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Study Finds, Robotic Prostate Surgery Compares Favorably to Open Procedure

New York (May 25, 2010)

an operating room

The robots in widespread use today bear little resemblance to the science-fiction fantasy robots of decades ago. Take a surgical robot, for example: it is controlled by a surgeon seated at a console, looking at a video screen, and using hand controls to move several large, jointed arms equipped with video cameras and miniaturized tools mounted above a nearby operating table. Surgical robots are becoming commonplace in operating rooms, where surgeons use them to operate on patients with prostate and gynecologic cancers and for cardiac problems. Whether the advent of the surgical robot has improved patient outcomes, though, has been a matter of debate. NewYork-Presbyterian/Weill Cornell Medical Center urologic surgeon Ashutosh Tewari, M.D. decided to shed some light on this question by comparing the outcomes of his prostate cancer patients to those operated on by surgeons using traditional, open surgical techniques.

During surgery for prostate cancer, the surgeon's goal is to remove all of the cancer while leaving the nerves that control 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 around the prostate," 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 number of cases in which pathologists found cancer cells on the surface of the surgically removed prostate – a so-called positive margin, and an indication that some cancer cells may have been left in the patient. They found that the incidence of positive margins in their patient group 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.

Robotic and open radical prostatectomy are very different operations, said both Dr. Tewari and Ketan Badani M.D., a urologic surgeon at NewYork-Presbyterian Hospital/Columbia University Medical Center trained in both open and robotic approaches. 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."

There are a few quantifiable things that are undeniably improved by minimally invasive, or robotic surgery, Dr. Badani pointed out. "Blood loss is definitely decreased around 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 after robotic surgery, 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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