Open, Laparoscopic, or Robotic Surgery for Prostate Cancer

Across Canada, hospitals are spending millions of dollars to purchase robotic surgical systems that doctors hope will enable minimally invasive, nerve-sparing approaches to the gold standard surgical treatment for prostate cancer – the radical prostatectomy.

Sunnybrook announced just last month that it will be one of the first Toronto hospitals to use the da Vinci ® Surgical System to enable surgeons to perform robot-assisted surgery. Other Canadian hospitals, including Vancouver General, Edmonton’s Royal Alexandra Hospital, Montreal’s Hôpital du Sacré-Coeur, and St. Joseph’s Health Centre in London, Ontario, have also purchased this system, which some experts call the most technologically advanced surgical robot on the market today.

The da Vinci robot stands about five and a half feet tall, weighs about 2,300 pounds, and has four arms. One holds a camera, which provides 3D, high-resolution video imaging of the surgical field, and the other three hold surgical tools. “We are able to see with a 10 to 12 times magnification using the robot,” reports Dr. Stephen Pautler of St. Joseph’s Health Centre.

A robotic prostatectomy is performed by making five or so small holes, or ports, in a man’s abdomen. One port is used for the camera while the others allow the robotic arms to enter the body and perform the various surgical functions, guided, of course, by the surgeon. The robot converts the surgeon’s movements into corresponding micro-movements, which, along with the increased ability to see provided by the magnifying camera, helps surgeons be more precise and avoid the nerves and blood vessels that control bladder function and erections. Or so supporters argue.

“For urology patients, the robot will reduce the risk of impotency and urinary incontinence, and improve outcomes,” says Dr. Mike Hobart, a urologist at the Royal Alexandra Hospital. Dr. Martin Gleave, Director of Vancouver General’s Prostate Centre, doesn’t go quite that far: “For prostate patients, robot-assisted surgery has been proven to result in less blood loss, fewer complications, shorter hospital stays, and more rapid return to normal activities.”

But how do robotic, laparoscopic, and open prostatectomy techniques compare in the research? (In a laparoscopic prostatectomy, surgeons also make a series of small holes in the abdomen and use microsurgical instruments to remove the prostate, but they do the surgery with their own hands, not a robot’s.)

To make a long story short, the verdict is not yet in. Although there is general agreement about the standards to use when comparing these different surgical approaches (in order of importance, which provides the best chance of a cure, maintains urinary continence, preserves erectile function, minimizes complications, and maximizes patient convenience), the debate continues. In fact, one article on the subject in the 2007 November/December issue of Urologic Oncology: Seminars and Original Investigations is called just that: “Debate: Open radical prostatectomy vs. laparoscopic vs. robotic.”

In part, it is difficult for the new techniques to offer substantial advantages because traditional surgery for prostate cancer, the open radical prostatectomy (RP), is so good. As Dr. Joel Nelson explains, “In the hands of an experienced surgeon, the bar represented by open RP for the real goals of prostate cancer surgery --- cure, continence, potency --- is high.” Also, there is the matter of definitions. How do various surgeons and researchers define positive margins, possible recurrence (as measured by PSA levels), urinary continence, and sexual functioning? Different definitions seem to yield advantages for different procedures.

All three surgical approaches report high rates of apparent cure and similar results in other areas. Less blood loss, faster postoperative recovery, and shorter hospital stays do seem to be more common with robotic-assisted prostatectomy, however.

It may be too early to make a fair comparison between these procedures. After all, open radical prostatectomy has been practiced and refined over the course of many years while the other two techniques are relative newcomers. And the minimally invasive techniques and technology require a substantial learning curve.

Perhaps, in the end, it’s the singer not the song. The outcome of surgery depends considerably on a surgeon’s skill, knowledge, and experience. And, as the debate continues, surgeons using all these techniques will grow in all three.

Related News: In the June 2007 issue of the Canadian Urological Association Journal, Dr. Joseph Chin, Dr. Patrick Lucke, and Dr. Stephen Paulter report on their “Initial experience with robotic-assisted laparoscopic radical prostatectomy in the Canadian health care system.” In a February 2008 e-mail to CPCN, Dr. Pautler reports that he has performed 135 robotic-assisted laparoscopic radical prostatectomies (RALRPs) since April 2005 and done a preliminary analysis of outcomes in 106 of these cases. So far, indications are that the procedure generally saves about one day of hospital stay, has similar cancer treatment outcomes as open surgery, and provides most men with an earlier return to continence. (Approximately 90% of Dr. Pautler’s patients were wearing 0 to 1 pad per day at 3 months of follow-up.) In one year’s time, however, there was no statistical difference between the rates of continence of men who have received RALRP or open radical prostatectomy. Dr. Paulter is the principal investigator in a study entitled “Robot-Assisted Laparoscopic Surgery in Urology: A Review of Surgical Outcomes.”