Robot-assisted prostate surgery no better than standard operation

Charlie Schmidt

Editor, Harvard Medical School Annual Report on Prostate Diseases

By: Charlie Schmidt

It’s been just over ten years since robot-assisted radical prostatectomy came on the scene for the treatment of localized prostate cancer. Its use has skyrocketed, driven in part by direct-to-consumer advertising and competition between hospitals. Nearly two-thirds of all radical prostatectomies now performed in the United States are done with the help of a robot. Thanks in part to advertising, many men with prostate cancer believe that they’ll get better results with robot-assisted prostate surgery than with more traditional open surgery. But so far, studies comparing the two approaches haven’t backed that up.

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Robot-assisted surgery was designed to help surgeons do a variety of operations. Instead of directly moving an instrument, the surgeon manipulates controls that guide a robot to move it. In theory, the robot can perform some actions more smoothly and accurately than a surgeon.

The latest comparative study has generated similarly ambiguous findings. Its take-away point is that good results depend far more on a surgeon’s experience than on the specific method he or she uses to remove a cancerous prostate.

“Going to an experienced surgeon, at an institution with a robust program is by far the most important consideration,” says prostate cancer expert Dr. Marc Garnick, a clinical professor of medicine at Harvard Medical School, an oncologist at Beth Israel Deaconess Medical Center, and editor in chief of Harvard’s Annual Report on Prostate Diseases.

Consistent findings

An international team of researchers analyzed data from the U.S. Surveillance, Epidemiology and End Results database for nearly 6,000 men who were treated with robotic or open surgery between October 2008 and December 2009. This database offers the most comprehensive statistics available on cancer incidence, stage at diagnosis, first course of treatment, demographics, treatment follow-up, and more.

The researchers compared how men differed 30 and 90 days after surgery with respect to a host of complications. After adjusting for socioeconomic status, tumor grade, stage, and other factors, the study authors found that:

  • Overall postoperative complications and readmission rates were similar at both 30 and 90 days for men treated with either method.
  • But men who had robot-assisted surgery had higher risks of genitourinary and miscellaneous medical complications both 30 and 90 days after surgery.

Based on their findings, published in the Journal of Clinical Oncology, the authors concluded that robot-assisted prostate surgery cannot be described as the safer procedure, but they also emphasized that it is safe based on the weight-of-the-evidence so far.

The new findings are consistent with a landmark study published in the Journal of the American Medical Association in 2009. For that effort, researchers reported that men treated with the robotic method had shorter hospital stays and also fewer respiratory and miscellaneous surgical complications than men treated with open surgery. But the men who underwent robot-assisted surgery also had more genitourinary complications and higher rates of incontinence and erectile dysfunction.

The new Journal of Clinical Oncology study updates the 2009 comparison with newer data gathered after robot-assisted prostatectomy became more widely used. But it also has some shortcomings. The men in the study had a mean age of 69 years at diagnosis, when surgical risks are high regardless of technique. That means the findings may not be as relevant to younger men with prostate cancer, cautioned the authors of an accompanying editorial. And given the limited follow-up, the study couldn’t tell if one approach was better than the other at controlling cancer over time.

“Buyer beware” is the message for men who choose to have surgery after being diagnosed with localized prostate cancer, the message is buyer beware. “Robotic techniques are too young to make any sweeping conclusions regarding their overall effectiveness in terms of cancer control,” says Dr. Garnick. “I find that patient satisfaction is comparable for both choices, as long as there has been an adequate discussion ahead of time about the associated pros and cons. A man selecting one approach over another should do so with his eyes wide open.”

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