Robotic Surgery for Prostate Cancer: An Automatic Choice?It's essential to consider a surgeon's experience when deciding on treatment.
A diagnosis of prostate cancer comes with a double whammy. The newly diagnosed patient deals not only with the fear of cancer itself, but also with concerns about two of the potential side effects of surgical treatment: incontinence and impotence. Such terrifying prospects have many of the thousands of men diagnosed with prostate cancer each year exploring alternatives to help control their cancer and hopefully minimize the risk of long-term side effects.
For many years, the prostate could only be removed by making an incision in the lower abdomen, a procedure known as "open" surgery. Eventually, techniques were developed to remove the prostate by laparoscopy—that is, by performing the operation through small puncture holes in the abdomen and removing the prostate through a small incision around the belly button. Although laparoscopic surgery leaves less scarring, it wasn't clear, according to surgeons, if it was as effective as open surgery in helping to minimize side effects.
Since 2000, though, a new form of laparoscopic prostate-cancer surgery, performed with the assistance of a robot, has rapidly gained popularity. According to Intuitive, the company that manufactures the DaVinci robot, roughly 75 percent of today's urologists are being trained in "robotic" surgery for prostate removal.
What is "robotic" prostate surgery?
When people hear the term "robotic surgery," it's easy to imagine a 21st-century cross between a human doctor and C-3PO from "Star Wars," wielding surgical instruments and operating on the patient with utmost precision.
That's a common misconception, says Patrick Walsh, M.D., a urologist at Johns Hopkins, where both open and robotic prostate surgeries are performed. (The regular laparoscopic surgery is not often performed any longer.) "Patients think the robot is doing the operation. They don't understand that it's the surgeon behind the robot who's actually performing the surgery."
It helps to imagine the actual surgical robot itself: three or four mechanical arms that hold the scalpel and surgical instruments. The movement of those robotic arms, however, is controlled solely by the surgeon, who sits at an attached computer console and manipulates the arms with two extremely precise joysticks.
The robotic technology gives laparoscopic surgeons more precise control and magnified vision. Because the surgeon is moving the instruments indirectly through the robot, any slight tremors of the surgeon's hands are eliminated. In addition, an automobile stick-shift-type control on the robotic console allows the surgeon to reposition his or her hands to a more ergonomic position during surgery, reducing operating-room fatigue. Finally, the screen that displays the details of the robotic surgery (there's a small video camera inserted into the patient's abdomen) shows a three-dimensional image that can be magnified up to 12 times.
"This magnification let's you see things more precisely," says Mani Menon, M.D., a professor at New York University and chair of the urology department at Henry Ford Hospital in Detroit, who pioneered the use of the robot for prostate surgery.
Because robotic prostate surgery is billed as minimally invasive, there's a tendency for patients for see the surgery as less serious than it really is.
"Many patients think [robotic prostate surgery] is somehow non-invasive and therefore don't see it as a 'real' surgical procedure," says Peter Scardino, M.D., a urologist at New York's Memorial Sloan-Kettering Cancer Center. "But you're not just putting a needle in and magically making the prostate disappear. You're still going inside the body, cutting out [the] prostate, cutting open the surrounding tissue, and sewing everything back together. It's the same operation but with a smaller incision."
Open vs. robotic prostate surgery: What the research says and doesn't say
When patients weigh the choice between open and robotic surgery, they usually have questions. Which approach is better at controlling cancer? Which approach is best for preserving continence and sexual function?
While the published literature on robotic surgery is growing rapidly, it’s still a developing field with more questions than answers. So far, the published literature has shown that, in the hands of a highly-skilled surgeon, robotic surgery gives quite good results. These results have been documented in a number of "series" studies, in which a single surgeon publishes his results with a particular surgical technique.
The most famous series study for robotic prostate surgery was published by Menon, who has personally performed more than 3,000 robotic prostate surgeries as well as 1,200 open prostate surgeries. Using the robot, Menon has achieved excellent results in controlling cancer, preserving continence and sexual function, and minimizing surgical blood loss. In addition, Menon says the enhanced precision and magnification of the robot allowed him to develop new techniques in prostate surgery, techniques that are now used by open surgeons as well.
However, such "series" studies don’t necessarily prove that robotic surgery is better than—or even equal to—open surgery. Instead, they merely show that the robotic technology itself is viable and that prostate surgeons like Menon are highly talented individual surgeons who are getting good results with the robot.
What’s missing are studies that do a head-to-head comparison of open versus robotic surgery. Known as “randomized clinical trials,” such studies are routinely used in comparing oral medications to alternative medications or placebos.
Although such a study of open to robotic surgery would give patients the clearest indication of which technique is better, both open and robotic prostate surgeons generally agree that a randomized clinical trial comparing the two surgical approaches will never happen.
"When I first started doing robotics, I wanted to do a randomized clinical trial comparing open to robotics, because at that time I felt that I was a very good open surgeon and the field of robotics was just starting to develop," Menon explains.
But as he informally surveyed patients to take their proverbial pulse on the idea, he discovered a significant roadblock. "Although the patients all agreed that a randomized clinical trial would ultimately end up giving the truth, none would want to participate themselves," says Menon. "Patients don’t want to be randomized because they know what they want. Some preferred open surgery because they knew I’d already done 1,200 cases. Others preferred the robot because they could see what the robot enhanced my ability to perform the surgery."
The next best type of research is the prospective study, in which researchers compare the outcomes of prostate cancer patients who chose open surgery with the outcomes of patients who chose robotic surgery. Recently, several such studies have been published.
"If you summarize all the literature we’ve got to date, it basically shows that for the long-term outcomes of curing cancer and recovering sexual and urinary function, the robotic surgery is either comparable to or not as good as open surgery," explains Scardino.
But that doesn’t actually mean that robotic surgery is less effective for cancer control. Rather, the differences are more likely due to differences in surgeon experience, since the robotic technology is relatively new.
"[In some of the comparative studies], even the more experienced robotic surgeons had less experience than the average open surgeons," says Scardino. "Once surgeons get more experience with [the robot], they should be able to do surgeries equally well with it."
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