Only a handful of surgeons in the country are trained to perform single-port robotic surgeries for bladder cancer and prostate cancer. Dr. Raj Pruthi, chair of the UCSF Department of Urology and a pioneer in robotic surgery for the past 15 years, is one of the few early adopters.
Dr. Pruthi recently performed the first single-port robotic radical cystectomy in California, as well as the first single-port robotic radical prostatectomy at UCSF. We talked to Dr. Pruthi about the procedures and their advantages.
Q: Can you tell us about single-port robotic surgery?
A: Single-port robotic surgery—an exciting innovation intended to improve patient outcomes--is the future of minimally invasive surgery. All four robotic instruments (a camera and three surgical instruments) are operated through a single 2.5 cm (1-inch) port. The instruments maintain all the advantages of multiport surgery, but now the endoscope is also fully wristed, providing excellent vision, precision and control. The cannula can rotate in any direction with 360 degrees of freedom.
Q. How is this different from the way prostate cancer surgery is currently performed?
A: Most prostate cancer surgeries are done using a multiport robotic approach: four ports, each almost 1 cm long. Single-port surgery maintains the benefits of multiport robotics. We can perform the same complex operations, but with the instruments entering through only one port and creating a single 1-inch incision.
Q. How about bladder cancer?
A: Most radical cystectomies in the U.S. (over 80 percent) are done through an open 10 to 12 cm incision extending from below the umbilicus to the pubis. The multiport robotic approach has provided the same benefits as for prostate cancer – less blood loss, less pain, less need for narcotic and, consequently, the potential for more rapid convalescence, all while maintaining excellent oncologic outcomes. The single-port approach may extend these advantages, but time will tell.
Q: What did the procedures entail?
A: For radical cystectomy, in males we remove the bladder and the prostate and lymph nodes. In the prostate cancer case, we removed the prostate and lymph nodes and did a nerve-sparing procedure to preserve potency and erectile function. At least in our first experience, it was flawless. There was no compromise in the ability to spare nerves and maximize continence.
Q: Is the equipment different?
A: The instruments maintain all the advantages of multiport surgery, but now the endoscope is fully wristed, providing excellent vision, precision and control. The cannula itself can rotate in any direction with 360 degrees of freedom. Because the instruments are much more flexible than the ones used in multiport robotics, they potentially provide a new level of vision, precision and control. When you're doing a radical prostatectomy that involves a delicate, nerve-sparing approach to maximize potency, the single-port robot gives you a little bit more control and flexibility in the dissection. I think that may be another benefit beyond the single incision.
I've benefited from being part of the initial wave of robotic surgery in the U.S. over 15 years ago. Now, many years and operations later, I believe robotics is the present and future. That said, single-port robotic surgery has a big learning curve. I'm not sure how rapid and widespread adoption will be. But I'm confident that single-port surgery is part of the future for the treatment of urology patients.
I'm grateful that UCSF has committed to investing in such cutting-edge technology. This is another example of UCSF’s dedication to advancing health and serving society. Pursuit of such innovation is also part of the Department of Urology’s commitment to provide pioneering and innovative treatments to improve patient’s lives.
Q: Is there an advantage for patients?
A: Single-port procedures are so new we don't yet have randomized clinical trials to provide high levels of evidence as to definitive benefits. In general, robotic procedures mean less pain, less blood loss, faster recovery and less scarring than open surgeries. This procedure is one incision instead of four. In theory, if you have fewer incisions, then maybe you have a little less pain and if you have less pain then maybe your recovery looks better. And, you have the cosmetic benefit of one scar instead of four. Though not proven yet, I think it holds promise.
Q: Would any patient with prostate or bladder cancer be a candidate?
A: In theory anybody is a candidate, but because it's early in our experience, we're selecting patients carefully, choosing those who have localized disease, and who have not had multiple operations.
Q: Does it make a difference to patient outcomes?
A: It's too early to say. Our initial experience has been very positive. Our patients have done well and have gone home early. That's probably all we can say at this point. We're just at the beginning of this innovation. We've proven we can do it and that we can do it safely and effectively. That gives me a lot of optimism.