The end to WHAT controversy?

In an extraordinary editorial in the July issue of the Journal of Urology, Dr. Michael Koch of the University of Indiana School of Medicine makes the following statement:

From my standpoint, as someone who has substantial experience with both [open and robot-assisted radical prostatectomy], robotic prostatectomy has superior or at least equal oncologic  efficacy and complication rates compared to open prostatectomy and in 2016 any small incremental expense justifies its use. I believe the current literature supports that view and the debate should finally be put to rest.

The problem, of course, is that whether the surgeon is using a robot or not has far less to do with the quality of the surgical outcomes that particular surgeon provides for his or her patients than the far more complicated question of whether he is a good enough surgeon to be doing the operation in the first place. And then there is the question of whether he is doing it on the appropriate patients. Dr. Koch doesn’t even address these rather important issues.

Earlier in his editorial, Dr. Koch had also written that:

patients have made up their minds on this issue with that being that whenever feasible, prostatectomies in the future will be performed with a robotic laparoscopic technique.

Of course patients have really had very little say in this discussion. RALP was seen as a vast marketing opportunity by Intuitive (the maker of the da Vinci system), by many hospitals, and by some urologists across America. Patients were told it was “better” than open surgery as far back as 2001 (on the basis of very few data), and many Americans equate new technology with “better” (whether that is true or not).

Now let us be very clear, Dr. Koch is absolutely correct about one thing. The vast majority of radical prostatectomies carried out in the future will indeed by carried out with robot assistance. Why? Because that is how every urologist in training in America and many other countries today learns how to do a radical prostatectomy — rightly or wrongly. The “New” Prostate Cancer InfoLink doesn’t actually have a problem with that. We couldn’t care less how a truly skilled urologic surgeon wants to carry out a radical prostatectomy — so long as the focus of the operation is appropriately balanced between the necessary removal of a truly cancerous prostate that needs removal and the optimization of the patient’s post-surgical quality of life (ideally with prompt and good recovery of both urinary continence and erectile/sexual function).

What we do care about a lot, however, is that most radical prostatectomies should generally be done by truly skilled surgeons for whom this a routine operation and who expect to do hundreds of such operations each year. This is a procedure that takes skill and experience to do well … and the best surgeons will tell you they are still learning how to do it better (with or without a robot) after doing thousands of such operations.

So — as a patient — don’t be overly concerned about the equipment the surgeon wants to use if you want to have a radical prostatectomy. But do be very concerned about the skill and experience of the surgeon, and the degree of attention that he brings to the table in discussing your operation with you and (potentially) your spouse or partner.

A poor surgeon with a robot is still a poor surgeon. And a great surgeon without a robot is still a great surgeon.

The long “controversy” over whether open surgery is “better” than robotic surgery has largely been an internal discussion between a small subset of physicians within the urology community. For most of the really good physicians, the only issue has been, “Can a robot help me and my colleagues and my students to be a better urologic surgeon?” For some it probably could and has. For others it may have made minimal difference. But the patients haven’t been the deciders here. If the technology hadn’t seemed to offer definable benefits to physicians and hospitals, the da Vinci robot would have sunk like a stone. Whether the benefits offered to physicians and hospitals were also, really, benefits for patients is a far more complex question.

Dr. Koch’s editorial in the Journal of Urology was actually written in relation to a new paper by Pearce et al. entitled, “Comparison of perioperative and early oncologic outcomes between open and robotic assisted laparoscopic prostatectomy in a contemporary population based cohort.”

3 Responses

  1. “most radical prostatectomies should generally be done by truly skilled surgeons for whom this a routine operation and who expect to do hundreds of such operations each year”

    No matter how many operations a surgeon does, Cavernosal nerves will always be indistinguishable to his eye. An effectively blind surgeon will always be an effectively blind surgeon.

  2. Good analysis.

    Two years ago, after I decided to have my prostate removed, I had to make another decision about which of two doctors at the center where I received my treatment. One was a highly published surgeon who performed only standard surgery. The other was slightly less experienced but he performed both types of surgery and choose RALP when he could.

    I went with the one who had experience with both modalities, figuring that he was in a better position to compare the two.

  3. Dear David:

    The question of when surgery is or isn’t appropriate is a whole different issue.

    It is certainly the case than many men who end up with loss of good erectile function might never have needed surgery and (indeed) might never have needed treatment at all.

    It is also the case that surgery may well be the best option for some patients who need to appreciate that there is a high risk for loss of erectile function, but that needs to be balanced against the high probability for elimination of cancer that really is clinically significant. Effective treatment of any type for such men is liable to lead to loss of erectile function because the relevant nerves will need to receive a high dose of whatever treatment is used.

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