Robotic Surgery in Urologic Oncology

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Presented by: Mark L. Gonzalgo, MD, PhD
Associate Professor of Urology and Director of Robotic-Assisted Urologic Cancer Surgery
Stanford University School of Medicine
January 14, 2010

Lecture Overview:

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  • Since the early 2000s, when robotic surgical systems were first used to treat prostate cancer, urologic surgeons have increasingly employed the technology and expanded its applications to kidney and bladder cancer.
  • Robotic surgical systems may offer advantages in the treatment of certain cancers, however they are not a “magic tool” and should be considered simply as one of the methods at a surgeon’s disposal.
  • The most important consideration for the cancer patient is not the surgical technique, but rather the skill and experience of the surgeon.
  • There is a dearth of randomized clinical trials involving robotic surgical systems and additional research is needed.

No matter the type of surgery used to combat prostate, kidney or bladder cancer, the urologic surgeon’s goals are the same: control the cancer and interfere as little as possible with the patient’s quality of life. Surgeons have traditionally employed either “open” or laparoscopic surgery methods to remove these cancers, which collectively strike more than 300,000 Americans annually.

Robotic surgical systems have added a new tool to the surgeon’s arsenal, allowing for increased surgical dexterity and a three-dimensional, high-resolution view of the operative area.

These robotic instruments have garnered attention, in part, for the futuristic imagery they evoke. We may eventually learn that they offer significant advantages with regard to post-surgical complications, blood loss, nerve preservation, and recovery times, but it is important to remember that robotic systems are only as good as the surgeons who employ them, explained Dr. Mark L. Gonzalgo, director of Robotic-Assisted Urologic Cancer Surgery at Stanford University Medical Center, at a January presentation sponsored by the Stanford Health Library. “Robotic instrumentation is simply another tool at the surgeon’s disposal,” he said. “It is not a magic tool.”

“One of the most interesting aspects of robotic instrumentation is that the surgeon is dislocated from the patient, at a console about 10 or 15 feet away,” Dr. Gonzalgo explained. “Because the surgeon is not next to the patient, he or she relies on a specialized surgical team at the bedside.”

Robotic Surgery and Prostate Cancer
Today, most prostate cancers are detected at an early stage through PSA (Prostate-Specific Antigen) screening and rectal exams. Most are curable. Risk factors for prostate cancer include age, race and family history.  According to statistics shared during the presentation, 192,280 men in the United States were diagnosed with prostate cancer in 2009 and 27,360 died.

If surgery is determined to be the preferred treatment, the primary options are: a retropubic prostatectomy (the incision is made in the abdominal wall), a perineal prostatectomy (the incision is made in the area between the anus and scrotum), laparoscopic surgery (small incisions are made in the abdomen and a camera is used as a surgical aid), and robotic-assisted laparoscopic surgery (a robotic surgical system allows the surgeon to see vital anatomical structures more clearly and to perform a more precise surgery).

No matter the option deemed appropriate for the particular patient, “the challenge for the surgeon is how to best remove the cancer while sparing the nerves and surrounding anatomy in order to preserve sexual and urinary function,” said Dr. Gonzalgo.

Questions remain about the extent to which robotic-assisted laparoscopic surgery leads to superior outcomes.

Dr. Gonzalgo cited an October 2009 study that appeared in the Journal of the American Medical Association. The study, which relied on statistics from Medicare databases, had “several limitations,” according to Dr. Gonzalgo. However, it is one of the few upon which we can draw conclusions.  The study showed that robotic-assisted surgery resulted in shorter hospital stays and fewer post-surgical complications. However, it also showed an increase in post-surgical urinary incontinence and erectile dysfunction. “When you look into the studies that have been published, it turns out what matters most is the experience of the surgeon and the accompanying knowledge of the anatomy,” Dr. Gonzalgo said.

Robotic Surgery and Kidney Cancer
In 2009, 57,760 Americans were diagnosed with kidney cancer and 12,980 died from the disease. The primary risk factors are smoking and there are also familial forms of kidney cancer. As is the case with prostate cancer, more people are being diagnosed at the cancer’s early, more-treatable stages. In addition, surgical advances in the past five to ten years have meant that far fewer patients are losing their entire kidneys in surgery.

“Five to ten years ago, a patient with a tumor that was two centimeters in size likely would have had his entire kidney removed,” Dr. Gonzalgo said. “That’s not true today. We are learning more and more about ways of preserving kidney function via partial nephrectomy.”

Treatment options for kidney cancer include surgery (open, laparoscopic, and robotic-assisted laparoscopic), ablative therapies (the use of cold or heat energies to destroy cancer cells) and active surveillance, also known as watchful waiting or observation.

Dr. Gonzalgo cited a recent study, the largest of its kind, which involved nearly 2,000 patients with kidney tumors of seven centimeters or less who underwent partial removal of their kidneys. The study compared laparoscopic surgery to traditional open surgery and found equivalent functional and early cancer outcomes.  Minimally-invasive partial nephrectomy, however, was associated with a higher complication rate compared to open partial nephrectomy highlighting the importance of surgical experience with this procedure.

Robotic Surgery and Bladder Cancer
In 2009, 70,980 people in the United States were diagnosed with bladder cancer and 14,330 died from the disease.  Smoking is a primary risk factor.  At the turn of the century in England, doctors found a correlation between bladder cancer and certain chemicals used in the manufacture of textiles, making bladder cancer one of the first cancers to be associated with exposure to environmental agents.

Evidence of blood in the urine is the most common way bladder cancer is detected. Often, the blood is at microscopic levels and is detected as part of a physical examination. Other times, the patient may observe blood in his or her own urine. Other symptoms of bladder cancer include an increase in the frequency of urination and painful urination. These symptoms are often associated with other health issues and are not necessarily indicative of cancer.

Cystectomy is the term for the surgical removal all or part of the bladder. The surgeon’s goal is to excise the cancer with the least impact possible on the patient’s quality of life. The surgeon will employ one of several techniques to make up for the loss of all or part of the bladder and urethra, including using a portion of the small intestine to create a conduit or an internal reservoir for the urine. Dr. Gonzalgo reported that researchers are in the early stages of using stem cells to create native bladders for transplant. “We are hopeful that in five to ten years, this could become a reality,” he said.

Meanwhile, surgeons are increasingly using robotic systems in bladder surgery, citing less blood loss, fewer transfusions, and shorter hospital stays. The robotic systems can potentially result in longer operating times. Nevertheless, length of the surgery is more dependent on the skill and experience of the doctor than any other factor, Dr. Gonzalgo said.

About the Speaker
Mark L. Gonzalgo, MD, PhD, is an Associate Professor of Urology and the Director of Robotic-Assisted Urologic Cancer Surgery at the Stanford University School of Medicine. He focuses on the treatment of prostate, bladder, kidney, and testicular cancer. He also is engaged in research into the role of DNA methylation in prostate and bladder cancer, which looks at how certain genes may be useful molecular markers for disease detection.  He received his MD and PhD from the University of Southern California, did his residency at Johns Hopkins, and completed a fellowship in urologic oncology at Memorial Sloan-Kettering Cancer Center.

For More Information:

Stanford Health Library can do the searching for you. Send us your medical questions.

Robotic-Assisted Urology Surgery at Stanford Hospital
http://stanfordhospital.org/clinicsmedServices/clinics/urology/robotic_surgery.html

Stanford Cancer Center
http://cancer.stanford.edu/

Stanford Urology
http://stanfordhospital.org/clinicsmedServices/clinics/urology/