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Robots to the rescue

Robotics has ushered in a new era of minimally invasive surgery that scores over both open (conventional) and pure laparoscopic surgery. Dr Ashutosh Tewari and Dr Abhishek Srivastava write.

health and fitness Updated: May 09, 2011 13:17 IST

Robotics has ushered in a new era of minimally invasive surgery that scores over both open (conventional) and pure laparoscopic surgery. Robotic surgery uses ergonomically-designed tele-manipulation devices that allow surgeons to perform complex surgical tasks with dexterity and minimal fatigue, expanded degree of movements, tremour filtering and 3-D stereoscopic visualisation.

Treatments for prostate cancer have two fundamental goals: complete eradication of cancer and minimal side effects. The ideal outcome is a “trifecta” of cancer control, continence, and the return of normal sexual function.

In order to meet these goals, we use a Da Vinci master-slave robotic system and have developed a minimally invasive, robotic-assisted radical prostatectomy technique by standardising a unique sequence of surgical steps, appropriate visual angles using different lenses, optimal retraction strategies (traction-free approach), precise suturing steps, and anatomical sparing of the neurovascular structures (trizonal neural hammock), as well as by incorporating open surgical principles.

This has been refined further by meticulous dissection without the use of thermal energy to control bleeding points. This technique, called ART (Advanced Robotic Technique), gives excellent outcomes with minimal bleeding. It leads to quicker recovery, reduced hospital stays, lesser painkiller requirements, lower blood transfusion rates, and improved preservation of physical appearance compared to open surgery.

Side effects

Balancing cancer control with continence and post-operative potency is like walking the tight rope. Cancer cells originate in the peripheral zone of the gland and slowly grow to invade the inner branches of nerves (peri-neural invasion), with 15-20% succeeding in reaching the exterior of the gland (extraprostatic extension or EPE) where they find the rich soil of connective tissue, fat, nerves, ganglia and blood vessels to grow.

EPE initially is a microscopic phenomenon, but if given enough time, it can become a visible tumour in the periprostatic tissue involving the nerves, fascia, muscles, rectum and bone. At this stage, the tumour has become locally advanced (T3 stage) and is a few steps away from spreading to distant structures. Unfortunately, neither clinical examination nor imaging tests are sensitive enough to capture this, so it often remains undiagnosed preoperatively.

Surgeons make decisions using tactile and visual cues to identify a phenomenon, which is actually microscopic. They are likely to either damage nerves or to leave cancer behind, and it is not surprising that 25-70% of patients actually become impotent and 10-40% have a positive margin. Similar disappointing results occur when surgeons cannot find a precise plane between the cancer and urinary sphincter and err on the side of cancer safety, leading to 5-20% rate of incontinence.

Thus, surgeons are judged not only by what you take out but also by what you leave behind. There is a very thin 2 mm zone of fascia in which the nerves are travelling. On the other side of this fascia, the cancer cells are waiting to escape into the neighboring structures. There is a very narrow margin of error that can decide the final outcome.