Robotic-assisted laparoscopic prostatectomy has become the most widespread treatment for organ-confined prostate cancer (J Robot Surg 2019; doi: 10.1007/s11701-019-00974-7). Advanced minimally invasive, robotic-assisted salvage prostatectomy performed via the da Vinci surgical system is an increasingly acceptable treatment modality for a prostate cancer patient who experiences a recurrence of cancer after radiation therapy.
Salvage robot-assisted radical prostatectomy refers to surgical removal of the prostate gland performed after postoperative radiotherapy radiation therapy when cancer recurs locally, known as biochemically recurrent prostate cancer, and is an increasingly common disease state with more than 25,000 cases annually in the U.S. (Am Soc Clin Oncol Educ Book 2018; doi: 10.1200/EDBK_200319).
Rabii Hussein Madi, MD, explained that hormonal therapy and cryotherapy are not as curative as removing the whole prostate. "In recent years, [for the] 30-40 percent of patients who elect radiation therapy, the cancer will recur," noted Madi, who is Director of Urologic Oncology and Robotic Surgery at the Medical Center at Augusta University, as well as Professor in the Division of Urology.
Prostate is a unique cancer and is the second leading cause of cancer death in males (Oncol Lett 2018;15(2):1823-1828). This year, it is estimated that 1 in 9 men will be diagnosed with prostate cancer. Despite this, the prostate cancer mortality remains stable over time, noting the 51 percent decline in prostate cancer-related deaths during the years 1993-2016.
"Because the prostate is a unique gland, every stage and every patient's presentation is unique," said Madi. "Therefore, each patient needs a tailored treatment plan to address their specific diagnosis. Fortunately, the technological advances in robotic surgery and the progress in research have supplied urologists with multiple modalities with respect to cryotherapy, hormone therapy, radiation therapy, and surgical removal or radical prostatectomy."
7 Degrees of Freedom
In 2000, robotic surgery with the da Vinci surgical system became the first robotic surgery system approved by the FDA for general laparoscopic surgery designed to facilitate complex surgery requiring a minimally invasive approach (F1000Research 2018; doi: 10.12688/f1000research.15480).
Almost 20 years later, the da Vinci robotic-assisted surgical two-component system is comprised of a surgical cart and a surgeon's console with high-resolution, 3D endoscopic camera optics. With a tremor filtration feature, surgeons can manipulate hand and foot controls to direct the robotic arms of the surgical cart. Instrumentation is configured to scale and refines the surgeon's motions to reach 7 degrees of freedom by increasing the range of motion as opposed to the human wrist as practiced in conventional laparoscopy. With real-time movement between the surgeon and the cart, all motions are direct translations of the surgeon's actions (Otolaryngol Clin North Am 2008;41(4):781-vii.).
"Compared to conventional laparoscopy, the pinpoint precision of robotic-assisted technology and 3D optics provides a clear pathway to the prostate so surgeons can clearly see vital anatomical structures," explained Madi, who practices the da Vinci prostatectomy modality at the Medical Center at Augusta University. "This enhanced vision is critical since the prostate gland is tightly confined and surrounded by nerves that affect urinary control and sexual function."
With 13 years of robotic surgical experience, Madi has conducted 1,600 robotic-assisted laparoscopic surgeries and is one of a growing number of clinical researchers dedicated to prostate cancer research. Among those surgeries, 20 were salvage robotic prostatectomies for radiation failure. Madi is in the process of analyzing short- and intermediate-term outcome of salvage prostatectomy.
The objective of Madi's research is to determine the safety and efficacy of salvage prostatectomy paying special attention to quality of life after surgery. "While it's not a big number, the early results of robotic salvage prostatectomy surgery were encouraging," he said. "The outcomes of the study showed that more than half of those patients were cancer-free and maintained their urinary continence."
1 Patient, 13 Years
While 30-40 percent of radiation therapy patients recur, the other 60-70 percent reveals a few success stories. "Historically and luckily, radiation therapy failure does not happen immediately," said Madi. "In one particular case, the recurrence presented 13 years after radiation."
After the initial radiation treatment, the patient's PSA level increased, suggesting recurrence of cancer, he noted. "After scanning the prostate, the cancer was indeed active. I conducted a biopsy which confirmed the cancer. At that point, a salvage prostatectomy was scheduled." After the 2-hour surgery, Madi said the patient went home the next day.
"Within a 9-month period, the patient's PSA level was undetectable-a zero," he explained. "Additionally, the patient recovered urinary continence within 6 months after the surgery.
"When the patient is in reasonable health and the biopsy reveals that the recurrence of cancer is located in the prostate only, the patient can expect a good functional outcome."
Amy Gallagher is a contributing writer.