Introduction
Keyhole robotic surgical removal of the prostate (robot-assisted laparoscopic prostatectomy / RALP) is nowadays widely performed all over the world. Robotic surgical systems are basically comprised of a remote surgical console connected to the actual operating robot with its specialised arms and attachments. An assisting surgeon and/or nurse practitioner attend the patient and will interact with the operating robot as required.
RALP performed with a robot offers surgeons distinct advantages. The vision received at the console display is high resolution and magnified. Coupled with the inherent precision and greater range of motion than open surgery, robotic surgery is considered a great inprovement in most cases.
The use of digital computers in surgery also allows for augmented-reality or image-guided surgery, which further improves the way the surgeon sees and removes (cancerous) tissue.
What we’ve done so far
Our institute has been one of the first in Australia to use the robot for robotic removal of the prostate. We have shown in multiple publications that it is possible to improve the functional and oncological outcomes of patients, even if a surgeon is already very experienced in open surgery (Doumerc, Yuen, Savdie, Rahman, Pe Benito, et al., 2010; Doumerc, Yuen, Savdie, Rahman, Rasiah, et al., 2010; Thompson et al., 2014, 2018). The open, classic laparoscopic approach and robotic approach have also been compared international with our data (Sooriakumaran et al., 2014) and a new way for the urethra and bladder connection (anastomosis) was developed (Beattie et al., 2013).
Another study showed that with good patient selection, nerve-sparing surgery was safe and improved outcomes (Moore et al., 2012). Age at time of surgery has been shown to be an important factor for urinary continence outcomes, with older men having a higher change for incontinence. But it was also shown that they suffered less from the actual incontinence (Gondoputro, Thompson, et al., 2022).
The change to a robotic set-up allowed us to look at robotic removal of lymph node metastasis that occurred after patients had been treated for their prostate cancer, and although image (PSMA PET CT)-guided robot-assisted salvage lymphadenectomy is safe, the oncological benefit was marginal (Siriwardana et al., 2017).
Besides the robotic approach, we have previously contributed to improvements in the predicted outcomes after surgery (Cagiannos et al., 2004; Graefen, Karakiewicz, Cagiannos, Klein, et al., 2002; Graefen, Karakiewicz, Cagiannos, Quinn, et al., 2002). Moreover, we also looked at specific histological (tissue) or cancer characteristics that predict a recurrence after surgery (Gupta et al., 2015; Karakiewicz et al., 2005; Savdie et al., 2012).
Ongoing projects
Currently we are running the DETECT study, in which we use a drop-in probe that is able to detect a tracer that binds to prostate cancer cells (PSMA tracer). The drop-in probe provides feedback whether a region is suspicious for prostate cancer, and can be used to guide resection of regions that are thought to harbor prostate cancer on preoperative scans (PSMA PET CT scan). Our initial results have recently been published (Gondoputro, Scheltema, et al., 2022).
Future directions
Robotic surgery is nowadays becoming the standard in prostate cancer surgery. The aim is to further improve the outcomes by image-guided surgery (for example the DETECT study), striving for excellent functional and oncological results by collaborating in data registries (for example the New South Whales registry) and to train a new generation of robotic surgeons.
Our Publications on Robotic Surgery
Beattie, K., Symons, J., Chopra, S., Yuen, C., Savdie, R., Thanigasalam, R., … Stricker, P. D. (2013). A novel method of bladder neck imbrication to improve early urinary continence following robotic-assisted radical prostatectomy. Journal of Robotic Surgery , 7 (2), 193–199. https://doi.org/10.1007/s11701-012-0371-2
Cagiannos, I., Karakiewicz, P., Graefen, M., Eastham, J. A., Ohori, M., Rabbani, F., … Kattan, M. W. (2004). Is year of radical prostatectomy a predictor of outcome in prostate cancer? The Journal of Urology , 171 (2 Pt 1), 692–696. https://doi.org/10.1097/01.ju.0000107260.98031.0e
Doumerc, N., Yuen, C., Savdie, R., Rahman, M. B., Pe Benito, R., & Stricker, P. (2010). Robot-assisted laparoscopic prostatectomy: analysis of an experienced open surgeon's learning curve after 300 procedures. Journal of Robotic Surgery , 3 (4), 229–234. https://doi.org/10.1007/s11701-010-0171-5
Doumerc, N., Yuen, C., Savdie, R., Rahman, M. B., Rasiah, K. K., Pe Benito, R., … Stricker, P. D. (2010). Should experienced open prostatic surgeons convert to robotic surgery? The real learning curve for one surgeon over 3 years. BJU International , 106 (3), 378–384. https://doi.org/10.1111/j.1464-410X.2009.09158.x
Gondoputro, W., Scheltema, M. J., Blazevski, A., Doan, P., Thompson, J. E., Amin, A., … Stricker, P. D. (2022). Robot-assisted prostate-specific membrane antigen-radioguided surgery in primary diagnosed prostate cancer. Journal of Nuclear Medicine : Official Publication, Society of Nuclear Medicine . https://doi.org/10.2967/jnumed.121.263743
Gondoputro, W., Thompson, J., Evans, M., Bolton, D., Frydenberg, M., Murphy, D. G., … Papa, N. (2022). How Does Age Affect Urinary Continence following Robot-Assisted Radical Prostatectomy? A Prospective Multi-Institutional Study Using Independently Collected, Validated Questionnaires. The Journal of Urology , 101097JU0000000000002391. https://doi.org/10.1097/JU.0000000000002391
Graefen, M., Karakiewicz, P. I., Cagiannos, I., Klein, E., Kupelian, P. A., Quinn, D. I., … Kattan, M. W. (2002). Validation study of the accuracy of a postoperative nomogram for recurrence after radical prostatectomy for localized prostate cancer. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology , 20 (4), 951–956. https://doi.org/10.1200/JCO.2002.20.4.951
Graefen, M., Karakiewicz, P. I., Cagiannos, I., Quinn, D. I., Henshall, S. M., Grygiel, J. J., … Kattan, M. W. (2002). International validation of a preoperative nomogram for prostate cancer recurrence after radical prostatectomy. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology , 20 (15), 3206–3212. https://doi.org/10.1200/JCO.2002.12.019
Gupta, R., O'Connell, R., Haynes, A.-M., Stricker, P. D., Barrett, W., Turner, J. J., … Kench, J. G. (2015). Extraprostatic extension (EPE) of prostatic carcinoma: is its proximity to the surgical margin or Gleason score important? BJU International , 116 (3), 343–350. https://doi.org/10.1111/bju.12911
Karakiewicz, P. I., Eastham, J. A., Graefen, M., Cagiannos, I., Stricker, P. D., Klein, E., … Kattan, M. W. (2005). Prognostic impact of positive surgical margins in surgically treated prostate cancer: multi-institutional assessment of 5831 patients. Urology , 66 (6), 1245–1250. https://doi.org/10.1016/j.urology.2005.06.108
Moore, B. M., Savdie, R., PeBenito, R. A., Haynes, A.-M., Matthews, J., Delprado, W., … Stricker, P. D. (2012). The impact of nerve sparing on incidence and location of positive surgical margins in radical prostatectomy. BJU International , 109 (4), 533–538. https://doi.org/10.1111/j.1464-410X.2011.10361.x
Savdie, R., Horvath, L. G., Benito, R. P., Rasiah, K. K., Haynes, A.-M., Chatfield, M., … Kench, J. G. (2012). High Gleason grade carcinoma at a positive surgical margin predicts biochemical failure after radical prostatectomy and may guide adjuvant radiotherapy. BJU International , 109 (12), 1794–1800. https://doi.org/10.1111/j.1464-410X.2011.10572.x
Siriwardana, A., Thompson, J., van Leeuwen, P. J., Doig, S., Kalsbeek, A., Emmett, L., … Stricker, P. (2017). Initial multicentre experience of (68) gallium-PSMA PET/CT guided robot-assisted salvage lymphadenectomy: acceptable safety profile but oncological benefit appears limited. BJU International , 120 (5), 673–681. https://doi.org/10.1111/bju.13919
Sooriakumaran, P., Srivastava, A., Shariat, S. F., Stricker, P. D., Ahlering, T., Eden, C. G., … Tewari, A. K. (2014). A multinational, multi-institutional study comparing positive surgical margin rates among 22393 open, laparoscopic, and robot-assisted radical prostatectomy patients. European Urology , 66 (3), 450–456. https://doi.org/10.1016/j.eururo.2013.11.018
Thompson, J. E., Egger, S., Böhm, M., Haynes, A.-M., Matthews, J., Rasiah, K., & Stricker, P. D. (2014). Superior quality of life and improved surgical margins are achievable with robotic radical prostatectomy after a long learning curve: a prospective single-surgeon study of 1552 consecutive cases. European Urology , 65 (3), 521–531. https://doi.org/10.1016/j.eururo.2013.10.030
Thompson, J. E., Egger, S., Böhm, M., Siriwardana, A. R., Haynes, A. M., Matthews, J., … Stricker, P. D. (2018). Superior Biochemical Recurrence and Long-term Quality-of-life Outcomes Are Achievable with Robotic Radical Prostatectomy After a Long Learning Curve—Updated Analysis of a Prospective Single-surgeon Cohort of 2206 Consecutive Cases. European Urology , 73 (5), 664–671. https://doi.org/10.1016/j.eururo.2017.11.035