"Robotic surgery" in prostate cancer
This new, minimally invasive method operates a doctor, while the robot is only supported him. The first results, presented among others in the German Urology Congress in 2008, are promising.
The robot-assisted radical prostatectomy (RA-RPE) was performed for the first time in 2000 and is a further development of the established since 1999 endoscopic surgery. In both optics (camera or endoscope) and instruments are inserted through several small incisions in the skin into the body ("keyhole surgery"). They are therefore considered as a minimally invasive (less invasive) procedures. The path to the prostate leads in both either through the abdomen (laparoscopic RPE) or outside of the peritoneum (the peritoneum, so extraperitoneal RPE) behind the pubic bone (pubic bone) along, as in open surgery, which can therefore retropubic RPE (RRPE) calls it.
Robotics
In contrast to the endoscopic RPE the surgeon sits at the RA-RPE on a console near the operating table. There he sees the images of a stereo camera inserted into the body through two eyepieces, and from there he can camera and instruments through handles (manipulators) and pedals control. The robot assist with the transfer of his movements inside the body, but does not perform independent steps (hence the quotation marks in the headline).
The advantages are in an ergonomic workplace for the operator (relaxed position), an optimal view (three-dimensional, variable magnification, selectable camera position) and the precise guidance of the instruments: Your movement has seven degrees of freedom possible (see notebelow ), also in a selectable reduction, which filters out even the natural slight hand tremor. In addition, the robot is intuitive movements, where necessary, enter reflected their direction, so that hand and instrument always move in the same direction. Because in endoscopic surgery, certain movements (eg lateral) are in opposite directions because of their diversion to the abdominal wall, which requires a learning process.
So, Robotics tries to combine the advantages of open and endoscopic surgery and improve at the same time: Intuitive movements with the dexterity of the human hand with stereo vision, however, requires only small incisions in the skin and also perform at the improved performance in a comfortable position in a confined space leave.
A disadvantage is that the operator, the fabric can not feel (lack of tactile feedback). Main drawback, however, is the high cost: Those of acquisition and maintenance of the robot system spread until hundreds of operations per year to an acceptable amount per intervention. In addition, the replacement of the expensive instruments latest comes after 10 procedures. Since the insurance companies do not cover these costs, the insured must therefore usually pay 2,000-3,000 EUR.
Surgery and complications
Specific contraindications (contraindications), there is neither for endoscopic RPE nor for the robot-assisted RPE (RA-RPE), including obesity, previous surgery in the abdominal cavity, a large prostate and a previous TURP (removal of the prostate due to an increase, s . surgical procedure for BPH treatment ). However, these circumstances may lead to a prolongation of the operation time, and after laparoscopic hernia surgery with insertion of a network is recommended for the RA RPE access through the abdomen.
The two new methods make high demands on the personnel in charge of this because of their complicated technology. For the operator, this means a learning curve, during which he learns to control it (usually both). In the case of RA-RPE, the curve should be as in endoscopic RPE steeper and shorter. In addition, the operation times tend to be shorter (2-4 hours with a little practice).
Otherwise, there is little difference: In both, however, a simultaneous lymphadenectomy (removal of lymph nodes) is possible in the RA RPE not in sentinel technique (after radioactive labeling, see Sentinel lymphadenectomy ). Similarly, the conservation of important for the erection nerves by separation of the neurovascular bundle (s nerve sparing ), in RA-RPE also using a novel water-jet device, which is supposed to be gentler on the fabric.
In case of difficulty, both methods allow the transition to an open operation (conversion). This is also used for RA RPE only rarely, as is severe complications, but may require a special treatment, or a second operation (for example, bleeding, inflammation, leakage of the urethra new connection). The nature of possible complications depends among other things on the selected access from (through the abdomen or extraperitoneal), the frequency from the experience of the surgeon.
Operation results
The effectiveness of new methods often increases during the initial period of strong since the first extensive experience lead to technical improvements and to standardize the application.This also applies to the endoscopic and robotic assisted RPE. However, the RA-RPE is already results which are comparable with those of the laparoscopic and open RPE:
Thus, the rate of R1 resections is (positive cutting edges, that is tumor invasion) for example 15% pT2 tumors (confined to the prostate) (not limited to 30% of pT3 tumors to the prostate, the TNM system S. growth and spread of prostate cancer ). More than 70% of the patients at least one-sided nerve preservation is possible, and at least two thirds (up to 97%) of the above potent regain erectile ability. The continence rate, ie the proportion of those who can hold the water and do not need any more originals, is the day after the removal of the bladder catheter at about 60% and at six months, more than 80%. And the PSA-free 5-year survival rate is 84% (proportion of women in whom the PSA level in this period after the operation does not rise again).
Compared to open surgery goes for the two new minimally invasive procedures during surgery less blood lost and the recovery (convalescence) accelerating,. So after RA RPE dismissal is usually already on the 3rd-5th Day after the operation at still lying catheter possible, or after removal of the catheter (approximately the 7th post-operative day). In the USA, leaving up to 95% of patients the hospital within 24 hours after the procedure, which certainly has economic reasons.
Conclusion
After endoscopic has, according to preliminary results, the robot-assisted radical prostatectomy (RA RPE) of the retropubic (open) method shown to be equivalent. However, a broader confirmation of these early results remains to be seen, while long-term results still largely missing.
However, many users keep the RA RPE today for a safe alternative to open surgery. It offers the advantages of a minimally invasive procedure (eg, less blood loss, rapid recovery) at relatively short learning curve and the optimum conditions for carrying out the procedure.
To achieve consistently good results, that is, so that the individual patient may benefit from these advantages, however, large numbers of cases are needed. This is offset in comparison to the endoscopic and open surgery significantly higher costs. Therefore, the RA-RPE is available in Germany only in a few hospitals. Unlike in the USA: there are about 40% in 2006 and 2007 about 70% of radical prostatectomies have been performed with the help of the robot. For this technique there has now replaced open surgery as the standard.
Technical Note
Degree of freedom is movement ability in mechanics. Thus, a rigid body moving freely in the room (eg an airplane), six degrees of freedom: three translational to change its spatial position (left / right, forward / backward, up / down) and three of the rotation to change its orientation (of heading, pitch and roll). At a joint, however, the spatial position is established, so that a maximum has the three rotational degrees of freedom: for example, the shoulder joint is a ball joint, in which the arm back and out laterally moved and can be rotated about its longitudinal axis. In robot arms, the sum of degrees of freedom of all joints is often given. Of course, there are position and orientation of the instrument at the top of a maximum of only six degrees of freedom variable (like an airplane, above). In addition, you can open and close some instruments (eg scissors).
Sources:
- Gerber, T., et al.: Influence of acting in laparoscopic Herniensanierung with mesh insert on the extraperitoneal robot-assisted radical prostatectomy. 60 Congress of the German Society of Urology, Stuttgart, 24.-27.9.08, Abstract P 6.3, Urologist 2008 (Suppl 1): 29
- Goepel, M.: Robotic surgery - a tightrope (letter to the editor to the article "Remote Control robot arms for delicate operations in prostate cancer" by Hildegard Kaulen, FAZ 18.06.08).FAZ, Frankfurt, 1.7.08, feuilleton
- Red ring, J., et al. 60 Congress of the German Society of Urology, Stuttgart, 24.-27.9.08, Abstract V 15.8, Urologist 2008 (Suppl 1): 105 *
- Red Ring, J., et al.: Robot-Assisted Laparoscopic Prostatectomy. Urology 2008 47:420-424
- Stoeckle, M.: Radical prostatectomy: robot-assisted. 60 Congress of the German Society of Urology, Stuttgart, 24.-27.9.08, Plenary Session 2 "prostate cancer - Interactive", Lecture 7 on 26/09/08
- Stoeckle, M., S. Siemer: robotically-assisted laparoscopy on the rise. Biermann, Cologne, Urological News 6/2008, pp. 10-11
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- Stolzenburg, J.-U.: Laparoscopy / robot. 60 Congress of the German Society of Urology, Stuttgart, 24.-27.9.08, Plenary Session 3 "The future starts today", Lecture 7 on 27.9.08
- Wirth, GJ, et al.: Robot-Assisted operations in urology. Urology 2008 47:960-963
- Witt, JH, et al.: Is there "the" learning curve? Results of 310 robot-assisted prostatectomy.60 Congress of the German Society of Urology, Stuttgart, 24.-27.9.08, Abstract V 7.5, Urologist 2008 (Suppl 1): 87
- . Witt, JH, et al: Robot-assisted radical prostatectomy - 320 consecutive cases. 60 Congress of the German Society of Urology, Stuttgart, 24.-27.9.08, Abstract P 6.5, Urologist 2008 (Suppl 1) :29-30
- Witt, JH, et al.: Waterjet dissection of the neurovascular bundle during robot-assisted radical prostatectomy. 60 Congress of the German Society of Urology, Stuttgart, 24.-27.9.08, Abstract Fi 2.4, Urologist 2008 (Suppl 1): 112
* Title deleted due mention of product names.
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