Hello all,

This is a subject that comes up all the time.  I recommend that all
people considering surgery read this.  I know Catalona is one of the
best.

In the Fall 2006 edition of QUEST, published by the
Urological Research Foundation, Dr. Catalona gave his
views on the effectiveness of robotic prostatectomy in
removing cancer and in preserving potency.  His
response can be found at the following website under
Q&A:

http://www.drcatalona.com

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Question:  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?

Answer:    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.

LFC