Robotic Urology

 

Hubert John · Peter Wiklund (Eds.)

Robotic Urology

 

Hubert John · Peter Wiklund (Eds.)

Robotic Urology With 116 Figures and 23 Tables

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  Hubert John Zentrum für Urologie Klinik Hirslanden 8032 Zurich Switzerland Peter Wiklund Department of Urology Karolinska University Hospital 17176 Stockholm Sweden

ISBN 978-3-540-74139-8           e-ISBN 978-3-540-74140-4 DOI 10.1007/978-3-540-74140-4 Library of Congress Control Number: 2007939484 © 2008 Springer-Verlag Berlin Heidelberg This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer Verlag. Violations are liable to prosecution under the German Copyright Law. The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: Frido Steinen-Broo, eStudio, Calamar, Spain Printed on acid-free paper 987654321 springer.com

Preface



Urology has traditionally been a technically driven specialty. Minimally invasive surgical procedures aim to reduce collateral surgical damage while optimizing functional and oncological results. Improvement of magnification, 3D imaging, articulated instruments, depth perception, and precise motor control are prerequisites to achieve these goals. Robotic technology has overcome most of these potential limitations and presently allows challenging laparoscopic interventions, not only in a few experts hands but also among a broad spectrum of urologists and patients who can benefit. Robot-assisted surgery presently operates on a “master−slave relationship basis,” and the primary system is the Da Vinci robot (Intuitive Surgical, Sunnyvale, Calif.). Urology is the leading field in robotic surgery, with radical prostatectomy being the most often performed robotic-assisted intervention. The birth of this instructional book is very timely, as many new robotic teams are experiencing their learning curve worldwide with great enthusiasm. The book highlights the standardized robotic procedures in urology. The authors have invested great effort and personal experience in order to support new robotic teams. As editors of this book, we tried to focus on the relevant urological procedures, knowing that the evolution of robotic urology will occur rapidly and involve many other urological operative indications in the kidney, ureter, bladder, and prostate surgery. Our thanks goes to Ms. Meike Stoeck from Springer, who helped to advance the project in a significant way. We are happy that our spontaneous idea to edit a textbook on robotic urology has come to a fruitful conclusion after 2 years of hard work. Personally (H.J.) I thank my teachers Peter Jaeger and Dieter Hauri for their influence and motivation in my clinical and research work during the past 15 years, and I am especially grateful to my wonderful wife, Manuela, for her support. September 2007

Hubert John, Zurich Peter Wiklund, Stockholm

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Preface

Hubert John and Peter Wiklund in the Swiss Alps, 4 February 2006, when they decided to edit this book

Foreword



This book will show that robotic surgery already has a definite place in the daily work of operative urology. The book shows that robotic surgery is increasingly used in operations such as pyeloplasty, nephrectomy, urethral implantation, and, to some degree, in cystectomy. I focus on the most frequently performed operation in urological oncology: the radical prostatectomy (RP). Although I am personally fascinated by the new technology and fully aware that further improvements are forthcoming, I am reluctant to state that robotic radical prostatectomy is superior to open radical prostatectomy. Being involved now for many years in the surgical treatment of localized prostate cancer, I have experienced many alternatives claiming to stop open retropubic radical prostatectomy such as brachytherapy, perineal prostatectomy, and laparoscopic radical prostatectomy. In our prostate cancer center in Hamburg we offer a wide range of therapeutic options to each patient including seed implantation, high dose rate brachytherapy, external-beam radiation therapy, laparoscopic radical prostatectomy, and robotic radical prostatectomy. When patients are objectively informed about long-term side effects and cure rates, however, the majority of patients prefer not to undergo any such therapeutic options. The majority of patients choose open radical prostatectomy. I am aware that this is in contrast to recent developments in the United States, where 40% of all radical prostatectomies were done using the Da Vinci technique in 2006, and it is estimated that this will increase to 60 or 70% in 2007. I am also aware of the fact that approximately 60−70 Da Vinci systems are installed in Europe. If we look at the Web homepages of centers that promote robotic radical prost­at­ ectomy, we get the impression that this technique is superior to the open approach. But what scientific evidence do we have for a comparison of the available techniques? Rojas-Cruz and Mulhall presented an abstract at the AUA meeting in May 2007 where they analyzed the stated advantages of robotic RP over open RP [2]. On 93 of 116 (80%) analyzed homepages it was stated that potency and continence rates achieved by the robotic approach are superior to open RP. Yet, only two (!) centers were able to give their own data on functional outcome, which demonstrates that scientific reality and arbitrary statements are presently in conflict with each other. The problem I have with such an approach is that we, as urologists, are able to judge such statements; however, a patient faced with prostate cancer seeking the best treatment is not informed in an ethically ideal way. Furthermore, this attitude will lead to high expectations of the patients, and I am convinced that many of them will be quite disappointed by the postoperative reality. At the same AUA meeting two groups presented a comparison of functional outcome of laparoscopic, robotic, and open RP. In both studies, which

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Foreword

included more than 1000 patients, open RP achieved slightly better results than the concurrent techniques [3, 4]. (By the way, I have not found this information on any robotic prostatectomy homepage.) Will we ever have the chance to objectively compare surgical approaches? At present, it is not feasible, and I strongly believe that it is the surgeon who is the most im­port­ ant factor for a successful procedure. Multiple single-center experiences are published that do not allow drawing any conclusion as to whether or not a certain technique is advantageous regarding cancer control rates and functional outcome. Cancer control rates are definitely more influenced by tumor selection than by whether we control our instruments by hand or via a console. With regard to functional outcome, again it is the surgical technique and the principles in combination with the experience of the surgeon, rather than the instruments we are using [5]. The nerve-sparing procedure, for example, should be started ventrally, coagulation and tension on the neurovascular bundles should be avoided, etc. [1]. Obeying these principles is what is leading to adequate results regardless of the way we get our instruments down to the prostate. In a recent study from the MSKCC it was furthermore shown that the surgeon’s experience is not only associated with postoperative morbidity and functional outcome, but also with cancer control rates [6]. In this study based on 7765 prostate cancer patients, the learning curve for prostate cancer recurrence after RP was steep and did not start to plateau until a surgeon had completed approximately 250 prior operations. The predicted probabilities of recurrence at 5 years were 17.9% for patients treated by surgeons with ten prior operations and 10.7% for patients treated by surgeons with 250 prior operations (difference = 7.2%,