Thursday, March 24, 2011

The Truth About Da Vinci Surgery

Talking to my patients and visiting numerous prostate cancer forums, I get the impression that the one treatment option for prostate cancer that everyone wants to know about is robotic or Da Vinci surgery.  Economically, it is a force to be reckoned with.  Hospitals are buying up million dollar robots as if they were bedpans and surgeons are rushing out to learn the new technology to be able to offer it to their patients.  Patients also seem to love it because it involves new, cutting edge technology.  All of this has led to a tremendous surge in robotic prostate surgery around the country which has led to an enormous increase in costs.  In the face of this Da Vinci tidal wave, patients all want to know if the procedure really lives up to the hype.  In this post I will attempt to separate the myth from reality and give you a more clear perspective on the benefits of robotic surgery for prostate cancer.

To begin with, in order to get a fair assessment of robotic surgery we need to compare apples to apples.  In so doing, lets see how this new technology stacks up to the gold standard: open radical prostatectomy.  To do this, let me first point out the technical differences between robotic and open surgery.  The traditional surgery involves making an incision about 5-7cm in length that starts midway between the belly button and the pubic hair and extends down to the pubic hair.  The prostate is exposed in the pelvis and the surgery is performed in the open.  Robotic surgery, in contrast, is performed with tiny incisions through which a small camera and robotic arms are inserted into the pelvis.  The surgery is performed within the body with the assistance of a three dimensional camera rather than through an open incision.  The benefit of the robot is that the robotic arms that are inserted have a great deal of range of motion.  What that means is that they can turn in several different directions at varying degrees.  Through this range of motion the robotic arms within the patient can simulate the motions of a human hand working through traditional surgery.  This ability is a significant advantage over simple camera surgery called laparoscopy.  In laparoscopy, the instruments can only make simple movements ( up, down, and side to side) which makes subtle, delicate parts of the procedure harder to do as compared with robotic surgery. 

Of course, the robot is not actually performing the surgery.  The surgeon sits at a computer console, usually within the same room as the robot and patient.  The surgeon looks through a specialized view finder and sees the surgery in 3D.  The surgeon places his hands and fingers within a specialized apparatus on the console.  As the surgeon moves his hands and fingers, the robot mimics these movements with its robotic arms within the patient.  The result is that the surgeon is performing the operation like he or she would during open surgery except that the surgery is done entirely within the body of the patient without an open incision. 

Any technology buff would be impressed by this innovation.  I mean doesn’t it sound amazing?  A surgeon can do with robotic arms inside the body everything that he could do with his own hands through an open incision.  You would think that through this new technology and the ability to see everything close up with a 3D camera, robotic surgery would blow traditional surgery out of the water.  The truth, however, is not that dramatic.  While the robotic surgery is a tremendous innovation, the original open surgery did a pretty good job in its own right.  This surgery, in its refined state, has been around for over 30 years and has actually produced some pretty good results in terms of cancer control.   Studies comparing traditional with robotic surgery have come to the conclusion that the two types of surgery are basically equivalent in terms of positive margins.  As a result, robotic surgery and standard open surgery do an equivalent job in removing the cancer completely and, in turn, curing patients of prostate cancer. 

While serving as a great operation in terms of cancer cure rates, standard open surgery has been haunted by its very well known complications.   Impotence and incontinence are feared by all men undergoing surgery for prostate cancer.  Studies have demonstrated that impotence affects approximately 50% of all men undergoing traditional prostatectomy for prostate cancer.  Fortunately, the rate of incontinence or leakage of urine is substantially less at approximately 15%.  You would imagine that robotic prostatectomy, with all of its innovations, would demonstrate substantial improvements over open surgery in terms of incontinence and impotence.  Unfortunately, studies comparing the rates of these complications from open versus robotic surgery have found few (if any) differences.

So what are the advantages of robotic surgery.  Well, there are a few.  First, robotic surgery leads to substantially less bleeding than open surgery.  In fact,  Da Vinci surgery results in only about 20% as much bleeding as its counterpart.  This difference can be critical for a patient with heart disease in whom more blood loss can increase the risk of heart attack and other complications during surgery.  Another advantage of the robotic surgery is hospitalization time.  While patients undergoing open surgery usually stay in the hospital for 2 days, those undergoing Da Vinci surgery only need to stay 1 day.  Similarly, the overall recovery time after robotic surgery is approximately one week shorter than that for open surgery.  These differences in hospital stay and recovery are mainly attributed to the fact that Da Vinci surgery usually results in less pain than the open surgery.  Finally, robotic surgeons usually remove the dreaded foley catheter from the bladder a few days earlier than open surgeons, avoiding a few extra days of discomfort.

What is the take home message from all of these comparisons?  Da Vinci surgery is a great innovation but it is not a cure all.  It is going to get you out of the hospital faster and allow you to go through surgery with minimal chance of needing a blood transfusion.  It will get you back to work faster and with less pain.  And it will lead to smaller scars on your belly when all is said and done.  That being said the presence of a robot at your surgery will not increase your chances of curing your cancer.  It will not increase the likelihood that you will maintain your erections after surgery.  It will also not decrease the probability, albeit small, that you may need to wear pads or diapers after surgery.  These critical outcomes (cure rate, potency, and continence) are dependent not on the type of surgery you get but who is doing the surgery.  Studies have repeatedly demonstrated that high volume prostate surgeons have much better results than those that perform the surgery a few times a year.  This is especially true for robotic surgery.  Surgeons who have mastered robotic surgery feel that at least 50 cases are necessary before they feel comfortable with the procedure.  The problem is that with this wave of demand for Da Vinci surgery, more and more surgeons are offering the procedure to their patients even though they have not mastered it. 

So what does this mean for you?  If you can find a GOOD robotic surgeon with a great deal of experience with the procedure, you should definitely consider it over open surgery given the advantages of the robotic approach.  However, if your choice is between an amateur robotic surgeon and an excellent open surgeon, you would be much better served undergoing the open surgery instead.  Remember, the robot is only as good as the surgeon operating it!

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  1. This comment has been removed by the author.

  2. It's a generalization to say that robotic surgery will get you out of the hospital in a day, or faster than open surgery. I had very successful robotic surgery on a Friday morning, but was not discharged until Monday morning. I don't know how common the longer stay is, but I will say that after talking with some friends who were discharged 24 hours after surgery, I feel I was fortunate to have the longer hospital stay. Discharging patients at 24 hours may save money, but I'm not convinced it's really good medical practice. (this is my wife's Google account. My name is Bill)

  3. Bill: The 1 day hospital stay I quoted was not really a generalization but a mean number that has been quoted in studies. Nonetheless, each surgery and hospitalization is unique to the patient. Some patients are very eager to leave the hospital for the comforts of home as soon as possible while others feel more comfortable staying under the supervision of doctors and nurses in the hospital. It is the feasibility rather than the necessity of leaving in 1 day after robotic surgery to which I am referring.

  4. Why do you think some of the most prominent cancer surgeons in the country have not converted to the robot? Is the idea that they have all the business they could possibly want/need, so no need to learn new tricks? Or they believe open is better for patients?

  5. chamorgadol: actually most if not all of the younger surgeons have converted to robotic surgery. The older, prominent surgeons have not converted for 2 reasons:
    1) They are too far in their careers to go through another learning curve
    2) They feel that their results with open surgery are excellent enough that they don't necessarily need the robot to improve them