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Dr. Catalona’s Response to DaVinci Robotics

by William J. Catalona, MD


“I do not believe the robotic prostatectomy is as safe a cancer operation as open radical prostatectomy.”

In my opinion, the robotic prostatectomy (often called the DaVinci prostatectomy) is not as effective as the traditional open prostatectomy for accomplishing sometimes competing goals of complete removal of cancer and preserving potency.

One of the reasons is that the robot lacks the "human touch" and it is not possible to appreciate how the prostate gland feels and how readily it separates from the nerves and other surrounding tissues. The robot does not handle the prostate gland as gently as the human hand does, and not infrequently the robot may puncture the capsule of the prostate, leading to positive surgical margins.
 
Another limitation is that with the robotic prostatectomy, the prostate is removed by burning it out with electrocautery or a so-called harmonic scalpel that cuts by heat, and if the heat is too near the nerves, it irreversibly damages them. Also, if the burning is too close to the prostate gland, it risks cutting into the prostate, resulting in positive surgical margins and possibly leaving cancer behind.
 
Advocates of robotic surgery say that there is less bleeding and greater magnification with robotic surgery. However, excellent magnification and visualization can be provided with open surgery, and with an experienced surgeon, few patients require blood transfusions from another person.

With robotic surgery, it is more difficult to suture and apply hemostatic clips quickly and it is more difficult to perform a lymph node dissection.

Enthusiasts of the robotic procedure claim it is "less invasive" and has a quicker recovery time. But actually it is more invasive because the surgeon has to go through the peritoneal cavity to get to the prostate (a more invasive approach associated for greater risk for injury to the bowel, major blood vessels, and the ureters and a greater risk for later intestinal obstruction from adhesions).  Usually 6 one-inch incisions are made for robotic surgery, while for open surgery, one 4 to 5 inch incision is made that does not enter into the peritoneal cavity. With the smaller incision now frequently used for open surgery, there is no material difference in the recovery time and return to normal activity. .  .  

The complications with robotic prostatectomy are more serious than with open prostatectomy and they lead to more postoperative emergency room visits, more re-hospitalizations, and more re-operations.

I believe that with the robotic or laparoscopic prostatectomy, the patient and the surgeon have to make more of a stark choice between removing all of the cancer or preserving the nerves to maintain potency.  I believe that there is a greater likelihood of accomplishing both objects with the increased access provided by the open approach.

Most importantly, however, the robotic prostatectomy has no track record in terms of long-term cancer control.  If small amounts of cancer are left behind, it may not become apparent for years.

Patients sometimes tell me that they know someone who underwent a robotic prostatectomy a few months ago and seems to be doing fine. However, the final outcome of the operation may not become apparent for up to 10 years. Thus, long-term cancer cure rates are needed before one can truly evaluate the effectiveness of the operation.

In sum, I do not believe the robotic prostatectomy is as safe a cancer operation as open radical prostatectomy, and I do not believe that nerve-sparing can be as readily or safely accomplished.

For patients, the most important outcomes of radical prostatectomy are: Is he cured of his cancer?  Is he continent?  Can he have erections sufficient for intercourse?

These questions have been well documented for open prostatectomy.  The jury is still out with laparoscopic/robotic prostatectomy. 

The most important factor is the surgeon and not the technique.

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