NEW ORLEANS — Using a robot to perform a minimally invasive radical prostatectomy resulted in less blood loss, faster recovery, and better surgical outcomes in a case series of 300 men, Vipul Patel, M.D., reported at the annual clinical congress of the American College of Surgeons.
The procedure has been available since 2001, when the U.S. Food and Drug Administration approved the prostatectomy application of the robot, the da Vinci Surgical System, made by Intuitive Surgical Inc. But it's not widely available, due to the machine's cost (about $1.3 million), the specialized training needed by surgeons, and the fact that hospitals and surgical centers lose money on every operation, said Dr. Patel, director of minimally invasive surgery at Urology Centers of Alabama, a private clinic in Birmingham. His case series consisted of the first 300 men who had the procedure at the clinic.
Detroit's Henry Ford Hospital has been a leader in prostatectomies with the da Vinci, reaching a total of 1,000 procedures in August. That center has reported less blood loss, better cancer control, and much lower rates of incontinence and impotence with the da Vinci, compared with standard open prostatectomy. Dr. Patel predicted that patients will increasingly demand the less-invasive procedure.
In Dr. Patel's case series, the average blood loss was less than 50 mL, which he said is 300–2,000 mL less than what is typically lost during open surgery. Fewer than 0.5% of patients required a transfusion.
The average age in his group was 63 years, and 70% had stage T1c disease. The average prostate specific antigen (PSA) level was 8.5 ng/mL. The patients generally required 1 day of hospitalization, compared with 2–3 days for the conventional procedure, and they returned to activities of daily living in 7–10 days, compared with 4–6 weeks for open procedures.
Dr. Patel said 95% of the patients were continent at 3 months. Potency rates are not yet available for his group, but he said he expects good results because “nerve sparing is technically much easier to perform robotically since we operate in a bloodless field with magnification and three-dimensional vision.”
During an average follow-up of 10 months, 95% of patients had no rise in PSA levels. The positive margin rate was 10% for all stages, and less than 3% for stage T2 tumors. It will, however, take at least 10 years to know if cancer outcomes are better with the minimally invasive approach, Dr. Patel added.
Dr. Patel also said that his patients are recovering more quickly with the use of a pain-management device that almost eliminates the need for narcotics. This device, the On-Q System, is approved by the FDA and is made by I-Flow Corp.
A subset of 250 men was treated with the On-Q, a ball that holds 300 cubic centimeters of 0.5% bupivacaine (Marcaine) and is worn on a belt around the waist. It pumps the drug into the wound continuously through a catheter over 2–3 days. The patient can remove the On-Q at home.
For those getting the On-Q, there were no narcotics on the initial orders; patients did receive ketorolac (Toradol) 15 mg every 6 hours, and 20 mg daily of valdecoxib (Bextra) starting 2 days after surgery. Overall, 85% of patients with the On-Q went without narcotics, compared with only 35% of those who did not receive the device.