Sunday, November 1, 2009
A diagnosis of prostate cancer can lead to a dizzying array of choices. Should you treat it immediately or opt instead for regular monitoring? If you decide to proceed with treatment, which treatment gives you the best chance for a cure with a minimum of side effects: surgery, radiation therapy, or hormone therapy? For men choosing surgery, the decisions don’t stop there. Should you have a traditional open surgery to remove the prostate, or should you have the prostate removed through a minimally invasive procedure performed using either laparoscopy or a surgical robot? At Memorial Sloan-Kettering, our team devises a plan for each patient that not only considers the latest treatments but incorporates a thorough evaluation combined with an evidence-driven approach to treatment, helping each man with prostate cancer to determine which treatment will result in the best possible outcome for him.
Traditional Open Surgery for Prostate Cancer
The ultimate aim of prostate cancer surgery is to eliminate a patient’s cancer completely while preserving normal urinary and sexual function. In most cases, prostate cancer surgery involves a procedure known as a radical prostatectomy. In this procedure, a surgeon removes the prostate gland and some tissue surrounding it. For many men, a sample of the nearby lymph nodes is also taken to determine whether the cancer has spread beyond the prostate. Depending on the size and location of the cancer within the prostate, nerve-sparing techniques may be used to preserve the tiny nerves and vessels that are attached to the prostate and are involved in the control of erections, thereby preserving sexual potency.
In a traditional open radical prostatectomy, the surgeon makes an incision that allows direct access to the prostate, seminal vesicles (the two glands that help produce semen), and lymph nodes. In the most common open radical prostatectomy procedure, the incision begins about an inch or two below the navel and extends to the top of the pubic bone. Once the prostate has been removed, the surgeon attaches the urethra (the tube that drains urine from the bladder to the penis) to the neck of the bladder, allowing for the resumption of urinary function.
Minimally Invasive Approaches
In a minimally invasive radical prostatectomy, the surgeon makes several small incisions in the abdomen in order to insert a thin, lighted telescopic camera, called a laparoscope, along with other specialized surgical instruments into the body. The camera projects a magnified, high-definition image of the surgical area, and the instruments are delicately manipulated to allow the surgeon to remove the prostate, seminal vesicles, and, when appropriate, nearby lymph nodes.
In a robotic-assisted laparoscopic radical prostatectomy, the operation is performed by the surgeon at the console of an advanced robotic device called the da Vinci® Surgical System. Five or six incisions are made in the abdomen to introduce miniaturized instruments and a high-definition 3D camera. Using hand, finger, and foot controls, the robot copies every movement of the surgeon, allowing for precise movements, while focusing on the goal of cancer removal, nerve preservation, and maintenance of normal urinary and sexual function.
Just as in traditional open surgery, the goal of minimally invasive prostate surgery is to cure the patient of his cancer and preserve his quality of life. The potential advantages of minimally invasive surgery for patients can be a reduced loss of blood, a shorter hospital stay, and a quicker recovery.
The use of minimally invasive surgical techniques to treat prostate cancer has surged in the last five years, with particularly large increases for robotic-assisted radical prostatectomies — a category that grew from 1 percent of all radical prostatectomies in 2001 to 80 percent in 2009. Some experts have cautioned that the recent popularity of minimally invasive and robotic surgery for prostate cancer has outstripped any large, clinical studies proving the potential benefits of these procedures.
JAMA Study Sounds a Cautionary Note
A multi-center study in the October 2009 issue of the Journal of the American Medical Association (JAMA) [PubMed Abstract] looked at the outcomes of about 2,000 men who had their prostate cancer treated with minimally invasive surgery between 2003 and 2007 compared with approximately 6,900 men who had open surgery. All the men in the study were 65 or older. The minimally invasive surgery group had shorter hospital stays (a two- versus three-day average stay) and fewer surgical complications when compared with men treated with open surgery. However, 18 months after receiving treatment, the minimally invasive surgery group had a greater risk of incontinence and erectile dysfunction when compared with men treated with open surgery. In addition, after the study’s authors adjusted for patient and tumor characteristics, men in both groups required similar amounts of additional cancer therapy (such as chemotherapy, hormone therapy, or radiation) — which, the authors note, correlates to cancer control and cure rates. These data suggest that claims of “superiority” of minimally invasive surgery compared to open surgery made by some must be viewed with caution.
Experience Matters
In general, irrespective of type of surgery, surgeons who see more cases of prostate cancer and who have more surgical experience are more likely to eliminate a patient’s cancer completely, preserve normal urinary and sexual function, and reduce the chance that a patient’s disease will recur. This is equally true for radical prostatectomy performed using either open or minimally invasive approaches. Memorial Sloan-Kettering’s urologic surgeons, for instance, performed nearly 800 radical prostatectomies last year.
“Prostate surgery is skill dependent,” says James Eastham, Chief of the Urology Service at Memorial Sloan-Kettering. “There are variances in how the technique is performed. As a result, experience matters.” Dr. Eastham emphasizes that there are certain patients who can benefit from some of the advantages that robotic-assisted radical prostatectomy offers. “Like any tool, however, it’s the person using the tool that’s important,” he notes. “I like to say that it’s not the pair of scissors someone’s using but the person using the scissors.”
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