AUTHOR AND EDITOR INFORMATION

Section 1 of 8  

• Authors and Editors
• Introduction
• Surgical Techniques
• Surgical Approaches
• Advantages and Disadvantages of Robotics Versus Laparoscopy
• Results
• Multimedia
• References

INTRODUCTION

Section 2 of 8  

• Authors and Editors
• Introduction
• Surgical Techniques
• Surgical Approaches
• Advantages and Disadvantages of Robotics Versus Laparoscopy
• Results
• Multimedia
• References

Prostate cancer is the second most common cancer in men, after skin cancer, in the United States, and, in 1990, it was the third most prevalent cancer in European men. After Walsh and Donker introduced the anatomic technique of nerve-sparing radical prostatectomy, open radical prostate surgery became a more attractive and popular treatment for organ-confined prostate cancer. The first successful laparoscopic radical prostatectomy was performed by Schuessler in 1992 and was reported by Schuessler et al in 1997. It did not gain widespread acceptance because of its extreme technical difficulty (operative times ranged 8-11 h, average hospital stay of 7.3 d) and the fact that it provided no advantage over the criterion standard of open radical retropubic prostatectomy.

Guillonneau and Vallancien in 1999 and Abbou et al in 2000, two groups from France, repopularized the laparoscopic approach by describing their modifications to the original technique. Even so, their operative times were 4-5 hours, the urethrovesical anastomosis demanded extremes of technical skill, and the average blood loss was 402 mL. With advances in medical technology, improved optics, and widespread use of laparoscopic aids such as ultrasonic cutting and coagulating surgical scalpels (eg, Harmonic scalpel, Ethicon Endo-Surgery, Inc; Cincinnati, Ohio), laparoscopic radical prostatectomy began to be performed in several centers around the world. However, the technical demands of the surgery prevented its widespread use by the average urologist.

The next significant advance in the surgical treatment of localized prostate cancer was the development of the da Vinci robot (Intuitive Surgicals; Sunnyvale, Calif). This is a system consisting of a 3-armed robot connected to a remote surgeon 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, they mimic 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. Several other groups have also published their experiences (Pasticier, 2001; Rassweiler, 2001).

Menon et al from the Vattikuti Urology Institute in Detroit, Mich, developed and popularized the technique of robotic radical prostatectomy (Menon and Shrivastava, 2002; Menon and Tewari, 2002; Tewari, 2002; Tewari, 2003). This technique is gaining widespread acceptance both in the United States and Europe. It encompasses the advantages of the minimally invasive approach, and the technique has a short learning curve, thus making it easier to master. It demands less technical skill, thereby permitting a surgeon with basic laparoscopic skills to perform the surgery. Menon et al at the Henry Ford Hospital have performed more then 700 surgeries to date, and they report mean operative time of 150 minutes, average blood loss of 130 mL, and hospital stay of less than 1 day.

For excellent patient education resources, visit eMedicine's Prostate Health Center, Cancer and Tumors Center, and Men's Health Center. Also, see eMedicine's patient education articles Prostate Cancer, Prostate Infections, Enlarged Prostate, and Causes of Erectile Dysfunction.

SURGICAL TECHNIQUES

Section 3 of 8  

• Authors and Editors
• Introduction
• Surgical Techniques
• Surgical Approaches
• Advantages and Disadvantages of Robotics Versus Laparoscopy
• Results
• Multimedia
• References

The 2 techniques for performing minimally invasive radical prostatectomy are robotic (robotic radical prostatectomy) and laparoscopic (laparoscopic radical prostatectomy). Either may be performed with a transperitoneal or an extraperitoneal approach.

Laparoscopic radical prostatectomy

The laparoscopic approach uses 2-dimensional monitors and conventional laparoscopic instruments (5 or 10 mm) with a 10-mm 0° and/or 30° telescope. The AESOP (automated endoscope system for optimal positioning) robotic arm may be used as an adjunct to the laparoscopic approach. The AESOP is a voice/pedal/hand-activated arm that holds the camera during the procedure. It provides stability and avoids camera shake caused by an assistant holding the camera. It also affords the surgeon full control over camera movements in 6° of freedom (Hemal, 2000).

Robotic radical prostatectomy

Currently, 2 robotic systems are available and have received approval by the US Food and Drug Administration. These are the da Vinci surgical system and the Zeus robotic surgical system (Computer Motion; Santa Barbara, Calif). Both have similarities in design.

• Surgeon console: This is the user interface of the robot for the surgeon. It consists of the following:
• • Display system: The system is a 2- or 3-dimensional stereoscopic display.
  • Master arms: These are the handles the surgeon uses for making surgical movements. These movements are translated into real-time movements of the instrument tips. They also provide a force feedback to the surgeon. In the da Vinci system, the master can control the camera movement by means of a clutch, whereas the Zeus system uses voice-activated camera controls.
  • Control panel: The control panel is used to adjust the display and control options (eg, 2- vs 3-dimensional, various levels of scaling, 0° vs 30° lens).
  • Central processing unit: This is the computer that controls the system.
• Robotic arms: Included are 2 surgical manipulators to hold the instruments (the newer da Vinci robots have 3 instrument arms) and 1 camera arm to hold the camera. The da Vinci system has the arms mounted on a cart, whereas the Zeus system has them mounted on the operating table.

SURGICAL APPROACHES

Section 4 of 8  

• Authors and Editors
• Introduction
• Surgical Techniques
• Surgical Approaches
• Advantages and Disadvantages of Robotics Versus Laparoscopy
• Results
• Multimedia
• References

Robotic transperitoneal approach (Vattikuti Institute prostatectomy)

The transperitoneal approach to robotic radical prostatectomy was developed and popularized by Menon et al at the Vattikuti Urology Institute at Henry Ford Hospital in Detroit, Mich. It differs from the other techniques in that the dissection proceeds in an antegrade manner and the first step is transection of the bladder neck. This permits the seminal vesicle dissection and all subsequent dissection to proceed in the direction of telescope vision, ie, antegrade, and hence facilitates dissection.

The patient is placed supine, strapped to the table, and placed in steep Trendelenburg position (45°). A total of 6 ports are used in an inverted V-shaped configuration. The Veress needle is used to establish the pneumoperitoneum, and a 12-mm port is placed just to the left of the umbilicus (camera port). A 30° upward-looking lens is then used to place the remaining ports; two 8-mm ports are placed as mirror images of each other, 10-12 cm from the camera port and 2 fingerbreadths below it. Two ports are placed in the right lower quadrant, (1) a lateral 10-mm port just above the right anterior superior iliac spine for retraction and passage of sutures and (2) a medial 5-mm port for suction and irrigation midway and slightly inferior to the umbilicus and right robotic port. Finally, a 5-mm left lateral port is placed as a mirror image of its right-sided counterpart.

The robot is then docked, and the robotic instrument ports and the camera port are fixed to the arms of the robot. This procedure takes approximately 15 minutes.

Development of the extraperitoneal space

This step is performed using a 30° upward-looking lens. A transverse peritoneal incision is made extending from the left to the right medial umbilical ligament and extended in an inverted U-shaped manner to the level of the vasa on either side. The extraperitoneal space is developed after transecting the medial and median umbilical ligaments. This dissection allows the bladder, prostate, and bowel to drop posterior and the remainder of the operation to be performed extraperitoneally.

Lymph node dissection

A 0° lens is used for optimum visualization, and 1:3 scaling is used for lymphadenectomy. Lymphadenectomy is performed if the preoperative serum prostate-specific antigen (PSA) value is higher than 10 ng/mL, biopsy Gleason score is greater than 6, or more than 50% of the biopsy cores are positive for cancer. The nodal package is sent for frozen section analysis only if the nodes appear enlarged.

Exposure of prostatic apex and endopelvic fascia

The 0° lens with 1:3 scaling is used for this part of dissection. This fascia is incised using the da Vinci hook or spatula. Dissection is carried distally until the urethra, with the surrounding puboperinealis muscle, is exposed and superior until the prostatovesical junction is identified.

Dorsal vein stitch

The nonscaled setting is used for this step. A figure-of-eight stitch is placed around the dorsal venous complex using a 6-inch, 1-0 polyglactin suture on a CT-1 36-mm taper needle. An additional suture is placed midway between the apex and base of the prostate for traction and rotation of the prostate during posterior dissection.

Retroapical dissection and release of the neurovascular bundle

The plane behind the prostatourethral junction is developed using a combination of blunt and sharp dissection. This dissection helps enormously to precisely identify the posterior apical margin of the prostate at the time of detachment of the specimen.

Bladder neck transection

The assistant provides vertical traction on the prostatic suture, and the anterior wall of the bladder is incised until the Foley catheter is observed. The assistant then retracts the catheter to provide countertraction as the posterior bladder wall is cut. The bladder neck is not preserved, and the bladder neck incision is elliptical so that the posterior lip is slightly longer than the anterior lip. This maneuver helps in better visualization of the posterior suture line during anastomosis. Using the da Vinci long-tip forceps, the surgeon grasps the cut end of the posterior bladder neck in the midline and gradually dissects it away from the prostate. The anterior layer of Denonvilliers aponeurosis (fascia) is now exposed. It is incised, exposing the vasa and seminal vesicles.

At this point, the left assistant retracts the posterior lip of the prostate anteriorly while the right assistant depresses the bladder posteriorly. This provides a clear operative field for dissection of the vas and seminal vesicles. The vasa are transected, and the seminal vesicles are skeletonized, avoiding damage to the neurovascular bundles.

Posterior dissection

Once the seminal vesicles are freed, the left assistant retracts the seminal vesicles anteriorly. At this point, the posterior layer of Denonvilliers aponeurosis can be observed between the 2 lateral prostatic pedicles. This fascia is incised close to the prostate, and a plane is developed between the prostate anteriorly and the rectum posteriorly. The plane of dissection leaves the most posterior layer(s) of Denonvilliers aponeurosis on the rectum. This dissection is carried down to the apex of the prostate.

Control of the lateral pedicles and the veil of Aphrodite (preservation of the neurovascular bundles)

The lateral pedicles at the prostate vesical junction are controlled using Hem-o-lock clips and bipolar coagulation (Van Velthoven, 2003). The clips are applied close to the prostate, and the pedicle is divided between them. Once the dissection enters the plane between the prostatic fascia medially and the levator fascia laterally, electrocautery is avoided and the anterior nerve-sparing dissection proceeds using sharp cutting with scissors and blunt dissection using the grasper. This dissection proceeds distally to the puboprostatic ligaments.

Incision of the dorsal venous complex and urethra

This is the final step of the dissection. Using a 0° lens with 1:3 scaling, the dorsal venous complex is incised tangential to the prostate to avoid capsular incision. A plane between the urethra and dorsal venous complex is gently developed to expose the anterior urethral wall. A van Buren urethral sound is used to identify the anterior surface of the urethra at the urethroprostatic junction. The anterior wall of the urethra is transected with the scissors a few millimeters distal to the apex of the prostate. The posterior wall of the urethra and the rectourethralis muscle are cut under direct vision. The freed specimen is then examined for adequacy of resection margins and is placed in a specimen retrieval bag.

Urethrovesical anastomosis

The urethrovesical anastomosis is performed using an MVAC suture (two 3-0 Vicryl sutures, one dyed and the other undyed, tied to each other to form a double-ended suture on RB-1 needles each 6 inches in length). The initial throw is placed outside in the bladder at the 5-o'clock position, and the dyed suture is pulled through so that the knot lies securely on the outside wall of the bladder posteriorly. The dyed suture is then used as a running stitch to suture the posterior bladder wall to the urethra. The dominant hand is used for the urethral pass, and the nondominant hand is used for the vesical pass. Approximately 5-6 throws are made posterior, with the assistant on the right side placing slight tension on the suture. At the corner, the surgeon reverses the suture within the bladder lumen and passes the suture outside-in on the urethra.

The post suture ends at the 11-o'clock position and is held on traction by the left assistant to prevent loosening of the stitch. The undyed suture is then used to perform the anterior part of the urethrovesical anastomosis extending from the 5-o'clock position to the 12-o'clock position. The 2 sutures are now tied to each other to complete the anastomosis. The bladder is irrigated with 200 mL of saline to look for any leaks. If a leak is found, reinforcing sutures are placed. A 20F indwelling Foley catheter is placed, and the balloon is filled with 30 mL. The specimen is retrieved and ports closed.

Robotic extraperitoneal approach

Abbou et al, from Hopital Henri Mondor, Creteil, France, published their small series of 4 patients treated with a robotic extraperitoneal approach. The patient is placed supine with 15° Trendelenburg position. A 3-cm horizontal incision is made 1 fingerbreadth below the umbilicus, and the preperitoneal space is entered. A blunt port Hasson canula is placed, and the preperitoneum is insufflated to 18 mm Hg. The space of Retzius is developed by blunt dissection using a conventional laparoscope until the pubic symphysis is reached. A 5-mm port is then placed in the midline 2 fingerbreadths above the symphysis to further develop the retropubic space. The right and left extraperitoneal robotic instrument ports are placed 4 cm below the camera port at the pararectal line. Two additional assistant ports are placed on the right side, (1) the first at the level of the umbilicus above the right robotic instrument port and (2) the second to the right and in line with the right robotic instrument port.

The procedure essentially follows the same steps of the Vattikuti Institute prostatectomy, but the dissection is entirely extraperitoneal. The Creteil group uses a 2-0 polyglactin on a 26-mm needle for the dorsal venous stitch and a 3-0 polyglactin on a five-eighths circle tapered cutting needle for the running vesicourethral anastomosis.

Laparoscopic transperitoneal approach

The widely used transperitoneal approach is the Montsouris technique described by Guillonneau and Vallancien from the Institut Mutualiste Montsouris, University Pierre et Marie Curie, Paris, France. The patient is placed supine with the arms at the sides and the legs spread apart. The patient is placed in extreme Trendelenburg position. One surgeon and one assistant perform the operation, with a right-handed surgeon standing on the left side of the patient. The Montsouris group uses the AESOP voice-controlled robot to hold the telescope.

Five ports are placed in a diamond configuration, (1) a 10-mm telescope port at the umbilicus, (2) a 10-mm port at the McBurney point, (3) a 5-mm port at the midpoint between the umbilicus and the pubis symphysis in the midline, (4) a 5-mm port at the midpoint between the left anterior superior iliac spine and the umbilicus, and (5) the final 5-mm port at the right pararectal line at the level of the umbilicus. The abdomen is initially inspected, and a pelvic lymphadenectomy is performed if required.

The procedure is begun with incision of the peritoneal fold between the rectum and bladder and the dissection of the seminal vesicles posteriorly. The seminal vesicles are retracted anteriorly, and the Denonvilliers aponeurosis is incised. The dissection is carried distally to the level of the rectourethral muscle, separating the prostate anteriorly from the rectum posteriorly. Attention is then directed anteriorly, and the peritoneum is incised to enter the space of Retzius, thereby causing the bladder to fall posteriorly. The endopelvic fascia is incised, and the levator muscle is pushed laterally to free the prostate gland. This is followed by ligation of the dorsal vein. The next step is incision of the bladder neck.

Finally, the lateral pedicles are dissected, and the urethra is transected to free the prostate gland with the seminal vesicles. The last step of the surgery is construction of the urethrovesical anastomosis. The Montsouris group performs the anastomosis with interrupted 3-0 resorbable sutures on a five-eighths needle. A total of 8 sutures are placed. Finally, a drain is placed, and the ports are closed.

The advantages of the transperitoneal approach include familiarity with anatomy, adequate space for dissection, and the presence of several reference points to aid the surgeon in orientation. Maximum mobility of the bladder is achieved in this approach, which helps provide a tension-free urethrovesical anastomosis.

Disadvantages of the transperitoneal approach include communication of the anastomotic site to the peritoneal cavity with the potential for peritoneal urine leak and ascites. The transperitoneal approach also increases the risk of bowel injury, ileus, and adhesions. However, a multiinstitutional review of complications cited a 1.2% incidence of bowel injury after laparoscopic radical prostatectomy.

Laparoscopic transperitoneal approach

Rassweiler et al from Klinikum Heilbronn, University of Heidelberg, Heilbronn, Germany, published a modification of the transperitoneal technique. They used a W-shaped port placement with 5 ports placed initially transperitoneally. The sixth port is placed in the right lower abdomen after access to the space of Retzius. The dissection is started distally, with incision of the endopelvic fascia, ligation of the dorsal venous complex, and transection of the urethra. The Foley catheter is held and pulled cephalad for retraction. The prostate is dissected starting distally and progressing proximally with division of the Denonvilliers aponeurosis to separate the rectum posteriorly. The lateral pedicles are clipped, and the neurovascular bundles are spared.

Once this part of the procedure is completed, the dissection shifts to the bladder neck, which is transected. The Foley catheter is now used as a loop retractor, and the vasa and seminal vesicles are dissected off the posterior bladder. Finally, the urethrovesical anastomosis is performed. The anastomosis is performed with a 15- to 17-cm 3-0 polydioxanone suture on an RB-1 needle using 5 interrupted sutures at the 6-o'clock position, followed by sutures at the 5-, 3-, 7-, and 9-o'clock positions, respectively.

Laparoscopic extraperitoneal approach

This approach was first described by Raboy, from Staten Island University Hospital, Staten Island, NY, in 1997 as a simulation of the open retroperitoneal approach to the prostate. The patient preparation, position, and draping are similar to the transperitoneal technique except that a steep Trendelenburg position is unnecessary.

A 1-cm infraumbilical incision is made and carried down to the preperitoneal space, which is bluntly dissected, and a Hasson canula is placed in this space. The extraperitoneal space is then developed by either blunt dissection using additional trocars or by using a visual balloon-dilating trocar or Gaur balloon dilator. Once the space is developed, the steps of the surgery mimic those of the transperitoneal approach except that the seminal vesicles and vas are dissected after transecting the bladder neck.

Theoretical advantages of this approach include its feasibility in patients who have had extensive abdominal surgeries and its minimal associated risk of bowel injury. The peritoneum acts as a self-retractor for the intestines, thus obviating the need for steep Trendelenburg positioning. Reports of simultaneous inguinal hernia repairs using prosthetic mesh have been published. The most significant limitation of this approach is the lack of adequate space for dissection and suturing. Also, because the peritoneal and urachal attachments of the bladder are not divided, tension at the urethrovesical anastomosis is a concern. As a result, the extraperitoneal approach should only be performed by experienced laparoscopic surgeons.

ADVANTAGES AND DISADVANTAGES OF ROBOTICS VERSUS LAPAROSCOPY

Section 5 of 8  

• Authors and Editors
• Introduction
• Surgical Techniques
• Surgical Approaches
• Advantages and Disadvantages of Robotics Versus Laparoscopy
• Results
• Multimedia
• References

The robotic techniques have several advantages over laparoscopic techniques for performing radical prostatectomy.

• Because the display system of the da Vinci projects the image in the direction of the surgeon's hands, the hand-eye coordination is restored (no hand-eye coordination in laparoscopy).
• The 11-mm telescope in the da Vinci system is a combination of two 5-mm optical channels (one for the right and one for the left eye), which have 2 separate 3-chip–charged coupling devices in the camera head. The 2 images are displayed to provide 3-dimensional stereoscopic vision to the surgeon, hence providing depth perception lacking in laparoscopy.
• The movements of the robotic system are intuitive (ie, a movement of the master control to the right causes the instrument to move to the right), as opposed to the counterintuitive movements in laparoscopy (ie, movement of the laparoscopic instrument to the right by the surgeon causes the tip of the instrument to move to the left inside the patient's body).
• The robotic systems provide increased precision by filtering hand tremors, providing magnification (10X or 15X), and providing scaling for the surgeon's movements (a 1:3 scaling means that a 3-inch movement of the master is translated into a 1-inch movement of the instrument tip).
• The robotic instruments have articulated tips, which permit 7° of freedom in movements (ie, they mimic human wrist movements, including rotation), which is unlike laparoscopy, with which only 4° of freedom are permitted.

Robotic techniques also have disadvantages.

• The current-generation robots are bulky and limit the working space of the assistants.
• Availability of instrumentation for the robotic systems is presently limited.
• Economically, the robotic system is viable only for centers with a high volume of cases. The system costs approximately $1 million, and the annual maintenance cost is an additional $100,000.

RESULTS

Section 6 of 8  

• Authors and Editors
• Introduction
• Surgical Techniques
• Surgical Approaches
• Advantages and Disadvantages of Robotics Versus Laparoscopy
• Results
• Multimedia
• References

The results of minimally invasive radical prostatectomy can be categorized as operative, referring to perioperative and delayed complications, and functional, referring to oncologic efficacy, erectile function, and continence.

Laparoscopic radical prostatectomy

Operative outcomes

The major advantages of laparoscopic radical prostatectomy over open radical prostatectomy relates to lower blood loss and transfusion rates, lower perioperative morbidity and analgesic requirements, and quicker convalescence, including early return to work (Guillonneau, 1999; Abbou, 2000; Guillonneau, 2000; Binder, 2001; Türk, 2001; Bhayani, 2003; Rassweiler, 2003). Following is a summary of the recent published series from major centers experienced in laparoscopic radical prostatectomy.

Table 1. Outcomes of Operative Parameters Using Laparoscopic Radical Prostatectomy

*Operating room

†Estimated blood loss

As can be appreciated, the mean OR time for laparoscopic radical prostatectomy is approximately 4.5 hours. Abbou has reported significantly shorter times with the extraperitoneal approach in a small series of 20 patients, and this has been reproduced by Dorschner et al. The mean intraoperative blood loss varies widely between series, from 185-1230 mL with an average of 400-450 mL. Mean catheterization times are 4-6 days, and patients stayed for a mean of 5 days in the hospital. Note, however, that European centers have longer hospitalization times compared with US hospitals.

The laparoscopic approach compares very favorably with open radical prostatectomy in terms of blood loss, hospital stay, and catheterization times. Operative times for laparoscopic prostatectomy are significantly longer than for open surgery, even after the learning curve has been mastered. In a 1999 report, Guillonneau also showed that the costs for laparoscopic approach are less than the open approach by $1200, indicating that the laparoscopic approach is economically viable.

Functional outcomes

Relatively fewer papers are available dealing with functional outcomes following laparoscopic radical prostatectomy. Most series are from the French surgeons as shown below.

Table 2. Outcomes of Functional Parameters Using Laparoscopic Radical Prostatectomy

Continence rates vary from 85-90%, and potency rates range from 40-59.9% according to unilateral or bilateral bundle preservation. Patient self-reported survey results are probably more reflective of morbidity results because the ratings of physicians and patients may be divergent. Especially in embarrassing clinical aspects, such as sexual and urinary symptoms, significant differences may occur between physician and patient assessments, as reported by Penson and Litwin in 2003. The much greater postoperative sexual and urinary dysfunction rates reported in recent surveys of patients after radical prostatectomy support that concept.

Preservation of neurovascular bundles, younger patient age, and an experienced surgeon are the main factors associated with the best results regarding erectile function; however, these factors are similar for both open and laparoscopic approaches (Menon, 2001; Walsh, 2000; Bollens, 2001; Walsh, 2000; Stolzenberg, 2003).

Earlier concerns of higher positive margin rates following laparoscopic radical prostatectomy have been shown to be incorrect in the recently published series (Bhayani, 2003; Katz, 2003; Rassweiler, 2003; Weizer, 2003).

Robotic radical prostatectomy

Operative outcomes

Robotic radical prostatectomy is a relatively new procedure, and only 4 centers worldwide have published results. Of these, the Henry Ford Hospital (Detroit, Mich) has the largest experience in robotic prostatectomy. Other centers include Johann-Wolfgang-Goethe University (Frankfurt, Germany), Hopital Henri Mondor (Creteil, France), and UCI Medical Center (Orange, Calif).

Table 3. Outcomes of Operative Parameters Using Robotic Radical Prostatectomy

Robotic radical prostatectomy is associated with significantly lower operative times and blood loss compared with laparoscopic or open surgery. Catheterization times and hospital stay are also less compared with open and laparoscopic approaches (Bentas, 2003; Tewari, 2003; Van Velthoven, 2003). The learning curve is less with robotic assistance compared with laparoscopy. The one significant question that remains unanswered pertains to the cost-effectiveness of robotic prostatectomy compared with open and laparoscopic radical prostatectomy.

Functional outcomes

Long-term follow-up after robotic prostatectomy is not available because the technique is relatively new; however, early functional results are available and are summarized below.

Table 4. Outcomes of Functional Parameters Using Robotic Radical Prostatectomy

*From abstract at World Congress of Endourology, Montreal, 2003

Preliminary results from the above series show that oncologic and functional results following robotic prostatectomy are significantly superior to those of either open or laparoscopic radical prostatectomy (Menon, 2001; Menon, 2002; Tewari, 2002; Tewari, 2003; Van Velthoven, 2003). The margin rates and rates of PSA recurrence are comparable, whereas potency and continence rates are better than those of open and laparoscopic approaches (Menon, 2001; Menon, 2002; Tewari, 2003). The better results from the Henry Ford group (Menon, 2001) probably reflect their extensive experience of more than 500 cases compared with fewer cases from the other groups.

Although early results from robotic series are encouraging and the interest in the robotic approach is expanding exponentially worldwide, long-term results are needed to establish the role of robotic radical prostatectomy in the treatment of localized prostate cancer.

MULTIMEDIA

Section 7 of 8  

• Authors and Editors
• Introduction
• Surgical Techniques
• Surgical Approaches
• Advantages and Disadvantages of Robotics Versus Laparoscopy
• Results
• Multimedia
• References

Media file 1:  Laparoscopic and robotic radical prostatectomy. Incision of the medial umbilical ligament. Courtesy of Vattikuti Urology Institute - Henry Ford Health Systems.
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Media file 2:  Laparoscopic and robotic radical prostatectomy. Division of the urachus and entry into the space of Retzius. Courtesy of Vattikuti Urology Institute - Henry Ford Health Systems.
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Media file 3:  Laparoscopic and robotic radical prostatectomy. Incision of the endopelvic fascia. Courtesy of Vattikuti Urology Institute - Henry Ford Health Systems.
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Media file 4:  Laparoscopic and robotic radical prostatectomy. Incision of the bladder neck. Courtesy of Vattikuti Urology Institute - Henry Ford Health Systems.
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Media file 5:  Laparoscopic and robotic radical prostatectomy. Dissection of the seminal vesicles. Courtesy of Vattikuti Urology Institute - Henry Ford Health Systems.
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Media file 6:  Laparoscopic and robotic radical prostatectomy. Clipping of the prostatic pedicle. Courtesy of Vattikuti Urology Institute - Henry Ford Health Systems.
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Media file 7:  Laparoscopic and robotic radical prostatectomy. Division of the urethra. Courtesy of Vattikuti Urology Institute - Henry Ford Health Systems.
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Media file 8:  Laparoscopic and robotic radical prostatectomy. Anastomosis. Courtesy of Vattikuti Urology Institute - Henry Ford Health Systems.
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Media file 9:  Laparoscopic and robotic radical prostatectomy. Anastomosis. Courtesy of Vattikuti Urology Institute - Henry Ford Health Systems.
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REFERENCES

Section 8 of 8

• Authors and Editors
• Introduction
• Surgical Techniques
• Surgical Approaches
• Advantages and Disadvantages of Robotics Versus Laparoscopy
• Results
• Multimedia
• References

• Abbou CC, Salomon L, Hoznek A, et al. Laparoscopic radical prostatectomy: preliminary results. Urology. May 2000;55(5):630-4. [Medline].
• Abbou CC, Hoznek A, Salomon L, et al. Laparoscopic radical prostatectomy with a remote controlled robot. J Urol. Jun 2001;165(6 Pt 1):1964-6. [Medline].
• Ahlering TE, Skarecky D, Lee D, Clayman RV. Successful transfer of open surgical skills to a laparoscopic environment using a robotic interface: initial experience with laparoscopic radical prostatectomy. J Urol. Nov 2003;170(5):1738-41. [Medline].
• Bentas W, Wolfram M, Jones J, et al. Robotic technology and the translation of open radical prostatectomy to laparoscopy: the early Frankfurt experience with robotic radical prostatectomy and one year follow-up. Eur Urol. Aug 2003;44(2):175-81. [Medline].
• Bhayani SB, Pavlovich CP, Hsu TS, et al. Prospective comparison of short-term convalescence: laparoscopic radical prostatectomy versus open radical retropubic prostatectomy. Urology. Mar 2003;61(3):612-6. [Medline].
• Binder J, Kramer W. Robotically-assisted laparoscopic radical prostatectomy. BJU Int. Mar 2001;87(4):408-10. [Medline].
• Bollens R, Vanden Bossche M, Roumeguere T, et al. Extraperitoneal laparoscopic radical prostatectomy. Results after 50 cases. Eur Urol. Jul 2001;40(1):65-9. [Medline].
• Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: initial experience and preliminary assessment after 65 operations. Prostate. Apr 1 1999;39(1):71-5. [Medline].
• Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: the Montsouris technique. J Urol. Jun 2000;163(6):1643-9. [Medline].
• Guillonneau B, el-Fettouh H, Baumert H, et al. Laparoscopic radical prostatectomy: oncological evaluation after 1,000 cases a Montsouris Institute. J Urol. Apr 2003;169(4):1261-6. [Medline].
• Hemal AK, ed. Laparoscopic Urologic Surgery (Transperitoneal and Retroperitoneal). 1st ed. New Delhi, India: Churchill Livingstone; 2000:. 289.
• Hoznek A, Katz R, Gettman M, et al. Laparoscopic and robotic surgical training in urology. Curr Urol Rep. Apr 2003;4(2):130-7. [Medline].
• Hoznek A, Samadi DB, Salomon L, et al. Laparoscopic radical prostatectomy: published series. Curr Urol Rep. Apr 2002;3(2):152-8. [Medline].
• Katz R, Salomon L, Hoznek A, et al. Positive surgical margins in laparoscopic radical prostatectomy: the impact of apical dissection, bladder neck remodeling and nerve preservation. J Urol. Jun 2003;169(6):2049-52. [Medline].
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Article Last Updated: Feb 28, 2005