Advancements in Robotic-Assisted Radical Prostatectomy in India

Prostate cancer is one of the leading causes of cancer-related deaths among men worldwide, including in India. However, with the rapid advancements in medical technology, the treatment landscape for prostate cancer has evolved significantly. One of the most innovative and minimally invasive surgical techniques is Robotic-Assisted Radical Prostatectomy (RARP). In this blog, we will explore the key aspects of RARP in India, its benefits, the state of the procedure's adoption, and the future of robotic-assisted surgery in the country.

Understanding Robotic-Assisted Radical Prostatectomy

Robotic-Assisted Radical Prostatectomy is a surgical procedure that involves the removal of the entire prostate gland and surrounding tissues to treat localized prostate cancer. The operation is performed using the da Vinci Surgical System, which consists of a robotic console operated by a skilled surgeon and a set of robotic arms that mimic the surgeon's movements with enhanced precision. The surgeon guides the robotic arms through the console, allowing for more precise movements and better visualization during the surgery.

Benefits of RARP

1. Minimally Invasive Approach: Traditional open surgeries for prostate cancer can be invasive and may lead to more significant complications. RARP, on the other hand, requires smaller incisions, reducing blood loss, postoperative pain, and scarring.

2. Improved Precision: The robotic system offers a three-dimensional view with magnification, allowing the surgeon to navigate intricate structures more precisely. This enhanced precision results in better cancer removal and preservation of surrounding nerves, which is crucial for urinary and sexual functions.

3. Quicker Recovery: Due to the minimally invasive nature of RARP, patients usually experience a faster recovery compared to open surgeries. They may be discharged from the hospital sooner and resume their daily activities more quickly.

4. Reduced Complication Rates: Studies have shown that RARP leads to lower rates of complications, such as infections and urinary incontinence, compared to conventional open surgeries.

The State of RARP Adoption in India

India has made significant progress in the adoption of robotic-assisted surgeries, and RARP is no exception. Over the past decade, several leading hospitals and healthcare centers in metropolitan cities have invested in the da Vinci Surgical System and trained their surgical teams to perform RARP.

The main driving factors behind the increasing popularity of RARP in India include:

1. Surgeon Training: Many Indian surgeons have undergone specialized training in robotic surgery, both domestically and internationally. This has enabled them to gain expertise in RARP and offer the procedure to patients.

2. Patient Awareness: As awareness about the benefits of robotic-assisted surgeries grows, more patients are actively seeking out RARP as a treatment option for prostate cancer.

3. Medical Tourism: India has become a hub for medical tourism, attracting patients from various countries seeking high-quality medical treatments at a fraction of the cost they would incur in their home countries. RARP is among the sought-after procedures in medical tourism due to its cost-effectiveness and superior outcomes.

The Future of Robotic-Assisted Surgery in India

The future of RARP and robotic-assisted surgery, in general, appears promising in India. As technology continues to advance, we can expect further improvements in robotic systems, leading to even better surgical outcomes. Additionally, the adoption of robotic-assisted surgery is likely to extend beyond major cities to smaller towns and cities, making advanced treatments more accessible to a broader population.

Challenges and Opportunities

While the progress of RARP in India is commendable, there are still challenges that need to be addressed:

1. Cost of Technology: Robotic systems are expensive, and the initial investment can be a deterrent for smaller healthcare facilities. As technology matures, there may be opportunities for more affordable robotic platforms.

2. Skill Development: Training surgeons to perform RARP requires time and resources. Continuous efforts should be made to expand the pool of skilled surgeons who can perform robotic-assisted surgeries.

3. Infrastructure and Connectivity: To ensure seamless surgery and real-time collaboration, reliable high-speed internet connectivity is essential, especially for remote surgeries or training programs.

Conclusion

Robotic-Assisted Radical Prostatectomy has revolutionized the treatment of prostate cancer in India. Its minimally invasive approach, improved precision, and faster recovery have made it a preferred choice for patients and surgeons alike. As technology evolves and awareness increases, RARP is likely to become more widely available and affordable, further improving patient outcomes and enhancing India's position as a leading destination for advanced medical treatments.

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Treatment for Advanced Prostate Cancer 

1 ) Minimally Invasive Techniques : 

a) SPAD – super selective intra- prostatic androgen deprivation : In this procedure, a radiopaque dye is injected into the vein of the leg after which an X-ray of the venous network is carried out (venography). Then a medicine that shrinks the blood vessels is injected into the vein (sclerotherapy) resulting in reduction of prostate volume. This provides relief in cases of nocturia, improves bladder emptying and increases urine outflow. There are minimum sideeffects as compared to traditional surgery. 
b) Transurethral microwave thermotherapy (TUMT) : 

• It is a very effective treatment in case of BPH and provides relief from lower urinary tract symptoms after a single procedure. 
• It is a minimally invasive technique performed under local anesthesia. 
• A special microwave urinary catheter is inserted through the urethra into the enlarged prostate. The microwave antennae are then heated up to at least 111 degree Fahrenheit which destroys the surrounding tissues. 
• The procedure takes around 30 minutes to 1 hour after which there is slight swelling and irritation in the prostate. A Foley’s catheter is placed in the bladder to allow bladder emptying without increasing the prostatic irritation and is removed within 3-5 days. 
• There may be a few risks like pain after the procedure, urinary retention and infection but the incidence is very less. 
• The problem of urinary retention resolves within a week’s time, but some patients replace the Foley’s catheter with a temporary prostatic stent to allow volitional emptying of bladder. This improves their quality of life. 
c) Transurethral needle ablation (TUNA) : 

• In this procedure low energy frequency radio energy is delivered through two needles placed inside the prostate by passing through the urethra, creating a high temperature in a small zone, which destroys the excessive prostatic tissue without damaging the urethra. 
• The procedure is performed under local anesthesia on an outpatient basis. It is a single session treatment procedure with the number of needles varying with size of the prostate. 
• It is fairly safe and effective and has minimal side-effects. 

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2 ) Surgical Procedures : 

a) Trans urethral resection of prostate (TURP) : 

• It is the most popular method among patients and doctors for resolving prostate related problems and is considered after medical intervention fails. 
• It involves removing whole or a portion of the prostate gland through the urethra. 
• The procedure is performed under spinal or general anesthesia and involves visualizing the gland using a endoscope. 
• A Resectoscope (which contains an electrical loop to cut the bulging prostate tissue and seal the supplying blood vessels) is introduced inside the penis. 
• The surgery lasts for around 1 and half hours, and cut tissue is carried by fluid into the bladder from where it is washed out. 
• The patient can go home after 3-5 days. Patient is advised to drink lots of fluids and avoid any strenuous activity for a few days (maximum 6 weeks) till the scar heals. 
• He is cured of the symptoms occurring due to urinary pathway obstruction like urinary incontinence, dribbling, nocturia etc. 
• This procedure has very few side effects and a faster recovery period. But sometimes it can cause backward ejaculation of semen (into bladder instead of urethra) during intercourse. This can be managed by certain drugs that keep the mouth of the bladder narrow to reduce backward flow of semen into it. 
b) Radical Prostatectomy : 

• It is the traditional open surgery method used when TURP cannot be performed due to reasons like highly enlarged prostate or bladder injury etc. 
• It is mainly indicated in prostate cancer but can also be done in cases of BPH. 
• The surgery is performed under general anesthesia and an incision is made in the lower abdomen just above the pubic bone (Retropubic approach). At times the incision can be made between the scrotum and the anus depending on the enlargement of the gland or spread of the tumor (Perineal approach). The incision of perineal approach is smaller and has lesser blood loss as compared to retropubic approach and hence has a faster recovery period. 
• On reaching the prostate gland, the gland and extra tissue is scooped out and in case of any injury to surrounding organ like the bladder; a tissue repair is carried out. The urethra is reattached to the bladder and a catheter is left in the bladder to drain out urine. 
• In case prostate cancer is suspected, then surrounding lymph nodes are also removed and sent for biopsy. 
• The patient stays in the hospital for a week and is discharged with the urine catheter in place that has to be kept for 1-3 weeks’ time. 
c) Laser Prostatectomy : is the latest trend in BPH and prostate cancer surgeries because they have lesser blood loss and quicker recovery period. But long term effects of this surgery are yet to be determined. 
There are four Types of Laser Surgeries: 
1. Green Light PVP Laser : This procedure uses green light to vaporize the prostate and useful for majority of patients with enlarged prostate. A tube with light and lens called the cystoscope is inserted into the penis. The laser beam is introduced through the cystoscope and directed towards the prostate. It creates high energy which vaporizes the excess tissue and relieves the urethral blockage. The procedure is done in a short time and the patient can go home the same day and resume daily non strenuous activities within a couple of days.
2. Holmium Laser : This is the most commonly used technique and is performed under general anaesthesia. The laser of 2140nm wavelength and 0.4mm penetration is introduced through the cystoscope that is inserted into the penis at the start of the procedure. The laser cuts and vaporises the enlarged prostate tissue and relieves urinary blockage. Some tissue pieces are directed to the bladder from where they are flushed out. The procedure is done in a short time and the patient can go home the same day or the next day and resume daily non strenuous activities within a couple of days. The procedure is relatively bloodless. 
3. VLAP : This procedure has many disadvantages and has become virtually obsolete with the coming of Holmium Laser. The technique uses neodymium:yttrium-aluminum-garnet (Nd:YAG) laser which has a wavelength of 1064nm. The laser beam is directed towards the prostate gland via the cystscope. The beam generates a lot of heat which coagulates the gland tissue. The surgery is performed under regional or general anaesthesia. The technique was not popular among patients as the coagulated portion caused irritation. Also the urine catheter had to be kept for long. Soon this was replaced by Holmium Laser. 
4. ILC : Interstitial Laser coagulation therapy was used to coagulate tumours which could not be cut and removed especially in the brain, neck, liver, pancreas etc. in this procedure the laser probe is in direct contact with the prostatic tissue and generates temperature of 60 degrees Celsius which destroys the cell protein. The destroyed cells are absorbed in due course of time and a shrunken prostate gland remains. The urethra is not affected. The procedure is performed under general or regional anaesthesia. The rigid laser probe is inserted through the cystoscope and pushed till it enters the prostate after which it is activated to produce the heat. The effect is localised to the prostate tissue only. 

d) Robotic Prostatectomy : This procedure is carried out using the computer and is an advanced form of minimally invasive surgery. In this technique, small incisions are made in the lower part of the abdomen and the entire surgery is carried out using Tele-manipulator. The surgeon performs actions, which moves the Tele-manipulator which in turn is connected to the robot’s arms which replicate the surgeons hand movements and perform the surgery. The surgery is controlled remotely but involves great precision because of which it is soon becoming very popular. The procedure has resulted in favourable outcome as there is less blood loss, faster recovery and shorter hospital stay. 
Surgeons also perform laparoscopic robot assisted surgeries using the Da Vinci system which uses miniature surgical tools to carry out the surgery through the keyhole incisions. This method is gradually gaining popularity in treatment of prostatic cancers as there is great precision involved while removing the prostate gland without affecting the other tissues. 

Robotic laparoscopy prostatectomy Cost in India - Prostate Treatment Hospital India

Robotic laparoscopy prostatectomy  in India

Robotic laparoscopyprostatectomy offers several advantages. Although experts do not agree as to whether robotic or open surgery is best, the majority of prostate cancer surgeries  are being done with the laparoscopic/robotic approach, particularly at high volume medical centers that specialize in prostate cancer treatment. The post-operative goals for treating prostate cancer are the same regardless of whether the operation is done with an open or laparoscopic approach.

Less Scaring

The first advantage to robotic surgery is that it is an application of advance technology and is minimally invasive. Instead of having a 5 or 6” incision to the skin and abdominal fascia (See image below, left), patients have a series of small “band-aid” incisions. (On right) 

A Shorter Hospital Stay

With smaller incisions, the postoperative pain is significantly less, which means your length of hospitalization is shorter - as is the time to return to usual activity.

After the laparoscopic/robotic prostatectomy patients typically do not require an inpatient hospital stay over one night. Surgery is done in the morning and they typically go home after lunch on the first operative day.

Comparatively, after the open prostatectomy patients spend at least two nights in the hospital primarily for pain control, nausea and difficulty getting out of bed and getting back to an activity level that would be appropriate for them to be discharged home.

Less Drugs, More Blood

Patients' need for postoperative pain medicine and narcotics is also greatly reduced after the laparoscopic/robotic approach compared to open surgery.

Another advantage to robotic surgery is decreased intraoperative blood loss. During traditional open surgery, it is not at all uncommon for patients to lose between 600 cc and 1000 cc of blood intraoperatively given the intense vascularity of the prostate and its surrounding tissues. This entails some significant risk of intraoperative or postoperative transfusion (and secondarily the attendant risk of transfusion) among these patients.

During robotic/laparoscopic prostatectomy, blood loss is usually 200 cc or less, which is very minimal and has a negligible risk of needing a transfusion. This is likely a minor difference as the transfusions are quite safe. However, the small difference among treatment approaches may be quite important to some patients.

Postoperative Catheterization

The third advantage of robotic surgery over open surgery is a reduction in the required postoperative catheterization time. After open surgery, foley catheters are left to drain the urine for usually two or more weeks. After the robotic approach, the catheter typically remains in place 5 to 7 days. The reason for this difference is unclear but may be related to the increased precision and visibility the robotic approach offers and also maybe that a running anastamosis (bringing the bladder neck and urethral sphincter back together) may be done in a water-tight fashion compared to the open approach.

Erectile Function

The fourth advantage of robotic prostatectomy is the (at least theoretical) improved ability to preserve the erectile nerves. During an open prostatectomy through an incision on the anterior abdominal wall, the nerves that provide erection are hidden behind the prostate. The approach taken using the surgical robot, enters the abdomen and the robotic arms are positioned posterior to the prostate with the nerves directly in front of the robotic/laparoscopic camera. In this way, the nerves maybe preserved, primarily because the anatomy can be seen more clearly compared to open surgery.

In addition, the decreased blood loss of the robotic approach improves the intra-operative visibility. As you can imagine, attempting to preserve delicate nerve structures can be quite challenging in the pool of blood versus in a relatively dry surgical field that is expected with the laparoscopic/robotic approach.

Robotic Prostate Surgery 

 Usually in conventional approach, surgeons make decisions using tactile and visual cues to identify a phenomenon, which is actually microscopic which is likely to damage nerves or to leave cancer behind. In the Advanced Robotic Technique (ART) surgeons uses a sophisticated mastr slave robot that incorporates 3-D high definition vision, scaling of movement and wristed instrumentation that gives him the ability to perform Prostate excision with minimal risk of leaving the cancer behind and also minimal bleeding and post operative risk of incontinence and impotence.

Neither clinical nor imaging tests are sensitive enough to capture a tumour at T3 stage where it has become locally advanced and a risk for spreading to other body parts. Sometimes it is difficult for surgeons to find a precise plane between the cancer and urinary sphincter or the nerves and err on the side of cancer safety leading to incontinence or Impotence Da vinci robot system minimizes side effects thereby greater control for the patient over urinary discharge i.e. continence and return to normal sexual function after the surgery.

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Advantages of Robotic prostatectomy

• Minimal Bleeding Faster return to normal daily activities .

• Reduced hospital stay Significantly less pain and scarring

• Lower blood transfusion rates

• Improved preservation of physical appearance.

• Three (3) D vision enables surgeon to perform Prostate excision with Cancer.

• Lower blood transfusion rates

• Control without risk of Post Surgery Continence (control over urinary and fecal discharge) and causing Impotency

Scope of Robotic assisted Laparoscopic surgery in Urology

• Prostate Cancer- Robotic Radical Prostatectomy

• Pelvi-Ureteric Junction (PUJ) Obstruction- Robotic Pyeloplasty

• Kidney Tumors- Robotic Partial Nephrectomy

• Bladder Cancer- Radical Cystectomy

• Ureteric Reimplantation

• Pelvic Tumor Excision

Robotic surgery involves use of the da Vinci robotic surgical unit in performing complex surgical procedures such as prostatectomy (removal of the prostate gland for cancer). Originally developed for space and military uses, this advanced technology allows the operating surgeon to sit behind a console and control the robot that is next to the patient to perform surgery.

This technology allows the surgeon to operate with very small and precise instruments under a 3 dimensional (3-D) vision, which is magnified up to 10 times. This is achieved by inserting the camera and the instruments into the patient’s body through small cuts (incisions) ranging from 5 – 12 mm in size.

Da Vinci Master Slave Robotic System

The surgical application of robotic systems is one of the most exciting and significant technological developments of this century; its future implications are incalculable.Huge strides have been made in the field of closed operations in the past 10 years and the use of robotic systems has emerged as the principle solution to technical limitations

The use of robotic surgical systems has numerous advantages. Whereas modern laparoscopic systems give only

 a two-dimensional vision, robotic systems give the surgeon a three-dimensional field of vision and depth, provide arms that, unlike the human hand, never tire and permit an unprecedented continuityin operations. Since robotic systemsexceed even the human hand’s freedom and facility of movement, far greater delicacy and dexterity is achieved. Modern robotic systems fall into three categories; active, semi-active and master-slave.But the most commonly used are master-slave systems distinguished by the surgeon’s absolute control of the robot via a remote control console.

The Da Vinci is a sophisticated master-slave robot that incorporates 3-D high definition visualization, scaling of movement, and wristed instrumentation. The operations with the Da Vinci System are performed with no direct mechanical connection between the surgeon and the patient. The surgeon is working a few feet away from the operating table, while seated at a computer console with a three-dimensional view of the operating field.

Robotic Prostatectomy, also known as Robotic surgery for prostate cancer or da Vinci Prostatectomy is a minimally invasive surgery that is now the preferred approach for removal of the prostate in those diagnosed with organ-confined prostate cancer. The da Vinci Prostatectomy may be the most effective, least invasive prostate surgery performed today. Though any diagnosis of cancer can be traumatic, the good news is that if your doctor recommends prostate surgery, the cancer was probably caught early. And, with da Vinci Prostatectomy, the likelihood of a complete recovery from prostate cancer without long-term side effects is, for most patients, better than it has ever been.

The operation is performed using the daVinci Surgical system and 3-D endoscopic and wristed instruments inserted through 5-6 small incisions across the mid-abdomen

Treatment for Advanced Prostrate Cancer in India - Best Cancer Hospital India

Prostate cancer refers to cancer that occurs in a man’s prostate gland. Prostate is essentially a small, walnut-shaped gland which produces the seminal fluid that transports the sperm.

One of the most common types of cancer in men, Prostate cancer generally grows and spreads slowly and often remains confined to the prostate gland. In such cases, it may not cause much danger. However, there are certain other types of Prostate cancer which are very aggressive and can spread rather quickly.Early detection of Prostate cancer offers better chances for successful treatment.

Prostate cancer is mainly caused when some of the cells in the prostate become abnormal. Due to the mutations in the DNA of these abnormal cells, they tend to develop and divide very rapidly in comparison to the normal cells. While the abnormal cells multiply, the normal cells would begin to die. The faster accumulation of abnormal cells could result in a tumor that can spread to the nearby tissues, thus damaging them too. Certain abnormal cells can even metastasize i.e. break off and spread to various other parts of the body.

Symptoms:

• Trouble in urinating
• Reduced stream of urine
• Blood in the urine or semen
• Swelling or inflammation in the legs
• Discomfort in the pelvic region
• Bone pain

Who are at risk ?

• Old age: Prostate cancer is common in men who are above 65 years.
• Black men are at a greater risk of prostate cancer when compared to men of other races. In black men, prostate cancer tends to be more advanced.
• Family history of prostate cancer
• Obesity

Complications of prostate cancer

Prostate cancer can spread to the various organs in the body. It can travel through your bloodstream or lymphatic system and spread to your bones. Moreover, it can block the ureters that transport urine from the kidneys to the bladder, thus resulting in kidney problems. If the prostate cancer is in an advanced stage, it can cause extreme fatigue, weakness and weight loss, pain and broken bones.

Incontinence: Prostate cancer and its treatment can result in urinary incontinence. Treatment for urinary incontinence may include medications, catheters and surgery.

Erectile dysfunction: Prostate cancer or its treatment including surgery, radiation or hormone treatments could lead to erectile dysfunction. However, certain medications and vacuum devices that help in achieving erection and surgery are available for the treatment of erectile dysfunction.

If you are suffering from either of these symptoms, consult your family doctor or a general practitioner. If your physician suspects that you are having a problem with your prostate, you would be referred to an urologist. In case you are diagnosed with prostate cancer, you would be referred to an oncologist or a radiation oncologist.

Diagnosis of Prostate Cancer

Digital Rectal Examination (DRE)

The rectum is located close to the prostate gland. The doctor will examine if there are any abnormalities in your rectum. If your prostate gland is cancerous, it may feel very hard and knobbly. In an individual who is suffering from Benign Prostatic Hyperplasia (BPH), the rectum is generally enlarged, firm and smooth. However, very often, the prostate may feel quite normal, even though cancer cells are present.

Prostate-specific antigen (PSA) tests

A sample of your blood is taken to check for prostate-specific antigen (PSA). Prostate-specific antigen is a protein produced by the prostate. A small amount of PSA is generally found in blood. Men who have Prostate cancer tend to have more amount of PSA in their blood. However, the PSA test cannot be always relied upon and sometimes, men who have prostate cancer will have normal PSA. The increase in the PSA level could be also due to several other factors such as urine infections, recent prostate biopsies, having a urinary catheter, prostate or bladder surgery or a prostatic massage. PSA levels higher than normal could be mostly due to prostate cancer and a biopsy would often be recommended. Men who have PSA levels of 5 ng/ml or above are mostly referred for further tests.

Trans-rectal Ultrasound Scan (TRUS)

Ultrasound scans make use of sound waves to create an image of a certain region or organ inside the body. A small probe is inserted into the rectum and an image of the prostate gets displayed on a screen. The TRUS scan is mainly used to assess the size and density of the prostate.

Biopsy

If the initial tests reveal that there is a possibility of cancer, you may be recommended a biopsy. In this process, numerous samples of tissue (generally around 12) are extracted from the prostate for careful inspection under a microscope. The biopsy is usually performed at the same time as the ultrasound scan.

Diagnosis of advanced prostate cancer

If the biopsy shows the presence of prostate cancer, several tests may be required to determine whether the disease has spread to other organs/regions in the body. These tests include.

• Isotope bone scan
• X-rays
• MRI scan
• CT scan

Treatment options for early prostate cancer

The major treatment options for early prostate cancer include:

• Watchful waiting
• Surgery or removal of the prostate gland
• External beam radiotherapy
• Brachytherapy

If the prostate cancer is likely to develop and spread slowly and if you are elderly and not good enough for treatment such as surgery or radiotherapy, you may be recommended watchful waiting. In case the symptoms start developing, you may required to undergo treatment, such as hormonal therapy, For older men, hormonal therapy may be recommended after radiotherapy.

Young people who have low-grade early prostate cancer may be recommended active surveillance. If the cancer starts to progress, they will be asked to undergo surgery or radiotherapy.

People who have moderate- to high-grade cancer are likely to be recommended Radical Prostatectomy or surgery to completely remove the prostate gland or radiotherapy of the prostate. These treatments help to eliminate all the cancer cells and thus cure the cancer. The radiotherapy can be given to the patient using an external machine or even directly into the prostate gland. This process is known as Brachytherapy.

Although for some people these treatments will cure the cancer, in certain others some of the cancer cells may still be left behind after the treatment. In some others, the treatment may help to do away with all the cancer cells for a certain period of time, but the cancer may regenerate in the future. Cryotherapy or high-intensity focused ultrasound (HIFU) treatment can also be offered to people who are in the early stage of prostate cancer.

Treatment options for men with locally-advanced prostate cancer

There are numerous factors which need to be taken into account prior to deciding the best treatment options. This includes:

• Your physical health
• The stage and grade of the prostate cancer
• The PSA level
• The potential risks or side effects of treatment
• Whether you had treatment before.

The treatment options for locally-advanced prostate cancer mainly include Radiotherapy, Hormonal therapy, Watchful waiting and Surgery. Sometimes, different combination of treatments will be provided to the patient.

It is extremely important for you to be fully aware of the benefits, disadvantages and side effects of each of these treatments before you decide on the treatment. Your doctor or specialist nurse will provide you detailed information on the various treatments.

Treatment for Advanced Prostrate Cancer

The treatment options for advanced prostate cancer mainly include Hormonal therapy, Surgery, Chemotherapy, Radiotherapy and controlling symptoms. Surgery to remove the prostate gland is not recommended for men with advanced prostate cancer. However, a transurethral resection of the prostate (TURP) can help to relieve problems associated with passing urine.

Unfortunately, if prostate cancer has spread beyond the prostate gland and has severely affected other parts of the body, it cannot be cured. However, you can undergo treatment to control the cancer for several years and relieve the symptoms if any. This will help to improve the quality of your life.