Overview

Prostate cancer is the most common type of cancer for men, in most countries. It is important and beneficial to know about all the treatment options available, including the advantages and disadvantages of each. This article will discuss what prostate cancer is, what are the existing mainstream treatment options and what place robotic surgery (we’ll also confirm what exactly robotic surgery is, no robots are performing any surgery here, don’t worry!) has in treating people with prostate cancer.

Prostate cancer

Prostate cancer develops when cells alter their usual structure and become abnormal cells in your prostate gland. They start growing in an uncontrolled way, forming a severe but very treatable tumour. The average age when people learn of this diagnosis is approximately 65-70. What exactly is a prostate though?

The prostate primarily, is anatomy only to a biological man, hence this condition will not concern women! It is located below your bladder, where you store urine; it is in front of the rectum, where your stool will be stored. It is usually the size of a walnut. Situated at the back of your prostate is a structure called seminal vesicles which produce fluid for semen. The organ labelled the urethra is the structure that takes your urine and semen out of the body through the penis.

Prostate cancer is a big concern to men because it disturbs normal urinary and sexual function. There are many treatment options for this condition; the earlier the diagnosis, the better. Prostate enlargement (medically known as Benign Prostatic Enlargement) is a condition of the ages because with age, the prostate will continue to grow and it becomes more susceptible to getting prostate cancer.

What are the symptoms of prostate cancer?

Symptoms do not usually occur unless the tumour has grown large enough to affect its neighbouring structures.

• Needing to use the washroom to urinate more frequently, especially during night-time
• Constantly rushing to the toilet
• Difficulty in starting to urinate
• Straining to urinate, taking a long time to urinate
• Poor urine stream/flow
• Feeling of inadequate emptying of your bladder
• Blood in your urine
• Blood in your semen
• In severe cases: weight loss, loss of appetite, pain in your front passage, back pain, bone pain

Evolution of prostate cancer treatment

After being diagnosed with cancer, there are a myriad of treatment options depending on the stage. The management plan is made by a team of doctors, from different specialities. They will look at the “Grade” of your condition and proceed. If it is decided to treat the condition surgically, it is also likely to follow up with radiotherapy and chemotherapy to ensure that all cancerous cells are eliminated.

A few of the surgical treatment options are as follows:

• Surgical removal of the prostate gland: Radical Prostatectomy
• Transurethral resection of Prostate (TURP)
• Greenlight laser prostatectomy
• High-intensity focused ultrasound (HIFU)
• Cryotherapy
• Holmium laser prostate surgery (HoLEP)
• Urolift procedure
• Open retro-pubic prostatectomy
• Steam Vapour treatment of prostate (Rezum)
• Prostate Artery Embolization

Robot-assisted Surgeries

• Robot-assisted laparoscopic partial prostatectomy
• Robotic-assisted laparoscopic radical prostatectomy¹

All these surgical options come with many benefits, and also with complications, as with any surgery. It is best to discuss all options with your doctor.

Robotic surgery

This is a novel field of surgery, although the idea has been around for some time, the actual implementation of it is relatively new. It is a type of surgery that focuses on minimally invasive techniques, in other words, trying to do less, to reap more. This type of surgery usually involves making small incisions at the site of surgery, then your surgeon will insert small instruments into that area, there will be devices needed for the surgery and also a camera that lets the surgeon view his field of surgery usually way better than in an open surgery. Then the surgeon will use the long end of the instruments from outside or a console, and manipulate the devices to carry out operation with more precision and finesse.^2,3

No robot performs your surgery. The entire procedure is designed to follow and mimic your surgeon's movements, and the surgeon has full control. The robotic system only responds to your surgeon's finger and hand movements. Your surgeon is with you in the surgical theatre throughout the entire process.

Rise of robotic surgery

Robotic-assisted surgery is gaining popularity and has been adapted into different surgical specialities including gynaecology, general surgery, and neurosurgery, among others. The idea is attractive as it allows for precise surgical movements directed by the surgeon in narrow and small spaces that are otherwise difficult to navigate. It also takes away hand tremors, rigid flexibility and loose suture ties.⁵

Robotic surgery was first conceptualized during the 1970s and the goal was to make a system that allows surgery to be done remotely (tele-surgery) in hazardous circumstances like war. It was officially introduced in the early 2000s and has been steadily gaining popularity and has been adopted in many hospitals worldwide.⁴

Key features of robotic-assisted surgery

The foundation for most of the robotic-assisted surgery is the arms of the device and the console. One arm will have the camera and the other will have the surgical instruments attached. The camera-holding arm will give a broad, specific and high-quality 3D view of the operating field that may show parts limited to the human eye and the instruments allow the surgery to proceed with improved dexterity.¹¹

There are a few systems that have gained approval and have been in use for some time now; such as  DaVinci Surgical System and ZEUS Robotic Surgical System. They are all designed to not act independently and require the surgeon to perform the surgery by using control devices to navigate the surgical field through the console.

The advantages of using robotic surgery

• Fewer complications during surgery
• Less chances of contracting an infection
• Less pain during recovery
• Minimal blood loss and need for blood transfusions
• Faster  recovery
• Shorter hospital stay
• Daily tasks can be adapted more quickly than with traditional surgery

Robotic surgery in prostate cancer

Robotic surgery has changed the scope of surgery in Prostate cancer and other urological surgeries. With the use of minimally invasive techniques, it will be possible in most cases to spare the vessels and nerves that surround the prostate and to directly shave off the prostate fully or partially (depending on your doctor's verdict) and in most cases, it has been noted that it retains the person’s ability to urinate normally, preserve normal bladder control and perform sexually as per usual. Men tend to recover within a matter of weeks and steadily get more physically active faster than with other surgical methods.^6,7

What can you expect from “robotic removal of the prostate”?

• The operating surgeon will make a few holes (<1-2cm) on your tummy
• The surgeon will then insert the “arms” through those incisions, usually, this will be a camera and a few tools needed for the surgery
• The surgeon will sit at the end of the bed, next to the console and control the movements through the console

During this process the surgeon may or may not decide to remove the surrounding lymph tissue as well, this is usually because cancer cells may spread through this tissue and it is removed as an added measure of eliminating cancerous cells. The surgeon will remove the prostate, either the whole prostate or only a part of it, depending on the stage and severity of the situation.^10,13

What are the side effects and risks associated with robotic surgery of the prostate?

Like with any surgery, there are potential risks associated with Robotic-assisted surgery. It should be known though that the majority of the patients do not have any complications following this procedure and most complications can be promptly dealt with in the hospital.^8,9

Common problems:

• Temporary problems with bladder control
• Problems with maintaining an  erection
• Inability to ejaculate (this is going to happen if the entire prostate gland is removed)

Occasional problems:

• Infection of the incision site
• Pain at the incision site
• Need for catheterization because of temporary difficulty in urinating
• Swelling of the scrotum
• Constipation  

These are a few of the reported problems that have followed robotic surgery.¹²

With the advancements in technology, there is going to be more movement towards robotic surgery because the benefits outweigh the risks and it is a sustainable and resource-sparing option. In the long run, this will become an affordable option for patients and it will enhance the possibility of remote surgeries and tele-surgery, with the aid of robotic technology with AI and machine learning integration. Current limitations are very high cost associated with installing a robotic surgery system into hospitals and the new learning curve for surgeons. But we stay optimistic! The future is running at an alarming pace and keeping up with the latest advancements is paramount!