The goal of surgery is to remove the cancer completely with minimal side effects. When the prostate is removed it is covered in ink, cut into fine sections and examined under the microscope. If cancer cells are present at the inked margin of the prostate (the edge of the prostate) the margin is called positive and the cancer, unfortunately, is up to 4 times more likely to recur.
A measure of the success of cancer surgery therefore is the "positive margin rate" or the percentage of patients in a surgeons experience with positive margins. Dr's Cozzi and Nash have, through many years of international training and experience, achieved consistently low positive surgical margin rates of the order of 6-8%.
This very low positive margin rate equates with a better chance of long term cure and is dependant on surgical volume, training and experience. Furthermore, this low positive margin rate is achieved whilst maintaining excellent outcomes for potency and continence.
Dr Cozzi recently reviewed the entire medical literature for publications on open surgery, laparoscopic and robotic assisted laparoscopic surgery.
- Open surgery had 7767 publications
- Laparoscopic surgery had 600 publications
- Robotic assisted had 160 publications
Laparoscopic prostatectomy was developed in Europe but did not gain widespread acceptance in Australia or the US because of the technical difficulties and poorer results for cancer control and functional outcomes. The table below demonstrates the high positive margin rate (shown in red) for all patients undergoing laparoscopic surgery in French centres of excellence and for those with pT2 cancers (confined to the prostate) and pT3 cancers (microscopic spread through the capsule or skin of the prostate).
| Guillonneau |
Abbou |
Gaston |
| Mountsouris |
Cretiel |
Bordeaux |
| 1000 |
700 |
413 |
| +sm % |
19.2 |
29.7 |
30.7 |
| 6.9 |
4.8 |
7.4 |
| 18.6 |
20.6 |
21 |
| |
|
24 |
| 30 |
42.3 |
43 |
| 34 |
50 |
46 |
|
Guillonneau, B. et al. J. Urol. 2003, 169, 1261-6. Curto European Urology 49(2006) 344-52
Furthermore, functional results are inferior to open surgery particularly with recovery of continence. One recent report suggested that only 15% of patients having laparoscopic surgery were pad free by 12 months compared with 90% of those having open surgery at the same hospital (Janetschek et al Abstract AUA 2005. Not yet published.)
Recently a machine has become available which shortens the learning curve for laparoscopic surgery allowing many surgeons unskilled in the technique to undertake the procedure. It is our view that the results of robotic surgery currently are inferior to open surgery and do not justify the learning curve of several hundred cases to return close to that which can be achieved with open surgery.
It is our view that robotic surgery would have to be far superior to open surgery to justify the expense and the learning curve.
Much information on the results of robotic surgery can be gleaned from hospitals which offer both open and robotic surgery. The table below demonstrates some of the comparisons which can be made between patients choosing this new treatment.
| Variable |
Open |
Robotic |
P value |
| pT3 |
19% |
13% |
<0.0001 |
| SVI |
8 |
2 |
0.011 |
| Gleason >7 |
14% |
4% |
<0.0001 |
| +SM |
20% |
30% |
<0.0001 |
|
Mouraviev et al. Urology. 69, 2, Feb 2007 311-14
It is clear from the results that patients undergoing robotic surgery had much more favourable cancers but poorer results with a 50% higher likelihood of a positive surgical margin (+SM). Patients have open surgery were more likely to have cancers spreading through the capsule of the prostate (pT3), more likely to have cancers involving the seminal vesicle (SVI), more likely to have aggressive cancers (Gleason>7) but because of the surgeons' meticulous open surgical technique these patients were much more likely to be cured long term of their aggressive and extensive cancers.
The reported benefits of robotic surgery include a shorter hospital stay however, a recent report confirms that patients undergoing robotic surgery go home exactly the same time as those undergoing open surgery. There was no difference in blood transfusion or post-operative care in either group. Re-admissions however were higher in the group that had robotic surgery. (Nelson et al, J. Urol. 177, March 2007, (3), 929-31).
The robotic surgery website and other websites which refer to it carry much mis-information about the potential benefits of the technique. The old adage that "when something sounds too good to be true it usually is" needs to remembered as the vast majority of the claims are completely unsupported by the literature. The abstract below details some of the misinformation on robotic surgery websites and was presented at the American meeting in 2007.
Cesar Rojas-Cruz, MD, John P Mulhall, MD. Weill Medical College of Cornell University, New York, NY
Introduction and Objective: Robot assisted radical prostatectomy (RARP) has become a well-established approach to the management of localized prostate cancer. Much of the marketing surrounding RARP is associated with advantages of this technique as it pertains to erectile function (EF) recovery. To date, there does not exist a comparative analysis of outcomes with RARP versus open radical prostatectomy (ORP). This analysis was conducted to define what the consumers are reading on the premier source of RARP information, the websites of the robotic prostatectomists.
Methods: From October 19-26th 2006 we surveyed the website links posted on the Intuitive Surgical web page (www.davinciprostatectomy.com) to hospitals and doctors that offer robot assisted radical prostatectomy (RARP). We reviewed the information related to EF outcomes posted on the center's web pages for accuracy and data support, specifically did the center mention that RARP was advantageous over ORP and was any scientific data presented to support these claims.
Results: 116 hospital web pages were reviewed. 75 of them had information regarding the DaVinci surgical system, surgery technique and outcomes. 40 (54%) were university hospitals, the remainder community based urologic practices. 42% contained text that that was explicitly copied from the DaVinci prostatectomy website. 40% (30) had a link to the Intuitive Surgical site. 61% had information related to erectile function (EF) being associated with RARP, however 39% had no sexual health information whatsoever. 78% of those that mentioned EF, stated that RARP is associated with a better EF outcome compared with ORP. 52% of the sites stated that RARP is better at preserving EF than OS, 26% stated that EF recovery with the RARP may be better than OS. 15% pages stated that the erectile dysfunction risk associated with RARP may be similar to OS. Only 7 sites (15%) had any specific EF data and only 2 had data pertaining to their own center, the others citing published series. No differences were noted in EF information between university and community centers. Conclusions: More than one third of the robotic prostatectomy websites had zero information regarding erectile function recovery. The majority stated that RARP had better EF outcomes compared to open prostatectomy, despite the absence of scientific data in support of these claims. This misinformation is giving patients who are considering radical prostatectomy unrealistic expectations.
Conclusions: Currently we believe the results in the literature do not justify the transition from a well established open surgical procedure which in experienced hands has excellent results. The Sydney Prostate Cancer Centre Urologists will constantly monitor the results of new technologies including robotic surgery and implement them when they are proven safe and effective.
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