Robotics Hold Promise But Risky Today

Men facing radical prostatectomy (surgical removal of the prostate gland) may like the idea of having it done with state-of-the-art robotic technology. And indeed, minimally invasive prostatectomies typically result in smaller incisions, less blood loss and quicker recovery. But — get ready, this is a big one — it also carries a higher risk for very unappealing complications, including erectile dysfunction. Any man considering this procedure should be aware that the trade-off can be considerable, especially since the newest version of the high-tech procedure is being aggressively marketed by hospitals eager to bring in patients — and the ads aren’t offering these details.

What Goes Wrong?

The disconcerting finding that minimally invasive radical prostatectomies (particularly when performed with a robot) have higher rates of genitourinary complications, including infection, incontinence and erectile dysfunction, was published in Journal of the American Medical Association. Comparing the minimally invasive procedure with open prostatectomy (in which a much larger incision is made to reach the prostate), researchers at Brigham and Women’s Hospital drew data from tumor registries and Medicare, evaluating surgical outcomes of 8,837 men with prostate cancer. Of these patients, 1,938 had minimally invasive prostatectomy and 6,899 had their prostates removed the traditional way. The researchers found that the minimally invasive prostatectomies resulted in…

  • Shorter hospital stays (two versus three days, on average)
  • Fewer patients requiring blood transfusion (3% versus 21%)
  • Fewer postoperative respiratory complications (4% versus 7%)
  • Less risk that problematic strictures or scar tissue will develop (6% versus 14%).

However, these men also had…

  • A higher rate of infection (5% versus 2%)
  • Greater likelihood of incontinence (16% versus 12%)
  • Higher rates of erectile dysfunction after the operation (27% versus 19%).

The need for additional cancer treatment was similar in both groups.

Do They Know What They’re Doing?

Jim Hu, MD, MPH, genitourinary surgeon at Brigham and Women’s Hospital, assistant professor at Harvard Medical School and lead author of the study, told me that he believes these important differences in outcomes occurred because many surgeons using the new techniques and technology haven’t yet developed expertise with it. Compared with the traditional open procedure, which has been used for 30 years, minimally invasive radical prostatectomy has been available just eight years. It’s exploding in popularity — where a minimally invasive approach was used for just 9% of all prostatectomies in 2003, use grew to 43% in 2007. Typically, surgeons performing open radical prostatectomy were either trained during their residencies or had more than 20 years of experience. In comparison, many of the minimally invasive radical prostatectomy surgeons in the study were learning “on the fly” during the study period. Dr. Hu said the laparoscopic practitioners start to perform procedures after a two-day course and being proctored for a few cases, rather than learning it more intensively in a residency or fellowship setting.

Ironically, this trend is being driven by consumer demand.  Ads tout the advantages the robotic technology offers, which promises less blood loss, less pain and a quicker recovery compared with minimally invasive radical prostatectomy without robotic assistance. In this study, researchers were unable to differentiate between the minimally invasive procedures performed with robot assistance and those done without, but according to Dr. Hu, it is the robotic procedures that people are asking for. In his words, requests from patients have “grown beyond the general surgical expertise of the surgeons at this time of rapid, unbridled adoption.” So it is especially important to be on the alert when this technology is new to a hospital — don’t just assume the training and experience are in place before the procedures are being done.

Ask Your Doctor

If you are considering robot-assisted minimally invasive radical prostatectomy, be sure to ask your surgeon:

  • How were you trained to do this procedure? Did you learn to do this during your residency or fellowship? A fellowship is an additional course of study for one or two years, where surgeons subspecialize. In contrast, said Dr. Hu, robot certification can be obtained after a two-day course.
  • How many procedures have you performed with this technology? Dr. Hu recommends at least 250 surgeries, and that a surgeon is performing at least four/week.

The good news, said Dr. Hu, is that as more surgeons become skilled in minimally invasive radical prostatectomy, with or without robotic assistance, the benefits of this approach will eventually outweigh the risks. Until then, proceed with caution.