Don’t believe hype about robot prostatectomy: study

Older men considering robotic surgery for prostate cancer shouldn’t trust the rosy ads promoting the expensive technology over low-tech surgery.

That’s according to a new survey that found complaints about sexual problems and urinary leakage were equally common after the two procedures.

“I wasn’t surprised at all,” said Dr. Otis Brawley, chief medical officer of the American Cancer Society, who wasn’t involved in the study.

“Unfortunately, robotic prostatectomy - like many things in prostate cancer - has gotten a lot more hype than it should.”

Robotic prostatectomy has caught on rapidly in the U.S., despite the fact that there is no good evidence to show it’s better than traditional prostate removal. It is, however, much more costly, adding some $2,000 in hospital costs per procedure.

The new study, published in the Journal of Clinical Oncology, is based on responses from more than 600 prostate cancer patients on Medicare, the government’s health insurance for the elderly.

About 400 of them had so-called robotic-assisted laparoscopic prostatectomy, in which the surgeon uses a robot to access the prostate through multiple small holes in the belly.

The rest of the patients had traditional open surgery, in which the prostate is removed through one long cut in the belly.

Nearly nine out of 10 men had a moderate or big problem with sexual functioning 14 months after their surgery, Dr. Michael Barry of Massachusetts General Hospital in Boston and colleagues found.

And about a third of the men said they had incontinence trouble after their surgery.

Overall, there were no differences between the two patient groups, although urinary problems appeared to be slightly more common after the robot procedure.

An editorial in the journal called the findings “sobering,” but added that it’s hard to compare the two procedures directly based on the new data. It’s possible, for instance, that men with high hopes for the robot procedure would be extra bothered by side effects afterward.

“The problem that is revealed in this paper is this question of expectations,” said Dr. Matthew Cooperberg, a urologist who co-wrote the editorial. “There is a known issue of regret related to robotic surgery.”

Part of the problem is heavy promotion, he told Reuters Health, which has catapulted robot surgery to its current status. Out of the tens of thousands prostate removals done annually in the US, some 85 percent are estimated to be robotic.

“To an extent it’s the manufacturer, to an extent it’s surgeons, to an extent it’s a culture that tends to put great faith in technology, even when the patient doesn’t understand it,” said Cooperberg, of the University of California, San Francisco.

“The robot is impressive technology, allowing the surgeon to sit at a console and direct a camera and two or three laparoscopic arms with six degrees of wristed motion for cutting, retracting, cauterizing, or suturing - all with high magnification and three-dimensional visualization,” Cooperberg and his colleagues write.


The robots, which cost a couple of million dollars each, do have some advantages. For instance, they reduce blood loss, which helps surgeons see better when operating.

But Cooperberg, who uses the technology himself, readily acknowledges that it probably doesn’t treat cancer any better than the old surgery and doesn’t have proven benefit in terms of side effects.

He said patients considering surgery should look for experienced surgeons rather than focus on technology.

“At the end of the day, these operations should only be done by surgeon who can demonstrate they have good outcomes,” Cooperberg told Reuters Health.

“The patients should be asking the question, ‘Dr. Jones, What are your personal outcomes?’” he added. “If a surgeon can’t answer that question, I would suggest that patients look elsewhere.”

Brawley agreed.

“I would not be afraid to go interview doctors,” he said. “Go with your gut feeling about who you trust. Realize that every doctor you interview is going to try to make themselves look good.”

But he added that many people with early-stage prostate cancer might not need treatment at all.

One study found that more than 120,000 American men diagnosed with prostate cancer every year are ideal candidates for observation, or watchful waiting. Still, the majority of them end up having surgery, radiation or other treatment instead.

“For a man who chooses to be aggressively treated I use that study to say, you have time to sit down and rationally choose what procedure to use,” Brawley told Reuters Health.

Intuitive Surgical, Inc., which makes the popular da Vinci robot, declined to comment on the new findings.

SOURCE: Journal of Clinical Oncology, online January 3, 2012.

Provided by ArmMed Media