Robotic-Assisted Radical Prostatectomy

Robotic assisted radical prostatectomy treatment for prostate cancer

Transcript

SPEAKER_00 0:11

Robotic radical prostatectomy is one of the treatment options for prostate cancer, particularly when it's localized. What robotic radical prostatectomy is, is the complete removal of the prostate through keyhole or what we call laparoscopic surgery with the assistance of computer technology to enable us to see better and to work in finer spaces with finer instruments. It's not a robot, it's what's called a master slave, but it enables you, the patient, to recover much quicker because it's less invasive. Since about 2002, and in my practice since 2006, I've done almost 3,000 robot-assisted radical prostatectomies, which is the second most in this country and the most in this state. And I found that this provides better outcomes and a quicker recovery for my patients. There is quite a long learning curve, and in fact, you never stop learning with this particular procedure, even approaching 3,000 cases. Prior to this, we used to do open prostatectomies with a cut, and that, if it was done well, gave very good results. But these days, with modern technology, the robot-assisted radical prostatectomy gives better outcomes not only in terms of recovery, but also in terms of potency, continence, and clearing the cancer. Up to now it's always been what's called a multi-port surgery, and just recently I introduced single-port surgery, which is a slightly less invasive treatment but similar outcomes, just a quicker recovery. It's being used very selectively in patients with small prostates, cancers that aren't too aggressive, where recovery is paramount, but the outcomes are no better in this particular area. So I'm using it very selectively. So who's suitable for robot-assisted radical prostatectomy? Pretty well everybody's suitable, unless they've got a terrible battle-scarred abdomen, which is just too difficult to do an operation on. There is one limitation and that's age. As we get older, the urinary sphincter becomes weaker, and if you do surgery on an older patient, then sometimes the chance of incontinence increases after the surgery. So my watershed's about 75 years of age, so I generally try and limit the surgery to people under that age. If you are an exceptionally fit person over the age of 75, you'll be considered for it, but I think you have to accept a slightly higher chance of incontinence. The other factor with surgery or robotic surgery compared to, say, radiotherapy, is the size of the prostate and urinary symptoms. If you've got a lot of urinary symptoms, then surgery gives a much better result than radiotherapy because surgery gets rid of the urinary symptoms, whereas radiotherapy tends to aggravate them. So that obviously poses the question that if you're over 75 and you've got a big prostate, what do you do? Well, one way around that problem is to do a preliminary operation to unblock the prostate called a transurethral resection of the prostate, and then after a period of healing, usually three to six months, follow up with radiotherapy. That way you avoid the risk of incontinence. At the time of surgery, certain decisions need to be made. The first decision is how much of the nerves, the erection nerves, can be preserved. This is called nerve sparing. The amount of erection nerves that are preserved are completely and utterly based on the extent of the cancer. The aim is to get rid of the cancer but still preserve as much of the nerve tissue as you possibly can. And there are different levels of nerve sparing, and with experience you really learn what level of nerve sparing is possible. The most nerve sparing is a hood procedure, the next level of nerve sparing is a high fascial release, the next level is intrafascial, the next level is extrafascial, and the next level is incremental, and of course the final level is non-nerve sparing. So all of those six levels of nerve sparing have to be tailored to the individual situation, and that's based on the biopsies, the MRI, the PET scan, and the intraoperative findings. All of them feed into that. And you know as a surgeon whether you're doing a good job based on the pathology report and the chance that the patients got their erections back. So the ultimate perfect case is a clear margin and a perfectly potent patient. That's what we all aim for. But the shades of grey during the operation that achieve that are often very subtle and require a lot of experience. And this is one of the things I've prided myself on for many, many, many years that I tailor the nerve sparing to the individual situation. The other factor that needs to be decided at the time of surgery is whether you're so worried about the aggressiveness of the cancer that you need to remove some lymph glands as well. These days, about one-third of my patients require the removal of lymph glands because of a high chance of them being involved. And the reason for doing this is to get an early warning sign that the cancer is more aggressive and may require some follow-up radiotherapy to the rest of the lymph glands. Again, this is dictated by the grade of the cancer, the PSA level, and the extent of the cancer. Another decision that's made during the operation is whether to get pathology while you're doing the operation. This used to be a popular technique, but it's fallen out of favour because it's very labor-intensive and it's very inaccurate for predicting how much more tissue you need to take. So let me take you through a scenario. Let's say you think that the cancer's a little bit further, and you take a piece of tissue, and it says you haven't got it all, and then you take more tissue and then find that in that extra piece of tissue there's no more cancer. You actually haven't done a service to the patient at that stage. What you've done is you've actually increased the chance of impotence without increasing the chance of cure. So that's the problem with frozen sections. There is one exception, and that's called Neurosafe, which was pioneered in the Martini Clinic in Germany, where they do a frozen section of the whole prostate, and then, based on that, take extra bits of tissue from the nerves as required. Even that's not perfect because 44% of the extra tissue that's taken has cancer in it, but 56% of the extra tissue has no cancer in it. Again, increasing the chance of erection problems without improving the cure. As well as that, a recent 10-year follow-up of that technique showed that the cancer outcomes were no better than actually doing a standard nerve-sparing procedure. So if you're a patient who's suitable for a nerve-sparing robot-assisted radical prostatectomy, and that's your choice after carefully considering all your options, then the process is as follows. Firstly, you have to prepare for the operation. That may require counselling. In my practice, my clinical manager Jane Matthews spends a couple of hours with you going through what happens before, during, and afterwards, so there are no hidden surprises. As well as that, it's been shown that doing pelvic floor exercises before the operation improves the urinary control after the operation, so that's another mandatory pre-operative preparation. A little bit of time is also helpful so that you can emotionally get ready for the procedure. So now we get to the day of the procedure. What happens? You fast for six hours beforehand, we put you to sleep, we do an operation, the operation takes me about two hours to perform, sometimes a little bit less, and then you recover and you go home about one to two days later. You have a catheter in for a total of six days, and my nurse takes that out in the office six days later. By two weeks you're part-time back at work, and by four weeks you're full-time back at work, and we like to avoid heavy lifting until six weeks to avoid hernias. And finally, the tiredness that a lot of people get after surgery disappears about the three-month mark. So that's the normal recovery after nerve-sparing robotic surgery. So, what are the aims of this surgery? The aims of this surgery is what I call the pentafecta. The pentafecta means I want an uncomplicated recovery, I want no complications, I want good urinary control, I want good erectile functioning, and I want a clear cancer margin. So that's the five things that we, I suppose, as surgeons judge ourselves on. And it's really important that we have an evidence-based way of getting those results to make sure we're up to scratch. So I happily allow my patients to be interviewed by the New South Wales Cancer Institute with validated questionnaires and through my research team to find out what my outcomes are. So I'm aware of my continence rate, I'm aware of my potency rate, I'm aware of my clear margin rate, I'm aware of my complication rate, and I'm aware of the time it takes to recover. And so I can then inform you as my patient exactly what those expectations are in an honest and evidence-based way. To give you a broad outline of outcomes, I can tell you that if you're under 70 and you have a good nerve sparing procedure, that 98% of my patients have pad-free incontinence by three months. I can also tell you that erection recovery with a good nerve sparing in the 60 to 70-year-old age group in a patient who had good erections beforehand is about 75 to 85% recovery, but it can take up to two years to recover. So there is a delay in recovery. The things that influence erection recovery are one, your age, two, how good your erections were beforehand, three, how good a nerve sparing is performed, and four, how good the rehabilitation program is to recover you. All those things make a difference, so I can't give you one number for any individual, it has to be dictated by all those other factors. And finally, the cancer outcomes. What's the chance that I will achieve a clear margin? A clear margin means that I've got a safety bit of tissue between the surgical resection and where the cancer is. That margin doesn't have to be centimeters, it can be millimeters. Now, if the cancer is contained to the prostate, that's called a PT2 tumor. If we have a PT2 tumor and I do an operation, my negative margin rate is 99.5%. I know that because the New South Wales Cancer Institute, as well as my pathologist, give me that report. That's one way of judging the accuracy of your surgery. So all these things are like my report card, and I try and impart that to every patient before their surgery so they have realistic expectations. So what does happen if you have a positive margin? Say you had a more extensive cancer and it was up to the edge, and despite all the experience, you've got a positive margin. Well, it may be necessary in that setting to have some follow-up radiation therapy. But in my experience, we can anticipate that very well in advance, and we can warn you about that well before the operation. So you've been through the surgery, you've recovered well, you had six little holes, or if you're in the new single port, one hole, and you want to know what the follow-up is. Well, the follow-up is simple: six monthly blood tests with the PSA, and once a year we check you to make sure that there's nothing that's bothering you, such as urinary incontinence or sexual dysfunction moving forward. Occasionally there's even a hernia that occurs through one of the wound holes. Usually at the five-year mark, we hand you back to your general practitioner for yearly PSA tests, and on 20% of cases the PSA starts to go up again. Usually this doesn't amount to anything and can be safely monitored, but occasionally it requires follow-up investigations and treatment with radiotherapy, and this usually can be anticipated by the pathology at the time of the surgery. So if you're in a higher risk category, say you've got a high grade cancer which was outside the shell, but we managed to get a clear margin, and three years later the PSA went up to 0.1, 0.2, 0.3, we'd then get a PET scan, and if the PET scan showed a small recurrence, we'd offer you radiotherapy to get rid of that small recurrence. And with modern day imaging, we can pick those recurrences up early and give you a second opportunity for a complete cure.