Robotic Surgery in Urology

Robots designed for surgery have three potential advantages over humans three-dimensional spatial accuracy, reliability, and the capability of achieving much greater precision. Surgical robots were initially used in neurosurgery and orthopedics. Surgical robots were used for stereotactic framing in neurosurgery 15 , and a robot was used to cut and ream bones with great precision for the fitting of joint prostheses or for replacing ligaments 16 . In urology, robotic systems have been developed...

Prostate Cryoablation

Rewcastle2 Summary. The incidence of prostate cancer in Japan has risen dramatically in the past four decades. This increase, along with the advent of prostate-specific antigen (PSA) screening, has meant that an increasing number of patients are diagnosed at an early stage of the disease, when cure is possible. Currently, radical surgery and external-beam radiation are considered the standards of care for curative treatment of localized disease. Although many...

Technique

The technique used at our institution is a modification of the one originally described by Onik and colleagues 10 and incorporates the advances reported from our center 11,12 . In our initial experience, patients were treated by a team consisting of a urologist and a radiologist. Currently, most treatments are carried out by a urologist proficient in the use of ultrasound equipment. Prostate cryoab-lation is usually an in-patient procedure requiring an overnight stay in the hospital, but it may...

Patient Selection

It has become apparent over the past 10 years that careful patient selection is vitally important to ensure optimal outcomes. Initially, patients with bulky, localized recurrent cancers and those with significantly elevated PSA levels were treated with the hope of salvaging their condition. As pointed out by Katz and Rewcastle 44 and by Chin et al. 43 , selection criteria that increase the likelihood that the recurrence will be confined to the prostate are of paramount importance. Therefore,...

Quality of Life

QOL outcome is increasingly being recognized as an important component in evaluating treatment for prostate cancer. In patients for whom different treatments are deemed to be similarly effective, QOL outcomes frequently will determine the choice of treatment from the patient's point of view. We have recently published the long-term outcomes of QOL assessment in patients treated with cryoablation. The results indicate that the outcomes are comparable or superior to QOL outcome following other...

The Future

Unlike radical prostatectomy and external-beam radiation, cryoablation can be performed in a targeted area of the prostate. Of necessity, the entire gland is removed during radical prostatectomy. Likewise, the entire gland is irradiated during external-beam radiation. Although most prostate cancers are multifocal 47 , there is debate about the significance of some of these lesions. Villers et al. 48 reported that 80 of incidental lesions were less than 0.5 ml, suggesting that many of the...

Discussion

In 1995, Madersbacher et al. reported the effect of HIFU (using the old Sonab-late 200) in an experimental study of 10 cases of histologically demonstrated, hypoechoic and palpable, localized prostate cancer 18 . The organs were subsequently removed in 2 weeks. The entire carcinoma had been ablated in two removed prostates, but in the other eight cases, a mean of 53 of the cancer tissue had been destroyed according to histopathological examination. In January 1999, we began HIFU treatment for...

HIFU High Intensity Focused Ultrasound and Gene Delivery

High-intensity focused ultrasound (HIFU) is a noninvasive surgical technique in which ultrasound energy is delivered transcutaneously to a discrete area within the body. The efficacy of HIFU has been demonstrated in the treatment of prostatic disease 28 . Preliminary experience with the use of HIFU in the treatment of renal-cell carcinoma has been reported 29,30 . HIFU also has the potential to assist in the noninvasive spatial regulation of gene transfer into the targeted tissue 31 . In...

Materials and Methods Patients

An institutional review board approved a clinical trial of percutaneous RF ablation with CT guidance of renal malignant tumors at Okayama University Hospital in May 2002. Between May 2002 and October 2003, 12 patients, who provided informed consent, were enrolled in this study. Sixteen malignant renal tumors in 12 patients (7 men and 5 women mean age, 57 years range, 23-83 years) were treated. These tumors included 15 RCCs and one metastatic tumor of the retroperitoneal leiomyosarcoma. Tumor...

Salvage Cryoablation

The treatment of locally recurrent prostate cancer following radiation therapy (either external-beam radiotherapy or brachytherapy) with cryoablation is frequently referred to as salvage cryoablation. Radiation therapy, in the form of either external-beam radiotherapy or brachytherapy, is used to treat large numbers of men with localized prostate cancer in North America each year. Unfortunately, 25 to 93 of these patients have a relapse of their disease, many with isolated local recurrences...

Results

As with all therapies for prostate cancer, PSA is used as a surrogate for treatment success or failure. Different authors report different PSA thresholds and cutoffs, ranging from less than 0.3 to less than 1.0ng ml. Table 3 shows the results of salvage cryoablation studies reported in the literature. These results incorporate early experience with this modality and include many patients with either very elevated PSA levels or bulky disease prior to the cryosurgical procedure. With increasing...

Brachytherapy Treatment Planning Standard Techniques and New Developments

The standard technique used for prostate brachytherapy planning is a preplanning method. With this approach, transrectal ultrasound imaging is obtained several days to weeks before the planned procedure to measure the prostate volume. A computerized plan is generated from the transverse ultrasound images, which will in turn demonstrate the optimal location of seeds within the gland to deliver the prescription dose to the prostate. Several days to weeks later, the implantation procedure is...

Telesurgery

In order to perform a telesurgical operation, one must have a robot at the remote site, a data input device at the local station, and a means of transmitting the information between the sites. A telesurgery system is a combination of a videoconferencing system and a robot capable of teleportation properly customized and programmed for the surgical case. The vital ingredient of successful telerobotic surgery lies in the speed of transfer of information from operator to robot and back again 1 ....

Long Term Outcome

Long-term follow-up is essential to fully judge the efficacy of treatment for localized prostate cancer.Ten to 15 years of follow-up data is considered optimal, and follow-up information of this duration is available in a small number of series for both radical surgery and external-beam radiation. At this time, 7-year results are the longest available in the literature for cryoablation 14 . Until 10-year results are available, the case for long-term efficacy of cryoablation cannot be...

Cryoablation as a Primary Treatment for Localized Prostate Cancer

Prostate cancer presents a spectrum of disease ranging from relatively nonaggressive, low-risk disease to very aggressive, high-risk disease. Therefore, assessment of treatment outcome is best done by stratifying patients into those with low-, intermediate-, and high-risk disease, as done by d'Amico et al. 13 . Low risk is defined as T1-2a, Gleason score of 6 or less, and PSA less than 10ng ml. Intermediate risk is defined as one of the following stage higher than T2a, Gleason score greater...

History of Modern Cryoablation

The application of extreme cold for the destruction of superficial lesions has been in use since the mid-1800s. A detailed history of these developments has been documented by Gage 3 and Rubinsky 4 . A cryosurgical milestone occurred in 1961 when Irving Cooper and Arnold Lee 5 successfully built an advanced liquid-nitrogen cryogenic probe. This small-caliber, vacuum-insulated, multilumen probe, which very closely resembles modern liquid cryogen probes, allowed for the initiation of effective,...

Postoperative Changes

Acute histological changes include ill-defined cell borders, epithelial exfoliation, vesicular nuclei, hemorrhagic glomeruli with capillary fibrin deposition, and intramural hemorrhage in large vessels 20 . Later changes are indicative of coagulation necrosis, which is eventually replaced by fibrotic scarring. For postoperative follow-up, gadolinium-enhanced MRI has been used 18 . On postoperative day 1, MRI routinely shows a concentric, nonenhancing defect in the ablated area. All lesions are...

Computer

Advanced technologies with surgical robots, three-dimensional medical images, etc., based on computer technology. This new surgical field is called computer-aided surgery (CAS) 1 . The reconstructed three-dimensional medical images provide the most recognizable information for medical doctors and advanced visualization for surgeons. Surgical robots function as advanced hands for surgeons. The advanced vision and hands available to surgeons are creating a new surgical environment (Fig. 1)....

Statistical Analysis

All statistical analyses were performed using commercially available software (StatView 5.0, Abacus Concepts, Berkeley, CA, USA). The chi-squared test assessed the correlation between preoperative and postoperative parameters. The distributions of biochemical disease-free survival rates were calculated according to the Kaplan-Meier method, and the log-rank test was used to compare curves for groups. Age, clinical stage, Gleason score, volume of the prostate, neoadjuvant hormone therapy, and...

Sequelae of LDR Brachytherapy Acute and Late Toxicity

Transient urinary morbidity related to radiation-induced urethritis or prostatitis represents the most common side effect after prostate brachytherapy. The symptoms include urinary frequency, urinary urgency, and dysuria. Because of the varying definitions of toxicity reported in the literature, it is difficult to quantify the true risks of treatment-related toxicities after seed implantation. Many reports have not described toxicity outcomes using actuarial methods, and in some studies only...

Clinical Application

When treating healthy kidneys of eight patients with extracorporeally applied HIFU in a phase 1 study, Vallancien et al. 19 did not observe any significant changes in the usual laboratory parameters, except for a transient increase in creatine phosphokinase after a long pulse. Side effects included skin burns. Kohrmann et al. 41 applied HIFU to healthy kidney tissue of 24 patients immediately before nephrectomy. In 19 out of the 24 cases, hemorrhage or necrosis was detected macroscopically....

High Intensity Focused Ultrasound HIFU for the Treatment of Localized Prostate Cancer

Toyoaki Uchida, Hiroshi Ohkusa, Hideyuki Yamashita, and Yoshihiro Nagata Summary. We evaluated 85 patients with localized prostate cancer treated with high-intensity focused ultrasound (HIFU) for biochemical disease-free rate, safety, morbidity, and predictors of biochemical outcome. A total of 85 patients underwent HIFU with the use of Sonablate and with at least 12 months of follow-up. The median age was 70 years (range, 54 to 86 years), and the median preoperative prostate-specific antigen...

Morbidity

With any cancer therapy, there is a fine balance between aggressive disease eradication and increased treatment-induced morbidity, with a corresponding negative impact on QOL. This balance applies to any of the treatment modalities available for localized prostate cancer. As the technique of prostate cryoablation is evolving, and as experience with this modality is increasing, the morbidity reported has steadily declined. Sexual dysfunction and bladder and bowel changes have the greatest...

Conclusion

For many reasons, transrectal HIFU appears highly attractive as a minimally invasive treatment for localized prostate cancer. HIFU treatment requires no incision or puncture, it is bloodless, it can be performed on an outpatient basis, and repeatable added even though patients with local recurrence have already been treated with radiation therapy. In addition, the option of HIFU may be more attractive to the patient who wants to avoid postoperative incontinence and erectile dysfunction for his...

Erectile Function

Although reports have noted relatively low rates of impotence after prostate implantation 33 , this endpoint was only evaluated at two years after implantation. There is a paucity of long-term data critically examining this issue. Stock et al. 33 also reported gradually declining erectile function with continued follow-up after brachytherapy in 89 patients. However, the median follow-up in that report was only 15 months. It appears that impotence rates after TPI are probably underestimated in...

Acute Urinary Retention

Acute urinary retention (AUR) is a known risk that can occur immediately after prostate brachytherapy. Locke et al. 20 reported the experience from Seattle in 62 consecutive patients followed after prostate brachytherapy. In that prospective study, all patients were evaluated with baseline AUA scores, urodynamic assessments, and prostate-volume assessments. The patients were contacted at monthly intervals to obtain accurate follow-up information. Catheterization was required in 42 (26 of 62) of...

Future Directions in Prostate Brachytherapy Integrating Biologic Based Imaging Information into Treatment Planning

Reports from investigators at the University of California San Francisco have indicated that magnetic resonance spectroscopy (MRS) may provide reliable information regarding the ability to more precisely localize malignant zones within the prostate gland 40 . MRS takes advantage of the significantly higher choline levels and significantly lower citrate levels in regions of cancer compared to regions of benign prostatic hypertrophy and normal prostatic epithelium. Detection was especially...

Development of a Telesurgical Robotic System

In 1994, a group at the Imperial College in London investigated a robotic system to assist the urologist with intraoperative percutaneous renal access 7 . They employed a passive, encoded, 5 degrees of freedom (DOF) manipulator equipped with electromagnetic brakes mounted on the operating table. The access needle was manually positioned as prescribed by a computer that triangulated the calyx location from multiple C-arm images 8 . In vitro experiments evaluating system performance demonstrated...

Urinary Tolerance

In general, almost all patients after prostate brachytherapy develop acute urinary symptoms such as urinary frequency, urinary urgency, and occasional urge incontinence. Depending upon the isotope used, these symptoms often peak at one to three months after the procedure and subsequently gradually decline over the ensuing three to six months. Most patients significantly benefit from the use of an alpha-blocker, which ameliorates such symptoms in 60 to 70 of patients. Grimm et al. 25 summarized...

Telesurgery Remote Monitoring and Assistance During Laparoscopy

Bhayani, and Louis R. Kavoussi Summary. Laparoscopic surgery is the most commonly practiced and accepted form of minimally invasive surgery. Laparoscopic surgery in urology has, in many instances, become the standard of care. However, laparoscopy is associated with a steep learning curve because of its complexity and difficulty.This learning curve causes long operative times and potentially increases operative complications. Interestingly, to date there are no formal...

Indications and Contraindications for Permanent Prostate Implantation

The ideal candidates for permanent interstitial implantation are those with favorable-risk prognostic features who have a high likelihood of organ-confined disease. This group includes those with prostate-specific antigen (PSA) levels < 10ng ml and with Gleason scores < 7. Although not essential for staging, pre-treatment magnetic resonance imaging (MRI) of the prostate with endorectal coil may be helpful in the assessment of the integrity of the prostatic capsule as well as the geometry of...

Materials and Methods HIFU Equipment

For this study, we used a modified second- and third-generation device called the Sonablate 200 and 500 (Focus Surgery, Indianapolis, IN, USA) in 35 and 50 patients, respectively. A treatment module includes the ultrasound power generator, multiple transrectal probes of different focal depths, the probe positioning system, and a cooling system (Fig. 1). The transrectal HIFU probes use proprietary transducer technology with low-energy ultrasound (4 MHz) for imaging of the prostate and for the...

Merging of Endourology and Oncology Endourooncology

Lee, and Arthur D. Smith Summary. There is a growing need to bring together endourological approaches and sound oncological principles to achieve minimally invasive cancer control in urologic malignancies. Reduced treatment morbidity and quality-of-life issues are becoming more valued by both patients and physicians. In this chapter, we present an overview of the most recent advances in endoscopic, laparoscopic, and energy-based ablation techniques for the treatment...

Robot Assisted Da Vinci Urologic Surgery An Emerging Frontier

Robotic urologic surgery is an interesting and new development in the field of urology that has tremendous possibilities for progress in the future. Reports from various centers worldwide of complex urologic procedures in humans performed with robotic assistance have documented their safety, efficacy, efficiency, and feasibility. This review attempts to define the incorporation of robotics into laparoscopic urologic surgery and also reflects on our experience with over 900 cases of...

In Vivo

The potential for gene transfection during shock-wave tumor therapy in vivo was evaluated by searching for shock-wave-induced DNA transfer in B16 mouse melanoma tumor cells 17 .A luciferase reporter vector and air at 10 of tumor volume were injected before shock-wave exposure to promote cavitation. Shockwave exposure enhanced luciferase expression in cells isolated immediately after treatment, and also in cells isolated after 1 day, which demonstrated gene expression within the growing tumors....

HIFU Procedure

Radical Prostatectomy

All patients were anesthetized by epidural or spinal anesthesia and were placed in the lithotomy position. A condom was placed over the probe, degassed water was used to inflate the condom, which was covered with ultrasound gel for close coupling of the ultrasound probe to the rectal wall, and the probe was inserted manually into the rectum. The probe was fixed in position by an articulating arm attached to the operating table. After selection of the treatment region of the prostate from the...

Complications Safety and Oncological Efficacy

Potential risks include urine extravasation, urinary obstruction, hemorrhage, thrombosis and hematomas, abscess, and dysfunction of the kidney and the tissue through which the waves pass. Up to now, none of these has been reported in association with the procedure. As described above, skin burns are common side effects 21 . They occur because of absorption of ultrasound energy at the interface between two materials that have different attenuation properties....

Problems in Telesurgery

Transferring speed, image quality, and the amount of transferable data may be considered technical problems. On the other hand, the protection of personal information and privacy and malpractice liability are considered legal problems. Table 3. Telementoring trials in Johns Hopkins University Table 3. Telementoring trials in Johns Hopkins University Conventional telephones and modems, Ethernet, ISDN, ADSL, and ATM are currently used for the transmission of information. ISDN is the most popular,...

Robotic Surgery Assisted by the ZEUS System

Aesop Robotic Surgical System

Urology has continuously embraced novel technologies, such as shockwave lithotripsy, lasers, and laparoscopy, that reduce patient morbidity yet maintain an excellent standard of care. To potentially increase the clinical applicability of laparoscopy, robots that enhance operative performance have recently been introduced for a variety of laparoscopic procedures, such as laparoscopic radical prostatectomy, pyeloplasty, and nephrectomy. Although the introduction of robotics has generated...