Telesurgical laparoscopic radical prostatectomy - Initial experience

Introduction: Telepresence surgery offers theoretically to overcome two mai n problems of laparoscopic surgery, i.e. the limitation to only four degree s of freedom and the lack of stereovision. Since 1998, telesurgical minimal ly invasive procedures have been performed with the da Vinci system mainly for cardiac bypass surgery. Clinical experience in urology is still very li mited. We want to present our initial experience using the device for robot -assisted laparoscopic radical prostatectomy. Material and Methods:The Intuitive surgical system consists of two main com ponents: the surgeon's viewing and control console with 3D imaging and the surgical arm unit that positions and maneuvers detachable surgical instrume nts. These instruments introduced via two 8-mm trocars allow movements in a ll 6 degrees of freedom due to the EndoWrist technology. The surgeon perfor ms the procedure seated at the console holding specially designed instrumen ts, Highly specialized computer software and mechanics transfer the surgeon 's hand movements exactly to the microsurgical movements of the manipulator s at the operative site. We have used a semilunar-shaped 5-trocar arrangeme nt with the robot's arms at the lateral trocars and two assistant trocars m edially. A sixth trocar was used in the right suprapubic area for retractio n of the gland. The left assistant used different instruments such as bipol ar forceps, Ultracision, Endoclip, whereas the right assistant mainly used the suctcion-irrigation device. Except the first case, the Intuitive System was attached after exposure of Retzius' space. Results:We have treated 6 patients (2 pT2, 4 pT3, median Gleason score 6). The OR time averaged 315 (242-480) min including pelvic lymph node dissecti on. No intraoperative complications occurred, 1 patient required transfusio ns. There were no positive margins, median catheter time was 5 days. 3 pati ents were completely continent after 1 month. Conclusion: Telerobotic laparoscopic surgery offers several advantages over all presently available techniques, such as all six degrees of freedom, de xterity enhancement, tremor filtering, and stereovision. There is a learnin g curve with the device, mainly because of the magnification, the 3D image and the lack of tactile feedback. However, only after a short period of tim e, the experienced, surgeon is able to get familiar with the device. Howeve r, there are still concerns with respect to the high investment and running costs of the device as well as regarding the necessitity of further develo pments of instruments for urological procedures. Copyright (C) 2001 S. Karg er AG, Basel.