Over the last five years, Hopkins urologists Li-Ming
Su, M.D., and Christian Pavlovich, M.D., have performed more than
600 laparoscopic radical prostatectomies (LRPs), and their results
are excellent: At three years after surgery, 97 percent of their
patients remain cancer-free, as defined by an undetectable PSA test;
70 percent of their patients had urinary continence at six months,
and 90 percent were continent at one year.
The robot’s arms are like ultra
high-tech Swiss Army knives, fitted
with multi-jointed tips loaded with
miniaturized scissors, graspers,
dissectors, and needle drivers.
Half of the men were potent at six
months, and 75 percent of the men who were potent before surgery,
and who underwent the bilateral nerve-sparing procedure were potent
one year later.
Su, Director of Laparoscopic and
Robotic Urologic Surgery at the Johns Hopkins Hospital, and Pavlovich,
Director of Urologic Oncology at Johns Hopkins Bayview Medical Center,
reported their results this year at the American Urological Association's
annual meeting. Could the use of a robot make these results even
better? Su and Pavlovich, along with fellow surgeons Jonathan Jarow,
Misop Han, Mark Gonzalgo, and Alan Partin, Director of Urology,
have begun investigating this possibility, using a sophisticated
robot with a genius's name—daVinci. Robot-assisted laparoscopic
radical prostatectomy (RALP) is the latest minimally-invasive surgical
technique to enter into the field of urology, Su explains. With
the daVinci technique, "the surgeon sits at a computer console using
hand and foot controls to manipulate a highly sophisticated robotic
device with three to four instrument arms. These are inserted into
keyhole incisions made in the patient's abdomen." The daVinci robot's
high-quality telescopic lens "gives us an unprecedented, three-dimensional
and magnified view of the operative field," says Pavlovich.
The robot's arms are like ultra
high-tech Swiss Army knives, fitted with multi-jointed tips loaded
with miniaturized scissors, graspers, dissectors, and needle drivers.
The idea is that the more specific tools available, the better the
surgeon can — operating within extremely cramped quarters — mimic
the versatility and delicacy of the human wrist. Because of its
capabilities, the daVinci Surgical System "is considered a device
that can help reduce the learning curve of accomplishing complex
laparoscopic procedures, suturing and knot-tying," Pavlovich adds.
"These are the most significant limiting factors for many surgeons."
Because the technology is making many aspects of laparoscopic surgery
relatively easier, the Hopkins surgeons note, RALP has grown in
popularity with both urologists and patients, "with an exponential
growth of cases performed each year," Su notes. "Much of this growth
has been fostered by a combination of aggressive marketing and a
peculiar fascination of patients with the use of new technology."
However, he cautions, "although RALP has some institutions as being
superior to open radical retropubic prostatectomy, many of these
studies were limited by their short-term outcomes and flawed because
they didn't compare the results to those of achieved by experts
at open prostatectomy."
The Hopkins surgeons are taking
great measures to evaluate RALP objectively. They believe that long-term
studies are needed to get past the hype — to determine the
true merits of the robot-assisted technique, its impact on cancer
cure, urinary continence, preservation of sexual function, as well
as its overall cost-effectiveness.