Robotics – Hype or Help?
Robot-assisted radical prostatectomy (RARP) and laparoscopic (LRP) surgery for prostate cancer have been widely advertised as highly preferable, minimally invasive alternatives to the conventional open radical prostatectomy (RP) performed under a surgeon's hands. After all, who wouldn’t want “DaVinci” performing his surgery? After all, who wouldn't want "DaVinci" performing his surgery?
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, wrote an editorial for the Journal of Clinical Oncology (Vol 26, No 14 (May 10), 2008: pp.2248-2249) in which he stated, “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.”
A study conducted by Jim C Hu, MD of Harvard and other researchers (J Clin Oncol 26:2278-2284 2008), reported 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. In the same study 9.1% of patients undergoing the traditional open prostatectomy reported the same local failures.
In his article cited above, 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. One study estimates as many as 100 procedures or more are required before a surgeon may be considered proficient (J of Urol. 2003 Nov;170(5): 1738-41). With this in mind, if you are thinking about treatment with LRP or robotic-assisted radical surgery, be sure to find a surgeon with a proven track record rather than a surgeon who is just starting out with any particular technique. Experience is absolutely crucial, as there is an unusually arduous learning curve for mastering the newer surgical techniques.
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.”
The 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 years and 10 years later? The bottom line is that the limitations of the conventional radical prostatectomy also apply to the laparoscopic and robotic approaches: all of these surgical procedures are necessarily performed "in the blind," in the sense that the patient's workup does not allow the surgeon to know with certainty in advance whether or not the cancer has spread beyond the prostate. In other words, the risk of having positive surgical margins is essentially the same regardless of which technique is used.
A retrospective survey conducted by the Memorial Sloan-Kettering Cancer Center compared the published results of LRP with retropubic radical prostatecomy (RRP) and reported as follows: "The 5-year biochemical recurrence rates range from 70-92% for the RRP versus 17-30% for the LRP" (Romero-Otero J, et al, Urol. Oncol. 2007 Nov-Dec;25(6):499-504). In our opinion, these results are far from acceptable given the attendant side effects.
The bottom line on radical surgery becomes all the more stark when we look at the long-term cure rates with high risk patients from Johns Hopkins, one of the leading surgical center for many years, in part based on the reputation of Dr. Patrick Walsh, who pioneered the nerve-sparing prostatectomy in an attempt to preserve erectile function for his patients. In 2010, Johns Hopkins published a study utilizing Dr. Walsh's data and reporting the 15-year results for a larger cohort of high risk patients as indicated by Gleason scores 8 to 10 (Pierorazio et al, Urology, 2010 Mar 27). The conclusion states, "The results of our study have shown that 80% of the men with Gleason sum 8-10 who undergo RP will have experienced biochemical recurrence by 15 years."
