Robot-assisted radical prostatectomy (RARP) and laparoscopic (LRP) surgery for prostate cancer have been widely advertised as highly preferable, minimally invasive alternatives to the old standard open radical prostatectomy. After all, who wouldn’t want “DaVinci” performing his surgery? Proponents tout fewer immediate complications and quicker recovery.
Several recent articles have revealed a darker side to the happy picture portrayed in the highly successful marketing campaigns for these procedures.
Michael Blute, MD, of the Mayo Clinic, writes in the Journal of Clinical Oncology, “Patients have been led to believe that hospital and recovery times are shorter and outcomes are better, but study has shown this expectation is not the case. RARP is simply an alternative method to extract the prostate.”
In a study conducted by Jim C Hu, MD of Harvard, and others, it was found that 27.8% of patients undergoing LRP/RARP were more likely to suffer local relapse and require salvage therapy with radiation therapy plus androgen deprivation therapy within 6 months of the procedure. (9.1% of patients undergoing the traditional open prostatectomy reported the same local failures.)
Blute also points out that patients undergoing LRP/RARP appeared to have more anastomotic strictures than in open surgery (15.2% vs 12%). Anastomotic stricture results in a significant decrease in urinary quality of life including difficult bladder emptying, recurrent urinary tract infection, bleeding and increased rates of urinary incontinence.
In addition, reported rates of other complications with LRP/RARP are surprisingly high: cardiac 6.6%, respiratory 11.7%, vascular 6.5%, wound/bleeding 3.6% and genitor-urinary 8% (total 35%).
The author concludes that many of the noted problems with LRP/RARP could be associated with the limited experience level of surgeons anxious to jump on the robotics bandwagon. Fewer complications were seen with patients treated by surgeons with significant experience with the technology. He goes so far as to suggest that a standardized training program be developed, sanctioned by a specialty medical society and required prior to board certification in the procedure.
An editorial comment by Nicholas Bakalar in the New York Times citing Dr. Hu’s article, quotes Dr. Mark L. Gonzalgo from Johns Hopkins (not involved in the study), as saying one of the laparoscopic disadvantages is loss of the surgeon’s tactile sense, “You can’t feel the cancer in robotic operations, and the ability to feel the cancer with your hands may provide some additional advantage.”
Meanwhile, a side note, darker side to all of the above is the 9.1% failure rate at only 6 months using the superior open procedure. What about 1 year, 2 year and later? Pandora’s box has once again been opened and also deserves commentary.