Robotic Prostate Surgery May Pose Risks

(AP)  A new study suggests less-invasive keyhole surgery for prostate cancer may mean a higher risk for lasting incontinence and impotence when compared with traditional surgery.

Laparoscopic, or keyhole, surgery is increasingly chosen by men having a cancerous prostate removed. And often it involves the highly marketed da Vinci robotics system. Da Vinci's popularity has been rising even though there's never been a rigorous head-to-head comparison between it and standard surgery.

"There's been a rapid adoption of this relatively new technique," said the study's lead author Dr. Jim Hu of Brigham and Women's Hospital in Boston. The results add to confusion around prostate cancer treatment. It's not clear that either surgery is superior to radiation alone or watchful waiting, which means simply monitoring the prostate for changes.

For the study, appearing in Wednesday's Journal of the American Medical Association, researchers analyzed data from the government's Medicare insurance program for the elderly for nearly 9,000 prostate cancer patients who had surgical treatment from 2003-07. Of those, 1,938 patients had minimally invasive surgery and 6,899 patients had standard surgery. The data did not indicate how many of the less invasive cases involved robotics.

The patients who had keyhole surgery left the hospital in two days, rather than three, on average. They also had lower rates of blood transfusions, breathing problems and internal scarring.

But they were more likely to report complications in the first 30 days after surgery involving genital and urinary function. About 5 percent of the minimally invasive surgery patients vs. about 2 percent of the standard surgery patients had these complications. And after 18 months, they had more incontinence and erectile dysfunction.

"The take-home message for men is they need to dig deeper than simply the message they might be getting from planted stories from device manufacturers or radio ads or billboards," Hu said.

In laparoscopic surgery, small incisions are made and the doctor uses a tiny camera and instruments for the operation. When robotics is used for this, the doctor sits at a console and manipulates similar instruments attached to robotic arms that work on the patient.

From 2001-06, use of the da Vinci system — the only robot available for this operation — rose from 1 percent to 40 percent of all radical prostatectomies. During that time, the stock price of da Vinci's maker, Sunnyvale, California-based Intuitive Surgical Inc., increased 11-fold.

To compete for patients, more hospitals are buying robotic systems and advertising faster recovery times. More doctors are taking the two-day training to learn Intuitive's da Vinci Surgical System.

But many doctors perform too few robot-assisted surgeries to get good at it, Hu said, and that could explain the lasting problems that showed up in the study. Previous research has shown doctors who perform the most surgeries get the best results.

Hu had his own learning curve. He's now done more than 700 robotic prostate surgeries, but "it took several hundred cases before I thought I was doing really well in preserving erectile function and continence," he said.

The researchers found that the less-invasive surgery was more popular among more affluent, highly educated men. So it might be that those patients are more likely to seek help for urinary and sexual problems compared to men who had traditional surgery, said Dr. Ashutosh Tewari, director of the Prostate Cancer Institute at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.

Tewari, who receives research funding from Intuitive Surgical and had no role in the study, faulted the research for lumping all minimally invasive surgeries together, both robotic and those using older laparoscopic techniques.

Ryan Rhodes, a spokesman for Intuitive Surgical, said there have been more than 800 previous studies on robot-assisted prostate surgery. "The overwhelming majority of these show superior results," both for cancer treatment and urinary continence and sexual function, Rhodes said in an e-mail.

Dr. Greg Zagaja of University of Chicago Medical Center, who does similar research but wasn't involved in the new study, said the Medicare billing codes don't necessarily represent the surgical outcomes. He noted there wasn't a difference in the rate of procedures for treating incontinence and sexual dysfunction between the two groups.

Zagaja said the best advice for men is to ask how many robot-assisted surgeries a doctor has done.

The study was funded by a Department of Defense grant to the lead author.

[DavidP123]

Any discussion of prostate cancer is incomplete without mentioning a
common side effect of surgical removal of the prostate; Peyronies Disease.
This disease, for which there is no satisfactory treatment, results from
formation of penile scar tissue, makes intercourse difficult or impossible
and is often accompanied by excruciating pain. It was reported in the 02,
July 2008, edition of Medical News Today that almost 20% of men developed
this condition after removal of the prostate. In another study, none of the men were aware that a Prostatectomy increased their odds of developing Peyronies Disease. Those in the robotically assisted group were the most unrealistic about regaining post operative sexual functioning.

When I developed this condition, I was unaware that a disease like this
even existed. In frustration, I started an informational website,
www.curepeyronies.net Every email I get describes a man in a desperate
situation with nowhere to turn. Urologists must do a better job of
informing patients of this rather common side effect, so they will be able
to give informed consent before undergoing treatment

[yarnplay]

The robotic devices increase time under anesthesia as well as creating a situation where the MDs don't have the experience or opportunity to speed up the process in anyway as the machine has to be re-angled to approach the patient's anatomy. Complications arise not just from inexperience but also the duration of the surgery. This is true for both men's and women's reproductive surgeries. Asthetics aside, making the choice for the robotic surgery will likely increase costs making it easier for the hospitals to pay for the devices foisted on them by the manufacturer. The complications may increase the costs of malpractice insurance. One can hope that their doctor cares about providing the best care possible, not using them to increase their "time behind the wheel".

Having said this, if the patient is a pediatric patient with reduced access points, the equipment in the hands of a qualified surgeon is very effective.

Patients advocate for yourselves.