Prostate cancer is now the third most common cancer in Singapore men. Fortunately, most prostate cancers can be picked up at its early stage. Currently, the most effective screening method is the blood test, prostate specific antigen (PSA). As long as the cancer is confined within the prostate gland, cure is still possible.
Curative treatment consists of radiotherapy or surgery. In most cases, surgery by means of a radical prostatectomy, still offers the best cure rate of 90% at ten-year follow-ups. However, many men are afraid of surgery for fear of excessive bleeding, wound pain, incontinence and impotence. For many years, radical prostatectomy surgery has traditionally been done through an open incision in the lower abdomen. Subsequently, the laparoscopic method was developed (Figure 1).
Since Year 2001, the robotic method is catching on as the better minimally-invasive method. Thousands of robotic prostatectomies have been performed around the world: USA, Europe, and now, Asia. In 2004, robotic assistance was used in 8000 prostate cancer patients, or nearly 10% of all radical prostatectomies performed in the United States. By 2007, this number has reached 60%. The exponential growth is due to the advantages provided by the Da Vinci robotic system (Intuitive Surgical, Inc., CA, USA), which allows surgeons to sit comfortably at a console and immerse themselves in a 10-fold magnified, 3-dimensional view of the pelvis and prostate (Figure 2).
The conventional method of open radical prostatectomy does not confer such a stereoscopic, magnified view. It is also hampered by the narrow male pelvis. Many urologists find it ergonomically difficult to stitch the bladder to the divided urethra after the prostate has been removed. This is where the Da Vinci system overcomes these limitations. The robotic instruments are ideal in such a confined space. The tiny instruments articulate with wrist-like movements that are superior to conventional laparoscopic instruments (Figure 3).
(Figure 2) (Figure 3)
Unlike conventional laparoscopic method, the surgeon is also in direct control of the camera and is further aided by computer-filtration, which eliminate hand tremors. The only limitation is the lack of tactile feedback, but with a regular team, robotic surgery can be completed in less than three hours. Figure 4 shows the robotic arms in the patient’s abdomen.
In terms of clinical outcome, clear benefits of robotic surgery are the reduction in postoperative pain and length of hospitalization because of the minimally-invasive nature of the surgery. Most patients can be discharged by the second day after the surgery. Blood loss is also minimal (less than 200 ml on average), resulting in negligible transfusion rates compared to open prostatectomy, which typically carries a transfusion rate of 30%.
As for the concerns of incontinence following radical prostatectomy, the robotic method gives better continence rates through better preservation of urethral length and a watertight anastomosis. As for the fear of impotence, the magnified visualization allows precise dissection and where suitable, preservation of the nerve supplying the penis. Data from various centres show faster return to continence and potency because of better preservation of the nerves responsible for sphincter and sexual function.
Not surprisingly, there is a trend for patients to go to leading hospitals that offer robotic surgery. This emerging trend is attributed to the measurable clinical benefits that robotic-assisted radical prostatectomy offers despite its higher cost. In Singapore, the Da Vinci robot made its debut in 2002 at the Singapore General Hospital. In 2004, Mt Elizabeth Hospital acquired the newer version, which has four arms, allowing the surgeon to use the fourth arm as the second assistant.
Robotic prostatectomy is the fastest-growing treatment for prostate cancer in the United States. Asia is likely to follow suit with more Da Vinci systems being installed to match the rising number of men being diagnosed with curable prostate cancer. The advantage to patients who opt to have their surgery done here is the relatively lower cost compared to Western countries.
Author’s note: Figures 1, 2 and 3 are provided, courtesy of Intuitive Surgical, Inc., California, USA.
Dr Chin Chong Min
Clinic: Chin Chong Min Urology
Address: 3 Mt Elizabeth, #16-11, Mt Elizabeth Medical Centre, Singapore 228510Tel: +65 6235 1180
Fax: +65 6235 1186