many years and generations of machines. In the late 1990’s initial reports of laparoscopic radical prostatectomy were published. At the time, open surgery was the only surgical option, with blood loss, erection problems and long hospital stays were common. Keyhole surgery was becoming established for other surgeries and a German group set to see if it would be possible to take the benefits of keyhole surgery to the tight space of the male pelvis. They concluded that it was possible, but very difficult and not worth pursuing. This all changed in 1999 when a French group of surgeons presented a large series of cases and a modified technique that was teachable and reproducible.
The main benefits at the time were much less blood loss and a one day hospital stay. Surgeons from around the world now wanted to offer this procedure to their patients and the majority of the original French surgeons were lured to the USA to teach and lead in the large US institutions. The benefits of keyhole surgery were clear,
Less blood loss
Very low transfusion rates
Short hospital stay
Less wound complications
Shorter catheter time
Better nerve sparing
But, there were limitations. The excellent results achieved by the top surgeons were hard to achieve for most others. The operation proved hard to learn and even harder to master. Surgeons needed to learn how to operate with limited feel, with instruments that had a small range, whilst looking at a TV screen in 2D.
All movements were a mirror, up to go down, left to go right etc. Attempts to make the instruments more like a human hand were complex and expensive.
Good results for laparoscopic radical prostatectomy was achieved only by those who dedicated significant time to training and regularly performed the surgery.
With the benefits of minimally invasive surgery becoming clearer the launch of robotics at the start of the 21st century was met with enthusiasm.
DaVinci Mechanical Knight
Leonardo DaVinci Mechanical Knight
Xi Arms Fanned
Da Vinci Robot
Leonardo DaVinci had described a model for his mechanical knight, a pair of arms controlled remotely by pulleys and levers, a system not dissimilar to the first generation Da Vinci surgical system. The first generation had only two arms and a camera holder, with a third arm added soon after. It had vision poorer than laparoscopic surgery, but in 3D with the instruments controlled at a console.
This took all sense of feel away from the surgeon. Compared to todays systems, the arms were very bulky and the instruments less capable, however the surgery was much more intuitive than standard keyhole surgery. The 3D view was more natural and there was no need to move in the opposite direction to where you wanted to go.
The instruments had a wristed action, making it feel as though you were operating with two small hands inside the patient. Robotic assisted surgery soon took off, with the expensive machines bought by hospitals keen to expand their services. Surgeons transitioned from open surgery to the new minimally invasive technique at a rapid rate. The Da Vinci was a commercial success, as the only robotic surgical system in the world. Unlike laparoscopic surgery, surgeons transferred to the robot surgery with minimal training and initially little oversight on their results. Problems were encountered due to the need for a steep head down position, long operations and unsuspected diathermy injuries to nearby organs from faulty injuries. The inferior view and limited instrument choices were also a problem. The FDA in the US investigated a spike in complications reported in 2013 and by Oct 2013 around 50 lawsuits were underway.
The company responded with a complete revamp of the system, launched in 2014. The patient cart moved to an overhead architecture, to reduce the need to head down positioning and look greater access to the abdomen with flexible port positioning. The arms were redesigned to allow greater movement and reach. They were made smaller to stop clashing and instruments resigned to prevent diathermy injury from faulty instruments. The vision system underwent a significant upgrade and the machine was made much easier to set up and use.
With the previous problems resolved and the major advances of the Da Vinci Xi, the first machine in Southern Hemisphere was purchased by Hollywood Hospital in 2014. We began surgery with the DaVinci system in late 2014, performing over 100 cases in 2015. We now have over 15 yrs experience in keyhole surgery, having performed over 1300 keyhole radical prostatectomies. Virtually all of these are now done using the DaVinci Xi system. This has allowed us to increase the use of keyhole surgery to more cases by improving access and flexibility over standard keyhole surgery
Advantages Over Laparoscopic Surgery
Image – The image is now higher definition than lap surgery and in 3D. The camera is under surgeon control, providing a stable, magnified view. The view is critical to performing an accurate cancer operation that preserves function. The Xi machine has the best vision system seen on a robot console.
Instruments – The longer instruments overcome issues of reach in larger patients. They are wristed, which enables better access to the male pelvis. This has been most beneficial in cases with locally advanced cancer, nerve sparing, lymph node dissection and where space in the pelvis is especially tight. The surgeon can now control 3, rather than 2 instruments at once by using the hands and feet at the same time. 4 of the 6 ports are under surgeon control. Access – The Xi instruments have a very wide range of motion enabling dissection through the whole pelvis without the clashing previously seen.
Shorter surgery times – Complex parts of the operation are made easier by the dexterity of the instruments, reducing anaesthetic and surgery times.
The Xi system has the promise of true single port surgery, with all the instruments inserted through a single abdominal incision.