Robotic Prostatectomy -- A Review

Assaad El-Hakim, MD, FRCS(C); Ashutosh Tewari, MD, MCh

Introduction

Objective: To review the current medical literature on robotic prostatectomy (RP) and report clinical outcomes of this newly developed technique.

Data Source: A MEDLINE search was performed using the following headings: prostate cancer, radical prostatectomy, robotics, robot assisted, laparoscopy, telesurgery. In addition, recently published abstracts on RP were reviewed.

Study Selection: Studies that reported clinical and pathological variables of patients undergoing RP were included in this meta-analysis.

Data Extraction: Data were extracted from published articles and abstracts.

Data Synthesis: Robotic systems enhance surgeons' technical abilities and offer the potential of precise surgical technique. Short-term follow-up studies demonstrate that RP is at least comparable in efficacy to open and laparoscopic prostatectomy, including clinical and pathologic parameters. RP has benefits of minimal invasiveness, decreased blood loss, and quicker recovery compared with open surgery. Functional and cancer control results are still immature, but most studies reported favorable outcomes.

Conclusions: RP is a promising minimally invasive surgical approach for men with prostate cancer. Short-term clinical and pathological results are comparable to those with open and laparoscopic prostatectomy.

Robotic prostatectomy (RP) represents the latest advancement in surgical treatment of prostate cancer. It relies on minimally invasive surgical approach of laparoscopic prostatectomy augmented by robotic technology. Schuessler and colleagues^[1] first performed laparoscopic radical prostatectomy in 1991, but they failed to demonstrate advantages vs open prostatectomy, and the procedure was abandoned. It was not until Guillonneau and Vallancien^[2] and Abou and colleagues^[3] described and validated their techniques of laparoscopic prostatectomy that interest resurged in minimally invasive surgical treatment of prostate cancer.

Several centers in Europe, and later in the United States, have since reported their short and mid-term results on functional and oncologic outcomes of laparoscopic prostatectomy, which compare favorably with open prostatectomy.^[4] Despite the large interest in this approach, laparoscopic prostatectomy has not been widely adopted by the urology community mainly because of difficulty in learning and the related technical challenges.^[5]

Feasibility of RP was first demonstrated in 2000 by 2 French centers with more expertise in laparoscopic prostatectomy than many other centers.^[6,7] This early experience was met with skepticism. However, shortly thereafter, pioneering work from the Vattikuti Urology Institute in Detroit, Michigan, paved the way for a new era in RP.^[8,9] A growing number of institutions in the United States and Europe have since embraced this technique.

The da Vinci surgical system (Intuitive Surgical; Moutainview, California) (Figures 1 and 2) incorporates 3 multijoint robotic arms with 1 arm controlling the binocular endoscope and the other 2 controlling small-wristed instruments (EndoWrist technology). This system is a "master-slave" robot that is controlled by the surgeon who is comfortably seated on the operative console (master), only a few feet away from the patient. Two finger-controlled handles housed in a mobile console control the 2 robotic arms and camera. The stereoscopic view of the operative field provides excellent 3-dimensional visualization with 10-fold magnification.

(Enlarge Image)

Robotic set-up showing da Vinci robotic system.

(Enlarge Image)

da Vinci robotic arms.

Manipulation of the masters is transmitted to a computer that filters, scales, and relays the surgeon's movements to the robotic arms and instruments. Hand movements can scale to 1:1, 3:1, or 5:1 movement at the tip of the instruments. This scaling allows for finer and precise execution of certain steps of the operation. Physiologic tremor is completely eliminated. There is no measurable delay between the movement of the handles on the console and the movement of the instruments within the patient. The instruments allow 7° of liberty (degrees of excursion) in their movement, simulating the human hand.

With its 3-D view, the da Vinci surgical system aids the surgeon in more easily identifying delicate structures, such as nerves and blood vessels surrounding the prostate gland. The EndoWrist instruments provide the surgeon with the dexterity not available using conventional laparoscopic instruments.

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Cite this: Robotic Prostatectomy -- A Review - Medscape - Oct 26, 2004.

Baseline Parameters
Series	Year	Number	FU Duration	Age (Years)	BMI	PSA (ng/mL)	Prostate Volume (mL)	G 2-5	G 6	G 7	G 8-10
Abbou^[25]	2001	1	NA	63	NA	7	NA	0	1 (100%)	0	0
Pasticier^[26]	2001	5	NA	58 (55-63)	NA	12.4 (8.7-23.6)	37.4 (30-50)	0	3 (60%)	1 (20%)	1 (20%)
Rassweiler^[27]	2001	6	NA	64.2 (57-71)	NA	8.4 (2.4-12)	31.3 (19-40)	0	4 (67%)	1 (16%)	1 (16%)
Bentas^[28]	2003	40	15 (11-23)	61.3 (45-72)	25.5 (20.7-31.4)	11.5 (0.5-53)	34.4 (15-100)	NA	NA	NA	NA
Gettman^[24]	2003	4	NA	62 (61-70)	NA	11.3 (3.6-24)	NA	0	2 (50%)	2 (50%)	0
Kaouk^[29]	2003	1	7	48	NA	12.5	40	0	0	1 (100%)	0
Ahlering^[30]	2003	45	Up to 9 months	61.4 (46-71)	28.1 (20.2-39.4)	7.3 (1.1-24)	52.5 (12.5-163)	G 6 or less--20 (44%)		16 (36%)	7 (16%)
Ahlering^[31]	2004	60	3	62.9 (43-78)	26.3 (20.6-33.6)	8.1 (0.1-62)	52.5 (18-135)	G 6 or less--37 (62%)		14 (23%)	9 (15%)
Tewari and Menon^[32]	2003	200	7.9	59.9 (40-72)	27.7 (19-38)	6.4 (0.6-41)	58.8 (18-140)	1 (0.5%)	86 (43%)	80 (40%)	21 (10.5%)
Samadi^[35]	2002	11	NA	67 (58-71)	NA	8.9 (3.9-32)	67.6 (37-120)	NA	NA	NA	NA
Weighted Means		373		61	27.3	7.6	53.8	G 6 or less 47.51%		35.71%	12.15%

FU = follow-up; BMI = body mass index (kg/m²); PSA = prostate-specific antigen; G = Gleason

Baseline Parameters
Series	Year	Number	FU Duration	Age (Years)	BMI	PSA (ng/mL)	Prostate Volume (mL)	G 2-5	G 6	G 7	G 8-10
Abbou^[25]	2001	1	NA	63	NA	7	NA	0	1 (100%)	0	0
Pasticier^[26]	2001	5	NA	58 (55-63)	NA	12.4 (8.7-23.6)	37.4 (30-50)	0	3 (60%)	1 (20%)	1 (20%)
Rassweiler^[27]	2001	6	NA	64.2 (57-71)	NA	8.4 (2.4-12)	31.3 (19-40)	0	4 (67%)	1 (16%)	1 (16%)
Bentas^[28]	2003	40	15 (11-23)	61.3 (45-72)	25.5 (20.7-31.4)	11.5 (0.5-53)	34.4 (15-100)	NA	NA	NA	NA
Gettman^[24]	2003	4	NA	62 (61-70)	NA	11.3 (3.6-24)	NA	0	2 (50%)	2 (50%)	0
Kaouk^[29]	2003	1	7	48	NA	12.5	40	0	0	1 (100%)	0
Ahlering^[30]	2003	45	Up to 9 months	61.4 (46-71)	28.1 (20.2-39.4)	7.3 (1.1-24)	52.5 (12.5-163)	G 6 or less--20 (44%)		16 (36%)	7 (16%)
Ahlering^[31]	2004	60	3	62.9 (43-78)	26.3 (20.6-33.6)	8.1 (0.1-62)	52.5 (18-135)	G 6 or less--37 (62%)		14 (23%)	9 (15%)
Tewari and Menon^[32]	2003	200	7.9	59.9 (40-72)	27.7 (19-38)	6.4 (0.6-41)	58.8 (18-140)	1 (0.5%)	86 (43%)	80 (40%)	21 (10.5%)
Samadi^[35]	2002	11	NA	67 (58-71)	NA	8.9 (3.9-32)	67.6 (37-120)	NA	NA	NA	NA
Weighted Means		373		61	27.3	7.6	53.8	G 6 or less 47.51%		35.71%	12.15%

FU = follow-up; BMI = body mass index (kg/m²); PSA = prostate-specific antigen; G = Gleason

Baseline Parameters
Series	Year	Number	FU Duration	Age (Years)	BMI	PSA (ng/mL)	Prostate Volume (mL)	G 2-5	G 6	G 7	G 8-10
Abbou^[25]	2001	1	NA	63	NA	7	NA	0	1 (100%)	0	0
Pasticier^[26]	2001	5	NA	58 (55-63)	NA	12.4 (8.7-23.6)	37.4 (30-50)	0	3 (60%)	1 (20%)	1 (20%)
Rassweiler^[27]	2001	6	NA	64.2 (57-71)	NA	8.4 (2.4-12)	31.3 (19-40)	0	4 (67%)	1 (16%)	1 (16%)
Bentas^[28]	2003	40	15 (11-23)	61.3 (45-72)	25.5 (20.7-31.4)	11.5 (0.5-53)	34.4 (15-100)	NA	NA	NA	NA
Gettman^[24]	2003	4	NA	62 (61-70)	NA	11.3 (3.6-24)	NA	0	2 (50%)	2 (50%)	0
Kaouk^[29]	2003	1	7	48	NA	12.5	40	0	0	1 (100%)	0
Ahlering^[30]	2003	45	Up to 9 months	61.4 (46-71)	28.1 (20.2-39.4)	7.3 (1.1-24)	52.5 (12.5-163)	G 6 or less--20 (44%)		16 (36%)	7 (16%)
Ahlering^[31]	2004	60	3	62.9 (43-78)	26.3 (20.6-33.6)	8.1 (0.1-62)	52.5 (18-135)	G 6 or less--37 (62%)		14 (23%)	9 (15%)
Tewari and Menon^[32]	2003	200	7.9	59.9 (40-72)	27.7 (19-38)	6.4 (0.6-41)	58.8 (18-140)	1 (0.5%)	86 (43%)	80 (40%)	21 (10.5%)
Samadi^[35]	2002	11	NA	67 (58-71)	NA	8.9 (3.9-32)	67.6 (37-120)	NA	NA	NA	NA
Weighted Means		373		61	27.3	7.6	53.8	G 6 or less 47.51%		35.71%	12.15%

FU = follow-up; BMI = body mass index (kg/m²); PSA = prostate-specific antigen; G = Gleason

Baseline Parameters
Series	Year	Number	FU Duration	Age (Years)	BMI	PSA (ng/mL)	Prostate Volume (mL)	G 2-5	G 6	G 7	G 8-10
Abbou^[25]	2001	1	NA	63	NA	7	NA	0	1 (100%)	0	0
Pasticier^[26]	2001	5	NA	58 (55-63)	NA	12.4 (8.7-23.6)	37.4 (30-50)	0	3 (60%)	1 (20%)	1 (20%)
Rassweiler^[27]	2001	6	NA	64.2 (57-71)	NA	8.4 (2.4-12)	31.3 (19-40)	0	4 (67%)	1 (16%)	1 (16%)
Bentas^[28]	2003	40	15 (11-23)	61.3 (45-72)	25.5 (20.7-31.4)	11.5 (0.5-53)	34.4 (15-100)	NA	NA	NA	NA
Gettman^[24]	2003	4	NA	62 (61-70)	NA	11.3 (3.6-24)	NA	0	2 (50%)	2 (50%)	0
Kaouk^[29]	2003	1	7	48	NA	12.5	40	0	0	1 (100%)	0
Ahlering^[30]	2003	45	Up to 9 months	61.4 (46-71)	28.1 (20.2-39.4)	7.3 (1.1-24)	52.5 (12.5-163)	G 6 or less--20 (44%)		16 (36%)	7 (16%)
Ahlering^[31]	2004	60	3	62.9 (43-78)	26.3 (20.6-33.6)	8.1 (0.1-62)	52.5 (18-135)	G 6 or less--37 (62%)		14 (23%)	9 (15%)
Tewari and Menon^[32]	2003	200	7.9	59.9 (40-72)	27.7 (19-38)	6.4 (0.6-41)	58.8 (18-140)	1 (0.5%)	86 (43%)	80 (40%)	21 (10.5%)
Samadi^[35]	2002	11	NA	67 (58-71)	NA	8.9 (3.9-32)	67.6 (37-120)	NA	NA	NA	NA
Weighted Means		373		61	27.3	7.6	53.8	G 6 or less 47.51%		35.71%	12.15%

FU = follow-up; BMI = body mass index (kg/m²); PSA = prostate-specific antigen; G = Gleason

Operative Parameters
Series	Installation Time (min)	Operative Time (min)	Total OR Time (min)	EBL (mL)	Blood Transfusion	Conversion/ Abortion	Hosp Stay (Days)	Catheter Duration (days)
Abbou^[25]	30	420	465	300	0	0	4	3
Pasticier^[26]	93 (76-149)	222 (150-381)	NA	800 (700-1600)	0	0	5.5 (4-7)	6.5 (5-9)
Rassweiler^[27]	47 (40-50)	315 (242-480)	NA	NA	1 (16%)	0	NA	7.3 (5-14)
Bentas^[28]	NA	500 (246-780)	594 (288-930)	570 (100-2500)	13 (32.5%)	2 (5%)	17.1 (6-32)	16.7 (5-49)
Gettman^[24]	NA	274 (1424-360)	NA	1013 (550-1500)	NA	0	5.3 (3-9)	2.7 (2-3)
Kaouk^[29]	NA	285	NA	300	0	0	2	21
Ahlering^[30]	23 (15-40)	209 (150-600)	228 (NA)	145 (25-350)	0	0	1.6 (1-7)	7
Ahlering^[31]	NA	NA	231 (160-340)	103 (25-400)	0	0	1.1 (0.75-4)	7
Tewari and Menon^[32]	NA	160 (71-315)	NA	153 (25-750)	0	2 (1%)	1.2 (< 1-5)	7 (1-18)
Samadi^[35]	NA	300 (200-4200)	NA	900 (400-1600)	NA	0	NA	NA (2-5)
Weighted Means	32	222	331	231	0.3% (3.9%)*	1.1%	1.4 (3.1)**	8.1

OR = operating room time (includes patient prep) ; EBL = estimated blood loss *The weighted mean transfusion rate is 3.9% for all reported series, and 0.3% if Bentas' series is excluded.
**The weighted mean of hospital stay is 3.1 days for all reported series, and 1.4 days if Bentas' series is excluded. Patients in this study were discharged home after catheter removal.

Pathologic Parameters
Series	pT2a	pT2b	pT3a	pT3b	pT4	LN+	SM+
Abbou^[25]	0	0	1 (100%)	0	0	0	0
Pasticier^[26]	2 (40%)	3 (60%)	0	0	0	NA	1 (20%)
Rassweiler^[27]	1 (16%)	1 (16%)	4 (67%)	0	0	0	0
Bentas^[28]	7 (18%)	18 (45%)	9 (22%)	6 (15%)	0	NA	12 (30%)
Gettman^[24]	1 (25%)	2 (50%)	1 (25%)	0	0	0	1 (25%)
Kaouk^[29]	0	0	1 (100%)	0	0	0	1 (100%)
Ahlering^[30]	6 (13%)	21 (47%)	11 (24%)	5 (11%)	1 (2%)	NA	16 (35%)
Ahlering^[31]	16 (27%)	29 (48%)	10 (17%)	4 (7%)	1 (1%)	NA	10 (17%)
Tewari and Menon^[32]	30 (15%)	144 (72%)	14 (7%)	12 (6%)	0	2 (1%)	12 (6%)*
Samadi^[35]	5 (45%)	3 (27%)	2 (18%)	1 (9%)	0	1 (9%)	3 (27%)
Weighted Means	18%	61%	14%	7.5%	0.5%	0.8%	15%

PT = pathological stage; LN+ = positive lymph nodes; SM+ = positive surgical margins

Pathologic Parameters
Series	pT2a	pT2b	pT3a	pT3b	pT4	LN+	SM+
Abbou^[25]	0	0	1 (100%)	0	0	0	0
Pasticier^[26]	2 (40%)	3 (60%)	0	0	0	NA	1 (20%)
Rassweiler^[27]	1 (16%)	1 (16%)	4 (67%)	0	0	0	0
Bentas^[28]	7 (18%)	18 (45%)	9 (22%)	6 (15%)	0	NA	12 (30%)
Gettman^[24]	1 (25%)	2 (50%)	1 (25%)	0	0	0	1 (25%)
Kaouk^[29]	0	0	1 (100%)	0	0	0	1 (100%)
Ahlering^[30]	6 (13%)	21 (47%)	11 (24%)	5 (11%)	1 (2%)	NA	16 (35%)
Ahlering^[31]	16 (27%)	29 (48%)	10 (17%)	4 (7%)	1 (1%)	NA	10 (17%)
Tewari and Menon^[32]	30 (15%)	144 (72%)	14 (7%)	12 (6%)	0	2 (1%)	12 (6%)*
Samadi^[35]	5 (45%)	3 (27%)	2 (18%)	1 (9%)	0	1 (9%)	3 (27%)
Weighted Means	18%	61%	14%	7.5%	0.5%	0.8%	15%

PT = pathological stage; LN+ = positive lymph nodes; SM+ = positive surgical margins

Morbidity and Mortality
Series	Minor Complications	Major Complications
Abbou^[25]	0	0
Pasticier^[26]	1 (20%) 1 superficial bowel injury	0
Rassweiler^[27]	0	0
Bentas^[28]	8 (20%) 2 venous bleeding 4 anastomotic leak 2 UTI	5 (12.5%) 2 PE 1 DVT 1 obturator nerve injury
Gettman^[24]	0	0
Kaouk^[29]	0	0
Ahlering^[30]	3 (7%) 2 anastomotic leaks 1 port site bleeding	3 (7%) 1 DVT 1 anastomotic disruption 1 leg neuromuscular injury
Ahlering^[31]	2 (3%) 1 anastomotic leak 1 ileus	2 (3%) 1 PE 1 delayed anastomotic bleed
Tewari and Menon^[32]	3 (1.5%) 3 ileus	4 (2%) 2 wound dehiscence/hernia 1 DVT 1 post-op bleeding
Samadi^[35]	0	0
Weighted Means	4.55%	3.75%

UTI = urinary tract infection; PE = pulmonary embolism; DVT = deep vein thrombosis

Postoperative Continence
Series	Total Number	Number Evaluated	Age (Years)	Follow-up (Months)	Evaluation Method	Continent (0-1 Pad)	0 Pads	1 Pad	2 or More Pads
Bentas^[28]	40	38	61.3 (45-72)	15 (11-23)	Questionnaire	32 (84%)	26 (68%)	6 (16%)	6 (16%)
Ahlering^[30]	45	NA	61.4 (46-71)	3	Questionnaire	NA (95%)	NA (81%)	NA (14%)	NA (5%)
Ahlering^[31]	60	NA	62.9 (43-78)	3	Questionnaire	NA	NA (76%)	NA	NA
Menon and Tewari^[33]	200	NA	59.9 (42-76)	6	Questionnaire	NA (96%)	NA (96%) [0 pad or 1 liner]	NA (4%) [1 or more pads]	NA
Weighted Means	245	NA	60.8	6.1	Questionnaire	94%	87.5%	7%	NA

Postoperative Sexual Function
Series	Total Number	Number Evaluated	Number Potent Preop	Age	UNS	BNS	FU (months)	Evaluation Method	Potent	Intercourse	Erection
Bentas^[28]	40	38	37	61.3 (45-72)	NA	NA	15 (11-23)	Questionnaire	8 (22%)
Ahlering^[30]	45	9	3	57.3 (54-59)	1 (33%)	2 (66%)	up to 9	Questionnaire	1 (33%)
Menon and Tewari^[32]	200	Only preop potent patients	NA	< 60	NA	NA	6	Questionnaire	NA (64%)	NA (64%)	NA (82%)
Menon and Tewari^[32]	200	Only preop potent patients	NA	> 60	NA	NA	6	Questionnaire	NA (38%)	NA (38%)	NA (75%)
Chien^[34]	16	16	16	59 (NA)	7 (44%)	9 (56%)	NA (1-10)	NA	8 (50%)	5 (31%)	14 (87.5%)
Weighted Means	301			59.6			7.7		46.5%	49.5%	79%

UNS = unilateral nerve sparing; BNS = bilateral nerve sparing; FU = follow-up

Postoperative Sexual Function
Series	Total Number	Number Evaluated	Number Potent Preop	Age	UNS	BNS	FU (months)	Evaluation Method	Potent	Intercourse	Erection
Bentas^[28]	40	38	37	61.3 (45-72)	NA	NA	15 (11-23)	Questionnaire	8 (22%)
Ahlering^[30]	45	9	3	57.3 (54-59)	1 (33%)	2 (66%)	up to 9	Questionnaire	1 (33%)
Menon and Tewari^[32]	200	Only preop potent patients	NA	< 60	NA	NA	6	Questionnaire	NA (64%)	NA (64%)	NA (82%)
Menon and Tewari^[32]	200	Only preop potent patients	NA	> 60	NA	NA	6	Questionnaire	NA (38%)	NA (38%)	NA (75%)
Chien^[34]	16	16	16	59 (NA)	7 (44%)	9 (56%)	NA (1-10)	NA	8 (50%)	5 (31%)	14 (87.5%)
Weighted Means	301			59.6			7.7		46.5%	49.5%	79%

UNS = unilateral nerve sparing; BNS = bilateral nerve sparing; FU = follow-up

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Robotic Prostatectomy -- A Review

Introduction

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