Every Day

Jan. - April Issue

Minimally Invasive Treatment Options for Prostate Cancer

Aaron Sulman, MD

Medical College of Wisconsin Urologist

Traditional treatments for prostate cancer include open surgery, radiation therapy and cryotherapy (freezing the prostate gland). Robotic surgery, a minimally invasive technique to remove the prostate, is the latest advancement in treating early-stage prostate cancer. Aaron Sulman, MD, who is fellowship-trained in minimally invasive surgery and robotic surgery, explains robotics and other minimally invasive treatment options for prostate cancer.

What is meant by “minimally invasive” treatment?

A minimally invasive medical procedure is performed by entering the body through the skin or a body cavity or opening, with the smallest damage possible to these structures.

Minimally invasive (laparoscopic) surgery involves making a few very small incisions. Small tubes (ports) are secured to the incisions, through which miniature video cameras and special surgical instruments are inserted. Images of the inside of the body are transmitted to a video monitor to guide the surgeon in performing the procedure.

What types of minimally invasive procedures are available for treating prostate cancer?

Froedtert & the Medical College of Wisconsin offer every available treatment option for prostate cancer including these minimally invasive therapies:

Standard brachytherapy — radioactive “seeds” are implanted in the prostate in a minor outpatient surgical procedure
High-dose-rate brachytherapy — many tiny catheters are placed into and around the tumor, and a high dose of radiation is delivered through the catheters to the tumor
Intensity modulated radiotherapy — a process that uses computers to plan the precise delivery of thousands of tiny, thin radiation beams to the tumor
Cyrosurgery — uses an instrument to freeze and destroy cancer cells in the prostate
Robotic-assisted laparoscopic radical prostatectomy — minimally invasive surgery to remove the prostate gland; to perform the surgery, the surgeon manipulates four computerized robotic arms
Nerve-sparing robotic-assisted laparoscopic radical prostatectomy — the same as above, with the addition of sparing the nerves that control a man’s ability to have an erection. Some men may not be candidates for this procedure. In order to spare the nerves, the surgeon must cut to the very edges of the prostate. If any cancer cells are likely to be present beyond the edge of the prostate, sparing the nerves risks incomplete removal of the cancer. In that case, the surgeon will need to cut out more of the surrounding tissue and, therefore, won’t be able to spare the nerves.

In addition to minimally invasive treatments, an open prostatectomy is another surgical method for removing the prostate that uses a standard incision. A nerve-sparing open prostatectomy removes the prostate while sparing the nerves that control a man’s ability to have an erection.

What is robotic surgery?

Robotic surgery, using the da Vinci® robotic surgical system, is the latest advance in surgically removing the prostate. Similar to open surgery, robotic surgery removes the entire prostate but involves making a few small incisions.

Robotic surgery is designed to help the surgeon see bodily structures clearly and perform surgery precisely. The system offers the same dexterity as the human hand by “translating” the surgeon’s hand movements into the precise movements of the robot’s micro-instruments.

The system’s magnification and 3-D visualization work together to enhance the viewing of the prostate, nerves, bladder and surrounding structures. This allows removing the prostate and nearby areas of concern, while sparing the nerves that impact sexual function. This also minimizes the chance for injury to surrounding structures and helps the surgeon perform the surgery in a manner in which urinary control can be maximized. The 3-D magnification and agility of the robot assist the surgeon in the goal of maintaining potency and continence.

During the robotic procedure, a man is placed under general anesthesia. Six small incisions — from ¼-inch to ½-inch long — are made in the abdomen. Hollow cylinders called ports are placed in the incisions, and an operating telescope, camera and surgical instruments are inserted through the ports and into the abdomen. The robot is then positioned at the operating table, and the robotic arms and camera are connected to some of the ports.

I sit at the console near the patient, controlling the robotic arms and the camera. I view the surgical area through 3-D goggles, which provide fine details of the body structures. The prostate is detached from its surrounding structures, and the urethra (urine tube) is reattached to the bladder. Removing the entire prostate is important so the pathologist can accurately determine the stage of the cancer.

What are some benefits of removing the prostate with robotic surgery?

Convalescence is shortened and blood loss is decreased. Results thus far show excellent results for cancer control and excellent rates of success in preserving both erectile function and urinary control.

What are some benefits of interventions other than robotic surgery?

Open prostatectomy allows the surgeon to feel the cancer, guiding the surgical removal of the prostate. An open radial prostatectomy also allows for a shortened anesthesia time. With this procedure, cancer control, potency, and urinary continence are also excellent. Brachytherapy and cryotherapy are useful in patients who may not be candidates for the surgical removal of the prostate. External beam radiation therapy is useful in patients who need treatment of tissue beyond the prostate or in patients who are not able to tolerate a general anesthetic.

How does robotic fit into the range of treatment options for someone facing prostate cancer?

It is one of many minimally invasive treatment options for prostate cancer. Many factors such as a man’s age and general health are involved in determining the most appropriate treatment. Robotic surgery is only one of a multitude of prostate cancer treatment options, and it is important to realize that the specific clinical presentation of each patient is best suited to a particular treatment. Robotic surgery is an excellent option for a subset of patients although this needs to be considered along with other options such as open surgery, radiation therapy, cryotherapy, and hormonal therapy.

Who is the best candidate for this robotic surgery?

A man who has early-stage prostate cancer, a life expectancy of more than 10 years, and no prior radiation therapy for prostate cancer is a good candidate for robotic surgery. He also must be able to tolerate general anesthesia.

What is the importance of being fellowship-trained in performing robotic surgery?

A fellowship is additional training in a specialty field beyond a physician’s residency training. During my fellowship training in robotic surgery to remove the prostate, I was exposed to patients with a wide variety of clinical histories and saw many complicating factors that can make surgery more difficult. The training provided the opportunity to see the variability in treating different patients.

Who should perform robotic surgery to remove the prostate?

A urologist who has had extensive fellowship training should perform this surgery. It’s the urologist – not the robot – who guides all of the surgical motions. The same caveat applies to all of the available prostate cancer treatments. Advanced training and disease focus on the part of the physician translate into better outcomes for the patient.

Source: Every Day, interview with Aaron Sulman, MD

Date: Jan. - April 2007