Mater newsletter March 2015

Robotic surgery with the latest generation of Robotics- The DaVinci Xi Surgical Robot

The Mater is now offering robotic assisted laparoscopic surgery with the first of a new generation of surgical robots to be installed in NSW.

The DaVinci Xi robot has distinct advantages over the current model and will expand the indications to further surgical specialties and the approach to many more Urological procedures.

The major advantages include-

  • A new overhead instrument arm architecture designed to facilitate anatomical access from virtually any position.
  • A new endoscope digital architecture that creates a simpler, more compact design with improved visual definition and clarity.
  • An ability to attach the endoscope to any arm, providing flexibility for visualizing the surgical site.
  • Smaller, thinner arms with newly designed joints that offer a greater range of motion than ever before.
  • Longer instrument shafts designed to give surgeons greater operative reach

This allows the Xi robotic platform to be used by many more. For example, the technology will allow 4 quadrant surgery within the abdomen which will be very useful for general surgeons, colorectal, Upper GI surgeons and Gynaecologists.

Urologists will be able to undertake further procedures which previously were unsuitable for robotics or required open surgery including complex kidney reconstructive procedures and retro-peritoneal lymph node dissections for young men with metastatic testis cancer.

The vast majority of Robotic cases currently performed in Australia are Robotic Assisted Nerve Sparing Radical Prostatectomy for clinically localized prostate cancer.

Prostate cancer surgery is highly effective for cure but is associated with significant side effects including urinary incontinence and erectile dysfunction.

Functional results depend almost entirely on the surgical technique and approach utilized which needs to be individualized to the patient and his pathology.

Recovery of urinary continence requires meticulous preservation of the urethral sphincter complex with avoidance of bladder neck scarring which is clearly facilitated by the improved vision of the prostatic apical dissection and the more secure continuous suture reconstruction undertaken with robotics.

Recovery of potency requires meticulous, athermal, atraumatic dissection of the neurovascular bundle which is facilitated by the magnification and instrumentation provided by robotics.

The Mater by acquiring the latest DaVinci Xi platform, will further refine and extend the benefits of this minimally invasive approach to a wider population of men.

It is generally accepted that benefits of robotic assisted prostate surgery compared to open radical prostatectomy include-

  • Faster recovery
  • Shorter hospital stay
  • Less bleeding
  • Lower transfusion rate

Emerging evidence supports-

  • Equivalent cancer control (no difference in positive surgical margins)
  • Faster and more complete recovery of potency
  • Faster return of continence
  • Less bladder neck scarring/stenosis
  • Fewer lymphocoeles

Several studies show peri-operative complications are fewer with robotics (RARP) than open surgery (ORP) in units performing more than 75 radical prostatectomies per annum.

Hosiptal-case-volume

The Mater is fortunate to have a very strong, cohesive and busy Urology department with Internationally trained Urologists who also work in major teaching hospitals. Most of the Department regularly perform open or robotic prostate cancer surgery in other hospitals.

Leveraging their combined experience will allow the unit to seamlessly, affordably and safely introduce the robotic programme to the Mater with the highest levels of corporate governance to ensure the best outcomes for patients.

John Pitsonis, General Manager said “We will have the Surgical Robot commissioned in the dedicated, purpose built, state of the art robotic operating theatre from June 1st, 2015 and I welcome the introduction of the latest and most advanced technology in Australia’

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New Minimally invasive options for men with Benign Prostatic Enlargement

Benign prostatic hyperplasia (BPH) is a histological finding invariably associated with benign prostatic enlargement which often, but not always, causing obstructive voiding symptoms.

Lower urinary tract symptoms (LUTS) describe a clinical entity which is a very common cause of middle aged and elderly men seeking medical attention.

It is important to note that not all men presenting with LUTS will have BPH as there are many other causes of LUTS including bladder stones, Urothelial carcinoma of the bladder and urethral stricture disease.

It is critically important that men are investigated appropriately before medical therapy for BPH is instigated.

More commonly, in recent times men, will be prescribed medical therapy including alpha blockers (tamsulosin, alfuzosin), 5-Alphareductase inhibitors (dutasteride, finasteride) or combination pills like duodart, a tamsulosin and dutasteride combination.

Often drugs are prescribed without much consideration given to the side effect profile, particularly those that are on the PBS and considered more affordable.

Medical therapy has very significant side effects including postural hypo-tension, lethargy, malaise, ejaculatory dysfunction for the alpha blockers and erectile dysfunction, loss of libido and cognitive impairment for the 5-Alphareductase inhibitors.

The rationale for medical therapy was to try to avoid the morbidity of surgery but medical therapy has a modest effect on LUTS from BPH and no medical therapy is curative.

Surgical options for men with BPH

Green light laser

The green light laser for the prostate is also known as Photoselective Vaporization of the Prostate, involves using a state of the art green light laser which is different to traditional surgery.
It is a minimally invasive procedure that evaporates the enlarged prostate tissue that is causing the block age to urine flow from the bladder. It uses state of the art high power laser energy, which is specifically absorbed by the blood inside prostate tissue. This energy absorption leads to vaporization of the targetted tissue, and opens up the once constricted passage to improve the flow of urine.
This treatment is sometimes referred to as “bloodless therapy” as the laser seals blood vessels beneath the area of vaporization during the procedure, resulting in significantly less bleeding compared to traditional surgery methods, including transurethral resection of prostate (TURP).

Which patients are suitable for Green Light Laser Therapy?

All men with prostate enlargement who require surgery or who are not responding to medical therapy are suitable for Green Light Laser Therapy. Green Light Laser therapy is especially advantageous for patients who are on blood thinning medications such as Aspirin or patients who are taking anti-coagulation drugs such as Warfarin

Bipolar TURP with plasma vaporization

The plasma vaporisation electrode is a new addition to complement the established Olympus TURis system (transurethral resection in saline). Unlike conventional vaporisation techniques, it is therefore not a monopolar but a modern bipolar system. By using physiological saline solution as the irrigation fluid and a locally restricted current flow (avoidance of an external neutral electrode) surrounding tissue and nerves are protected, tissue denaturisation is minimized and TUR syndrome is entirely avoided. Using bipolar technology further increases the safety of the operation.

Plasma vaporization represents the most innovative therapeutic operating procedure for BPH. Bipolar Energy transforms the irrigation fluid around the active electrode into a plasma corona forming a “cushion” around the electrode. This plasma, when in contact to the tissue, causes instant local vaporization of cells. As with all TURis bipolar applications there is neither direct contact of the electrode nor current flowing through the tissue. In this way, modern plasma technology makes it possible to selectively vaporize upper layers of tissue without subjecting the surrounding tissue and nerves to any unnecessary thermal load. Simultaneous coagulation of the tissue surface means that the vaporization electrode leaves smooth surfaces and enables virtually bloodless tissue ablation to take place. Due to the excellent coagulation properties, the procedure is particularly suitable for treating men with a high risk of haemorrhaging (e.g. due to anticoagulant therapy), but also increases safety and comfort levels for all patients.

The plasma vaporization electrode at the bladder neck to begin
The plasma vaporization electrode at the bladder neck to begin
The electrode has “vaporized” through the obstructive tissue
The electrode has “vaporized” through the obstructive tissue

Prostatic urethral lift (Urolift)

The Urolift is a novel, permanent transprostatic implantable prostatic retractor comprised of a nitinol (nickel-titanium) capsular anchor and PET suture with stainless steel urothelial anchor

urolift    urolift2

An example of the device which is tensioned invivo for optimal results

urolift4

uroloft1  urolift2

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The advantages of the technique include

  • Novel approach to BPH
  • Rapid relief
    • AUASS reduced 11 points, flow rates increase 4 ml/s
    • Significant improvement by 2 weeks
    • Adverse effects mild/moderate resolve by 2-4 weeks
  • Preserves ejaculatory and erectile function
  • No cases of urinary incontinence reported
  • Well tolerated under general anesthesia as day surgery procedure without catheterisation
  • Durability to 2 years established
  • Consistent performance across global studies

In summary, many minimally invasive surgical options are available to the man suffering from LUTS due to BPH who has failed to respond to medical therapy or prefers a more permanent solution and is keen to avoid side effects of the commonly used BPH drugs.

Patients and their doctors should actively discuss these options after thorough investigation to exclude other causes for LUTS and be aware of the many newer and less invasive approaches available.

A/Prof Paul Cozzi MBBS, MS, FRACS