The arrival of robotic technology has dramatically enhanced a surgeon's abilities to perform minimally invasive surgery with precision and speed. With the da Vinci robot system, the surgeon is seated comfortably a few feet away from the patient at a control console, while his assistant stands by the operative table. Surgery is performed through tiny incisions, like standard laparoscopic surgery. However, the robotic instruments, about the diameter of a pencil, have wrist-like maneuverability, allowing the surgeon to move them like his own hand, as opposed to standard laparoscopic instruments, which have a much more limited range of motion. The advanced optics allow the surgeon to view the operative field at high magnification, while maintaining a three-dimensional perspective unlike standard laparoscopic surgery. Finally, the dexterity of the surgeon's hand is enhanced by the robotic system, scaling motion to allow microsurgical movements, unequaled with either open or standard laparoscopic surgical approaches.

Overview

The Surgeon Console: Using the da Vinci Surgical System, the surgeon operates while seated comfortably at a console viewing a 3-D image of the surgical field. The surgeon's fingers grasp the master controls below the display with hands and wrists naturally positioned relative to his or her eyes. The technology seamlessly translates the surgeon's hand, wrist and finger movements into precise, real-time movements of our surgical instruments inside the patient.

Patient-side Cart: The cart provides the three or four robotic arms -- two or three instrument arms and one endoscope arm -- that execute the surgeon's commands. The laparoscopic arms pivot at the 1-cm operating ports eliminating the use of the patient's body wall for leverage and minimizing tissue damage. Supporting surgical team members assist in installing the proper instruments, prepare the 1-cm port in the patient, as well as supervise the laparoscopic arms and tools being utilized.

EndoWrist™Instruments: A full range of instruments are provided to support the surgeon while operating. The instruments are designed with seven degrees of motion that mimic the dexterity of the human hand and wrist. Each instrument has a specific surgical mission such as clamping, suturing and tissue manipulation. The instruments are small and typically fit within the circumference of a dime. Quick-release levers speed instrument changes during surgical procedures.

InSite™VisionSystem with high resolution 3-D Endoscope and Image Processing Equipment: The component provides the true to life 3-D images of the operative field. Operating images are enhanced, refined and optimized using image synchronizers, high-intensity illuminators and camera control units.

There many excellent options available to patients for the treatment of localized prostate cancer. We try and tailor treatment for each individual patient that matches each unique circumstance. Ideal patients are without extensive prior abdominal surgery or radiation therapy. In our experience, patients who have had prior laparoscopic hernia repair may successfully undergo robotic prostatectomy, but in about 50% of those patients, surgical mesh obstructs either the prostate or the pelvic lymph nodes requiring open conversion to properly perform an adequate operation from an oncologic standpoint. With Dr. Slawin’s prior extensive experience performing open radical retropubic prostatectomy, this does not expose the patient to any additional untoward risks and can be equally successfully performed.

How does the Texas Prostate Center 's Robotic Prostatectomy Technique differ from others?

Our philosophy is to maximize cancer control rates without sacrificing the patient's quality of life with regards to potency and continence. Furthermore, we strongly believe that both cancer control and quality of life outcomes are more dependent on the surgeon's knowledge of the natural history of prostate cancer growth and spread in the prostate, the intricate surgical anatomy of the prostate and surrounding structures, and the surgeon's experience in this specialized type of surgery. Less important are the tools or methods used to perform the surgery. At the Texas Prostate Center, we take the time to evaluate the unique features the differentiate every patient's case, including the amount, grade and location of the tumor, and then apply an individualized approach to maximize cancer control without sacrificing quality of life outcomes like continence and potency. However, it is well established that in some men with larger, higher grade tumors, a wider excision of the prostate that may damage some of the erectile nerves or require a wider removal of the bladder neck is necessary in order to remove the cancer in its entirety and in these cases we have utilized specialized techniques like bladder reconstruction and nerve grafting of the erectile nerves to achieve these goals. Especially in these cases, we take an unrushed approach during surgery recognizing that more time may be need to perform these more complicated techniques, like extended node dissection, Axogen Avance nerve grafting, en bloc resection of the bladder neck with bladder neck reconstruction, and others necessary to achieve an optimal outcome.

Through a careful process of quality improvement that includes systematic capture of cancer control and quality of life data on every patient beginning prior to their surgery, and continuing at every follow-up visit afterwards, we continue to accumulate a comprehensive database that allows us to measure the impact of even the smallest changes in technique, keeping those that demonstrate a clear benefit and discarding those that don’t add significantly to the quality of the results. Some key maneuvers that we have validated using this approach include both anterior and posterior reconstruction of the urinary rhabdosphincter, maneuvers that reconstruct both the natural suspension and angle of this important sphincter, measurably speeding the rate of return of urinary continence after Robotic Prostatectomy.

Through this methodical, data driven process, we have made a myriad of additional subtle changes, resulting in unique techniques for performing both open and Robotic Prostatectomy. We are one of only a few centers that perform the surgery without actually entering the abdominal cavity. We believe this makes the surgery safer for the patient, speeds the patient's recovery after surgery allowing him to return to normal activity and work more rapidly, and avoids potential complications for the patient down the road related to intra-abdominal surgery. We have now demonstrated in a new study soon to be published that we have maintained our low positive margin rates, traditionally seen with our mini-incision open radical prostatectomy technique with robotic laparascopic-assisted radical prostatectomy. Furthermore, we have adopted approaches that minimize the use of electro-cautery near the neurovascular bundles to improve the quality of our nerve sparing techniques. Careful study, using questionnaires, of all patients who have had surgery with us, has led us to make fine adjustments in our surgical technique that have led to clear, measurable improvements in our outcomes. Finally, regardless of the approach (open or robotic), we work intensively with all patients post-operatively to improve the rate of return of both erectile function and urinary control.