Robot’s are better cancer surgeon!!!

There is a revolution going on in prostate cancer surgery over the past several years since the introduction of robot assisted surgery in 2000. But the question that has not been answered to date in a meaningful way is whether or not all the hype about the robot is in fact born out by the evidence. A recent article in the Journal of Clinical Oncology (JCO), along with an accompanying editorial, suggests that the advantages of the robot may be real in some respects, but may not be so great when it comes to the most important outcome, which is whether or not a man’s prostate cancer is effectively treated. Where to get prostate cancer surgery is one of the more common questions I am asked by people who ask my advice. I find it interesting that men (usually with enough money to make the trip) will travel across the country to get robotic surgery by an “expert,” when a very competent and highly regarded prostate cancer surgeon is available in their home town.  The problem, these men tell me, is that Dr. So and So doesn’t use the robot, and they want the robot. That’s part of the hype that can come along with any new procedure.  You learn as a doctor that sometimes what seems so new and special may not be so new and special after all.  Just more “space age,” more “gee whiz”, more “fancy.”  But not necessarily better. I have asked some of my expert urology colleagues—the type that deal with urology related issues of national interest—who they think the best prostate cancer surgeons are.  They give me a list, and frequently these surgeons do the traditional “open” prostate operation.  They are not all using the robot. When I ask my surgical friends why this is, they tell me very straightforwardly that having a robot doesn’t make up for the experience of a surgeon who does a lot of open prostate cancer operations. Nonetheless, the medical arms race continues. So what does the evidence say? The JCO article looked at Medicare data from 2003 to 2005, and examined the claims records of about 2700 men who had either a robot-assisted surgery or a traditional open operation during that time. They found that the men who underwent the robot procedure had shorter hospital stays after surgery (1.4 compared to 4.4 days) and fewer complications (29.8% vs. 36.4%). However, the researchers also found that the odds of requiring further treatment within the 6 months after the surgery (meaning that the prostate specific antigen levels, a marker of complete resection of the prostate and possibly cancer containing tissue, didn’t fall low enough) was 27.8% for the men who had robotic surgery compared to 9.1% of the men who had the standard operation. In plainer words, over 1 out of 4 men failed to get an adequate resection of their cancer with the robot compared to about 1 out of 11 men who underwent the open procedure. The men who underwent robot surgery also had a higher incidence of strictures (scarring) of the urethra after the surgery compared to the men with the open procedure.  This meant more difficulty urinating and more chances they would have to undergo additional procedures over time which could result in further discomfort and a higher chance of incontinence. One important cautionary note about these numbers is that the men who underwent robotic surgery tended to be older and had a higher number of other serious medical conditions, so one would expect they would be at greater risk of problems.  The study found just the opposite. The study also found that there was a significant shift in urology practice over the two years of the study, with the percentage of men treated with the open procedure dropping from 82% to 66.1%, and the number of men treated with the robot increasing from 12.1% to 31.4%.   Clearly, the robot is catching the fancy of both doctors and patients. This study wasn’t ideal, as the authors pointed out, since the information was gleaned from Medicare claims data.  There is a lot about these men that the researchers couldn’t determine, and this was not a randomized trial which hopefully would eliminate differences between the two groups.  That said, however, this is at least a study that gives us some idea of the differences in the benefits and risks of the two procedures. The authors also point out that “open radical prostatectomy is preformed through a relatively small incision that is infrequently associated with significant pain”, and that length of sty in the hospital for the open procedure are relatively short, averaging 1 to 3 days at high volume referral centers.  “Nevertheless, many patients intuitively perceive minimally invasive approaches to reduce complications compared with conventional open operations and prefer them due to smaller incisions requiring less analgesics and shorter hospital stays even at greater costs.” But you can’t ignore the recurrence data, which is significantly higher in the robot patients as well as the risks of becoming incontinent because of the strictures in the urethra postoperatively. The authors also point out that doctors who do a lot of robotic surgery do have lower complication rates, fewer strictures and less risk of salvage therapy at 6 months.  The same, however, is also true for doctors who do a lot of open procedures. What is the “right” number of surgeries your doctor should do in order to demonstrate they are good at either of these operations? For robotic surgery, the paper says your doctor should have done at least 40 to 150 robotic surgeries before they do one on you.  They also say that in a recent survey, 37% of urologists “reported doing fewer than 11 radical prostatectomies per year, while 84% reported doing fewer than 31 per year.  Consequently, the learning curve may be extended for years.  Paradoxically, there is no formal certification process…Surgeons may perform the procedure after completing brief courses lasting 2 days or less.” My friends, I urge you to ask your doctor about their qualifications and the number of procedures—both open and robotic—they perform a year and how many in their career.  If the answers don’t add up to a lot, then find someone who does have the experience you want and you need. In an editorial published in the same issue of the Journal, a urologist from the Mayo Clinic points out that the numbers of complications in the “open” group is much higher than that seen in centers that do a high volume of the traditional radical prostatectomy, or open procedure.  The length of stay in these centers is also much less than that reported in this paper, on the order of two days as opposed to the four days reported in this study. This doctor also points out that the long term recurrence and survival results from open surgery are well documented and well known, while similar statistics for the robotic surgery don’t exist since the procedure is so new. He concludes, “Currently, open technique is the state-of-the-art procedure in experienced hands, as the long term results for (robotic surgery) do not exist.  The published literature fails to answer whether (robotic surgery) meets ‘quality standards.’” So what do you do? What this paper and my discussions with my experienced colleagues tell me is that robotic surgery remains an option for prostate cancer surgery, but it is only an option.  If you are going to drive down the street and pass by the world expert because they don’t do robotic surgery, I would think twice.  Experience clearly matters when you are having your cancerous prostate removed, and I suspect that a highly experienced surgeon who does open surgery is every bit as good as a highly experienced robot surgeon. Just remember: the operative word here is “experienced.” Which leads me to another observation, which I have also discussed with several colleagues recently. Experience counts, as noted above.  The way you find out about experience is to ask the doctor how many procedures they have performed in a week, or a year, or in their career.  Increasingly, we hear back from people that when they ask their doctor how many of these robotic operations they do, the answer is frequently in the hundreds if not over one thousand. I guess that’s possible, but some of us are beginning to question some of those numbers, especially from young doctors.  There simply aren’t enough prostates to go around.  Yes, the world experts have those kinds of numbers, but not a whole lot of doctors are world experts. So when you hear a number, just keep in the back of your mind that there just may some “number inflation” going on here.  Unfortunately, there is no way for you to confirm the accuracy of a doctor’s reported experience.  Perhaps it is time for the hospitals—when they certify doctors to perform certain procedures—to determine accurately how many procedures of a certain type they have performed over the past year or so as part of the credentialing process. One thing is clear, however, and that is if your doctor doesn’t do a lot of either type of operation, experts would advise you to find one that does.  This is simply a procedure where research has shown that “practice makes perfect.”