Las Vegas-The development of a robot-assisted method for laparoscopic radical prostatectomy could lessen morbidity, cut recovery times, and shorten the learning curve for urologists who have not been trained in the procedure.

"The future is now, and I think it is going to be robotic," said Ralph Clayman MD, professor and chair of urology at the University of California-Irvine Medical Center, during a lecture at the AUA Western Section annual meeting here.

Dr. Clayman

Dr. Clayman predicted that laparoscopy could eventually replace open radical prostatectomy if more effective laparoscopic robotic training was instituted. And he said he believes robot-assisted systems have the capacity to do just that.

'Good teacher' Using the three-armed daVinci robotic system (Intuitive Surgical, Sunnyvale, CA), Dr. Clayman said his colleague Thomas Ahlering, MD, are able to perform a sterile, mechanically assisted laparoscopic prostatectomy while sitting at a console. Urologists who use it need not scrub up nor don surgical gloves.

However, the benefits of the daVinci approach to laparoscopic surgery may go beyond these advantages. The robot is also proving to be a good teacher for "laparoscopically nae" surgeons, he stressed.

One of the hurdles to performing laparoscopy has been the didactic and extensive hands-on laboratory instruction it involves, Dr. Clayman said. Although a majority of urologists now report having received training in laparoscopy, surveys show practice penetration is low, with only about one-third of urologists using the technique regularly in a practice setting.

Photo shows mobilization of the neurovascular bundle during robot-assisted radical prostatectomy. (Photo courtesy of Thomas Ahlering, MD)

Dr. Clayman conducted an impromptu poll at the meeting, noting that about half of the audience-almost exclusively West Coast urologists-indicated they performed laparoscopic surgery of any type. Indeed, for physicians who went through residency programs before 1990, laparoscopy has been a procedure learned largely at workshops and other post-graduate training sessions, he said.

Moreover, the results of studies on laparoscopic training have shown that the learning curve for attaining proficiency in laparoscopic radical prostatectomy, in general, is estimated to be 40 to 60 cases.

Lowering the curve In 2003, Dr. Clayman and colleagues began assessing how robotic assistance could aid in lowering the learning curve. In the initial trial, a fellowship-trained, skilled oncologic surgeon at UC-Irvine (Dr. Ahlering), inexperienced with laparoscopy, was given a 2-day robotic training course followed by a 2-day cadaver course aimed specifically at performing laparoscopic radical prostatectomy. Using the robotic interface, Dr. Ahlering proceeded to perform a laparoscopic radical prostatectomy.

The vas and seminal vesicles are dissected during robot-assisted radical prostatectomy. (Photo courtesy of Thomas Ahlering, MD)

By 10 procedures, his operative time had fallen to 4 hours, and the average hospital stay was only 29 hours (J Urol 2003; 170:1738-41; J Am Coll Surg 2003; 917:693-6).

The findings indicate that, with a robot-assisted laparoscopic radical prostatectomy, an experienced open surgeon can rapidly and effectively transfer open surgical skills to a laparoscopic setting with a learning curve comprising as little as 5 to 10 patients.

"That represents, in my opinion, an important advance," Dr. Clayman said.

"The goal here is to increase the common denominator so that more skilled urologic surgeons can bring laparoscopic surgery into their practice," he said, adding that laparoscopic prostatectomy in several series has been noted to have a lower rate of complications, fewer transfusions, and shorter length of stay (J Urol 2003; 169:1689-93; J Urol 2002; 168:945-9; Urol 2003; 62:292-7).

However, one question needs to be asked about the impact of robotic assistance on surgical expertise:

"You spend a million dollars. Does it make you a better surgeon? The answer appears to be yes," Dr. Clayman said, citing studies by Mani Menon, MD, and others showing that the laparoscopic surgeon, even when highly skilled, is able to operate more efficiently with a robotic interface (J Endourol, in press).

Following robotic-assisted prostatectomy, patients at his center generally return home after slightly more than a day, while Dr. Menon reports hospital stays of less than 24 hours, Dr. Clayman said. The verdict is still out on long-term results with regard to continence and potency, while margin-negative status approaches or equals that of open prostatectomy.

"This procedure is still in evolution. It is still a moving target," he said.

UC-Irvine is an Intuitive/daVinci training site and is paid for participating in the training of urologists on the daVinci robot.UT