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Radical Prostatectomy - The Robotic Way

May 17 | 3:30 PM

Robotic radical prostatectomy is a technique of minimally invasive surgery in which the entire prostate is removed using surgical robotic equipment. Surgeons can use the robotic laparoscopic approach to operate through small ports rather than big incisions, resulting in faster recovery, fewer complications, and shorter hospital stays. Let's watch the procedure with Dr. Raj Nagarkar, Consultant & Director, HCG Manavata Cancer Centre, in this episode of- Theatre and learn how surgical robotics combines minimally invasive treatments with cutting-edge clinical technology.

[Music] hello and good evening one and all on behalf of the entire team netflix i welcome each one of you for coming and joining in tonight for the super interesting session on radical prosthetic to me the robotic way so today it is indeed a privilege to get this opportunity to learn from dr raj nagar so about this very super interesting topic a little background on our uh extremely renowned speaker dr raj nagarkar is managing director and chief of surgical oncology and robotic services at hcg manager cancer center so now as we all know robotic radical prostatectomy is a technique of minimally invasive surgery in which the entire prostate is removed using surgical robotic equipment sir has over 21 years of experience in the field of oncology and so has been serving the entire nation especially the maharashtra especially the maharashtra region and all libraries of oncology sir did his surgical oncology training at the tata memorial hospital mumbai followed by mrcs at royal college of surgeons edinburgh he started his surgical oncology practice in the year 2000 at national can established qut manavita cancer center in 2007. it is now the first nabh and nabla credited dedicated cancer care hospital maharashtra and has over 700 plus well skilled and compassionate hands to care for the patients it is now recognized by the national board of examinations for dnp in surgical oncology and radiation oncology sir has performed over 470 robotic surgeries in less than two years and it has been a global landmark he has been involved in more than 350 phases of phase one to three and investigate the initiated clinical trials and has multiple authorships international and national publications to his credit i think the answer thank you netflix for this opportunity once again and to all those who have logged in at this point of time to understand about carcinoma prostate and how robotic radical prostatectomy is actually changing the way forward or making uh surgery much more easily uh acceptable for the patients is what i would uh put it before coming on to the surgical video part let's have something in brief about the epidemiology and the etiology of prostatic carcinoma as we all know in men prostate cancer the most common non-cutaneous malignancy and the second most common cause of a leading cause of solid tumor related mortality is that over 60 percent of new cases are diagnosed in men age 60 years and older and the mean age at diagnosis is around 67 years in the recent past we have been seeing patients who are much younger age as young as 48 and 49 years also being diagnosed with prostate carcinomas if you look at the african-american males affected more than white men the african-american males are affected more in india the incident this is said to be about six to ten per hundred thousand population per year men population per year what are the risk factors as far as prostate carcinoma is concerned uh familial uh incidence like a family predisposition accounts for the 15 percent cases of prosthetic carcinoma certain genetics particularly the fox b13 braca hp1 hpc2 are the other risk factors which increase risk insert certain familial h2 the 8q24 chromosomal locus is also known to be a risk factor recurrent inflammations and infections are also said to have a predisposing factor as far as prostate carcinoma is concerned certain molecular factors include androgen exposure and estrogen effect based on receptors the igf leptins and vitamin d deficiency smoking accounts for increased risk in 9 to 30 percent of patients who are diagnosed with prostatic carcinoma obesity and increase occupational exposure to cadmium are also the other risk factors of prostatic carcinoma now how do we evaluate a patient when as far as prostate cancer is concerned all we know that as far as screening is concerned the serum psa or prostate specific antigen happens to be one of the most common screening modalities and in fact psa is also said to be a good prognostic factor as well as used for monitoring the response to treatment as long as the patients continue to hormone sensitive digital rectal examination helps us to clinically evaluate the prostate and find out any modularities trust the trans factor ultrasound helps to pick up certain abnormalities in the prostate which also can be used for transguided biopsies also in low risk patients mri as a screening modality is not indicated however once a patient is diagnosed as prostate cancer then mri particularly for the local regional spread of the cancer happens to be the most important staging diagnostic modality psma pet scan psma pet scan is the most sensitive and specific imaging modality to find out the staging as far as the disease is concerned in those areas where psma pet scan is not available a technician 99m label bone scan can be used particularly for symptomatic patients uh the staging guidelines which are being followed as far as prostate cancer staging are the tnm staging based on the national comprehensive cancer network these are the 2022 version 4 guidelines and these are entirely depend upon the extent of the primary tumor the regional lymph nodes and the distance metastasis is concerned as we know that t tumor is the t1 tumors are those which are clinically in apparent tumor and they are not palpable there is incidental diagnosis after turp or on a biopsy t2 tumors are those which are confined to the prostate t3 tumors are associated with extra prosthetic extension it could be either unilateral or bilateral or microscopic invasion of the bladder neck the t3b tumor is associated with the involvement of the seminal vesicles and t4 tumors are those which are fixed into the adjacent structures including the seminal vesicles or the external sphincter rectum bladder levator muscles and of the pelvic wall is concerned uh regional nodes is either n zero no positive original nodes or n one n one is the regional nodal metastasis is concerned based on uh the clinical pathological features are concerned prosthetic carcinoma patients are further sub classified based on the risk group analysis where we subclassify them as very low risk group low risk intermediate risk high risk group or the very high risk categories it is entirely based on the psa level as well as the tumor stage the tnm t1c or the grade of the tumor which is concerned so this determines as to what patients who should be subjected for the modalities of treatment what are the therapeutic options which are available for carcinoma prostate uh in those patients who have got a read a less survival possibility or who are a very very low risk group category even active surveillance or watchful weighting is said to be a type of a therapeutic option which can be offered for a selective group of patients the as long as the tumor is localized to the prostate radical prostatectomy happens to the gold standard or the other option could be radical radiation therapy which could be either imit or igit technique ablative therapies it could be radio frequency ablation also has been used in selective group of patients hormone therapies which could be either surgical castration or medical or medical castration including the lhrh agonist and anti-androgens has also been a standard hormone therapy chemotherapy uh has now actually started be has been used more frequently even right from the onset of the therapeutic options rather than waiting for the tumors to become hormone resistant and then adding chemotherapy now chemotherapy and hormone therapy are usually started simultaneously immunotherapy has started having some role in those patients who are like you know who have failed one or multiple lines of therapy in fact psma therapy also the prostate specific membrane antigen label therapies are also effective in a selective group of patients now if you look at the management of prostate carcinoma based on the dre ps and the gleason score we say that if the patient's life expectancy is less than 10 years and if they're asymptomatic we even a watchful surveillance no further treatment or treatment options can also be offered wherever the patient is symptomatic or has got a good life expectancy based on the tnm staging based on the psa level uh the ctr mri imaging we sub uh we do the risk stratification into the very low low risk intermediate or high risk tumors or very high risk tumors based on that further treatments can be planned out now if you look at treatment based on the risk category and stage of the tumor very low and low risk group patients can be offered active surveillance and particularly this we need to exclude patients with prominent ductal calcium and sarcomatic or small cell carcinoma or even neuroendocrine tumors of the of the prostate that option could be primary external beam radiotherapy or brachytherapy can be given and if the patient has got a expected good survival of more than 10 years with no major comorbidities radical prostatectomy should be offered for patients with the intermediate risk group there is no clear evidence as far as active surveillance should be considered for favorable or intermediate group however radical prostatectomy over active surveillance particularly the pivot trial has found to be much better outcomes have been shown and those patients who are not willing for androgen deprivation therapy radical radiation can be offered high-risk group patients there is no doubt that a radical prostatectomy is the best option particularly the patients who have a tumor less than the t3 stage where there is no involvement of the pelvic side walls no invasion invasion of the urethral sphincters and a low tumor volume followed by an accident radiation for this group of patients in case of locally advanced carcinoma prostate in a selective group of patients now even t3 t4 n0 or n1 lesions as a part of multi-modality therapy where pre-operatively hormonal therapy is given and at 6 weeks to 12 weeks after giving androgen ablation we can offer the patient a radical prostatectomy and radiation to be given in the adjacent sitting to all these patients if psa is the only site of recurrence early salvage only evidence of recurrence early salvage at radiotherapy is also offered recurrence after radiation for those patients who have received radiation and have a locally recurrent disease and yet no co-morbidities at initial stage what t1 t2 salvage radical prostatectomy can be offered keeping in mind that these patients tend to have a higher risk of perioperative complications as compared to those who undergo upfront surgery single agent hormone therapy versus observation in low urus group are also other options which are there in metastatic carcinoma prostate hormone therapy with or without chemotherapy is now taken as the standard of care now radical prostatectomy now uh restricting myself to this evening as far as the surgical part is concerned radical prostatectomy still remains the gold standard for carcinoma prostate wherever the disease is localized and is amenable for complete resection what are the goals of surgery most important is the complete r0 resection which by itself is going to get translated into improved survival for the patients and it also helps to remain for the patient to remain continent and preserve the potency unlike that in radiotherapy patients now what are the approaches which can be used for a radical prostatectomy it could be the open radical retropubic prostatectomy approach or open radical perennial prostatectomy laparoscopic radical prostatectomy and robot assisted radical prostatectomy i think in the current era the in the current area the chances of open prostate may have definitely gone down significantly in fact majority of the patients are now undergoing either minimally invasive or robotic radical prostatectomy only if you look at the risk stratification and patient selection for radical robotic we usually uh offer it for those patients whoever favorable uh intermediate risk and if the lymph node but if particularly the favorable intimate risks that the expected survival is more than 10 year there are indications for robotic prostatectomy and indications for pelvic lymph node dissection if the probability of lymph node metastasis is more than or equal to two percent for unfavorable uh intermediate risk where there is more than 10 years of expected survival it is uh always better to do a retropie with a lymph nip lymphadenectomy that palutelyphenectomy for all high or very high risk and regional risk patients of pelvic lymphedema should be done for patients now i would like to show a video of a robot a robotic prostatectomy i am using the versus versus robot from the cambridge medical robotic and this is the ooty scenario in which the patient's position is there and we have the individual bedside unit the second image shows the positioning of the ports for these patients where we usually put the super umbilical port along with the two ports on either side and usually use the three arm approach and this is the video i will just play the video it is about 12 to 13 minutes where uh patient is a 68 years old gentleman no major comorbidities uh psms can choose no evidence of extra prosthetic spread no evidence of lymphatic nectar lymphatic uh lymphadenopathy and hence uh with all fitness we plan to uh do a robotic radical prostatectomy i start uh posteriorly i'm using on the left hand side you can see is a bipolar grasper right side is the hot scissor we need to release the peritoneum the bladder that you are coming across the stem anal vesicles as we incise the peritoneum and move deep usually start from either side from the obliterated umbilical arteries so vast difference which is coming up over there as we go in the space the hot seasons and the magnification actually makes a big difference because we can visualize as compared to laparoscopic prostatictomys having the magnification 3d image and the camera under the surgeon's control really makes a big difference as far as the clarity and the ease of surgery is concerned it's a vast difference which is dissected out from the receptor on the right side we cut the vase over there vector segment of the difference is usually cut and that can be delivered out because invariably if you try to do give traction on it it tears off that's the gas on the left side and i just deliver it out to my assistant and continue with the dissection this is the artery to the which accompanies the vast inseminal reciprocal and go on dissecting the effects over there gently i need to be careful over there because the rectum behind gently traction at the same time with the hot scissors when it is not being activated you can just do some gentle dissection peeling of the tissues helps you to dissect it very comfortably the bipolar grasper ensures that while reaching at the level of the prostate we dissect out the victim easily once that is done we move anteriorly umbilical ligament and then when the right plane badly pervascular plane move laterally coming to the periprosthetic fat anterior to the prostate these are the nerves be careful over here if possible if you feel it's very close avoid using the the pugo prosthetic ligament over there cauterize it and cut this is the very prosthetic yeah that's the tissue and the bbc is taken take a stitch at the dvc but this is the notorious area where it can bleed this patient had a small prostate once you identify the can you take stitch and identify the neck bladder neck making sure that you are not too much in the prostate the bladder neck is identified fortunately if a patient does not have a big median lobe open up the bladder over there the catheter pulleys actually helps it acts as a retractor then you go on to the posterior bladder wall a proper dissection in the pre-rectal space and particularly the seminal vesicle helps over here because we can just gently dissect the posterior wall of the prostate moving laterally and deliver the vast difference and the seminal vesicles and going lateral to the prostate gently teething over there ensuring again that we do not cause we are not very close to the nerve because all the efforts of nose preparing prostatectomy would be futile if you end up doing thermal injury to the nerves the third arm of the robot has ensured that the seminal vesicles and the vas defense have been held and retracted anteriorly so that gives a traction whatever the bladder which is held behind is dissected off now we move on to the perius thread tissues that is the even after stitch you can encounter some more will be opening up the urethra with those fibers of the pelvic floor and splinter we ensure that we do not damage any of those and this the assistant plays a very major role over here because the section at least this point of time without interfering in the hot scissors or the retractor we can even use a gentle cold saline lavage irrigation at this point of time if there is bleeding there is no harm in increasing the intraperitoneal pressure the co2 flow rate can be increased slightly to act as a hemostasis this entire prostate is now being released from the bladder neck yes but there's a bad neck which is being freed and we take the stitch usually i start in the midline the gentle traction using the other things the grasper the bladder neck is pulled down start from the midline go towards one side inside out outside in once you reach one end then it is always better this is a strata fix once you reach one end then take the second piece second uh suture material which again starts from the midline to go on to the opposite side this is the second sata fix which starts from towards the left side in this particular patient fortunately the prostrate was not very bulky hence the bladder neck which was cut was not very wide so there was no need to repair the bladder neck you could just ensure that the urethra and that next suturing did not leave any wide angle open as far as the bladder is concerned robotic prostatectomy i think the the most beautiful part is the suturing part because you can do the suturing with at most ease and ensure that you are able to achieve a water tight closure in fact because that's coming onto the anterior wall which is the easier part once you come at the end clear wall both the sutures the left and right suture material you come and tie it in the middle line a leak test is being performed if the leak test is clear you deliver the prostate into a endo bag and after it is it is usually brought out by a small incision in the right eyelid process is what i really prefer or if required in the suprapubic region now if you try to review the literature for robotic versus lab versus open radical prosthetictomy this was one study by zhuan wu it was a large study of about 1400 plus patients where comparison of acute and chronic surgical complications following robot assisted laparoscopic and traditional open radical prosthetic among men in taiwan was done a study involving 1400 patients where they evaluated the hospital stay as well as the operative time and in this study uh the patients underneath robot assisted radical prosthetic as well associated with fewer acute and chronic post-operative complications rather than those undergoing the open or the laparoscopic robotic prostatectomy another large study is a series from more than 782 patients from the european association of urology also showed that robotic assisted radical prostatectomy significantly better continence uh recovery at three months after the surgery as compared to open or laparoscopic as compared to laparoscopic procedures and this is another paper from the european association of urology which also showed that on extended follow-up calibrated over the previous report at 12 months of a persistent robotic assisted radical prosthetic they definitely had a benefit as far as potency was concerned so i think though at this point of time a robotic assisted radical prostatectomy has not demonstrated any survival advantages or outcomes however even if not survival advantages it definitely has a significance as far as reduction in the incidence of perioperative complications are concerned also early return to normalcy for bladder function and as well as potency is concerned second part we've seen that as compared to patients who undergo a laparoscopic or open prostatectomy patients of robotic prostatectomy tend to have a much lesser pain score as compared to laparoscopic or open surgery because the pore site pin is significantly less in these patients the risk of dvt is less in those patients who have undergone who need a pelvic lymphadenectomy the yield of lymph nodes open versus lab versus robotic has also found to be similar the blood transfusion or the bleeding risk is much lesser in patients of robotic prostatectomy as compared to labor open prostrate i think uh thank you very much for this opportunity to share this video and a brief about robotic process to me if there are any questions i would be happy to take them just give them a moment uh dear audience please put in your questions in the comment box and i'll take them and i'll convey them to talk to that so we have one question from dr s mithal he wants to know prostate artery embolization effectiveness for benign prostatic hyperplasia will it have lower side effects sleep or benign prostatic hyperplasia i think you don't need to do a open or a robotic prostatectomy a transurethral prostatectomy or even a laser prostatectomy each are equally efficient and much more easily acceptable modalities worldwide okay thank you so much i hope that answers your question i suggest taking other questions so we have a question how to prevent prostate artery embolization to prevent prevent prostate remoralization any precautions we can take while operating uh see basically prostate artery i'm i'm not gay about getting that question why would one need to do embolized during surgery no uh can can the question come back again uh yes uh dear doctor if you could just rephrase your question and take that again uh so we have a question from dr sanket how do you identify lobes in lab and is there any possibility for post-op structure formation yes there is a risk of prostop post-operative structure formation and in fact for that particular reason one needs to be very very uh careful while doing the urethra to bladder anastomosis is concerned so optimum bachelor's anastomosis prevents the risk of stricture formation and in case the patient yeah in case if patients do have a mild structure it can be easily dilated or very rarely it so happens that the patient we ask the patient to do a self-catheterization uh surgical on ketogenic is preferable it's patient with multiple methods rather than or radical prostatectomy so is it the case sir yeah that's true see i mentioned in my presentation that radical prostatectomy is for only patients who have early disease or loco regional disease once the disease has spread beyond the prostate into the surrounding organs or into the lymph nodes or rectum or lateral wall and in case it is to the skeletal meds then there is no role of surgery it has to be a hormonal manipulation which are because 95 percent of prostate cancers are hormone sensitive hormone manipulation can be done either by surgical archetectomy or by medical castration drugs like lh agonist and anti-androgens are equally effective uh as compared to doing a surgical architecture right industry thank you uh so i'll just add one more question uh this was really good inside uh so how do you identify lobes and laparoscopy is it a possible post of structure formation or is there a possibility for poster of stricter formation it's a question yeah i know that's what i answered there is a small risk of a stricture formation but that risk is hardly five to seven percent and that can be prevented at the time of surgery by taking care of the urethral anastomosis the suturing which is done it should not be very tight or very narrow which is there as far as identification of the lobes uh at the time of uh laparoscopy or robotic which is there one does not the most important look we need to identify the median lobe particularly in patients who have a large median lobe which is protruding inside the bladder there one needs to be careful while cutting the bladder that the urethric orifices might come very close to your bladder neck suturing over there so there could be a narrowing or a stricture at the united korea price so we have a question from dr ashley the enzyme replacement to prevent prostate activity to prevent prostatectomy see it's like you know again there are in days if you do a hormone therapy then as those patients who have a bulky prostate or a large volume then pre-operatively we tend to give them a la charge account is to reduce to shrink the prostate and operate after six to 12 weeks but there is no such enzyme replacement to prevent prostate cancer which is there and now uh where as i said one of the major uh familial causes of prostate cancer is the braca mutation which is there and since we are doing backup mutation or genetic counselings are being done more frequently in the recent past so all patients who have a familial risk of breast carcinoma or endometrial or ovarian cancers we advise draca mutation and like the germline mutation for the entire family and in case the males who are positive then we advise them to be under an active surveillance as far as prostate cancer is concerned right uh thank you sir uh so i'll just take a few more questions and then uh we can wrap up so post off period uh which level of psa is reasonably safe and so there is one more related question uh from dr uh dr so do you prefer uh total psa or free psa uh so what's advisable and follow the question a free psa is always preferable and uh see it's like you know it's a psa is for screening and it is for follow-up so many times though the normal range of psa is zero to five but if a patient whose psa after surgery has dropped down to one and if it if it increases from one to two and two to three even if that three is less is within the normal limit but a serial rising psa should not be disregarded it has to be taken care that probably there is some amount of risk of recurrence either biochemical recurrence or there is some metastases being growing somewhere i hope that answers your question and one more dr naresh uh stem cell therapy was the role of stem cell therapy or interested cancer as as of now there is no rule of thumb yeah yeah so we have a question from dr mitchell again a high volume metastatic prostatic cancer phi lesion in bony areas the beautiful thoughts and management see high volume prostate cancer at the time of diagnosis metastatic disease age of the patient if the patient is fit equal status 0 or 1 no major comorbidities a combination of chemotherapy along with hormone therapy either surgical or medical cascading is the best modality of treatment if a patient is not fit enough to go through chemotherapy or dosage taxes based chemotherapy then we can use drugs like enzymatomy is there ibulatron is that these are wonderful drugs which should be tried along with chemotherapy along with hormone therapy thank you so much dr raj i hope that answers your question so we have a question regarding the robotics equipment like the latest preferred model if you could just shed a little light on that stuff see as of now uh the commercially available robots which are there the davinci of intuitive was one system what i am using is the versus system from cambridge medical robotic and there is another now which has come in which is the comedian uh robot also has come but in fact most of them davinci has a two decade long existence in the industry the cmr is there for almost two and a half years i have been using the versus system from october 2019 and just to update you that my the surgeries have crossed 555 surgeries in the last about uh how much would say around 28 29 months i've brought them more than 550 odd proceed 555 plus procedures so and now the new uh covidien also has come yeah i we expect in the next couple of years there will be many more robots and availability of these robots in the market is actually good for the patients because the competition will ensure that the prices are much more within the reach of the patients and also as a as a doctor and as a surgeon i think that there is a responsibility on the medical field or the medical community that quality of surgeries quality of training that has to be ensured that they have to be audited so that we do not do more harm than good by utilizing these newer technologies yes so apologies if i'm taking this question again uh we have a question regarding the follow-up protocol in your institute or otherwise post a radical prostatectomy poster radical prostatectomy usually immediate perioperative patient is asked to walk around in six hours after four to six hours we make him walk around next day morning liquids are started if the drain which is kept in 48 to 72 hours once the drain reduces to less than 50 ml it is reduced it is removed we usually do a leak test at the time of surgery the leak test is negative day three or day four the catheter is removed and patient is sent home ah once the histopathology report is there if there are all margins are negative modes are negative then for first two years we usually advise the patient loopride depot injections every three months and ask the patient to come for follow-up once in three months for first one year with a psa and mri is done at the end of six months second year it's a six monthly follow-up and a psms can annual space okay so would you also prefer mri for the diagnosis to make the diagnosis yes yes before the surgery mri pelvis is mandatory because we cannot rely on psma pcp scan as far as the local invasion or implementation is concerned perfect so we had a question regarding that as well so i hope that answers your question represented [Music] so just finally going through all the questions uh post-op period what level of psa is that be safe i think that i usually usually we see that in within one month after the surgery the psa drops down to the near normal limits so you've covered all the questions uh beautifully thank you so much for giving us your time it was very exciting and we consider ourselves privileged to have this opportunity to learn from you tonight thank you so much and the netflix team it was a wonderful opportunity to interact with all of you thank you so much we would love to have your metrics again thank you so much thank you for joining in we look forward to seeing you in a lot of more sessions in the coming week

BEING ATTENDED BY

Dr. Bharadwaj Sarmah & 942 others

SPEAKERS

dr. Raj Nagarkar

Dr. Raj Nagarkar

Managing Director & Chief of Surgical Oncology and Robotic Services, HCG Manavata Cancer Centre

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dr. Raj Nagarkar

Dr. Raj Nagarkar

Managing Director & Chief of Surgical Oncolog...

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