The Robots Have Landed

BY RALPH BLUM

Nearly every industry on God’s good earth has become mechanized in some form or another over the past 200 years, and the Prostate Cancer Industry—yes, it’s an industry, folks—is no exception. Enter the da Vinci Robot.

In 2009, according to Intuitive Surgical Systems (the company that manufactures the da Vinci robot), 85,000 American men, 86%  of those who underwent prostate cancer surgery that year, had robot-assisted surgery. Furthermore, roughly 75% of today’s urologists are being trained in robotic surgery, and the da Vinci robot is now found in more than 1000 hospitals and clinics across the country, snipping, slicing and dicing the family jewels. These are fairly staggering statistics. So let’s examine this infatuation with the robot.

Undoubtedly robotic surgery is currently the most advanced treatment option for men with localized cancers who still belong to the “just cut it out” school of prostate cancer. In the hands of an experienced robotic surgeon, you will experience less blood loss, less pain, a shorter hospital stay—usually only one or two nights—and faster recovery. Some men claim to be teeing off in a week. All great selling points. But what is the downside?

Obviously recovery varies from man to man depending on age, general health, and cancer stage. However it is not at all clear whether the long-term results or survival rate after robotic surgery are better, worse or the same when compared to the traditional open prostatectomy. And despite the marketing frenzy surrounding robotic surgery, studies to date show that rates of incontinence and impotence are virtually identical to the results obtained with the traditional methods, and ultimately depend on the skill and experience of the surgeon.

According to a recent study, a year after robotic surgery only one out of four men had recovered the ability to have intercourse. Another new survey showed that half of the men who undergo robotic surgery experience a greater incontinence problem and less sexual function than they anticipated.

A radical prostatectomy, whether traditional or robotically assisted, is a complex and intricate surgery. The prostate is located within millimeters of the bladder and the rectum, giving the surgeon very little room in which to work. And blood pooling in the operative field makes it seriously challenging to avoid damaging the nerves—thinner than a human hair—that run along each side of the prostate and control erections. Even in the hands of the most highly skilled surgeon you are fortunate if you achieve what Dr. Peter Scardino, Chief of Urology at Memorial Sloan-Kettering calls a “Trifecta:” negative margins (meaning no cancer left behind after the operation), maintained potency, and preserved urinary control. However, in less skilled hands such  good results are extremely unlikely.

Remember, it’s the surgeon behind the robot who is actually performing the operation. Even the best surgeons report impotence rates of up to 50% and incontinence rates of 10%. And not all surgeons are created equal. Too often, operations are being performed at community hospitals by surgeons without sufficient experience.

Opinions differ widely about how many robot-assisted operations a surgeon needs to perform in order to be considered “proficient.”  Some researchers estimate as few as 150 to 200 procedures. Others claim that as many as 1,600 operations are required in order to gauge with 90% accuracy how much tissue surrounding the prostate needs to be removed to get all the malignant cells.

Bottom line: A good outcome depends on the experience and skill level of your surgeon. So choose carefully. And before you decide, be sure to ask how many robot-assisted prostatectomies he has performed. You do not want to be part of your surgeon’s learning curve.

The lure of the robot is high-tech glamorous. The promise of a less invasive surgery with faster recovery time, plus the expectation of a better long-term outcome (based more on marketing hype than on actual studies), has almost doubled the number of radical prostatectomies performed each year in this country. So before you make what is sure to be a life-changing decision—and especially if your prostate cancer is the low-risk variety or you are 70 or over—don’t let all the publicity, or your urologist’s bias in favor of robotic technology, persuade you that surgery is your best treatment option.

Data from the recent Prostate Cancer Intervention Versus Observation Study (PIVOT) indicates that a vast majority of the 85,000 prostate cancer surgeries performed in 2009 were simply unnecessary. In other words, most of those men would live just as long without any surgery at all, and would be spared the risk of impotence and incontinence. Clearly men are failing to get the full picture of the risks and benefits of all the different options—Surgery, Seeds, IMRT, Testosterone Deprivation, Hormone Blockade, Focal Cryotherapy, Active Surveillance—before they commit to robotic surgery.

So, yes, the robots have landed. And whatever else is still uncertain, one thing is for sure—they employ first-rate Madison Avenue publicists.