New Delhi: When a man is diagnosed with prostate cancer , the doctor and the patient have two major concerns. The first is cancer-free survival. The second is reducing the complications of bladder control (incontinence) and impotence, two side effects of prostate cancer surgery that patients fear the most.
These side effects are often inevitable for at least a short period of time. For an unlucky some, these side effects can last their lifetime, taking a toll on both their psychological and physical wellbeing.
Reduced side-effects and improved recovery time have made robotically-assisted radical prostatectomies (RARP) hugely popular in recent years. Since the procedure is less invasive, it reduces blood loss and offers a better quality of life post-surgery over the traditional “open” techniques.
In a robotic surgery , the operating surgeon sits behind a console where she/he views the surgical field via a small camera inserted inside the patient’s abdomen. At the same time, a patient-side team of surgeons, physician’s assistants and nurses help the operating surgeon remotely manoeuvre surgical tools within the body. Since the camera magnifies and presents a virtual 3D-field, the surgeon can better visualise the surrounding area of the prostate.
Even during a robotic surgery, however, a patient’s potential for quick recovery from radical prostatectomy depends on a multitude of other factors – most notably the nature of the cancer and the surgeon’s skill at sparing the nerves.
A patient’s ability to retain his sexual function and urinary continence after surgery depends on the unique anatomy of nerves around the prostate. The size of a large walnut, the prostate gland sits between the bladder and the penis, surrounding the urethra like a donut. On either side of the gland, one could imagine nerves like a hammock or a spider web, branched and bundled to form a surrounding network. When the brain tells these “branches” to innervate the surrounding tissues, this allows a man to have an erection or control urination.
A surgeon removing the prostate from the body must skillfully cut away the tissue lining the sides of the prostate – called fascia – where a web of nerves is embedded, which puts them at risk of injury. About 30% of the time, a tumour encroaches so close to the edge of the prostate that the surgeon needs millimeter-conscious precision to preserve the plexus of nerves with the least mechanical or thermal damage. The nerves don’t just need to be saved, they need to be protected so they retain their functional purpose.
The robot’s magnified 3D-field offers the surgeon more control over movements and technique. This advantage, combined with a delicate appreciation of the patient’s anatomy, is what we call ART – or “Anatomical Robotic Technique.”
Albeit the procedure’s complexity, a surgeon’s task is straightforward: to balance the extent of nerve-sparing against the risk of cancer being left behind in the body.
A Surgeon’s Technique
Relying on different pieces of information about the patient and the cancer, the surgeon takes steps to ensure that nerve-sparing is done properly. The first step in a nerve-sparing RARP is individualisation, and it starts with determining the patient’s personal preferences and whether their expectations can be met within medical limits. If a patient has already experienced impotency or incontinence, the surgeon prioritises minimising the chance of the cancer recurring rather than sparing the patient’s nerves. The surgeon also takes accounts for the stage of cancer and intel provided by tests such as PSA, biopsy and MRI imaging.
Next, the surgeon plans for the surgery based on the patient’s medical history, personal attributes, state of health and distinct details of his anatomy. The size of the prostate, genetic make-up, and even the narrowness of a patient’s pelvis play a role in how the prostate will be removed.
Once the procedure begins, unexpected issues or challenges may occur, such as the patient’s pelvis having more inflamed tissue or the cancer being more aggressive than what the tests indicated. Or the surgeon may discover that the tumor is bulging slightly more from the prostate than he anticipated. The surgeon then takes the next step in modifying their strategy by making certain adjustments, such as leaving more cancerous tissue on the prostate before removing it from the body.
Once the prostate has been removed, a pathologist will examine it in a laboratory to determine whether any cancer is left in the body. This technique is called “NeuroSAFE,” whereby the surgeon must then react in real-time and continue operating according to the test results. If the “margin” of prostate tissue is positive for cancer and the patient is still at risk for disease, the surgeon will remove more tissue from the area.
All of these steps in conjunction can be used by surgeons to carryout a successful RARP, and leave a patient with the highest chance of recovering from incontinence and impotency.
Although most patients are well enough to walk the same evening of their surgery, they must deal with their expectations according to what their doctors tell them. While some studies report that RARPs produce similar results to open prostatectomies, they fail to take into account that the experience, knowledge and ART-ful skill of the surgeon matter tremendously. Patients should trust their surgeon’s judgment. As importantly, they must adopt a healthy lifestyle that includes of proper diet, exercise and not smoking to complement the healing process.
Dr Ashutosh K. Tewari is the chairman of urology at the Icahn School of Medicine at Mount Sinai Hospital in New York City; Sonya K. Prasad is a clinical research assistant at Mount Sinai Hospital