Robotic prostate surgery turns three men into believers

David Roberts was treated for his prostate cancer using the da Vinci Robotic Surgical System.

Patrick Chierichella slowly opened his eyes to find himself in a bustling recovery room at North Shore University Hospital (NSUH). The 66-year-old awoke after his prostate surgery to a flurry of activity around him; nurses and doctors attentively conversed, working on what seemed like hundreds of different tasks. The last thing he could remember was walking through a set of giant stainless steel doors that led to a large operating room with a space-age machine.

“The entire moment was like something out of science fiction,” said Mr. Chierichella, a retired science teacher for the Sachem School District in Suffolk County. He had heard in passing and read about robots being used in surgeries. But here he was, approaching the enormous machine that was going to perform his radical prostatectomy.

Radical prostatectomy is a treatment option for prostate cancer when it is localized to the prostate gland, with the prime goal of removing the cancer completely before it has a chance to spread to other parts of the body. The procedure entails removal of the entire prostate gland, the attached seminal vesicles (a pair of glands that produce part of the semen) and the vas deferens (the muscular cord that pumps sperm from the testicles to the urethra).

Cancer control is the goal

“The robotic approach to radical prostatectomy is my favored approach and the gold standard for prostate cancer cure,” said Lee Richstone, MD, chief of urology at NSUH, and vice chairman of the Arthur Smith Institute for Urology at the Monter Cancer Center.

“Depending on the grade or stage of the cancer, most of my patients have a 90 to 95 percent chance of total cure. I firmly believe that this procedure offers the best option for cancer control.”

Using the da Vinci Robotic Surgical System, the surgeon sits at a computer console and operates by manipulating master controls to four robotic arms, which are connected to a variety of surgical instruments. The system’s state-of-the-art technology allows the surgeon’s hand movements to be scaled, filtered and translated in real time, while the surgeon views the operation through 3D cameras that transmit magnified images of the organs to a video monitor.

When David Roberts, 65, felt nervous before his upcoming surgery, he and his wife, Dianne, sat with Dr. Richstone, who walked them through the procedure, step by step, while they watched a video of him performing the robotic prostatectomy. “I felt very good that everything was so magnified.

What normally looks small, looks gigantic on his monitor,” said Mr. Roberts, a former Shirley resident who recently retired to North Carolina. “Watching how the machine’s arms actually moved like real hands made me feel more comfortable.”

There are three surgical approaches to radical prostatectomy, including the open technique that involves a six- to eight-centimeter incision between the belly button and pubic bone, and the laparoscopic method, a minimally invasive procedure that begins by inflating the abdomen with carbon dioxide gas to create a working space. The surgeon then inserts thin instruments into the body through several small incisions to perform the operation.

The third technique, the robotic approach, begins the same as laparoscopic surgery, but the surgeon makes several one-centimeter incisions in the abdomen, in which the surgical instruments are inserted into the patient’s body and maneuvered remotely from the console.

Tough decisions

Diagnosed with prostate cancer when he was only 45, Paul Riley of Wantagh was married with two sons starting high school and middle school. “I was shocked when I got my diagnosis. In my head, I thought, ‘I’m young, I’m active, I’m thin. I am doing everything right. Why is this happening?’”

In addition to robot-assisted surgery, Mr. Riley was given the option of radiation therapy using radioactive seed implants. “I researched the radioactive seeds, but it did not seem to be a viable treatment option for me because of my age,” said Mr. Riley, who works at the trading desk of a brokerage firm in Manhattan. “The seeds would be inside me permanently, and I didn’t want to walk around with them for the remainder of my life. I preferred the robotic surgery option because it was more modern and seemed more precise and controlled. I think Dr. Richstone explained that it’s ‘a better pair of scissors’ and I liked that.”

The robot’s instrumentation provides greater mobility, range of motion and movement precision, which is an important advantage in prostate surgery, where fine motions are needed to protect neurovascular bundles and reconstruct the urinary tract to ensure continence.

“In addition to complete removal and eradication of the cancer, my focus during surgery is on preserving urinary continence and erectile function,” said Dr. Richstone.

“Ninety-five percent of my patients become totally continent, without the need for long-term use of pads. The majority of my patients also return to normal sexual function. For most men, robotic prostatectomy gives them some of the best outcomes with respect to their quality of life.”

Like it never happened

The robotic prostatectomy is a minimally invasive procedure that is performed in approximately four hours. Blood transfusions are almost never needed, and a vast majority of patients go home the next day.

When family and friends visited Mr. Chierichella in the recovery room shortly after his surgery, they were dumbfounded because he looked like he just woke up from a nap.

“I know I had major surgery; I know these mechanical arms were in my body, but for the fact that I never felt anything, it is amazing,” said Mr. Chierichella. “From the time I awoke in recovery to the time I was in my car to go home, it was 48 hours. The idea that I was mobile and walking around so quickly after the procedure, that I was still in control of my own life, for this I am so grateful. I was out playing golf within a month of the surgery. I could not have been happier.”

Dr. Richstone currently performs all radical prostatectomy procedures using the da Vinci Robotic Surgical System. And he is one of a few people in the world to perform single-site prostatectomy, the removal of the entire prostate through the belly button. He believes this procedure may soon take on a greater role in prostate cancer surgery. In addition, Dr. Richstone and others at the Smith Institute are investigating a novel surgical approach called the NOTES (natural orifice transluminal endoscopic surgery) radical prostatectomy, in which the prostate is completely removed by going through the opening of the penis, and is therefore a scar-free procedure without a single external incision.

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