Prostate news article, August 2009

LAPAROSCOPY OR ROBOTICS: WHERE DOES THE FUTURE LIE?   Article by:   Professor Roger Kirby, Chairman, Prostate UK and Krishna Patil

Introduction
Radical prostatectomy (RP) is now an accepted treatment for localized prostate cancer in men with more than 10 years of life–expectancy. It has shown a definite survival advantage compared with active surveillance¹. The quest for minimally invasive techniques has encouraged urologists to develop conventional laparoscopic RP (CLRP) as well as robotically-assisted RP (RARP). Conventional laparoscopy does require extensive training and experience, and is very demanding for surgeons to learn and perform. However, it is less costly than RARP and has similar overall outcomes with its open and robotic counterparts. On the other hand, robotics is considerably easier to learn, with less training, but is relatively expensive, and also incurs substantial maintenance costs.

In which direction does the future lie?
Upper tract laparoscopy is becoming the standard of care for several upper urinary tract conditions, such as nephrectomy. Lower urinary tract laparoscopy for prostate and bladder cancer is also becoming increasingly accepted, and in the era where patient choice is so important, patients are rightly requesting these minimally invasive procedures. Increasing numbers of young urologists are obtaining modular training in pelvic laparoscopy. Training in laparoscopy is a demanding task, made much easier if there is a firm commitment to a structured training programme. Although CLRP has all the advantages of minimal access surgery, such as reducing the blood transfusion rate to <1.3%, minimal postoperative pain with reduced analgesic requirements, and shorter hospital stays², laparoscopy is difficult to learn, and requires a significant commitment to acquire the requisite skills to operate speedily and safely. Eden et al.³ recommended that CLRP should not be self-taught and should be learned within an "immersion" teaching programme. In their experience the "learning curve" for operating time and blood loss was overcome within the first 100–150 cases, but complications and continence rates took 150–200 cases to reach the plateau. The longest learning curve of all was for potency, which did not plateau until 700 cases. However, Stolzenberg et al reported that by using structured modular training it is possible for novice laparoscopic surgeons to learn this complex procedure relatively quickly. It is apparent that in a dedicated centre a surgeon with no previous experience in open RP can be trained to competently perform CLRP in 3 months, and the level of previous open surgical experience was not significant⁴.

Laparoscopic surgery is difficult to learn because of the two-dimensional, "reverse image" visualisation and the limited degree of freedom of movement of present laparoscopic instruments. Normally the individual surgeon takes some time to adjust to the change in visual orientation, and to acquire the skill of manoeuvring laparoscopic instruments with four degrees of freedom of movement. Once the skills have been acquired, however, they become second nature. It is clear that surgeons with limited laparoscopic skills find this difficult to accomplish, and therefore adopt robotic technology to overcome the handicap. For a skilled laparoscopic surgeon the learning curve for achieving proficiency with RP is estimated at 40–60 cases. For the laparoscopically naïve surgeon the number is estimated at 80–100 cases. By comparison a laparoscopically naïve, yet experienced open surgeon successfully transferred open surgical skills to a laparoscopic environment in 8–12 cases using the robotic interface⁵. Some of these problems will likely be reduced as we train the next generation of surgeons brought up on video games and computers, with well developed hand–eye coordination. Three–dimensional laparoscopes and endo–wrist laparoscopic instruments with greater degrees of freedom of movement are currently being developed which will further reduce the learning curve.

Laparoscopy skills are generic and can be used for other operations, such as upper tract procedures, including nephrectomy. By contrast, robotic technology has mainly shown its usefulness in pelvic surgery [6]. Laparoscopy is certainly here to stay and will continue to have an effect on the treatment of patients with early prostate cancer. Urologists have always been at the forefront of embracing new technologies for the benefit of their patients. Urology was one of the first specialities to take advantage of the robot, particularly in RALP, which was performed for the first time by Binder in 2001 in Frankfurt, Germany⁷]. However, Menon et al.^8,9 developed and popularized their Vattikutti Institute Prostatectomy and promoted this procedure.

The word "robot" comes originally from the Czech word for manual labourer. The idea of surgical robots was originally developed for use in the battlefield¹⁰. The three-dimensional vision and endo–wrist instruments have made this surgery much easier for the less experienced laparoscopic surgeon. The operating field is magnified X 10, giving the surgeon a significant visual advantage. This gives the opportunity for more precise dissection of the fine tissue planes around nerves, vessels and sphincters. The endo–wrist instruments have seven degrees of freedom of movement; which is one more than the human wrist. This is particularly useful when operating within the tight confines of the pelvis. Creating the vesico–urethral anastomosis is also much easier than in either the open or the laparoscopic procedure. In addition, the robot has the ability to scale down the movements of the surgeon's hands, thus nullifying the physiological tremor. This arguably allows the surgeon to perform more accurate and precise dissection.

There are some considerations that need particular attention. The present robots are large and require sizeable operating theatres for installation. This has caused significant problems within the confines of existing theatre departments, although the latest da Vinci robot is much smaller and lighter and also has a dual console facility that facilitates training. Although laparoscopic surgeons have criticised the robot for the lack of haptic feedback, it is questionable whether this is essential in robotic-assisted surgery, as the results of many robotic surgery series are comparable to the results of open and laparoscopic surgery. Research is ongoing to develop the new generation of robots with tactile feedback.

The "learning curve" for robotic surgery is definitely shorter than laparoscopy, but still underestimated by many. Surgeons of limited laparoscopic experience can acquire good robotic skills, particularly when training with an experienced team and using the dual console system of the latest da Vinci SI model^11,12. Gaining this experience is complex and is difficult to quantify. Some surgeons learn more rapidly than others and some continue to learn for longer. For safe outcomes, proper training and mentoring is mandatory, and the mentor should assess the competency of the trainee before allowing him or her to perform the procedure independently, to avoid mishaps. The importance of the patient–side surgeon with laparoscopic experience cannot be overemphasized. As always, effective teamwork between surgeons, anaesthetists and theatre staff is critical to achieve successful outcomes¹³.

Although experienced laparoscopic surgeons sometimes question the benefits of robots, with the relatively higher cost, in terms of RP the robot has the edge over conventional laparoscopy. The tremor–free dissection and the excellent suturing ability facilitates a mucosa–to–mucosa watertight anastomosis. Also one cannot ignore the additional comfort that robotic surgeons enjoy over their laparoscopic colleagues at the time of surgery. Nevertheless the "trifecta" of outcome measures proposed by Bianco et al.¹⁴, i.e. cancer clearance, continence and potency, have been shown to be comparable in a study by Rozet et al.¹⁵ with both procedures.

Although cost is an issue, the technology is developing and, like any other technology, the cost seems likely to reduce in the near future. Scales et al.¹⁶ reported the cost equivalence of RALP with open RP based on 10 cases per week, and cost superiority if there were 14 cases per week, in the USA.

Conclusion
The debate between CLRP and RALP is ongoing; each of these techniques has its advocates who claim advantages over the other. However, it is should be remembered that the robot is nothing more than a surgical tool. It is the skill of the surgeon that determines the outcome and it is not the case of the robot replacing the surgeon or the laparoscope substituting the surgeon's skills. This is supported by the investigators at the Memorial Sloan–Kettering cancer centre¹⁷, who concluded that after RP the risk of disease recurrence is strongly affected by the experience of the operating surgeon, for both open and laparoscopic procedures.

Currently bio-engineers are busy developing single-port instruments, and incorporating real–time imaging like CT and MRI into robots. Consequently, navigational surgery is on the horizon, which will allow surgeons to excise or replace complex anatomical structures, causing little or no significant collateral damage¹⁸. Laparoscopy and robotic surgery should be considered complementary techniques in developing technology, and urologists should welcome them in that perspective.

It seems sensible therefore that laparoscopic and robotic technology should be considered not as rivals, but rather as a platform for the future developments. It will undoubtedly be those surgeons who take up these minimal–access techniques who will push the boundaries of surgery to the next level.

References:
1. Bill-Axelson A, Holmberg L, Ruutu M et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med 2005; 12: 1977–84 .

2. Stolzenburg J, Rabenalt R, Do M et al. Intrafascial nerve-sparing endoscopic extraperitoneal radical prostatectomy. Eur Urol 2008; 53: 931–40.

3. Eden CG, Neill MG, Louie-Johnsun MW. The first 1000 cases of laparoscopic radical prostatectomy in the UK. evidence of multiple "learning curves". BJU Int 2009; 103: 1224–30.

4. Stolzenburg J, Schwaibold H, Bhanot SM et al. Modular surgical training for endoscopic extraperitoneal radical prostatectomy BJU Int 2005; 96: 1022–7.

5. Ahlering TE, Skarecky D, Lee D, Clayman RV. Successful transfer of open surgical skills to a laparoscopic environment using a robotic interface: initial experience with laparoscopic radical prostatectomy. J Urol 2003; 170: 1738–41.

6. Dasgupta PD, Kirby RS. The current status of robot-assisted radical prostatectomy. Asian J Androl 2009; 11: 90–8.

7. Binder J, Kramer W. Robotically-assisted laparoscopic radical prostatectomy. BJU Int 2001; 87: 408–10.

8. Pasticier G, Rietbergen JB, Guillonneau B, Fromont G, Menon M, Vallancien G. Robotically assisted laparoscopic radical prostatectomy: feasibility study in men. Eur Urol 2001; 40: 70–4.

9. Menon M, Shrivastava A, Searle R et al. Vattikutti Institute Prostatectomy. a single-team experience of 100 cases. J Endourol 2003; 17: 785–90.

10. Richard M, Satava. Robotic surgery: from past to future-a personal journey. Surg Clinics North Am 2003; 83: 1491–500.

11. Artibani W, Fracalanza S, Cavalleri S et al. Learning curve and preliminary experience with da Vinci-assisted laparoscopic radical prostatectomy. Urol Int 2008; 80: 237–44.

12. Mayer EK, Winkler MH, Aggarwal R et al. Robotic prostatectomy: the first UK experience. Int J Med Robot 2006; 2: 321–8.

13. Goldstraw M, Patil K, Anderson C, Kirby RS. A selected review and personal experience with robotic radical prostatectomy: implications for the adoption of the technology in the UK. Pros Canc Pros Dis 2007; 10: 242–9.

14. Bianco FJ Jr, Scardino PT, Eastham JA. Radical prostatectomy: long term-cancer control and recovery of sexual and urinary function ("trifecta"). Urology 2005; 66: 83–94.

15. Rozet F, Harmon J, Cathelineau. X et al. Robot-assisted versus pure laparoscopic radical prostatectomy. World J Urol 2006; 24: 171–9.

16. Scales CD Jr, Jones PJ, Eisenstein EL et al. Local cost structures and the economics of robotic assisted radical prostatectomy. J Urol 2005; 174: 2323–9.

17. Vickers AJ, Savage CJ, Hruza M et al. The surgical learning curve for laparoscopic radical prostatectomy: a prospective cohort study. Lancet Oncol 2009;10: 475–80.

18. Pierre M, Locelyne T, Dan S. Urology robotics at the John Hopkins University, Baltimore, MD. Current Opin Urol 2009. 19. 114–9.

Abbreviations: RP, radical prostatectomy; CLRP, conventional laparoscopic RP; RARP, robotic-assisted RP.