Laparoscopic Robotic Radical Prostatectomy-Bladder Neck Video Clip

YouTube - Broadcast Yourself.

Many patients and colleagues have requested a short video clip. This short segment demonstrates the bladder neck dissection. Half-way through the clip you will see the foley catheter raised anteriorly to expose the posterior bladder neck. The prostate is at the top of the screen, the bladder is at the bottom of the screen.

Laparoscopic Robotic Radical Prostatectomy: Is it the new TURP?

Increasingly, patients are being diagnosed with early organ confined and in some circumstances incidental prostate cancer. Prostate screening programs have led to what some would say is an overly aggressive campaign in which we are diagnosing insignificant prostate cancers. Without a doubt this may be true in some circumstances. Conversely, we are diagnosing aggressive disease earlier and we have observed a stage migration. Ultimatley this should lead to less morbidity and lower death rates from prostate cancer within the screening population.

However, what is the morbidity of treating incidently discovered prostate cancer? Any form of treatment carries the risk for potential urinary incontinence, lower urinary tract symptoms and erectile dysfunction. Could there be a hidden benefit?

An interesting thought recently occurred to me. Do patients whom have had a laparoscopic robotic radical prostatectomy have fewer urinary complaints than most of our patients that are being treated medically for BPH or who have undergone a transurethral prostatectomy (TURP)? Without having done a prospective randomized trial, I would say my personal experience is that most patients undergoing robotic radical prostatectomy on the whole have far fewer urinary complaints and thus lower AUA (urinary complaint) scores than our average patient who is being medically treated or previously undergone a TURP.

Am I suggesting we perform robotic radical prostatectomy in our patients with bladder outlet obstruction secondary to BPH? Certainly, I am not making that recommendation. However, I am intrigued by the question. Is incidently discovered prostate cancer treated with radical prostatectomy (particularly in the often impotent male) any more morbid than a TURP? Is there greater risk?

Would urinary outcomes be better?

We may never have the answer to these questions. As ridiculous as it may seem, there may be a day when laparoscopic robotic prostatectomy replaces TURP. In many circumstances, in practice, is already has replaced the TURP.

Robotic Radical Prostatectomy; The New Gold Standard?

In 2002, Menon et al. reported on their initial experience with the Robotic Radical prostatectomy with the DaVinci robot (Intuitive Surgical Inc, Sunnydale, CA). Five years later the majority of prostate cancer surgery in the United States is now being done robotically. Physicians in my practice adopted the technology early. Since that time four teams of surgeons at 4 different hospitals have a combined experience with the procedure of nearly 2000 cases. Why?

Prostate cancer surgery has an extirpative as well as a reconstructive component. The cancer must be resected with the intent of achieving “negative margins”. At the same time, it is essential to preserve the quality of life our patients. Laparoscopic robotic surgery allow the surgeon to operate under magnification with excellent dexterity. Clearly, debate exists on whether robotics is any better than a standard open procedure. Certain points, however, remain undebatable.

First, robotic radical prostatectomy has consistently in virtually every series shown a lower risk of blood loss. Blood transfusion rate is lower (less than a 1%) than the standard open approaches to prostate cancer surgery (10-30% depending on series). Additionaly, hospital stay is shorter (usually 1 day compared to 2-5 days), and convalescence is shortened. Cancer control (margin status) has been shown to be equal if not better.

While patients with more extensive disease, larger prostates, previous abdominal surgery, or higher body mass indexes (heavier set patients), may still be offered open surgery, we are now routinely are able to offer this subset of patients the robotic approach while achieving excellent outcomes.

Most urologist would agree that this technology is “here to stay”. Robotic surgery is now part of the routine training that Urology residents are receiving at many institutions. As with any new technology or procedure, (laparoscopic cholecystectomy, laparscopic nephrectomy and partial nephrectomy) there always exists a period of time of learning and transition. In the last five years, we have witnessed a very rapid transition from open prostate cancer surgery to robotic laparoscopic prostate cancer surgery. The debate may continue for a number of years on whether it is the new gold standard. However, the ultimate winner will be our patients, who will routinely be offered this procedure when appropiate .

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Introduction

I am a board certified private practice Urologist in a large single specialty group located in Indianapolis. I trained at Northwestern University Feinberg School of Medicine. My subspecialty interests are minimally invasive approaches to prosate cancer and kidney cancer. I have extensive experience in performing laparoscopic robotic radical prostatectomies as well as laparoscopic kidney surgery. These minimally invasive approaches lead to less pain, shorter hospital stay, earlier time to recovery, and allow for excellent functional outcomes for my patients.