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Robotic System Provides Increased Precision and 3-D View For Laparoscopic Prostatectomy

On June 21, 2004, Christopher S. Ng, M.D., a urologist specializing in minimally invasive procedures, performed a laparoscopic, robot-assisted operation to remove the cancerous prostate gland of David Hayball, who was able to return to work less than four weeks later. Situated deep behind the pelvic bone, the prostate is not always easily accessible, but the laparoscopic robotic instruments have joints that provide greater precision and dexterity inside the body. The robotic camera has two lenses at the tip to give the surgeon a magnified, three-dimensional view of the surgical site.

Los Angeles - June 24, 2005 - The prostate-specific antigen (PSA) test was supposed to be a routine part of a routine physical exam. But the level was slightly elevated, leading to a biopsy and the eventual diagnosis of early-stage, moderately aggressive prostate cancer.

June 21 marked a year to the day when Reseda resident David Hayball, 52, says he got his life back – the day Christopher S. Ng, MD, a urologist at Cedars-Sinai’s Urology Academic Practice, led a surgical team performing a laparoscopic, robot-assisted operation that removed the gland, taking the cancer with it.

“The great thing about the surgery is that the cancer is immediately taken care of. At least, it was in my case,” said Hayball, a lighting technician in the TV and motion picture industry. “You get back on your feet and return to your daily life and your work life and you can continue to enjoy the lifestyle that you’ve enjoyed.”

Radical prostatectomy – complete surgical removal of the gland, seminal vesicles and sometimes nearby tissue – is one option in the treatment of prostate cancer. It can be accomplished by “open surgery” through a six-inch incision from the navel to the pubic bone, or it can be done laparoscopically, through several tiny incisions – thin instruments and a telescope are passed through these ports, providing the surgeon a magnified view of the surgical site on a video monitor. Laparoscopy typically results in less scarring, reduced pain and shorter recovery times.

Regardless of the approach, surgeons work to preserve to the extent possible the nerves around the prostate to minimize the risk of erectile dysfunction after surgery. Another critical step that demands precision comes after the prostate is removed, as the surgeons connect the urethra directly to the bladder to preserve urinary continence.

But positioned deep behind the pelvic bone and surrounded by other structures, the prostate, urethra and the lower part of the bladder can be difficult to access by traditional surgery. Fortunately, the recent addition of robotic technology to the laparoscopic procedure offers increased precision and better visualization in such tightly confined spaces, said Ng, who used Intuitive Surgical’s da Vinci® Surgical System during Hayball’s operation at Cedars-Sinai.

“Standard laparoscopic instrumentation is certainly less invasive than open surgery but has a limited range of motion. But the robotic instruments have two joints that give the surgeon more dexterity and precision inside the body. This is especially important when suturing the bladder to the urethra after the prostate is removed, and also during the prostatectomy when we’re trying to spare the nerves,” he said. “Also, the robotic telescope actually has two lenses at the tip, so it provides binocular vision, like a left and a right eye. Each input goes to a central computer that processes it and projects it to the surgeon at the console in 3-D.”

The shock of his cancer diagnosis sent Hayball – who had possessed a spotless health history – in search of information. “I had to come to grips with the fact that I had cancer. That sort of stops the clock on everything else in your life. I spent a few sleepless nights trying to figure out what I was going to do. I went to the Internet and started learning everything I could about every procedure that’s offered for prostate cancer,” he said. “One of the things I found out is that there is no silver bullet that’s one treatment for everybody because different people have different priorities in their lives and they’re at different stages of their lives. But I felt from what I saw that the laparoscopic procedure was the one that would best fit where I was in life, with my needs and the needs of my family.”

Ng said physicians and surgeons help patients sort through the options to make the best decision for their unique circumstances. The choices range from conservative to aggressive, depending on the stage and type of cancer as well as the age and health of the patient.

“One option is watchful waiting, which means closely monitoring the PSA level and re-biopsying the prostate at certain intervals to detect a change in status of the prostate cancer prior to undergoing definitive treatment.

The basis of this approach is that many prostate cancers progress very slowly, and the side-effects of treatment may outweigh its benefits for some patients,” Ng said.

Hormone therapy is another option that may be considered, particularly when the cancer is advanced.

“Prostate cancer is hormone-sensitive, driven by testosterone. Therefore, testosterone-blocking medications may slow down the cancer and palliate symptoms, but they are not a cure. For definitive treatment, the two options are surgery and radiation,” said Ng, noting that radiation therapy may include traditional external radiation treatments or the implantation of radioactive seeds into the prostate.

Ng said surgery is often recommended for younger patients or those with aggressive cancers. Aggressiveness is measured according to “Gleason’s scores,” which range from two to 10. Higher scores represent more aggressive cancers, which typically do not respond as well to radiation.

“We have very good data suggesting that radiation is probably equivalent to the outcomes of surgery as far as a cancer cure for less aggressive cancers for up to eight to 10 years. But we don’t have much data after that point, so for a patient who has radioactive seeds implanted when he is in his 50s, we don’t know what the cancer cure is going to be like when he is 65 or 70. But with surgery, we know that when it’s out, it’s out,” said Ng.

“We also discuss with patients the risks of each procedure, with the main quality of life issues being incontinence and loss of sexual function,” added Ng.

“The effects of radiation are latent, meaning that the day after radiation, the patient feels the same as he did the day before, but over time, the radiation effects may become more prominent, mainly on erectile function but even potentially on urinary control. With surgery, the effects are immediate but they improve over time. Some studies have shown that at two or three years after the procedure, the paths intersect – symptoms for radiation patients get worse, those for surgery patients get better, and at around two or three years, they have about the same end result.”

For David Hayball, who went back to work less than four weeks after surgery and gradually resumed his usual activities, side effects have been minimal.

“The most irksome thing was having a bladder catheter after surgery,” he said. The catheter usually remains in place for seven days after the operation.

“When I went in and saw Dr. Ng for the first time, I told him where I was in my life, what my objectives were, why I thought the procedure would work for me and why I thought I was going to be a good candidate,” Hayball recalled. His top priority was to “get this cancer out of my body,” followed by regaining urinary function as quickly as possible and having the nerves preserved for sexual function.

“I think this procedure accomplished all of the goals I had perfectly,” said Hayball, who credits PSA screening for detecting his cancer at the earliest stage.

The death rate from prostate cancer is at an all-time low for both white and black Americans, and at least one major study suggests that the PSA blood test, introduced as a standard screening device in 1986, has played a significant role in this decline. Theoretically, at least, the PSA test is finding prostate cancer at earlier stages, when treatments are more successful. The American Cancer Society advises black men at age 45 and white men at 50 to discuss with their doctors the advantages and risks of being screened for prostate cancer. Those with a strong family history of the disease are encouraged to talk to their doctors even earlier.