Intuitive Surgical

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da Vinci Robotic Surgery System
Leading the treatment of prostate cancer Galway
Clinic
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What is the prostate?

• Male sexual gland
• Adds nutrients and fluids for sperm
• This fluid is added to sperm during ejaculation
• Urethra (urine channel) runs through the middle
  of the prostate

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Prostate Cancer
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What is prostate cancer?

• Abnormal cells growing out of control
• Spreads and invades local tissues
• Prostate Cancer
• Begins with a small tumor in the gland
• First spreads to the local lymph nodes
• Then spreads to the bony skeleton and other areas
  of the body

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Prostate Cancer Facts

• Prostate cancer
• 543 prostate cancer deaths in Ireland in 2002
• Leading type of cancer in men
• 2nd most common cancer killer of men
• Estimated 15,000 men living with prostate cancer
• Projected increase of 270 over the next 12 years
• Note 400 Road Deaths in Ireland in 2005

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Early Detection

• Early Detection
• Best prognosis is early detection
• Recent data on lower mortality rates of prostate
  cancer
• Affords patients many options for treatment

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Early Detection

• Digital Rectal exam (DRE)
• Prostate Specific Antigen blood test (PSA)
• Any abnormality in the PSA or DRE will require
• Biopsy of the prostate
• Ultrasound guided
• Usually performed in the office
• Short procedure

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Biopsy results

• Prostate cancer graded on appearance of cancer
  cells
• Gleason grading system
• Gleason grade ranges from 1 (least aggressive) to
  5 (most aggressive)
• Gleason score (2-10)
• Most common cell grade (first) added to second
  most common cell grade
• i.e Gleason 7 (34)

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Staging of Prostate Cancer

• PSA
• Digital Rectal Exam
• Trans Rectal Ultrasound
• Gleason Score
• Bone Scan
• /- CT scan or MRI
• Biopsy and TNM staging system
• Tumor, Nodes, Metastases

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Prostate Cancer T1 disease

• Cannot be felt
• T1a cancer found in 5 TURP specimen
• T1b - cancer found in 5 TURP specimen
• T1c cancer found as a result of PSA elevation
  only

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Prostate Cancer T2

• Can be felt during DRE (digital rectal exam)
• T2a felt on one side of prostate
• T2b felt on both sides of prostate

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Prostate Cancer T3

• Has spread beyond the prostate
• T3a extra capsular extension
• T3b tumor invades seminal vesicle(s)

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Prostate Cancer T4

• Cancer has invaded local organs
• Bladder invasion
• Invasion into surrounding pelvic side wall
• May cause pain in joints and back

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Treatment Options

• Dependent upon
• Stage of disease
• Patients age and health
• Patients personal preference

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Treatment Options

• Radiotherapy
• Brachytherapy
• Surgery
• Open Radical Prostatectomy
• Laparoscopic Radical Prostatectomy
• Robotic Assisted Radical Prostatectomy

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Goals of Radical Prostatectomy

• Remove the prostate and cancer
• High cure rates for localized disease
• Preserve urinary function
• Preserve erectile function
• Analyze the prostate after surgery to assess risk
  of recurrence of cancer

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Laparoscopic Surgery

• Minimally invasive surgery
• Ability to operate through small keyhole
  incisions
• Camera and instruments fit through the keyhole
  incisions
• Better visualization than open surgery

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Conventional Laparoscopic Surgery Drawbacks

• 2D flat image video
• Rigid instruments - chopsticks
• Instruments controlled at a distance - fulcrum
  effect
• Decreases your surgeons precision, dexterity and
  control
• Higher surgeon fatigue
• Makes complex operations more difficult

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How can we overcome these drawbacks?

• Provide a high resolution 3D color image
• Interpose a computer between the surgeons hand
  and the instrument tip
• Increase the surgeons dexterity for the
  difficult aspects of the procedure
• Sparing the nerves to preserve erectile function
• Preserving continence
• Preserving quality of life
• Robotic Assisted Surgery System

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Main Intellectual Drivers of Robotic Surgery

• Department of Defence
• NASA
• MIT
• Stanford University

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History of Robotic Prostatectomy

• 1980s master slave remote operating developed by
  NASA and US military
• Patents held by 3 competing companies
• 1999 merger with Intuitive Surgical,CA
• USA sole ownership
• Device is Da Vinci Robotic Surgical System
• 2001 FDA approval for use on humans

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What is the da Vinci Robotic Surgical System?

• Powered by state-of-the-art robotic technology
• Surgeon is in control and operates at the console
• Assistant surgeon is next to the patient

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Vision System

• Surgeon is immersed in 3-Dimensional image of the
  surgical field

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The Surgeon Directs The Instruments

• The surgeons hands are placed in special devices
  called masters that direct the precise instrument
  movements
• Instruments move like a human wrist unlike
  traditional laparoscopic instruments
• Instruments are small and are able to fit through
  keyhole incisions

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Advantages to the Surgeon

• Access
• ROM- 8 degrees
• 3D binocular vision
• X10 magnification
• Pneumoperitoneum
• Tremor filter
• Ergonomically intuitive
• Benefits of MIS

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Advantages to the patient

• Minimally invasive keyhole surgery
• Less blood loss
• Shorter hospital stay
• Decreased postoperative pain
• Less scarring
• Faster return to normal activity
• Earlier return to urinary continence
• Earlier and improved rates of erection
• Better cosmesis

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Comparison of Open Surgery and Robotic- Assisted
Procedure

• Open Procedure
• Long Incisions
• Hospital Stay of 5-7 days
• Blood Loss 900ml
• Catheter removal 14 to 21 days
• Robotic-Assisted Procedure
• 5 or 6 small keyhole incisions
• Hospital stay of 2-3 days
• Blood Loss 153 ml
• Catheter days 5 to 7 days

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Robotic-Assisted Surgery Access
Open Surgical Incision Robot Assisted
Prostatectomy Incision
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Worldwide applications of Da Vinci Robotic
Surgical System
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da Vinci Surgical System U.S. Installed Base
1999 2006
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da Vinci European Installed Base 1999 2006
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UK Experience

• Imperial College
• Six centres including Cambridge University
• Averaging 3.8 procedures per week

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Galway Clinic, Ireland

• Consultant Urologists Drs. David Bouchier Hayes
  and Paddy OMalley have proven track record in
  performing this surgery in leading Australian
  centre of excellence.
• Da Vinci Robot purchased by Galway Clinic in July
  2007
• Capital costs of 2.7 million provided by
  investors and members of the board of Galway
  Clinic
• VIVAS, VHI QUINN all cover this procedure.
• First robotic assisted prostatectomy in
  Irelandwas performed in November 07.

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Other Roles for Robot Assisted Surgery

• Cardiac Surgery
• Mitral Valve Repair
• Single Vessel Bypass Graft
• Anti-Obesity Surgery
• Thoracic Surgery
• Partial lung removal for cancer