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Patient Outcomes After Robotic Prostatectomy Compare Favorably to Traditional Surgery, Surgeon Finds

New York (May 25, 2010)

an operating room

Surgical robots are becoming commonplace in operating rooms and their use is widespread in the treatment of patients with prostate and gynecologic cancers and for cardiac problems. Approximately 70 percent of all radical prostatectomies are now done robotically in the United States. Whether patient outcomes are improved following robotic surgery, though, is an ongoing matter of debate. To determine whether loss of tactile feel in robotic surgery compromises outcomes among patients in his own practice, NewYork-Presbyterian Hospital/Weill Cornell Medical Center urologic surgeon Ashutosh Tewari, M.D. conducted a single-institution review of 1,340 consecutive patients who underwent robotic-assisted laparoscopic prostatectomy (RALP). He compared these to outcomes published by surgeons using traditional, open surgical techniques. The resulting study was published in BJUI 3/2010.

During radical prostatectomy, the surgeon's goal is to remove all of the cancer while leaving the posterolateral nerves controlling sexual and urinary function intact. "The surgeon wants to save the nerves but always fear that they are going to leave some cancer cells in the margins," said Dr. Tewari. "I wanted to find out if I leave more cancer behind because I'm operating using a robot, so I looked at the published data on open surgery and at my more than thousand patients, and there was no difference."

Ashutosh Tewari, MD
Ashutosh Tewari, M.D.,
M.Ch.

Dr. Tewari and his colleagues analyzed the incidence of positive margins (cancer cells on the surface of the surgically removed prostate, indicating the likelihood that cancer cells remain in the patient), and found that in their patient group it was 2.1 percent, compared with 2.8 to 9 percent among open surgeons. The group had videotaped every procedure, and went back and reviewed the operations to determine which techniques were correlated to negative margins. They then refined their surgical planning and operating procedures based on this information and were able to lower the incidence of positive margins to 1 percent in the last 100 patients in the study.

Comparing robotic and open prostatectomies, both Dr. Tewari and Ketan Badani, M.D., a urologic surgeon at NewYork-Presbyterian Hospital/Columbia University Medical Center, described the two procedures as very different. Surgeons who perform traditional open prostatectomies rely on tactile feedback. "Their sense of feel tells them if an area of the prostate is a little rough or irregular, and they then decide if the tissue is abnormal and whether or not to sacrifice adjacent nerves," Dr. Tewari said. But open surgeons, who wear a double set of latex gloves, often now operate on patients whose disease has been detected early. "Because of early detection, we are not seeing many cancers that are already very advanced and active and are very palpable," he added.

Ketan Badani, MD
Ketan Badani, M.D.

In robotic surgery, the surgeon has no sense of feel, but very improved vision, with a view of the operating area magnified by 12 to 15 times. "Robotic surgeons learn how to use vision to compensate for the other senses," Dr. Badani said. "In neither type of surgery can you use all five of your senses as well as you want. So you have to accommodate with one or two that you do have." Dr. Tewari reported that his highly enhanced vision during surgery enabled him to "feel" things by just seeing in such detail, and he has termed this phenomenon "intersensory integration."

Dr. Tewari's study provides insight into his own group's results, and other surgeons are undertaking similar analyses, he said. But research that would provide an indisputable comparison of robotic and open surgical outcomes would require that prostate cancer patients were randomly assigned to either type of operation, said Dr. Badani. "Today's patients have educated themselves, and know what they want, so a prospective randomized study like this is never going to happen."

A few factors have been shown, through clinical studies, to be improved by robotic surgery, Dr. Badani pointed out. "Blood loss is definitely decreased by about ten-fold in robotic surgery because surgeons can cauterize very small vessels in a much more controlled manner." Length of stay in the hospital and the pain after surgery are also decreased, he added. But with the more important factors – cancer control via margin rates, urinary continence outcomes, and sexual potency outcomes, "there's no magic in the robot and there's no magic in open surgery, it's who's doing the operation and what their experience and outcomes are as a surgeon," he said. "You have to ask the surgeon, 'What are your outcomes?'"

More important than the technology is the surgeon's experience dealing with competing goals – cancer control, sexual function, and urinary function, Dr. Tewari agreed. "Tools help, but more important is how passionate the surgeon is about this operation. I would go to a very good open surgeon any day, rather than a robotic surgeon who is not very experienced or who has not published the data on his or her outcomes."

Faculty contributing to this article:

Ashutosh Tewari, M.D., M.Ch. is Director of Robotic Prostatectomy and Prostate Cancer-Urologic Oncology Outcomes at NewYork-Presbyterian/Weill Cornell Medical Center, and a Professor of Urology and Associate Professor of Public Health at Weill Cornell Medical College.

Ketan Badani, M.D. is Director of Robotic Surgery at NewYork-Presbyterian Hospital/Columbia University Medical Center, and an Assistant Professor of Urology at Columbia University College of Physicians and Surgeons

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