Table Speech

Robot-Assisted Surgery for Prostate Cancer

December 2, 2015

Dr. Choichiro Ozu
Doctor of Medicine
National Hospital Organization Tokyo Medical Center

In 2000, the first robot-assisted laparoscopic radical prostatectomy (RALRP) was performed in the US, using the Da Vinci Surgical System developed by Intuitive Surgical. This System was introduced to Japan in 2006 at Tokyo Medical University, Kanazawa University and Kyusyu University. I have been performing RALRP at Tokyo Medical University since then.

A prostate is a walnut-sized gland that is a part of the male reproductive system. It surrounds the urethra just below the urinary bladder. It has three functions: to secrete prostatic fluid, one of the components of semen; to regulate urination; and to control sexual function through androgen formation. Three major diseases of the prostate are prostatitis, benign prostatic hyperplasia (BPH) and prostate cancer. BPH develops in the inner prostate called the transition zone and causes difficulty to urinate or frequent urination. About 30% of men, mainly above age 60, suffer from this benign disease that does not metastasize. Prostate cancer develops in the outer prostate called the peripheral zone and can metastasize or invade into other organs.

Both the rate and number of morbidity keep increasing in Japan. Currently, prostate cancer is the 3rd common cancer among males in Japan, following lung cancer and stomach cancer. It is predicted to become the 2nd common by 2020 and the most common cancer by 2030.

Prostate cancer patients are classified into 4 stages, on the basis of how far the carcinoma has progressed, to identify the best treatment method. Early-stage patients with localized cancer have wider options, including total extirpation for definitive cure. Radiotherapy and hormone therapy are applied when the cancer has spread from the prostate gland. Once the carcinoma has metastasized to the bones and other organs, patients have fewer options of hormone therapy and chemotherapy.

Radical prostatectomy is classified into open surgery, laparoscopic prostatectomy and robot-assisted prostatectomy. Open surgery became common worldwide in the 1990s. Its conventional well-established procedure has shortened the operation time but surgeons must make a large abdominal incision. Laparoscopy became popular to replace open surgery, allowing surgeons to operate through a few small incisions using an endoscope. Once it became very popular in Japan but the number keeps decreasing lately, as surgeons find it challenging to operate through a two-dimensional projection on a monitor, which results in loss of depth perception.

Robot-assisted prostatectomy is a revolutionary method that combines laparoscopy with robotic functions. Medical robot Da Vinci consists of three parts: surgeons sit at a Surgeon Console placed just a few feet from the patient; a 3D monitor provides high-definition images; and a surgical machine with an endoscope and robotic arms carries out the surgeon’s commands. The System was originally developed for military purposes, enabling surgeons to perform surgery remotely to injured soldiers at battlefields. I envision performing remote surgeries from Tokyo to patients in distant locations. I believe this System has a promising future.

Currently, the USA has the largest number of Da Vinci units totaling 2,400. Japan follows second with 200 units as of September, 2015. In 2014, there were 650,000 robot-assisted surgeries performed worldwide, of which 200,000 cases (32%) were urological surgeries. Robot-assisted prostatectomy enables surgeons to operate with enhanced precision and dexterity through a few small incisions. It offers various benefits over laparoscopy, including less bleeding, more precise removal of cancerous tissues, improved urethra reconstruction as well as erectile nerve preservation. Less postoperative pain also leads to faster recovery and return to normal activities.

I have performed over 800 robot-assisted prostatectomies and there was not a single patient who needed blood transfusion or suffered from rectal injury which is the most common complication. To date, as many as 1.59 million robot-assisted surgeries have been conducted throughout the world but there has been no deaths reported, proving its high level of safety. As a surgeon, you feel less stress to be seated on the Console and looking at the monitor while conducting an operation. This superior medical device is also very user-friendly.

I have explained all the advantages. So what are the drawbacks? I must say money is the major issue. Initial cost for a device installation totals about 300 million yen. In addition you have to pay for the annual running cost as well as expendable supplies. For example, a single robot arm forceps can cost 400,000 yen

Our hospital plans to perform robot-assisted surgeries, at patient’s own expense, to operative procedures not covered by insurance in Japan. Increase in surgical cases can lower the cost so it is important to carry out many surgeries safely. While there are 200 medical robots in Japan, I must say there are less than ten qualified surgeons capable of utilizing this advanced technology. We must train surgeons with expertise.

I have two sons, age 18 and 7. My dream is to install three Surgeon Consoles and carry out operations together. I hope to be fit enough to perform operations in my late 60s. Today, robot-assisted surgeries are in full bloom across Japan. It is my sincere wish that people will deepen understanding of its advantages to ensure further progress of this superior medical treatment.