Published in UAB Insight, Winter 2006
Abstract: Several choices for surgical treatment of prostate cancer are available, including an open procedure, a laparoscopic prostatectomy, or robotically assisted laparoscopic prostatectomy.
CME Objective: The reader will be aware of different techniques for radical prostatectomy and their advantages and disadvantages.
Christopher L. Amling, MD, no conflicts of interest
While minimally invasive surgical techniques have simplified procedures such as cholecystectomy and hernia repair, some complex procedures are difficult to adapt.
“Laparoscopic radical prostatectomy, for example, is one of the most technically challenging minimally invasive procedures,” explains urologic oncologic surgeon Christopher L. Amling, MD, new director of UAB’s Division of Urology. “The prostate is located deep within the pelvis, surrounded by a dense network of delicate blood vessels and nerves. When surgeons began performing laparoscopic prostatectomy, operating time averaged 6 to 10 hours, versus about 3 hours for standard open surgery.”
Although reduced blood loss, magnified view, shorter hospital stays, and reduced postoperative pain are advantages of laparoscopic prostatectomy, many surgeons found the steep learning curve and lengthy operating times unacceptable, Amling says. “With concurrent improvements in open radical prostatectomy, including nerve-sparing techniques, most urologists choose not to perform the considerably more difficult laparoscopic procedure.”
Proven Technique
Radical prostatectomy is an increasingly popular treatment choice among the 230,000 American men diagnosed annually with prostate cancer; about 40% now choose surgery over other treatment options, which include watchful waiting, radiation therapy, and hormone therapy.
Radical prostatectomy significantly reduces disease-related mortality, Amling says. A recent Scandinavian trial randomized 695 men with newly diagnosed prostate cancer to either radical prostatectomy or watchful waiting. After 8 years follow up, surgery reduced cancer-specific mortality and frequency of distant metastases by 50%, although overall survival between the two groups was not significantly different (N Engl J Med. 2002;347:781-789).
Surgeons perform open radical prostatectomy with one of two approaches: retropubic or perineal. Long-term cancer control and full recovery of continence and potency are the ideal postprostatectomy outcomes, Amling says.
Patient Comparison:
Outcomes of Robotic versus Open Surgery
|
| Data |
Robotic |
Open
|
| Age (yr) |
62.9 (43-78) |
62.7
(50-78) |
| Body mass index |
26.3
(20.6-33.6) |
26.5
(20-34.5)
|
Preoperative PSA (ng/mL)
|
8.1 (0.1-62) |
8.4
(1.1-39.6) |
| Operative time (minutes) |
231
(160-340) |
214
(175-275)
|
| Transfusions (%) |
0 (0) |
1 (2)
|
| Postoperative day 1 Hb change (g/dL) |
-1.6 (0.2-3.4) |
-3.3
(0.3-6.1)
|
| Hospital stay (hours) |
25.9 (18-96) |
52.8 (48-192) |
| Prostate size (g) |
52.5
(18-135) |
50.7
(30-108)
|
| Complications (%) ) |
4 (6.7) |
6 (10) |
| Catheter time (days) |
7
|
9 |
| Continence (0 pads) at 3 mo (%) |
76 |
75
|
Unless otherwise noted, data in parentheses are ranges. Source: Aherling TE, et al. Robot-Assisted Versus Open Radical Prostatectomy: A Comparison of One Surgeon’s Outcomes.
Urology. 2004;63:819-822. |
“Prostate cancer recurrence rates depend on serum PSA level, cancer grade, and disease stage,” he says. “About 30% to 40% of men develop biochemical recurrence, defined as detectable PSA levels following prostatectomy, but not all these men have clinically significant cancer requiring further treatment.” A recent study showed it may take as long as 8 years for men with biochemical recurrence to develop distant or metastatic disease, and another 5 years for them to die from prostate cancer. Many older patients die from other causes before this occurs.
“Open surgical modifications have reduced hemorrhaging from the surrounding vasculature and allow surgeons to concentrate on achieving clear surgical margins while sparing neurovascular bundles,” he says. “These refinements allow more men to maintain postsurgical potency and continence. Potency is largely determined by age and preoperative erectile function. Up to 80% of men in their 40s maintain potency after nerve-sparing prostatectomy. When patients are in their 50s, that number falls to 70%, and about 50% of patients older than 60 years remain potent after prostatectomy.”
A large majority of men now achieve full continence after prostatectomy. “More than 90% of men can expect postsurgical continence, which is defined as not having to wear pads,” Amling says, adding full recovery of continence and potency can sometimes take as long as 2 years.
Cutting-edge Advance
When performed by experienced surgeons, open radical prostatectomy is often curative, but the invasive procedure requires a lower midline incision and significant recovery time. Robotically assisted surgery is a newer minimally invasive alternative, offering all the advantages of the standard laparoscopic procedure, while resolving many of its technical challenges.
UAB’s urologic surgical team, which includes Amling and Donald A. Urban, MD, commands the da Vinci™ robotic surgical system from a master console about 12 feet from the patient. The system incorporates three multijoint robotic arms: one arm, directed by a foot pedal, controls the binocular endoscope; the others control two articulated arms that mimic human wrist and hand movements and direct them to pencil-sized microsurgical instruments. Unlike traditional laparoscopic instruments, the da Vinci system translates large natural movements to identical, but scaled down, micromovements at the surgical site, increasing precision and accuracy.
The system immerses surgeons in the optical field, providing a stereoscopic three-dimensional view with 10-fold magnification of tissue planes and neurovascular bundles; standard laparoscopic procedures are viewed two-dimensionally, Amling says.
“The system simulates the natural dexterity of surgeons’ fingers, creating a virtual reality encounter that improves surgical control and precision,” he says. “With robotically assisted surgery, blood loss is less than 150 cc compared with 500 cc to 700 cc with open prostatectomy. In addition, much smaller incisions speed recovery times.” Catheterization times can also be reduced with the less-invasive approach.
Open versus Robotic Surgery
Although safety of robotically assisted laparoscopic radical prostatectomy is well established, few randomized controlled trials have compared open prostatectomy with robotically assisted surgery, Amling says.
“During robotically assisted surgery, the abdomen is inflated with gas, which can be associated with ileus. Because open prostatectomy is performed outside the abdominal cavity, robotic surgery may be associated with a longer delay in return of bowel function than open prostatectomy in some cases,” he says. “In other respects, intraoperative and immediate postsurgical complications of the two procedures appear similar.”
Mature 5- and 10-year follow-up data on prostate cancer recurrence after robotic surgery are not yet available, but Amling believes recurrence rates are equivalent.
“Open radical prostatectomy and the robotically assisted procedure also appear to produce comparable return of continence and potency, although we need more long-term data,” he says. “Robotic surgery clearly results in less bleeding and postoperative pain than conventional surgery. Many younger men, who desire a quick return to normal activities, favor the robotic technique. As larger series comparing procedures for radical prostatectomy mature, I think data will show at least equivalent primary outcomes measures, and perhaps, some advantages to robotically assisted surgery.”
For more information
Dr. Christopher Amling
1.800.UAB.MIST
mist@uabmc.edu