With all of the different options for the treatment of prostate cancer, patients often ask me why I recommend robotic prostatectomy. I'll share the reasons with you now.
1. The complete removal of the cancer. Surgery is the only way to completely remove the cancer. Occasionally a tiny portion of tumor is left behind (a positive margin), but we know when this happens and can tailor our management accordingly. Additionally, we remove the lymph nodes, which are involved with cancer in a small proportion of patients.
2. Better knowledge of the cancer. The only information we have of the prostate cancer prior to treatment is from the prostate biopsy and CT or bone scans, which are known to be inaccurate. Often, the prostate cancer is different than the biopsy, which would have led to either too much or too little treatment if that were the only piece of information we had.
3. Different side effects. Following radiation, it is not uncommon for men to develop diarrhea and bleeding from the rectum, which is because the rectum also receives radiation. Men also can feel the need to urinate all the time, and sometimes cannot urinate at all, requiring a catheter in the bladder for a long period of time. The risk of developing problems with erections after radiation is about the same as after surgery.
4. Easier post-operative cancer monitoring. The PSA test is a very sensitive marker of prostate cancer. After surgery, it should drop to zero. If a recurrence occurs, the PSA will start to go up, and we will know about it very quickly. With other treatments, the PSA does not go to zero, and it's difficult to know if increases in PSA are due to recurrences or not. This can lead to quicker treatment of recurrences, improving the chance of cure.
5. Easier treatment of recurrences. In the unfortunate event that the prostate cancer comes back after surgery, it is much easier to treat than after other treatments. For example, it is easy to give radiation to the prostate bed after surgery, but surgery after radiation is very difficult. Such surgery has high rates of side effects and complications, especially incontinence.
6. Risk of second cancers. Although radiation is used to treat cancer, it is also known to cause cancer in normal tissue. Studies show higher rates of bladder, rectal and lung cancer in men who received radiation for their prostate cancer than in those who had surgery.
7. Robotic prostatectomy: I use a 3 dimensional camera that magnifies the field of surgery, working in a bloodless field. As a result, I don't need to use any tactile feedback. If I can see it, I don't need to touch it. In open surgery touch factor was important since there was a lot of blood and working in blind areas of the surgery mandated tactile feedback but that is not necessary anymore.
For these reasons and others, it is my opinion that a radical prostatectomy in the hands of an experienced surgeon is the best option for a man newly diagnosed with prostate cancer.
Which way should the prostate be removed?
There are three options: open, laparoscopic, and robotic. I'll go over these three methods, listed in the order of their historical development, and their relative benefits.
1. Open radical prostatectomy. This is an operation that has been performed since the 19th century, involving an approximately 6 inch incision below the belly button. Because the prostate is located deep in the pelvis, the surgery needs to be performed with very long instruments. Perhaps the most critical portion of the surgery, sewing the bladder back to the urethra, can be challenging because of problems seeing the urethra and getting the long instruments into place. Most patients go home after a two to three day stay in the hospital and usually require a blood transfusion.
2. Laparoscopic prostatectomy. A newer form of prostatectomy, the laparoscopic approach offers several advantages to the open approach. The surgery is done through four or five small incisions, all less than an inch (although one needs to be extended to get the prostate out). As in open prostatectomy, the instruments are long and can be difficult to maneuver into the right places. One advantage is that there is much less blood loss, making it easier to see during the surgery and avoiding the need for blood transfusion. Most patients go home the next day.
3. Robotic prostatectomy. The newest form of prostatectomy, the robotic approach only begun in 2001. This is a form of laparoscopy where a robot is attached to the long laparoscopic instruments. Again, several small incisions are made for the robotic instruments to enter the body. Unlike robots in automobile factories, the robot does not do the surgery itself. Rather, the surgeon sits at a console nearby and manipulates the instruments. The instruments have very small hands and flexible wrists, making it easier to operate (and especially to sew) deep in the pelvis. Because the magnified camera is inside the body, it is easier to see places that would not be able to be seen with your eyes from outside the body.
I have been trained in all three methods, and believe that the robotic approach is the best option. Better vision, less blood loss and easier sewing enables me to perform the best operation for my patients. More than 80 percent of prostatectomies in the U.S. are now performed robotically, which shows that I'm not the only surgeon who feels this way.
All available studies show that patients go home sooner and have less blood loss following robotic prostatectomy, however, some have not shown significant improvement over the open approach. Very few have shown that patients do worse with robotics. This is likely because the robotic procedure is very new, and some of these reports comparing open to robotic prostatectomy are based on older information. But more important than which method of surgery you choose is the experience of your surgeon. Surgeons who have done more procedures tend to have better results, regardless of whether they do surgeries open, laparoscopically or robotically.