Conventional or Robotic Surgery for Prostate Cancer?

After lung cancer, prostate cancer is the second most observed cancer in men and is seen in 1 out of 6 men. Urologists are confronted with 3 different major scenarios in new diagnosed prostate cancer cases:

  1. Cancer is exclusively located in the prostate when diagnosed and did not spread into the adjacent tissues or the capsule enveloping the gland and seminal vesicles. Patients in this stage mostly benefit surgical treatment and almost 90 % are saved off cancer. This stage is termed as T2 and further divided regarding the extent of cancer in prostate as T2a, T2b and T2c.

As depicted in the figures:

  • T2a is the earliest diagnosed stage where cancer is located in one lobe of the gland as an inception
  • T2b is the stage where cancer involves one half of the prostate
  • T2c is a relatively advanced stage where cancer engages both lobes and approaches but not invades the capsule surrounding prostate
Fig 1. Representation of T2 stages in prostate cancer
  1. When cancer invades the prostate capsule and extends out of the gland but does not spread into the seminal vesicles it is termed as T3a.

When cancer enters seminal vesicles, this stage is named as T3b. Stage T3 means a locally advanced disease denoting a disease with invasion of prostatic capsule and spreading out of the gland with/without seminal vesicle extension but not having distant organ metastases. In addition to surgical removal of the entire prostate gland (Radical Prostatectomy) a wide surgical excision must be carried out in conjunction with extended lymph node extraction for the cure of cancer in this stage.

Fig 2. Representation of T3 stages in prostate cancer
  1. Metastatic disease is the term used where cancer has spread to bones or abdominal lymph nodes or other organs of the body. This stage is referred to T4.

In Which Stage Surgery Should Be Performed?

Better survival rates are reached when prostate cancer is diagnosed at an early stage as T2. This is the most proper phase for the best cure of the disease and can be accomplished by widespread annual use of the simple blood test PSA after 50 years of age. Surgical management is the choice of preference in patients who are suitable for surgery in T3 stages.

There must be 3 benefits for patients diagnosed in stage T2 when a surgery for cure has been performed:

  1. Entire removal of prostate gland and seminal vesicles without leaving a cancerous tissue behind is strictly correlated with surgeon experience. Whatever the stage is, a qualified surgeon must be capable of accomplishing this outcome with no residual tumor. At this stage, our rate of residual tumor after radical surgery for prostate cancer is 0 %.
  2. Urinary continence after the operation is the second goal to be achieved and it is, yet again closely connected to surgical experience and meticulous dissection. In our series we have an incontinence rate of 1 %.
  3. During the operation fine dissection of the nerves to the penis that are responsible for erection provides maintenance of penile erection postoperatively. This may not be achievable nearly in half of the patients owing to numerous factors such as the extent of cancer, age of the patient, anatomical variations and finally surgeon experience.

How Should Surgery Be Performed: Robot Assisted or Conventional?

I have tried to quote the results of recent comparative data about the two surgical approaches published in countries with advanced medical technologies as USA/European Countries and the urology guidelines of European Association of Urology (EAU), Canadian Urological Association (CUA) that urologists should consider in decision making.

The surgical operation performed for the cure of prostate cancer is termed as Radical Prostatectomy which includes removal of the entire prostate gland together with seminal vesicles and anastomoses of bladder with the urethra. This is a challenging and difficult surgery demanding a learning curve.

Conventional (Open) Surgery

  • First described in 1982, a 10-12 cm midline incision below umbilicus is made to enter pelvic cavity with muscle splitting and access the prostate behind the pubic bone.
  • Surgeon wears 3.5 magnifying spectacles to better view tissues and has the opportunity to touch and feel. It is highly valuable to feel the solid and firm areas or the nodules in the prostate because a solid area implies malignancy.
  • The surgeon performing the operation is himself/herself is involved personally at the operation table.
  • Open surgery is a reliable technique which has proved worldwide perfect outcomes in removing the cancerous tissue totally, preserving continence and keeping erectile function.
  • As it has been conducted for a well lengthy period (15-20 years), long-term results are available.

What is Robotic Surgery?

  • Has been introduced since 2001
  • It is a laparoscopic surgery that is performed through six small holes of 2 and 2.5 cm in diameter made on the abdominal wall. After insufflation of carbon dioxide gas into the abdominal cavity the attachments of the robotic device carrying a high-resolution camera and special instruments are introduced into abdomen. So, this surgery comprises abdomen.
  • The camera introduced magnifies the view 10 times and provides a 3-dimensional sight. However, the surgeon performing the operation does not stand by the patient. He/she is seated on a console apart from the patient thus, can neither touch nor feel the tissues.
  • Robotic surgery is a relatively novel surgical technique and carries the disadvantage of lacking long-term results concerning cancer free rates, continence status and erectile function. Research on the issue is still underway.
Surgeon performing Robotic Surgery on the Console
Shots taken showing assistant by the patient during robotic surgery

Comparison of The Results of Conventional (Open) Radical Prostatectomy and Robot Assisted Laparoscopic Radical Prostatectomy

Critical evaluation of the results of both techniques published in prestigious scientific journals and links for those willing to read the articles are added when writing this subject.

  1. Pain in the early and late postoperative period: During the early postoperative days, that is the first 3-4 days of hospitalization and initial 30 days, conventional open surgery has less pain than robotic surgery which is attributed to intestinal adhesions as it is performed via abdominal cavity. All through, no muscle is cut in conventional surgery and when entering pelvis, abdomen is not compromised, thus, pain is similar to robotic surgery during the early postoperative period while it is less in the late period.

Link: https://www.ncbi.nlm.nih.gov/pubmed/26936203

  1. Functional Outcomes (Urinary continence and preservation of penile erection): One of the major expectancies of radical prostatectomy in both techniques is preservation of urinary continence after the operation.

Various investigations conducted on the subject have found no significant difference between the two techniques; both conventional and robot assisted surgeries have the same results concerning urinary continence.

Link: https://www.ncbi.nlm.nih.gov/pubmed/27474375
         https://www.ncbi.nlm.nih.gov/pubmed/25770484

Preservation of erectile function is possible in tumors confined to prostate and no advantage of both surgeries over each other has been found in T2 tumors.

Link: https://www.ncbi.nlm.nih.gov/pubmed/27474375
         https://www.ncbi.nlm.nih.gov/pubmed/24454607
         https://www.ncbi.nlm.nih.gov/pubmed/20428292

  1. Patient Satisfaction: Patients preferring robotic assisted surgery are found to be 3 to 5 times more regretful then the patients in the conventional surgery group. This is attributed to the high expectancies of the patients from robotic surgery and subsequent dissatisfaction.

    Link: https://www.ncbi.nlm.nih.gov/pubmed/18585849

  2. Oncologic Outcomes (Residual Cancer and the Need for Additional Therapeutic Measures After Surgery): Main purpose of oncologic surgery is the entire removal of cancerous tissue and leaving no malignancy behind. Pathology report of a prostate removed for cancer must not have the assessment stating ‘positive surgical margin’ which means there is residual cancer cells remaining at the borders where prostate has been removed. The rationale of cancer surgery is achieved when pathologic assessment confirms ‘negative surgical margins’ meaning no cancer cells are left behind.
  • emoval of entire cancerous tissue is highly dependent on surgeon experience. In particular T2 tumors act as a barometer for the surgeon showing his dexterity in eliminating all cancerous tissue with clean surgical margins. We have a 0 % positive margin rate in our T 2 patients who underwent conventional open radical prostatectomy.
  • In advanced stage prostate cancer patients, i.e. T3, the rate of positive surgical margin is contingent to both the extent of the disease and surgeon experience. Our rate of positive surgical margins is 18 % in patients with T3 stage.
  • A multicenter study published in respected journals dated 2014 from Turkey denotes a 6.1 % positive surgical margin rate for robot assisted surgery for T2 patients (our rate for conventional open surgery is 0 %) and 37.1 % for T3 patients (ours for conventional surgery is 18 %).

    Link: https://www.ncbi.nlm.nih.gov/pubmed/25216924
  1. Wound Infection: No significant difference has been determined. Wound healing and infection are strongly associated with hospital and operation room settings.
  1. Prof Prokar Dasgupta (GB) addressing conventional or robot assisted radical prostatectomy during 2018 meeting of European Association of Urology in Denmark :

    Link: http://eau18.uroweb.org/robotic-surgery-is-unnecessary-in-the-developing-world/
    (    Bu konuşmada özetle robotik cerrahinin gelişmemiş ülkeler için aşırı lüks ve pahalı olduğu belirtilmektedir.)
  1. Cost: Robot Assisted Laparoscopic Surgery is more expensive than conventional open surgery even after accounting for lower hospitalization costs. In addition to purchasing and maintenance costs there are additional expenses for disposable attachments of robotic arms.

Review

Radical Prostatectomy is the primary ideal therapy for T2 and T3 stages of prostate cancer.

Currently there are mainly 2 surgical procedures for performing radical prostatectomy:

  • Conventional (Open) surgery
  • Robot Assisted Laparoscopic surgery

Both procedures:

    1. Have similar oncological outcomes
    2. Produce comparable functional results in continence and erection
    3. Possess alike pain scores in the postoperative period; robot assisted surgery has a slightly more abdominal pain attributable to intestinal adhesions

Robotic surgery:

  1. Has a slightly shorter hospital stay (2 -3 days versus 3-4 days)
  2. Comprises fewer blood loss; however, both surgical approaches do not require transfusion
  3. Costs more expensive than conventional surgery

 

***European Association of Urology (EAU) recommends patients:***:

“Whichever procedure you select is not significant, you should choose the experienced surgeon; the surgeon who is skilled in the procedure you choose.”

We discuss with our patients the pros and cons of both procedures in his settings and decide the surgical procedure, either conventional open radical prostatectomy or robot assisted radical prostatectomy, together.

 

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