Removal of the prostate gland (radical prostatectomy) is the mainstay of treatment for most men with early prostate cancer. It was first performed in the early 1900’s, but was associated with a high rate of devastating side effects including impotence and urinary incontinence. It was rarely practised until the pioneering work of Patrick Walsh at John Hopkins Hospital in Baltimore (USA) in the early 1980’s. He went back to the anatomy dissecting room and produced detailed drawings of prostatic anatomy and, particularly, the relationship of the all-important erectile nerves to the prostate. He subsequently developed the technique of nerve-sparing prostatectomy and the side-effects of this surgery were reduced dramatically. Men had a better than 50:50 chance of preserving their erections, and the risk of significant incontinence fell to approximately 5%.
Until the late 1990’s, nerve-sparing prostatectomy was typically performed as an open surgical operation despite the trend towards laparoscopic (”keyhole”) surgery in other areas of urology. There was a view that laparoscopic prostatectomy was too difficult, due to the confined space of the pelvis, and the difficulty of rejoining the bladder to the urethra once the prostate has been removed. Suturing with laparoscopic instruments is difficult; they do not have the ability to flex – they are like a human arm without a wrist joint. Additionally the surgeon’s 2D view with standard laparoscopic camera systems makes orientation of the suture needle difficult.
Robotic technologies have the ability to overcome these shortcomings. The da Vinci robot, the only surgical robot in common usage currently, returns the surgeon’s 3D vision and has wristed instruments. These mimic the movements of the human hand, making the technology intuitive to use and opening up an array of procedures which are difficult to perform with conventional laparoscopic instruments. The robot functions well in the confined space of the male pelvis, operating through five or six keyholes. The surgeon has a magnified 3D view of the pelvic anatomy, improving precision and aiding visualisation of the all-important nerves which run close to the prostate. The wristed instruments facilitate the suturing required to reconnect the bladder to the urethra once the prostate is removed, creating a water-tight join.
The advantages of the robotic platform are not confined to prostatic surgery, and it can greatly facilitate partial nephrectomy in which a part of the kidney is removed –typically because it is cancerous. In this operation, the blood vessels to the kidney are clamped to reduce bleeding as the tumour is excised and the kidney can only safely tolerate 30 minutes of interrupted blood supply. The robot facilitates the suture repair step which needs to take place whilst the blood supply is cut off, and additionally the use of reconstructed imaging visible in the robotic console may in the future allow better appreciation of the anatomy making the surgery safer.