Robotic Radical Prostatectomy: What s s the Advantage? Matthew T. Gettman, M.D. Associate Professor Department of Urology

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1 Robotic Radical Prostatectomy: What s s the Advantage? Matthew T. Gettman, M.D. Associate Professor Department of Urology

2 Prostate Cancer Epidemiology: 2009 Estimated new cases: 230,000 Estimated deaths: 30,000 Most common cancer in men In screening era: Mortality decreasing Age of diagnosis decreasing American Cancer Society, 2008 Clinically Localized Prostate Cancer: Definitive Treatment Options Surgery: Ablation: Open Cryoablation Laparoscopic HIFU RoboticRobotic Radiation: External beam Brachytherapy

3 Radical Prostatectomy Goals Big 3 Goals Cancer control Urinary control Sexual function Live without negative quality of life years Alaska Hawaii Robotics in the United States: through Q3 close

4 Radical Prostatectomy: 2009 Projections Robotic 67% Retropubic 28% Perineal 4% Laparoscopic <1% What is the advantage of robotic RP?

5 Provide Minimally Invasive Surgery Popular in all specialties (e.g. cholecystectomy) Smaller the incision: Quicker recovery Shorter hospitalization Less time off work Improved cosmetic result Less pain Laparoscopic Radical Prostatectomy Less invasive Good treatment Accepted by patients Difficult to perform

6 Degrees Of Freedom Coordinated Robot/Surgeon Motions 4 DOF 6 DOF Intuitive motion Ergonomic Surgeon safe Laparoscopy Robotics

7 davinci Performance Features Wrist action No tremor Enhanced motion (scaling) More precise Superior 3-D imaging 3-D D Vision System Open surgery orientation

8 Robotic RP: 1 st Bona Fide Competitor for RRP Instrument dexterity Better vision Goals of Robotic RP Improve operative precision Overcome limitations of laparoscopy Increase use of minimally invasive surgery

9 Early Robotic RP Observations Improves LRP applicability Shortens initial learning curve: Menon: : 18 cases to LRP times Ahlering: : 12 cases to 4 hr time Perioperative Outcomes Operative time EBL & transfusions Margin positivity Complications Length of hospitalization

10 Our Initial 1500 cases Operative time 2.5 hrs Transfusions <1% Margin positivity 12% Complications 8% Mayo Matched Comparison: Anastomotic Complications Robotic RP (n=294) 1.2% RRP (n=588) 4.6% p = 0.01 Krambeck et al BJU Int. 103:448, 2008

11 Most Important Variables Cancer Control Continence Potency

12 VIP: Contemporary Results Henry Ford (N= 2652) Surgical dates: 3/01 9/06 Complete data: 1142 patients Followup,, median: 36 months PSA progression: 2.3% (26/ 1142) 5-yr progression-free estimates: 92% Menon et al. Eur Urol 51:648, 2007 Mayo Biochemical Progression Data: Prospective Matched Comparison 3-year PSA PFS Years after Surgery RARP RRP 92.2%, RARP 92.4%, p=0.696

13 Continence and Potency Continence (%) Difficult to measure and compare in the literature: No randomized trials Varying QOL assessment techniques No standard definitions Patient reporting issues Author Joseph Zorn Patel Tewari Tewari Mattei Hakimi Menon Yr N mo 6-mo 6 12-mo (4 mo)

14 Mayo Matched Comparison: 1 year Continence Potency: Importance of Cavernous nerves Robotic RP 92% RRP 93% p = 0.34 Walsh & Donker 1982 Krambeck et al. BJU Int. 103:

15 Relationship of Neurovascular Bundle Prostate Costello, AJ et al BJU Int 2004; 94:1071 Courtesy: A. Costello, MD Kourambas J et al Brit J Urol,, 1998;82:408

16 3 dissection planes Neurovascular Bundle Preservation Arnauld Villers

17 Proximity of NVB to SV Courtesy of RP Myers, MD

18 Potency: Standard VIP vs. Veil Menon et al. At 1-yr 1 Follow-up: Standard VIP n 23 Sex (%) 74 (17/23) Author Zorn Patel Madeb Badani Yr Potency (%) N Bilateral NS (%) NR NR 82 NR Intercourse, 12-month (%) VIP + Veil (34/35) Hakimi Tewari Menon et al. J Urol 174: 2291, 2005 NR = not reported

19 Mayo Matched Comparison: Potency Results in Learning Curve Robotic RP 70% RRP 63% p = 0.08 Conclusions Robotic RP increasingly common Reported outcomes for robotic RP already largely comparable to RRP Surgeon skill & team very important Critical evaluation required for oncologic & QOL variables Krambeck et al. BJU Int. 103:

20 Prostate Cancer Screening American Urological Association: Digital rectal examination PSA Yearly at age 50 if no family history Yearly at age 40 if: Family history of prostate cancer African American

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