LAPAROSCOPIC RADICAL PROSTATECTOMY: Robot Help or Hype?
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
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.