Laparoscopy Robotized

    This technique has lead to significant progress in operative technique thanks to the quality of the anatomical vision that it brought with it, as well as the precision of the dissection steps and suture that it allows. The advantages of this minimally traumatic approach quickly became obvious for the patient: decrease in post op bleeding, easy follow up, decreased healing period, decreased post op pain, cosmetic aspect… Our histological results show that with a significant level of experience, the rate of lesion margins can be compared to classical open technique. No complications specific to the use of laparoscopy have been detected, such as local abnormal recurrence or seeding of the trocarts by cancerous cells.

     Concerning the functional results, and more specifically the erectile functioning, it is difficult to guarantee that laparoscopic route gives better results than open surgery, because it is difficult to obtain clinically credible comparing studies with validated results. But the fact that laparoscopy is less invasive and less traumatic represents an important factor for the preservation of the vasculo-nervous structures and for their later functional healing. Radical prostatectomy by laparoscopy has more than 10 years of existence.

     Its practice by trained team has allowed for the definitions of important principles, presentation of various techniques and it also allowed for the evolution of the operative technique to a quality level that was not expected. Around 2000, the operative robotic system appears and this type of technical assistance is suggested to urology for radical prostatectomy, via the Da Vinci (Intuitive) system, which is the only one existing nowadays.

Presentation of the Da Vinci system

     This system, well known from urologists is composed of 3 elements:

The operative unit, the technical column and the control panel

     The operative unit is constituted of an central axis fixed to a turning table, that is placed at the patient’s feet and that carries the 4 arms of the robot: a central arm that has the optics and 3 operative arms on which are placed different types of instruments

     The control panel is away from the operative unit (in the same or another room) The operator uses it while sitting down and looking within the binocular system, to “dive in” the operative cavity, with a 3D vision.

     He can move the instruments and the optics using joysticks and foot pedals.

     The technical column has a monitoring screen (2D vision) at the upper level and instruments for coelioscopy at the lower levels, as well as the computer central brain of the robotic system.

      It is placed on the left of the patient, oriented toward the assistant that is sitting on the right of the patient.

Installing the system is done in 2 steps:

Preparation of the robot: covering of the arms by sterile gowns, fixation of the instruments at the arms extremities. With a standardized protocol and a properly trained team this step should not take more than 20 minutes.
Adaptation of the robot to the patient: this step starts by placement of the trocarts: one of 12 mm for the optics placed at the umbilicus, 3 trocarts of 8mm for the operator arms at the level of the iliac fossa (one on the left and one on the right) and 2 additional coelioscopic trocarts (5mm) on each sides of the operator arm, for the passage of the instruments by the assistant. Once the trocarts are in place, the robot can be brought closer to the patient and the arms extremities fixed to them.

     This step requires 20 additional minutes
     Therefore 40 minutes are required between the time when the patient enters the operating room and the real start of the intervention by the surgeon. The operative team is limited to 2 persons: the surgeon and the assistant.

     The latter is sited on the right of the patient, manipulates 2 instruments via the coelioscopic trocarts (aspirating system and exposition instrument) and he verifies the functioning of the robot’s arms to prevent conflict and adapt the positioning to the patient’s specificities. The intervention uses 6 trocarts in total, therefore one more than the classical laparoscopic procedure.

Operative protocol

In our practice the intervention is done through trans-peritoneal route. However the sub-peritoneal route is not incompatible with the use of the robotic system.

Peritoneal incision and anterior vesico-prostatic dissection.
Vesico-prostatic separation with or without preservation of the urethra according to the indications.
Posterior plan dissection (seminal vesicles).
Prostato-rectal dissection after incision of the posterior leaflet of Denonvilliers’ fascia.
Lateral dissection with treatment of the vaculo-nervous threads and choose of a dissection plan more or less close to the peri-prostatic fascia, according to the characteristics of the tumor.
Apical side, treatment of the venous plexus and urethra section.
Placement of the specimen in a waterproof pocket.
Vesico-urethral anastomosis by absorbable sutures. The anastomosis can be preceded by posterior cervical reduction in case of a large cervix.
Checking the waterproof ability and placement of a red

If there is indication for lymph nodes curettage, it is done with the robot according to the usual rules of the ilio-obturator curettage. It is practical either at the beginning of the anterior dissection in case of necessary frozen section o at the end of the procedure if the result of the analysis dies not modify the indication for prostatectomy.

The pocket that carries the specimen will be removed at the end of the procedure, after removal of the robot and the widening of the umbilical access.

Additional advantages of the robotic system

The operative protocol described has not been modifies to ba adapted to the robotic system. It is strictly the same as the one for laparoscopic surgery, but trying to improve the difficult parts of the procedure with the robotic technique.

Quality of operative vision :this is the main advantage of this technique with regard to classical laparoscopy. High definition vision, good lightening with a complete colour scale, in addition to a 3D vision of the operative field, which gives the dimension of depth that was lost with classical laparoscopy. This vision obviously leads to a better operative dissection (precision of the detection of structure, choice of the plan of dissection, possible correction in case of errors of plan…) Coelioscopic surgery already allowed a advancement in this domain, by bringing “surgery to anatomical plans” Robotic surgery gives a higher quality of anatomic definition therefore a superior level of precision and security. Finally robotic operative vision is easier for the surgeon who will not suffer from the “bright” effect of the monitor which is usually bothering in coelioscopic surgery, and the light absorption as well as the degradation of the red colour in case of bleeding.
Efficient operative manoeuvre : the second revolution of the robotic system is brought by the quality of the operative procedure that it allows. The instruments now more and more sophisticated have 6 degrees of freedom, allowing movements without limitation in orientation or rotation. For instance scissors dissection can use an oblique plan with a flexed orientation and a rotation movement. This disappearance of physical limitations is of major importance for the difficult steps of dissection prostatectomy: urethra dissection, post and lateral dissection… it improves the quality and he precision of sutures by simplifying their realisation even in difficult areas. This improvement of operative procedure allows the realization of dissection with very high precision. It is not necessary to mobilise or pull away neighbouring sutures in order to reach the dissection site.

On the results

     With a good knowledge of the technique of prostatectomy by laparoscopy, and experience of robotic surgery, it is possible to obtain a good quality of ablations with a lesion margin similar to other techniques. However, the appreciation of functional results and gain that can represent robotic surgery in this domain is difficult and premature.

     In fact, it is based on prospective studies with questionnaires pre- and post- operative. It seems that empirically erectile function recuperation could be superior to the one observed with classical laparoscopy, and that the delay of recuperation is reduced.

     However one should wait for the European Groups of Robotic urology (EGRU) in 2006 to get full proof of all these results.

Disadvantages and limitations of this technique

     The main limitation of the robotic system is cost. In fact, other than the purchasing price, its maintenance and material used at each intervention (2100 euros for a radical prostatectomy) leads to a highly elevated cost, which makes it impossible for it to be covered by our medical system.

      In addition, a surgical intervention using robotics occupies an operating room for a longer time than classical laparoscopy.

      Finally, the surgical team needs a certain number of procedures to be done in order to be cost effective regarding the purchasing of the technique, and proper training of the team.

Conclusion

The Da Vinci operative robotic system gives a quality standard superior to classical laparoscopy for radical prostatectomy, especially by the operative vision that it offers, as well as the operative characteristics manoeuvre that it allows to realize.

The effect of this technical revolution on the patient regarding anatomic and functional results should still be proven by prospective studies. Its price does not allow the generalization of its use for this intervention.

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