What do you guys think?

Q: I have been hearing a lot of good things about DaVinci Robotics for
removing the prostate.  I know that you do not practice the procedure,
but what would you say about its benefits for preserving potency and
continence?  And which patients should consider it as a treatment
alternative?

A:    In my opinion, the robotic prostatectomy (often called the
DaVinci prostatectomy) is not as effective as the traditional open
prostatectomy for simultaneously accomplishing 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, and not infrequently the robot punctures 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 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 rostatectomy.  The
jury is still out with laparoscopic/robotic prostatectomy.

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