Chapters Transcript Live Robotic Prostatectomy Surgery David Lee, MD performs a Robotic Prostatectomy Surgery, live from Penn Presbyterian Medical Center. we I work here at the University of pennsylvania and urology. And we wanted to show you today what we do for men who have what looks like organ confined prostate cancer. So meaning it's early. But then the main treatment for this is going to be either surgery or radiation. So then this this gentleman opted to have surgery done. And so we're going to take out his prostate. But one of the really cutting edge ways that we do this now is with a robotic technology. So the robot that we use is called the da Vinci surgical system. Um it helps us to do the same operation that can be done open but through small six small incisions, all about that big. So our chief resident cara has gotten that's a good start here with this case and then we'll get well get moving further with the caves. And then yeah, if there any questions as things go along, I think if somebody there can message me and then we can talk about what we're doing or what's going on. But I'll try to do what's going on as well as we're moving along. Okay, great, great, great. So when we first get started, the bladder is actually kind of up here like this. So then um looking down into the pelvis, we see um the sigmoid colon going down and then as that goes down towards the feet of the patient and then the head was gonna be like up that section and then the belly buttons up there and then the spine is down there. So then as we're looking in towards the feet the bladder is actually usually stuck up here. So then um cara has released the bladder for us and that's dropped that down so that we see right into the pelvis. And then as as we make our way further down here you see this big white structure down here and so that's the bone and that's kind of the front of the pelvis. He's got a little hernia raise here. So that's a place where there's a little weakening of the abdominal wall and that allows stuff in some people this to slide down there over time. Um And then as we again and because I think we'll need to release a little bit of that here. Still we can see the bladder down here and then the way that we can tell that is the foley balloon. So that foley was placed um right after the patient went to sleep but before we put any of our instruments in. And so that helps to drain the water out of. But then that also gives us a landmark because we can see the round shape of the blown and then down here is the prostate. So then looking down into the prostate, we see these muscle fibers over here that makes up the pelvic floor and you can see it acts like the cone almost where everything's tapering downward into that very small area down at the bottom of the palace. And so we'll see all the way down there what exits down there is on the back side of the rectum, but then just next to that is the urethra and that's going to be right down here. And so we'll see that with the holy balloon coming up. Let's release a little bit more of this over here. So the calling. Uh huh. Yeah. By taking this down a little bit, that's gonna hopefully give us a little bit more room in the pelvis. The pelvis is always the narrowest part and so it makes it more challenging because the working room is limited. So we try all of these little maneuvers to try to give us as much space down there as possible. So this is one of the things that can help very often there are these little adhesions or attachments that hold the side of the, calling up to the side of the body wall. And then so if we release those and sometimes we can get lucky and gather, get ourselves a little bit more working space. And then this gentleman also has her knee on this left side too. I'll take down this flap of tissue. So this is the inner lining of our body wall. It's called the peritoneum. But then you can see there's a little bit of an opening right there and then that opening is allowing a little bit of extra tissue to go down in his anatomy. So I'll try to pull that down a little bit and then that can give us a little bit more room to. Yeah, Hey, so then let's look back down in the pelvis. We're looking at the end of public fashion right here, the care has opened up and so we will continue to open this up very superficially here. They're often these little small blood vessels that live that feed into the sidewall into sometimes even the prostate right here. Then these can bleed nothing big but cause a little bit of annoyance. Um and we want to maintain really good vision because it's important to see what we're doing obviously. So then I think there's gonna be another little blood vessel right there. So I'll cauterize that my left hand instrument that I'm using right there is called a bipolar Maryland grasshopper. Um that has a nice little curved tip to it, But it allows electricity to go from one tip to the other. Um When I hit the foot pedal at the console that I'm working at now, we've gotten all of that tissue released here on the side. Big blue structure that we see right here is called the deep dorsal vein. And so we need to do something to control that because if we don't do a good job with that, it can bleed again. We want to maintain good vision. And then that little whiter structure that I cut is called the pupil prosthetic ligament that helps to anchor the prostate to the pubic bone. Um and give it support. But in order to get the prostate out, we have to cut through that at some point. So that looks really well released. Their. Well look here on the left side, we have a really nice plane there continue to move upward. Yeah, there's a little blood vessel that we talked about that could potentially be there on the right. Yeah. But if we take my small little snips then we should be able to see most decent sized blood vessels coming like that one right there. If I snip into that thing that would have bled. But just taking our time and approaching that methodically can see it coming usually pushing away the rest of that muscle here from the side wall. We hope now bipolar this and then if I just spread here now then I can get the rest of that muscle to push down. And then we're looking for that deep dorsal vein to come into view. The as of which I think is going to be all right about here. Try to get just a little better vision on that. Which I think we do right. They're just great. And then so in order to control this era, I'm going to put a big future all the way around and then squeeze that really pinch off the blood supply. And so I'll take the needle drivers in the stick please. So the general steps of the operation here will take care of the dorsal vein uh And then we'll come back and do some um see you know we will take the bladder off the prostate. Okay so here's our big needle, we can get that all the way across the bottom side. Um So then what? See our little area that we opened up here and start passing the needle or use my right hand to kind of show ourselves the other side and hopefully get that needle to come out about where we want to to come to. And I do want to get that needle come out as this still as possible meaning towards the urethra side. That gives us more room to pinch that down. Okay great. So then now I can pull on that pretty darn hard, that really closes down the opening and then I'll pass this around the back of the door a couple times here now to really make sure that it's secured. And once we get that first stitch and it becomes a lot easier to pass those next couple. So then now here really shorten up on that future and really give it a good poll. Okay so that's really tight. Now now we're going to anchor this to the bone that sits up top here and then what this allows is that later on when we divide the urethra um The Eureka is not going to run away from us because we've anchored that top side of it. So that helps us to preserve a little bit of urethral length, which we think is important to maintain good you're in control in the long run. But it also helps us to do our sewing together, which we're going to have to do where we take the bladder and sew it back to the your wreath. So then I have a couple of good stitches behind a couple of good stitches into the bone here. Okay, that's gonna who's on us? So we'll try to cauterize that here in a second. Okay, I'll take the money. I'll take this batch for and bipolar in the 30 down. So what we're doing here now is switching the lens so we started off with the zero degree lens. So that means we're, you know, the lens direction is that's the direction that we have the vision. But then now we have different lenses that we can use. This one's a 30 down. So you know the direction of the lens is actually probably going this way. But our vision is this way so it gives us a little bit of a downward perspective on what we're looking at. Okay, good. So then now we'll start this process of taking the prostate from the bladder down here and so I feel like our junction between the two is right here. So then what I like to do is actually start taking off some of this fat from the side of the bladder. So the fat the fatty tissue here obviously looks all yellowish. But then as we do a little dissection through that bad we see the bladder wall coming into view. Um For me I find that really comforting because then I know exactly where the bladder wall is and then we can tailor that down so that we're right at the junction between the prostate and the bladder. Okay? And yeah here we're starting to see the side of the bladder come down really well then I'll continue that upwards towards towards the junction between the prostate and the bladder. Okay so now now I think this looks very different than what we're looking at before. Um So robotic surgery um I think this is a really great development for patients I think for surgeons because this allows us to do you know really the same operation that we used to do through a bigger incision with these small incisions. And so um and then you see the device around section that's my a wonderful Physicians assistant Alice who's assisting me. And so she's running that um suction device which can also irrigate and then she also creating counter tension. So I'm lifting up with my hand but she's pushing down on the bladder down below. And you know that's what key surgical principles in order to give yourself good vision. You always want to have good traction and counter traction. Um But then I am running the camera which is the obviously how we can see. But then you can see my bipolar sealing device. You can see this spatula right here that is packed, learn and Um and then we have my 4th arm which is up here. So I toggle back and forth between these two. And then that um Gives me actually four instruments that I'm controlling. Um Alice is using the suction device. And then she is she also had another purport that she's using in order to Number one for the section but then also for um you'll see clips going in. She tasks that big needle in through that lateral assistant toward. And then the whole concept of doing robotics are really isn't possible in this setting without of the our technology of insulation. So you know without insulation. This space that we're working in really doesn't exist because um you know when we're walking around on the street we don't have extra gas volume inside our abdomen which is holding things open. So then we have to artificially create this situation. And so one of the ports that Alice is working through there is some tubing that's connected to that. And that allows us to pump in pure carbon dioxide into the abdomen. Um and maintain that at a steady constant pressure. And that allows this area to be held open. And obviously then that's crucially important for us to be able to do this type of procedure. Uh And so laproscopic procedures commonly are done um whenever possible because you can do that with smaller incisions through the gas insulation. one Nice feature that that give us for um prostatectomy is that there are a lot of small veins so that this is not a vein. This is a little artery can tell that because it's actually shooting blood. That means that's at a higher pressure. But then the small veins that live down here, they lied to. But then the force behind that blood and those vessels is much much lower. That's usually only about 5-8 mm of mercury. Whereas arteries are going to be more like 80-100 mm of Mercury pressure. And so that's why there's such a stark difference between how they look when they're bleeding. But with laparoscopy we're holding the pressure inside the abdomen at about um 15 mm of mercury pressure. And then that actually is greater than the pressure of our venus system. And so that does have physiologic consequences. So we have to be careful how much pressure that we use and having a nice steady pressure is very important rather than the pressure that kind of goes up and down. Um So here we're seeing a lot of lot of little blood vessels but having that pressure that the no my parents knee um or the carbon dioxide provides helps to stop venus bleeding but obviously we have to take care of this arterial bleeding. Can I get a lens clean? Yeah. If we were doing this lap laparoscopically without the robot then we have a camera lens in obviously. But then that camera is being held by another person. And then so even when somebody is really good at driving camera, we still all have a little bit of comer in our hand and then we're relying on our assistant who's holding the camera. Um If you're the operating surgeon you have to hold the other instruments and you can't hold the camera. One thing that we're encountering here in this gentleman, it looks like as prostate is quite enlarged. So this area where we're the second in the bladder away from the prostate is taking more time than usual. And it's a little bit more bloody with all of those little blood vessels that were encountering. But you know having the robotic technology really helps to um make these slightly more difficult cases really not that much more difficult because we have good vision. I'll have these steady instruments and then you'll see as we're finishing the case up and actually doing the sewing together the bladder to the urethra which I'm taking the bladder completely off the prostate. And then to effectively take out the prostate when there's prostate cancer in and we have to take that whole thing out. And then so we literally cut it off on the bladder side and then cut it off on the resource side. So they were left with two holes, one in each structure that we have to sew together with needle and thread. So then that's sewing together area. When your doing standard laparoscopy, it's very difficult because um you have it's nice to have the ability to make turns. So that's a big artery right there um that we typically don't see, it's so big. And guys with more normal sized prostate. But then when you're sewing it's nice to have um a few extra degrees of freedom in the motion of your instruments. Because there's lots of little turns that you have to make and lots of little different angles which if you can do it unless you put the needle where you want it to be a but with standard laparoscopic instruments, if you really just have an instrument that goes in and out and it can turn, but there's no wrist. But you can see here there's a wrist where you can put this pretty much in any orientation that you want. And so having those extra degrees of freedom really helps with the reconstruction part. And prostate cancer is the most commonly diagnosed cancer in men in the United States. There's close to 200,000 every year. And so uh And there are about 60 70,000 role. Um radical prostate techniques for prostate cancer performed in the United States. So it's it's a big issue a common operation. But common diagnosis. But the other problem is then have enlargement of the prostate. Can you deflate the foley That causes um difficulty with urination because the bladder actually has to push the water through the prostate to get to the outside. And so if your prostate is really big it's really just causing obstruction of flow. Um that can really actually carry lots of serious quality of life consequences because as men get older than their bladder doesn't empty as well. And so they have to get up and I have to go pee. Their stream gets really slow. They get urgency. They have to go to the bathroom and so it can really cause a lot of bother. And then some men who have a really big prostate all of a sudden men can go into retention where they just can't pee. Um And then so then guys need this catheter in. And so this is the tip of the catheter. Um This part was the balloon that was inflated. So it gets actually about that big after it's inflated. But now it's deflated in the report. Actually attention please sits outside. Great. But then yet this this whole kind of area here is all enlarged prostate tissue which we don't normally see during these operations. But you know the nice thing about a guy with enlarged prostate issues though is that once we take out his prostate for the cancer then typically they're urination symptoms will be much much better. And then this is this is a whole another lobe of prostate that's sitting right here. So yeah getting this out of the way is really going to help this guy actually a lot as far as um had a urinary bother symptoms technique. So here's the vast deference on the left. So the another structure here that we have in the summer of vesicles. So both attached directly into the prostate. Uh schools help to store seamen and give a little bit of extra nutrients the um for the sperm and then the sperm actually come from the testicles down to the prostate via these these vast difference. Um We have to take we have to at least cut across the vast difference because you know they're they attach right in and then the seminal vesicles. We we just take out completely because they're blinding exact and don't go any other place. Another uncle logic reason to do that. Is that the um the seminal vesicles are often involved. If a guy has a really aggressive prostate cancer. Okay got a quick and I'll take the Kateri scissors to please. Okay so Alice has brought in a clip. Yeah. Great thanks padre scissors. Okay so we're gonna cut across that bess and there's lots of little blood vessels here. So we have to be careful again they're not very big but can cause a lot of annoying bleeding. And then the tip of the seminal vesicles. I think it's coming up right around there. But yeah there's another little blood vessel that we've got to take care of all. Okay the section down there. Uh huh. Very very few. Probably less than 1% of uh prostatectomy is in the U. S. Were being done minimally invasively uh Robotic Technology. And prostate cancer has gotten so strong now that in 2000 I think for the past Five years it's close to 90% of the prostate cancer. Surgery is done with the robots. So we've seen a drastic and then yeah the robot is now being utilized in multiple specialties. You're all in neurology. We use it for. Oh yeah so here's so I'm getting I'm lifting the prostate up and we have it pushed up against the pubic bone. Uh Down back behind there is the rectum because obviously everything gets really close down here. So I'm pushing away the rectum from the back side of the prostate. It's important to lift up on that really well as we're working. And then I'm pushing down all of this post here attaching tissue to the backside and we're gently doing this to get as wide as possible and then as distal or down towards the urethra as possible. And yeah this is coming down really nicely. Um So here on this side we're getting uh we're starting to get into the main blood supply that carries blood to the prostate that kind of comes in at this angle. And so we're just starting to get into that area. But I want to get all of that post your tissue pushed down as well as we can before we get too much in here and then we'll start putting clips on here that'll control that potential bleeding a little bit better. Okay and then that left. Sorry looks pretty good. Me redo my retraction. Yeah. Oh mm. Yeah we'll come back up top and it's a big big prostate. It's taking up a lot of the room. Let's hear. Okay so um. Uh huh. And cutting open a couple of these very flimsy superficial layers here on the lateral side of the prostate in order to see where our neurovascular bundle is. So here we're just gonna do a partial nurse bearing on this left side because most of this gentleman's cancer is on the left side. And so these structures help with direction function because that's one of the consequences of Getting the prostate out these nerve bundles that live right along the edge of the prostate often no matter how carefully we do the operation as we peel them away they're gonna get damaged and injured. So high majority of the guys who do the 30 for bear erections go away at the outset. Um If we do a really careful job saving them and then the guys had a good function going in then um a moderate percentage of the guy when uh so then we've got our good plane there as far as where I think we need to go and take down a lot of this more superficial tissue. And then try to see where these blood vessels are that we need to clip. I think we're okay just dividing that. Yeah there. Yeah. Okay. Great. Yeah sure. That was a good time. Yeah. Okay. Yeah. Okay. Yes. So we're going to answer a couple of scholar questions. Um So we've gotten quite a few about the difference between doing this type of a procedure with the robot versus doing it. Just regular sort of by hand laparoscopy. Is there a difference like how do you decide which one to do and is there a difference in the recovery time afterwards? Yeah. Great question. So um I don't do open radical my practice. I never have because I think that this this you're better procedure. Mhm. Again I think I mentioned that pretty much 90 plus percent of radical process techniques in the US are done done with the robot is where that losing is coming from. And you know the reason why is um the quicker recovery. So um you know that technical advances that the robot provides really stands out most in how well the guys recover just like getting back to work having less pain um getting back to the normal activities quicker. So this is an overnight hospital stay as opposed to 123 days after an open radical process techniques. The guys usually feel like they can go back to work all day after this procedure as opposed to Um maybe three or 4 with an open Radical process technique. I tell these guys that after after they can run swim, lift golf, tennis bike. Yeah. The three main things that are important in regards to prostates stuff. So the answer you're in control. Um All right. And the results when you go to a really good center with experienced surgeons. Yeah that's great. Um For those parameters are outstanding. And so I don't think we can say that yeah when we use the robot versus open but I think it's really technique dependent based on your experience with whatever technique that you use. So um I think I do a much better robot process technique than I can an open radical prostate technique and therefore um I feel really comfortable and you know I think this is the right thing to do for the guys that we see to offer them a robot prospecting our clip please. Um But and you know I think I do a better job with our nerve sparing in my hands with the robot and I could do open. So I do think if you're really good at what you do then you'll have good results. But I think even if you had just equal results um then why not have robotic surgery because you're gonna then have just as good kind of primary outcome results and Yeah suction right in there Alice. Yeah it's like racking up, staring out. How long would you say it took you to fully learn and get completely comfortable with using the da Vinci? And do you have like a favorite part of this type of procedure or a favorite sort of part of the job? Um Very part of. Yeah so so it's it's a little bit fuzzy as to how long it takes to learn the operation because I think I'm still learning. Um But you know the differences in our results. I think they change in a small way but I do think I keep appreciating this operation more and more um As far as the favorite part of the operation. Um. Yeah no I think just the technology part I really like because I think this is um. Ergonomically I'm sitting during this operation and then it's almost like you know when I when I feel like I got too much to do but then you know I really look at what I do. I go I get to play video games for work that's not terrible. Um The but you know I think the best part about being a physician is just uh your patient interaction and being able to make a difference in people's lives. Can you speak a little too like what the purpose of the clamps that we're seeing what those are for? And are those things that will be removed before the procedures? Yeah they stay put they stay put. So these are plastic clips, they are pinching down on the blood vessels, the main blood vessels that supply blood to the prostate. So um it and you know that's just certain preference. Do you want to use clips or stuttering or um stapling or energy to take care of those those blood vessels? I think the clips are easy and easy to deploy. They're made out of plastic um for the most part but then the ones that we use these are made out of an absorbable material so then they'll actually stay for probably two or three months and then slowly dissolved. So um yeah so you know there there's different different things to use but that's that's the reason that we use those. Okay so now we have a really good dissection plane all the way down around here on this side. I left a little bit more tissue on the prostate because he has more cancer on this side. Um Here we're down all the way to the apex on the downside. We see your ether up here, we see the stitch on the dorsal bean complex flipping around, yep ade. Um. Mhm. Uh huh. Yeah our dissection playing here is a lot cleaner. So we bust more. We left more of the nerve with the patient here on the right side and then we're getting real close to our proper dissection plane here on the BBC urethra. Okay so then we'll divide um that the venus complex try to stay really close to that stitch that we put in. Okay. And then so once we start seeing front side of the reef to it actually looks a little bit like muscle and it's because there is a little bit of muscle here and that's what we want to save to help provide good you're in control results in this area. And then another key consideration is to get a good length of your ether. A so then we're going to start pushing the prostate down away from the urethra. So we can save uh some more tissue length here now as a rock this prostate over then it can start just chipping away at this tissue that's around the urethra. Hopefully get us a nice plane right here. Get some good length. Then I'll flip it around to the other side. Uh huh. Is there a special tool that characterizes or can any of the instruments we see sort of become hot to do the colorado. No so there's specific ones. Yeah so the scissor that we're using now obviously that spatula that were using before the bipolar that's in my left hand. Those are the Kateri devices. But then you'll see the needle drivers coming in here in a second. Um And then that other grasshopper that I've been using that progress that does not have the capability of transmitting any kind of electricity. Yeah. So it's very um specific to the instrument. Okay, so now I think we have a really good length of your wreath right here now. Um yep. So the bags there. So this is our lapper, skupin chapman sex. We have our prostate in the bag that we can control that for our um attraction we have. And then um yeah, I will. Let's do the anastomosis first here. Yeah, yeah, needle drivers in the stitch. Yeah. And then now we'll do our reconstruction again that we talked about. That's really difficult. Standard laparoscopically. But with the robot instruments much much easier. So here's our first stitch that we're gonna put in. It's going to help re approximate but not bring all the way together the bladder to the restore but it's gonna help take some of the tension off. Can you push the needle driver in please? Great things. Okay, so we see the catheter going in up there. So that's gonna give us our target, so to speak at the top side. Okay. Catheter bag as you were in school and still learning do procedures like this. Did you use the da Vinci on like a dummy ever or what was that learning process this equipment? So yes, anywhere fellow with dr claimant that's really one of the centers that started using the robot. But then we actually had a robot in our training lab there, which is great. So then I learned how to, you know, set up the robot take it apart. You know, I knew what all the parts were. And then we had some training models that were used to allow first us to suit her. So I would so it's not a like a mannequin or anything like that, but it's just piece of rubber bladder, quote unquote quote bladder and then rubber tubing for urethra. And then I you know did a whole lot of practicing to learn how to sew on the robot. And then I spent a lot of time just in the dry lab learning how to suit her laparoscopically. So yeah, so I could and I could so pretty well laproscopic we already but then you know the robots just so much easier. But yeah, I know all of that, all of that training that people can do the, you know, simulation is becoming a huge part of medical education. Um So um you know and you can simulate a lot of the cognitive stuff to like learning how to run a medical code, you know cpr all of that stuff which requires just as much if not more just thinking what the right situation is and then practicing those under you know, kind of quote unquote stressful situations. You know, it's really really helpful and can I think increased quality and reduce errors. Uh huh. Yeah, but you know, stuff like this for surgical skills. Um You know it's super super important. So we see the Catherine going back, I've passed this future inside out, I mean outside and on the bladder at 5:00, Now it's coming also inside out on the urethra at five o'clock, six o'clock. So then we have two going in here, I'm going to pass one more here, that's gonna be our four o'clock stitch. And then I think he can see how that first future really helped to re approximate and take the attention off so that you really don't have much tension on the your east right here, which I think is really important. So that's our four o'clock stitch. We'll tuck that needle down here and then I can just kind of side to side pulling that's gonna pull that bladder up to the urethra and get this back wall, you know, the 456 o'clock air area. Really solid. Um which is nice to see, you know, when the catheter goes in, it goes right over the top of that back of the bladder wall. And so here we'll finish off by putting a stitch at each one of the points on the clock face. Uh So then I have a six o'clock, seven o'clock cinch this up again, right, And then once I get, once I get this up to 8:00 and then the other side up to 3:00 and it would be really, really solid won't go anywhere. Thanks for hearing me. Yeah, and then any other questions while we finish off this and ask nemesis or sewing together. Yeah. And so you know a lot of men, even if they have recurrence of their prostate cancer will actually die of something else because they can manage their recurrence pretty effectively for a lot of the guys. And it's really only the very all right aggressive aggressive cells which the guys will get into long term risk of dying of cancer. But you know that's all based on screening if we catch the guys early enough, that's kind of the key. Um And the screening that we do for prostate cancer is just the blood test is called the P. S. A. Blood test. Um We usually recommend that the guys do that once a year, starting at age at least 55 if not earlier. Especially if there's a family history or African American man. Uh huh. Got any other questions. So some of our scholars might start departing their auditory soon for their right. Yeah. So welcome to me to film for a little while more. Okay. Yeah, I speak a little too. Just what the rest of the procedure will look like. You kind of close up the patient and yeah so we're yeah, I'm just gonna do a little lift. No dissection here at the end. Um And then we'll pull out the ports will pull out the strength through the camera ports, close all those little incisions and then that's pretty much it. So we have the we have the catheters in. Right guys. Yeah. Okay good and then go ahead and irrigate, yeah great thanks. Yeah. So then now we're filling with water but then as I'm pushing down we can see there's no there's no leak from where we saw the bladder back to the urethra. So that's that's really the primary thing that we're looking for. Um And then I'm gonna gonna take someone's nose out here. Got the scissors and bipolar please. And then yeah and then we'll get out of dodge to speak. Yeah? Okay. Okay so good say thanks for your attention all the good questions and enjoy the rest of your good summer. Okay thanks very much scholars and thank you so much dr li until your whole team here at the presbyterian. Great great thanks. Created by Related Presenters David Lee, FACS, MD Chief, Division of Urology, Penn Presbyterian Medical Center
