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Robot prostatectomy cuts incontinence, surgeon finds

SUMMARY: 95 percent of the men who had robot surgery for prostate cancer said they lowered the rate of urinary complications, compared to 83 percent of the others with hands-on surgery.
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NEW YORK (Reuters Health) - Robot surgery for prostate cancer lowered the rate of urinary complications compared with hands-on surgery in a new Italian study.

While the study was small and contradicts earlier results, it's important because robot surgery has quickly overtaken cheaper alternatives in the U.S., helped by hospitals aggressively marketing the technology.

Yet there is no ironclad science showing it's any better, and many doctors have voiced concerns about the higher costs.

In the Italian study, one surgeon operated on 120 men, each of whom had been randomly assigned to a minimally invasive surgery called laparoscopy with or without the help of a robot.

During the robot procedure, a surgeon sits at a video console and manipulates two or three arms, one tipped with a tiny camera, that reach into the patient through small cuts in the belly. There, the doctor cuts out the cancer-ridden prostate gland using the robot arms. The hand-on version is done the same way, but without the robot middleman.

The researchers found no reliable difference in blood loss, operating time, length of hospital stay or cancer outcomes at one year.

However, men reported less use of diapers after the robot procedure than after the traditional operation. At one year, for example, 95 percent of the men who had robot surgery said they used none or at most one safety diaper a day, compared to 83 percent of the others.

Another common side effect of prostate removal is impotence. Of the men who been able to get an erection before their surgery, 80 percent in the robot group had recovered it within a year versus just 54 percent in the laparoscopy group.

Robotic surgery costs between $1,000 and $2,000 more than traditional laparoscopy, in addition to the upfront cost to the hospital of the machine itself.

"This is certainly the strongest evidence to date the laparoscopic surgery done with robotic assistance is going to yield better outcomes than traditional laparoscopy," said Dr. Matthew Cooperberg, a urologist at the University of California, San Francisco.

"Nobody is saying this is definitive, but it is probably the best study we will get answering this question."

According to Cooperberg, few doctors in the U.S. today offer laparoscopic surgery without robot assistance, despite the lack of good evidence that using the machine is better.

Some doctors do open surgeries, however, operating through one long incision in the belly. That leads to more blood loss and longer recovery times than laparoscopy, but the cancer outcomes appear to be similar.

LIMITED STUDY

Dr. Francesco Porpiglia of San Luigi Gonzaga Hospital in Turin, who did all the surgeries in the study, did not respond to a request for comments.

But in the journal European Urology, he and his colleagues say the better results with the robot could be due to higher surgical precision given the 3D magnification and wide range of movement of the machine.

They also recognize that their study is limited by the small number of men who participated, which makes it hard to draw solid conclusions.

As a case in point, another Italian study published last year found no difference in incontinence rates after robot and traditional laparoscopic prostatectomy, respectively. That study did, however, show that men treated with the robot had better chances of remaining potent.

Observational studies, in which researchers look back at larger datasets, haven't been able to agree that one method is better than the other, either.

"Our results depend strictly on the single surgeon and do not represent a real-life situation," the researchers caution.

Cooperberg said surgeon skill and experience is more important than the technology they use. Patients, he added, should not be afraid to ask their surgeon about his or her outcomes.

And that, perhaps, is the strongest conclusion from the new report.

"If you are going to see Dr. Porpiglia for prostatectomy, definitely get the robot," Cooperberg, who uses the technology himself, said.

According to the American Cancer Society, one in six men will get prostate cancer at some point in his life, but a minority will die from the disease. There are several ways to manage it, including simple surveillance to see if the tumor ever becomes a real health threat or can be left alone.

SOURCE: http://bit.ly/MwltHt European Urology, online July 20, 2012.

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