Is Robotic Radical Prostatectomy Ready for Prime Time?
Dr. William J. Catalona
Chicago, Illinois
Patients contemplating radical prostatectomy for prostate cancer want the answers to many important questions. Will I be cured of my cancer? Will I be continent? Will I be able to have spontaneous erections? What is my risk for other complications? How long will it take to return to my regular activities? Open nerve sparing radical retropubic prostatectomy is the gold standard for the surgical treatment of prostate cancer, and the answers to these questions are well documented for open prostatectomy. The results have shown that high volume surgeons usually achieve excellent outcomes. Recently largely due to hype and aggressive marketing, there has been increasingly widespread use of robot assisted laparoscopic radical prostatectomy in the United States.1 Reports directly comparing open and laparoscopic procedures are just beginning to be published because of the relatively recent use of laparoscopic operations to treat prostate cancer. However, during the last year several highly credible studies on comparative data have indicated important disadvantages of these minimally invasive approaches in terms of achieving cancer control, urinary continence and patient’s satisfaction.2-4 Furthermore, recent studies have called into question whether robotic surgery offers any material advantage in terms of side effects or recovery time.5,6 These comparative studies are more informative than reports merely claiming that laparoscopic or robotic surgery has significant advantages compared to open surgery.
Using a sample of the Medicare database, Hu et al compared open and minimally invasive surgery from 2003 to 2005. Men undergoing minimally invasive surgery were more than 3 times (27.8% vs 9.1 %) more likely to require treatment for tumor recurrence within 6 months. For those men treated by low or medium volume minimally invasive surgeons, the need for further treatment for tumor recurrence ranged from 40% to 32%, respectively. However, even those patients treated by the highest volume minimally invasive surgeons were more than twice as likely (19%) to require salvage therapy as those treated by all open surgeons combined (9%). Although there were significantly fewer medical complications (cardiac, respiratory, vascular etc) with minimally invasive surgery, the need for a subsequent procedure to remedy a surgical complication such as anastomotic stricture was 40% higher. These results call into question whether all patients with prostate cancer are receiving high quality care in this country.
Touijer et al reported that patients treated by a leading expert in laparoscopic surgery were less likely to regain urinary continence than those treated with open prostatectomy.3 Patients who underwent laparoscopic surgery also had a higher rate of emergency room visits, hospital readmissions and further surgery for complications. Schroeck et al reported that patients who chose robotic prostatectomy were 4.45 times more likely to regret their decision than those treated with open surgery, possibly because of the higher expectations associated with an innovative procedure.4
Do laparoscopic and robotic approaches even offer patients a quicker, less painful path to recovery? Nelson et al reported that patients treated with robotic or open surgery recovered on essentially the same clinical pathway.5 Similarly Wood et al reported that short-term recovery after discharge home including time to normal and full activity, driving and post-discharge narcotic use, was comparable between robotic and open procedures.6
With laparoscopic and robotic surgery there is generally less blood loss, but when bleeding occurs it cannot be controlled as quickly without thermal energy as it can with open surgery. Therefore, ultrasonic shears or electrocautery is frequently used by many laparoscopic surgeons in or near the neurovascular bundles to stop the bleeding. However, hemostatic energy sources can irreversibly damage the neurovascular bundles. Thus if the dissection is carried widely to encompass the cancer, the nerves get cooked, and if the dissection is carried too medially in attempting to spare the nerves, there is a risk of cutting into the prostate or, worse, leaving behind prostate tissue and tumor.
Other disadvantages of robotic surgery also come into play such as the lack of tactile feedback and inferior global visualization. In addition, the transperitoneal approach to robotic prostatectomy is more invasive than the extraperitoneal approach with open surgery, and there is a greater risk of vascular, bowel and ureteral injury as well as intraperitoneal adhesions that predispose to subsequent intestinal obstruction. The 6, 1-inch incisions (with 1enlarged to extract the prostate) used for robotic prostatectomy in contrast to a single 4 to 5-inch incision with open prostatectomy beg the question of superior cosmetic results with robotic surgery. Thus despite the overstated claims and widespread use of robotic prostatectomy, it is far from established that the laparoscopic or robotic approach is as safe an operation for cancer as classic open prostatectomy, or that nerve sparing can be as readily or safely accomplished.
The marketing and hype of robotic prostatectomy have not fooled all of the people all of the time. New York Times columnist Tara Parker-Pope commented on the report of Schroeck et al in her blog “Well,” writing, “The research … is the latest to suggest that technological advances in prostate surgery haven’t necessarily translated to better results for men on which it is performed. It also adds to growing concerns that men are being misled about the real risks and benefits of robotic surgical procedures used to treat prostate cancer.”4,7
In the short term the holy grail of the trifecta for patients with prostate cancer, including cancer cure, potency and continence, is driven primarily by continence and potency. In the long term cancer control is the big issue. If the cancer comes back salvage radiation or hormonal therapy can nullify any early gains in potency achieved at the expense of complete tumor excision. Therefore, the most important and as yet unanswered question is what will the prostate specific antigen recurrence rate be 10 years after surgery?
The jury is still out with laparoscopic and robotic prostatectomy. Time will tell but to date much of the important evidence leaves claims of superiority to or even of equivalence with open prostatectomy in doubt.
I. Eastham JA: Robotic-assisted prostatectomy: is there truth in advertising? Eur Urol 2008; 54:720.
2. Hu TC, Wang Q, Pashos CL et al: Utilization and outcomes of minimally invasive radical prostatectomy. J Clin Oncol 2008; 26:2278.
3. Touijer K, Eastham JA, Secin FP et al: Comprehensive prospective comparative analysis of outcomes between open and laparoscopic radical prostatectomy conducted in 2003 to 2005. J Urol 2008; 179: 1811.
4. Schroeck FR, Krupski TL, Sun L et al: Satisfaction and regret after open retropubic or robot-assisted laparoscopic radical prostatectomy. Eur Uro1 2008; 54:785.
5. Nelson B, Kaufman M, Broughton G et al: Comparison of length of hospital stay between radical retropubic prostatectomy and robotic assisted laparoscopic prostatectomy. J Urol 2007; 177: 929.
6. Wood DP, Schulte R, Dunn RL et al: Short-term health outcome differences between robotic and conventional radical prostatectomy. Urology 2007; 70: 945.
7. Parker-Pope T: Regrets after prostate surgery. In: Well: Tara Parker-Pope on Health. The New York Times, August 27, 2008.
How does use of robotics affect the ability to perform pathology? Is the pathology report as useful and/or as informative in case radiation is needed later?
Since a lymph node dissection is rarely done robotically, it can impact the decision to do adjuvant radiation therapy later.
Incredibly great article. Honestly.