Advancements in Prostatectomy: Single-Port Transvesical Robot Assisted Radical Prostatectomy

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals, exploring the latest innovative research in clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig Phase 1 and sarcoma programs. Today, I'm happy to be joined by Dr. Jihad Kaouk, director of the Center of Advanced Robotic and Image-Guided Surgery at Cleveland Clinic's Glickman Urological & Kidney Institute. Today he's here to talk to us about single-port transvesical robot assisted radical prostatectomy. So, welcome.

Jihad Kaouk, MD: Thank you so much. I appreciate the opportunity.

Dale Shepard, MD, PhD: So maybe I gave a little brief introduction of your titles here, but tell us a little bit about your role here at Cleveland Clinic.

Jihad Kaouk, MD: I've been at the Cleveland Clinic for the last 22 years. And the Cleveland Clinic is known as a hub for innovations. We all know that medicine keep making advances very quick and change a lot every year. And that's what we do at the clinic here is try to find what is the best way to serve our patients. And it's never enough. It has to keep improving.

Dale Shepard, MD, PhD: Yeah. And I guess this is a particular area. There's been a lot of change over the years. So we have a wide range of people who might be listening in. Can you maybe start? We're talking about prostatectomy, give us an idea where we started and where we're at now.

Jihad Kaouk, MD: Yes. Prostate cancer is a very common cancer in men. Actually, it's the most common cancer after lung cancer. There are variety of treatments available. One of them is surgery. Surgery 20 years ago is totally different than what we offer today. 20 years ago, it was common to give a blood transfusion. We used to select our patients. Basically the morbidity is significant and the recovery takes time. These have changed because of the minimal invasive approach we do to prostatectomy. We use the robot. And the robot go through keyhole surgery to do the same efficient surgery as we used to do open, but with less collateral damage, more precision that translated into a quicker recovery for patients.

Dale Shepard, MD, PhD: And so we started with an open procedure, then it went to laparoscopic, and then we went robotic, and now, we're really pushing the boundaries. So tell us a little bit about single-port techniques.

Jihad Kaouk, MD: So the robotic approach, the standard way is called multi-port approach. That mean the robot have a camera and three instruments. Each of these will need a small cut keyhole surgery so that we can introduce these instruments into the patient. That is a precise way to do the surgery, but another emerging way is the single-port. So now we have a robot that looks like a cannula, one cannula requiring one small incision. And through that cannula, multiple instruments will spread inside the patients. So the one cannula goes inside the bladder, let's say, and then we spread our instruments and operate in a smaller area.

The whole concept is to regionalize the surgery to where the disease is. In this case, it's the prostate, but we have many other applications. And the concept is that if you regionalize the surgery to where the disease is, you are going to have less collateral damage. That also quickens the recovery of the patient.

Dale Shepard, MD, PhD: And even within the single-port procedure, you've made innovations. And you mentioned the bladder. So tell me a little bit about that.

Jihad Kaouk, MD: Yes. So one requirement to do robotic surgery is to create a gas bubble, and you work inside that gas bubble. The standard way is to fill the entire abdomen, the inside, where the bowel is. And all the organs with that gas bubble, that becomes the surgical field. We regionalized that bubble into just the bladder. So now the robot cut goes from the skin straight into the bladder. And the gas bubble is only in the bladder. So now my surgical field is just inside the bladder without seeing bowel, touching bowel, retracting bowel, none of this.

So that by itself is an advancement. And we were able to modify the surgery to work in a small area and be precise as much as the other standard way. The difference is patients now enjoy quicker recovery of urine control. The urine control takes time, usually few days to few weeks after the prostate is removed. But because we worked from within the bladder and did not cut the attachments of the bladder to get to the prostate, we are noticing that the time to continence is much faster than the standard way. And we are very excited about that. What that mean, the need of having pads, wearing pads after surgery for few days or weeks till the urine control comes back is now reduced or eliminated in some patients.

Dale Shepard, MD, PhD: And then I guess when we think about this procedure, are there particular patients that from a patient selection standpoint, are there concerns about whether there might be capsular involvement or seminal vesicle involvement? Or is it really not matter so much even with this particular procedure?

Jihad Kaouk, MD: Absolutely. The key to successful surgery is selection. Starts with appropriate selection of patients. And that's very important today where we custom make our approach to every person. There is no one size fits all. So when we go through the bladder, we select patients who don't have an aggressive disease or locally advanced disease. We select patients who have disease limited to the prostate inside the capsule and away from the attachment with the bladder. By that, we can keep the cancer control in an excellent way and afford these patients a quick recovery and maintenance of their quality of life after surgery.

Dale Shepard, MD, PhD: And when we think about recovery times, can you compare what someone might have as one of the traditional laparoscopic or robotic surgeries to a single-port surgery? How that compare?

Jihad Kaouk, MD: Yes. Laparoscopic prostatectomy faded away and transitioned almost completely in the US to robotic. And the standard robotic, the multi-port approach, in general requires a one night in the hospital, pain medicine for the first day or two, fully catheter for one week, and three weeks of recovery time. We reduced that using the single-port through the bladder to discharge same day within four hours of surgery.

Typically, the Foley catheter is removed half of the time. That means three to four days after surgery. And typically patient get their urine control immediately. That means, after the catheter is removed in half of the patients, the other half, within less than three weeks, they get their urine control back. 90% of the patients don't take any narcotics for pain after surgery, because there is no severe pain after this approach. Even recently started doing selectively, again, some of these procedures under epidural or spinal surgery. That means they don't need the tube through the throat and the ventilator machine. And we were able to do that because the gas bubble is limited to the bladder, not to the entire abdomen. So it does not push on the diaphragm. That means the patient can breathe comfortably on the operating table, and we give them Twilight sedation with the epidural and perform the surgery.

We are still investigating the impact of this approach compared to the general anesthesia, the standard way. We think that it may help patients who have some cognitive impairment or respiratory problems and things that we are still defining.

Dale Shepard, MD, PhD: And I guess just to follow up patient selection, are there particular patients that this is either better or contraindicated from patient characteristics comorbidities? What does that look like in terms of patient selection?

Jihad Kaouk, MD: So patients with locally advanced prostate cancer, this approach may not be the best approach, because you may need to take a lot of lymph nodes, you may need a wider area of surgical field. So we don't go through the limited approach of through the bladder for these patients. Also, prostates that are very large, usually 30, 40 gram prostate is what we see. I've done this transvesical approach up to 100 gram prostate. But when it's 200, 300 gram prostate, the transvesical approach runs out of space, obviously, and that will not be a good fit.

Dale Shepard, MD, PhD: Are there things like obesity or cardiovascular disease or anything that makes this either better or worse?

Jihad Kaouk, MD: We think that actually heavy patients or respiratory problem will benefit from the single-port transvesical approach, because in this approach, we keep the patient flat on the table rather than head down. We do not need gravity to pull the bowel out of the pelvis to see the prostate. And with the patient being flat, then there's no compression on the patient's lungs, so we can ventilate them more effectively.

So the obese patients or respiratory comorbidity, we think that single-port may fit them well. Also, patients with a significant history of abdominal surgery. Remember, every time surgery happen, there will be scar tissue left behind. So those who've had many surgeries before, it becomes risky to go again between the bowel, because you can injure a bowel. So when we go through the bladder, we avoid that entire area where the bowel and discord is untouched, away from the field.

Dale Shepard, MD, PhD: Oftentimes, patients who are having surgery for their prostate cancer are concerned about sexual dysfunction. How does this procedure impact sexual dysfunction?

Jihad Kaouk, MD: Sexual function evaluation is very subjective. That's why it takes time and a big number of patients to be able to give a scientific answer to your excellent question. We see that we do the same amount of percentage of nerve sparing with the single-port compared to what we used to do with the multi-port. So our technique, our approach is still the same in terms of selection for nerve sparing. We think that we may offer better advantage in saving the nerves, because we are more delicate. Working in a smaller area avoid forceful retraction and pushing on tissue. So basically you're more delicate working in a very much zoomed end approach to where you're cutting and suturing.

So the expectations is that preservation of sexual function will be at least the same as the multiple. We expect it to be better. That's yet to be scientifically proven.

Dale Shepard, MD, PhD: What are the gaps? This seems like a tremendous advance from making a really large incision to now having a one incision into the bladder. What are the gaps? What do we need to try to improve upon? And how are we going to get there?

Jihad Kaouk, MD: So experience learning curve is important. Having few people doing a procedure is exciting, but really the big impact would be spreading the knowledge, training more people, having the surgery reproducible in the hands of the majority of surgeons who do this surgery. That will give a big impact on the community at large. So that's what we are now working on, on how we can do simulators.

Now, we have a 3D printing program where we take the MRI of the prostate and we 3D print the bladder, prostate, seminal vesicle, rectum, urethra. And in difficult cases, we even can do a rehearsal surgery on the 3D print. Because it's robotic, we can cut it and suture it and then come do the actual surgery on the patient. So we keep trying to get our precision more. We keep trying to minimize the area around the prostate that we need to cut through. So again, regionalize the surgery to where the disease is.

Dale Shepard, MD, PhD: And then you mentioned access. How accessible is this in other centers?

Jihad Kaouk, MD: The technology is spreading fast. So far, this system is provided by one company, but there are at least three other companies working on similar technologies. So new innovation take time from the early adopters to the majority of practice, usually about two to three years. So I think that's the bottleneck at this point. And always the value comes from the outcomes data. So there are clinical outcomes that are being collected to see how effective are we in serving our patients and what can we improve better?

Dale Shepard, MD, PhD: So in your position, not only within prostate, but overseeing robotic surgery program at Glickman, what else is exciting right now? What other things are going to be really pushing forward the envelope?

Jihad Kaouk, MD: Our focus in this discussion today is about the prostate, but we are doing similar work on the kidney, kidney reconstructive and kidney cancer surgery. So, for example, with the single-port, instead of making the incision close to the kidney itself in the upper abdomen, that means where there are a lot of muscles overlapping that you need to cut through, we are making incisions all the way down in the pelvis area and then get that cannula robot like sneaking in from the pelvis all the way up to where the kidney is and do the surgery there. By that, less muscle, less pain, quicker recovery, less hernia in an effective way. So that's just an example of what we're doing.

Regarding beyond the robot itself, we are working on focal therapy, focal surgery, the question do you need to remove the entire organ if there's a cancer in one part, can you save the good part and remove only the cancerous part? So this is all exciting areas that is evolving fast.

Dale Shepard, MD, PhD: And the advances from a technical standpoint. You certainly have the robot itself, but it sounds like the instrumentation is a huge component of that.

Jihad Kaouk, MD: Yes. Innovations always work hand in hand with industry. So we push the limit, define a need, companies come and fill the need with new systems and instruments that we take to the next level, and the cycle repeats itself.

Dale Shepard, MD, PhD: The whole field's changing so dramatically, with changes in imaging and PSMA imaging and what is metastatic disease and things. Within the department there, what's the current thought on removal of primaries, even in a setting with micro metastatic or metastatic prostate cancer?

Jihad Kaouk, MD: Definitely, we were missing a lot in terms of being specific on defining who really spread and who didn't. The bone scan is so superficial. Now, these PET scans are giving us the ability to, with confidence, say the disease is only in this area or not in this area. Also, the imaging in robotic surgery is changing. So now you have isotopes specific to PSA. So it lights up any place that there is a spread. So you look with the camera and you can see lymph nodes that are positive lighting up in front of you. This is new.

So this is not yet commercial, but once it's commercial, you can see that, that's going to make a big shift. We're going to start getting more aggressive in the oligometastatic prostate cancer treatment.

Dale Shepard, MD, PhD: Well, some pretty impressive work. And I appreciate you sharing your insight with us today.

Jihad Kaouk, MD: Thank you so much for the opportunity. And we are excited to spread the awareness in the prostate cancer month.

Dale Shepard, MD, PhD: To make a direct online referral to our Taussig Cancer Institute, complete our online cancer patient referral form by visiting clevelandclinic.org/cancerpatientreferrals. You will receive confirmation once the appointment is scheduled. This concludes this episode of Cancer Advances. You will find additional podcast episodes on our website, clevelandclinic.org/canceradvancespodcast. Subscribe to the podcast on iTunes, Google play, Spotify, SoundCloud, or wherever you listen to podcasts. And don't forget, you can access real-time updates from Cleveland Clinic's cancer center experts on our Consult QD website at consultqd.clevelandclinic.org/cancer. Thank you for listening, please join us again soon.