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Advent 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 Intuitive Surgical, Inc. It developed robotic interface for use in human surgical applications, the Da Vinci Surgical System.

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 degree of freedom, including rotation capabilities (i.e., mimicking the movements of the human wrist), and a special robotic EndoWrist.

Advantages of Robotic Techniques

Because the display system of the Da Vinci projects the image in the direction of the surgeon’s hands, the optically correct hand-eye coordination is restored. This is more difficult with laparoscopy, in which the camera is sometimes offset to the plane of dissection.

The 11-mm telescope in the Da Vinci system is a combination of two 5-mm optical channels (one for the right eye 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 (3-D) stereoscopic vision to the surgeon, providing depth perception lacking in laparoscopy. The conventional laparoscopic technique does not provide a 3-D depth of view.

The movements of the robotic system are intuitive (i.e., 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 with fulcrum movement effects (i.e., 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-in movement of the master is translated into a 1-in movement of the instrument tip).

The robotic instruments have articulated tips, which permit 7 degree of freedom in movements (i.e., they mimic human wrist movements, including rotation), which is unlike laparoscopy, with which only 4 degree of freedom are permitted.

Preoperative and Preanesthesia Screening

Perioperative preparation

Once the patient is confirmed as an appropriate candidate, he must undergo an appropriate preoperative preparation to minimize complications and to facilitate operative success.

On the day of surgery, a preoperative enema is performed, sequential compression stockings are placed, and a large-bore intravenous line is begun with preoperative antibiotics that cover both genitourinary and skin flora.

Equipment for Robotic Radical Prostatectomy

This is the user interface of the robot for the surgeon and consists of the following:

  • Display system: The system is a 3-D stereoscopic display for the console surgeon and is generally available for view in 2-D form by assistants and observers.
  • Master arms: These are the controls the surgeon uses for making surgical movements. Movements of the master arms translate to real-time movements of the instrument tips and may be scaled for fine movements. The master arms also provide basic force feedback to the surgeon but are limited in their ability to discriminate complex haptic feedback. Camera movements are controlled with a clutch mechanism. In the 4-arm systems, the surgeon can toggle between instruments.
  • Control panel: The control panel is used to adjust the surgeon console display and control options. The control panel allows toggling between 2- and 3-D display, adjusting various levels of scaling, and choosing the camera perspectives (0 degree vs. 30 degree lens).
  • Central processing unit: This is the computer that controls the system and integrates and translates robot control inputs from the surgeon.

Robotic Arms

The robotic arms consist of 3 arms for mounting surgical instruments, and 1 camera arm is provided for camera manipulation. The robotic arms are mounted on a surgical cart that is sterilely draped and moved into position over the patient. The arms are then mounted to 8-mm trocars placed through the patient’s abdominal wall. The surgeon console is connected to the surgical cart via cables.

The patient is placed in the supine position with the head down. This head-down position allows for gravity to facilitate the natural retraction of the pelvic tissues.

Carbon dioxide is then insufflated into the abdomen to achieve pneumoperitoneum.

Technique

In this technique, the dissection proceeds in an antegrade manner and releases the prostate from the bladder neck early in the procedure, allowing the prostate to be manipulated with traction to aid in visualization for nerve sparing. The seminal vesicles and all subsequent dissection proceed in the direction of telescope vision (i.e., antegrade), facilitating visualization.

Categorization of Results

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

Robotic radical prostatectomy versus laparoscopic or open surgery

Robotic radical prostatectomy offers significantly lower operative times and blood loss than laparoscopic or open surgery. Catheterization times and hospital stay are also superior to those associated with open and laparoscopic approaches.

Long-term follow-up after robotic prostatectomy show that oncologic and functional results following robotic prostatectomy compare very favorably with those of either open or laparoscopic radical prostatectomy. The margin rates and rates of prostate-specific antigen (PSA) recurrence are similar, but potency and continence rates are better than those of open and laparoscopic approaches.

The excellent results reported from several large-volume centers suggest that the data are reproducible with appropriate surgical volume. Long-term functional and oncologic results are needed to establish the role of robotic radical prostatectomy in the treatment of localized prostate cancer.

Final Comments

The literature supports improved operative and perioperative parameters with Robotic techniques, including decreased blood loss, shorter hospital stay, and decreased time of catheterization. In the available studies, robotic prostatectomy seems to improve functional parameters, namely potency and continence, compared with open prostatectomy.

Reported oncologic outcomes for robotic prostatectomy are comparable with those of open series.

Post operative Advice:

Kegels exercises three times a day till 3 months after return of continence.

Penile Rehabilitation for return of erections including PDE 5 Inhibitors and Vacuum Therapy system