It’s not the robot, it’s (almost certainly) the humans that are the problem

Prostate Cancer International, on this site and even more so on its associated social network, has long emphasized the importance of physician focus, skill, and experience as being key factors in the diagnosis and management of prostate cancer — regardless of the specific types of technology that may be being applied.

Specifically, when it comes to the execution of radial surgery in the treatment of localized prostate cancer, there is considerable evidence that — for the vast majority of surgeons — it takes about 250 procedures to learn how to do this operation reasonably well, and the very best surgeons are likely to tell you that they are still learning, even after they may have done thousands of radical prostatectomies.

Then, there is the question of whether “robot assistance” actually has positive or negative impact on the outcomes of men who are given radical prostatectomies.

From the day that The “New” Prostate Cancer InfoLink went on line in 2008, we have stated clearly and frequently that precisely how a specific surgeon carries out radical prostatectomies was never the key issue for a patient to focus on. What is important is how good the individual surgeon is at doing this operation in the way with which he is  most comfortable — with or without the use of a da Vinci robot, and whether or not he prefers to do the operation through the abdomen or through the perineum. We still believe this to be the case. It is true that, in general, use of robot assistance may help patients have less risk for blood loss, lower the time patients need hospitalization post-surgery, lower risk for post-surgical pain, and permit shorter post-surgical recovery, but really skilled surgeons who use non-robotic forms of laparoscopic radical prostatectomy — and even some really skilled surgeons who still practice open radical prostatectomies — can do that too!

What is disturbing, however, is that there are at least suggestions that — as more and more hospitals have acquired da Vinci robots — there has been increased pressure for rapid uptake of the use of this equipment with (perhaps) a less than sufficient focus on learning how to use this equipment really well. Now these suggestions are turning into lawsuits. Why? Because some people receiving robot-assisted surgery (and not only for prostate cancer) appear to have had less than stellar outcomes. Clearly that isn’t inherently the fault of the robot, which does only what human hands “instruct” it to do … but others may have some guilt on their hands here, including:

  • Surgeons who fail to invest enough time to learn how to use robot assistance with a high level of skill
  • Hospitals and other surgical centers that place pressure on their surgeons to start using robotic equipment for economic reasons
  • Marketers of robotic equipment who may “push the envelope” by placing insufficient emphasis on the importance of extensive training before surgeons start to “fly solo” using robot assistance

A new article posted on the web site late Wednesday evening is headed, “Intuitive robosurgery training seen lacking in lawsuits.” At the beginning of this month we had noted that the U.S. Food & Drug Administration was also looking into “problems” with the use of the da Vinci technology.

Let us be very clear … We do not think it is the technology that is the problem here. However, humans have a strong tendency not to behave as well as we might like (because of their egos, their greed, and a whole host of other reasons). For the man with prostate cancer who is considering surgery, please don’t get the idea that there is necessarily any problem with robot-assisted radical prostatectomy (RALP). The important issues you need to be considering are the skill and experience of the surgeon, how many RALPs s/he has carried out, and whether others can help you to feel confident of his or her skill level in the use of this technology!

8 Responses

  1. Too bad the current professional vetting system for urologic competence and skill is seemingly flawed and protected by the very industry that would benefit by oversight.

  2. Dear Elucidated1:

    Please let’s be very clear that this situation is absolutely not (in any way) unique to urology. It is a problem that is endemic to medical care. “See one, do one” may have been a valid way to think about learning how to do medical procedures in 1913, but not in 2013.

  3. No one is discounting the fact that “this situation is not unique to urology.” But on this entire website and blog, the topic is about urology. And if the topic is RALP, how many urologists were in over their heads with minimal experience doing da Vinci in the last decade?

    This is not just about stitching up a wound and the patient getting an infection. This is about the very manhood a person being compromised resulting in psychological and physical changes by professional mistakes.

    And to the demise of thousands men, having their penises shortened/becoming impotent/incontinent all because they may have not chosen the most competent surgeons who were skilled at sparing the nerve bundle is unconscionable. One can find negative personal experiences from patients on YANA and elsewhere on the internet.

    What is difficult to find is a list of competent urology surgeons by area that have been vetted by patient successes and peer review.

  4. Dear Elucidated1:

    This entire website is not all about urology at all. It is about the management of prostate cancer. This is affected by a multitude of physicians, which certainly includes but is far from limited to urologists. It is also affected by the attitudes of patients (like you) whose personal experience colors their personal priorities. You might want to think about how many US-based physicians started doing HIFU procedures with minimal experience. They weren’t all urologists, by any manner of means.

  5. My mistake. Using urology synonomously with prostate cancer is a misnomer.

    You are exactly correct. My prostate cancer experience has “colored” my views. And that is the exact reason I am here. I found so many negative stories (read incontinent/impotent) from prostate cancer patients after RALP that I chose HIFU and never looked back. And after interviewing dozens of prostate cancer patients who did RALP, more than one just “wanted their prostate back.”

    I am just one patient who cannot overstate how well my HIFU went. That cannot be said or even quantified for patients after RALP to the detriment of future prostate cancer patients, thanks to a less than transparent data base provided by US urologists.

    For the sitemaster to compare HIFU with RALP, though is a little much. da Vinci surgeries continue to be seen as the de jour of prostate cancer so far and thousands are done every week in the US. HIFU does not even compare in numbers, since is it still being vetted by the FDA. You, yourself have described the challenges of identifying and sparing the nerve bundles in RALP.

    And with regard to your point about the number of “US based physicians who started doing HIFU procedures with minimal experience” … it is in the dozens since they have to leave the country to do it using Ablatherm or Sonablate. A little different than the hundreds/thousands of physicians who choose to offer surgery.

    One very unique thing about US urologists who are being trained in HIFU, is that almost every one of them believes in less invasive solutions in dealing with prostate cancer. How novel.

  6. Less invasive is the key!

  7. Less invasive, treat the cancer.

  8. A new report on the Bloomberg web site today provides further evidence that surgical competence, training, and marketing may have been a major issue in poor outcomes associated with the use of the da Vinci system.

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