Prostate Cancer Surgery: Choose Carefully
There are many talented surgeons who use a robot to help remove prostates safely and with excellent results. And there are thousands of American men who are very satisfied with the results of their robot-assisted prostate cancer surgery (prostatectomies).
However, if you are diagnosed with prostate cancer and are looking at the various treatment options, it is not the technology that should be your focus, but rather the experience of the physician treating you.
The surgical robot is an impressive piece of medical equipment that has captured the interest of hospital administrators, doctors, and patients. A 2016 study has found that when it comes to prostate cancer surgeries, robot-assisted laparoscopic prostatectomy (RALP) is now performed five times more than open radical prostatectomy, and accounts for 85 percent of all prostate surgeries performed by urologists.
To determine how robotic prostatectomy affects practice patterns of urologists, researchers conducted an analysis of more than 6,500 doctors using six-month case log data of certifying urologists from 2003 to 2013 from the American Board of Urology. The researchers found that 41 percent of all prostatectomies were performed by 10 percent of the urologists, indicating that there were only a few physicians performing very high volumes of surgery.
Overall, the average number of radical prostatectomies—two per surgeon—was very low, while the average number of RALPs was eight, with more than half of the doctors performing fewer than these numbers during the six-month period.
Although a minimal surgical volume for proficiency has yet to be established, it’s generally accepted that in terms of complication rates and cancer control, most surgeons obtain proficiency with RALPs after 250 procedures. However, this study suggests that for a high percentage of doctors, it will be many years before they perform the number of surgeries needed for that level of proficiency.
The aggressive marketing of the daVinci robotic system by its manufacturer, Intuitive Surgical, Inc., more than a decade ago made many promises for this high-tech and ultra-expensive medical tool. Even though there was a distinct lack of legitimate outcomes data, many hospitals and prostate surgeons took the promises at face value, and thus began the robotic medical revolution in the United States.
Because it was such a technological marvel, many men came to believe that robot-assisted prostate cancer surgery with a million-dollar machine was better than a procedure performed with a simple scalpel.
Years after hospitals throughout the country bought the million-dollar robots, the results from the first-ever randomized trial comparing robotic-assisted and open prostatectomy are available. Reporting in the journal Lancet, Robert Gardiner, M.D., of the Royal Brisbane and Women’s Hospital in Brisbane, Australia, found there was no difference in urinary or sexual function at six weeks or twelve weeks after prostate surgery.
• Patients said they experienced better quality of life at six weeks after undergoing a robotic procedure, but not at 12 weeks.
• At six and 12 weeks, quality-of-life outcomes were virtually the same, whether the surgery was performed with a scalpel or with a robot.
These findings go counter to the claims that have been repeatedly made to promote robotic-assisted surgery, going back to 2001, when the robot was first used. Had this Lancet study appeared when the daVinci was first being marketed, it’s very unlikely that the technology would have achieved such a significant foothold in the prostate cancer world.
The Australian research that was presented is just the first phase of an ongoing study of 326 men, all between the ages of 35 and 70, who were expected to live at least another decade after their procedure. The second phase picks up at the 12-week mark after surgery and will follow the same group of men up to the two-year anniversary of their procedures. Those results are expected to be published in 2017.
Now that we know that robotic assistance does not yield better results in prostate cancer surgery, ignore the marketing hype. Instead, when it comes to prostate surgery, look for the surgeon who can achieve the best results with whatever surgical approach he or she is comfortable with.
A highly experienced surgeon is most likely to achieve clear margins, which means that the outer edge of the surgical specimen contains no cancerous cells—an indication that all the malignant tissue was removed.
This surgeon also is more likely to know how to avoid damaging the erectogenic nerves surrounding the prostate that are necessary for firm erections. The risks of other complications, such as urine leakage and urethral strictures—the narrowing of the urethra by scar tissue—are also reduced when an experienced surgeon performs surgery.
Finally, your quality of life and, ultimately, the length of your life, will be in the hands of the doctor who treats your prostate cancer, so choose carefully. Ask questions about your prospective surgeon’s personal results with cancer control, sexual function outcome, and urinary control. And don’t forget to ask about the number of prostate cancer surgeries the doctor has performed in the past year.
Read more about A More Accurate Prostate Grading System.
Jacek L. Mostwin, M.D., D. Phil., is a professor of urology and director of the division of neurological and reconstructive urology at the James Buchanan Brady Urological Institute at Johns Hopkins Medicine in Baltimore. A urological surgeon at Johns Hopkins, he focuses on prostate cancer and has performed more than 3,000 radical prostatectomies. Among his major research interests are urinary continence and bladder function. Most of his scientific publications have dealt with lower urinary tract problems.