Our laparoscopic radical prostatectomy (RP) programme started in October 2000, when Bertrand Guillonneau (France) performed the first laparoscopic RP at our institution. Over the next year, Guillonneau and Guy Vallancien performed 50 procedures with us. In November 2000, Vallancien carried out our first robotic RP; we started using the procedure independently in June 2001. Perhaps because we were not skilled laparoscopic surgeons, but had an extensive background in open RP, we found the robotic procedure much easier than standard laparoscopic RP. The surgical movements were intuitive, and three-dimensional visualization enabled small precise movements. ‘Wristed’ instruments enabled us to dissect with ease around corners and angles, allowing better preservation of the neurovascular bundles and a more precise dissection than with straight laparoscopy or with open surgery. These tools allowed us to develop an approach to robotic RP identical to the open approach, described previously . In addition, the robotic approach allows us to take very precise periurethral soft tissue biopsies, lowering the apical positive-margin rate from 24% to 5%. We have termed the procedure that we developed the Vattikuti Institute prostatectomy (VIP). As of November 2002, we have carried out> 300 robotic RPs and 270 VIPs. Currently our operating time is 2–2.5 h, depending on whether a pelvic lymphadenectomy is performed or not; the robotic RP time is 45 min less. Allowing for a theatre turn-over of 1–1.5 h, we can undertake three operations during a normal working day. Over 95% of the patients are discharged within 24 h; over the last month, half have gone home within 6 h of surgery.
No patient has required an intraoperative transfusion. Six patients have had major complications, five requiring secondary surgical procedures (two port-site hernias, two pelvic haematomas and one repair of a small bowel injury). After 2 months, 90% of the patients are continent, and 60% of initially potent patients have had unassisted intercourse by the 6 month follow-up. Table 1 compares the operative variables during radical, laparoscopic RP and VIP.
|Operative time, min||164||248||140|
|Blood loss, mL||900||380||< 100|
|Positive margins, %||24||24||5|
|Score, n (%)*||6 (100)||4.5 (75)||2.3 (38)|
There appear to be two unresolved issues about robotic surgery, i.e. the cost of the procedure and the intensity of training. The da Vinci surgical system (Intuitive Surgical™, France) costs US $1.2 million, with a maintenance fee of $100 000/year after the first year. The average cost of disposables is $1500 per patient. These extra costs are balanced by the cost savings of decreased hospitalization, fewer blood transfusions, decreased theatre time and a lower complication rate. While it is notoriously difficult to calculate precise hospital costs in the USA, the best we can determine is that the robotic procedure still costs an average of $150 more than the open procedure. This has changed over the last few months, with costs actually favouring robotic surgery, as the operating times for VIP have become shorter than for open RP.
The issue of training is even harder to address. Most surgeons with experience in open RP can become very good at VIP, usually even better than at open surgery. The operation is learned best if there is commitment on the part of the team, which should include a skilled open and a skilled laparoscopic surgeon. Cases should be scheduled frequently, at least one every other day. The team should be the same, and new assistants introduced only after the primary team has become confident with the procedure. Before and after surgery the team should analyse what is being planned and what has been done. The console surgeon should be willing to take advice from the assistants. Finally, it helps if a three-dimensional imaging system is also set up for the assistants. (Most of these recommendations are also true for learning minimally invasive cardiac surgery ). Ideally, the team should witness 30 VIPs and then be mentored for 1 week before they start performing the operation independently.
In conclusion, VIP is a technologically sophisticated procedure that can easily be learned by skilled open surgeons. We predict that once the procedure is learned, most surgeons will be able to carry out a better RP with the robot than without it.