Not all patients diagnosed with prostate cancer are candidates for surgical removal of the prostate gland. Those who are will benefit greatly from the da Vinci robot-assisted prostatectomy, now widely performed at most major hospitals throughout the United States.
Having practiced urologic surgery for more than 40 years and having treated more than 10,000 patients with prostate cancer, I have seen prostatectomy techniques evolve from a rather crude, open operation, to a more refined, nerve-sparing, open procedure, to a laparoscopic radical prostatectomy, to the elegant, precise, da Vinci laparoscopic robot-assisted prostatectomy practiced today.
In all my years of practice, I have seen no single entity evolve so dramatically in terms of technical advancement, patient comfort, nerve preservation, and continence protection as with this surgical technique. New alone does not mean progress, but new and better does!
The use of the robot-assisted da Vinci surgical system has quadrupled in just the last four years and is currently used in some 2,000 hospitals around the world. The reason? It is a better mousetrap.
The da Vinci robot is not actually performing the prostatic surgery; its arm merely mirrors the movements of the surgeon’s hands on two joy sticks, as the surgeon sits at a console and controls the robot.
No large incision is necessary when using the da Vinci system. The operation is performed laparoscopically with instruments that are inserted through ports (small keyhole slits) in the abdominal wall. The da Vinci “wrists” allow the “surgical hand” to rotate 360 degrees and angulate at almost an infinite number of angles. In addition, the surgeon sitting at the da Vinci console sees the field via a 3-D camera, which brings both clarity and magnification to the surgical field. Any experienced surgeon who has participated in the evolution of the traditional open operation to the da Vinci robot-assisted operation will attest to the dramatic improvement.
Unlike the rigid tools in traditional laparoscopic surgery, the wrists at the tip of the da Vinci arm allow the surgeon to pivot and twist the wrist in such a manner not possible by any other technique. And, unlike many surgeons who become fatigued, the robot filters out any apparent hand tremors.
But some feel that the da Vinci talents may not be up to those of physicians. Dr. Marty Makary, a surgeon at the Johns Hopkins School of Medicine in Baltimore, has stated, “For the patient, there’s clearly no difference.” I strongly disagree. Although, as Dr. Makary says, “There’s never been a study showing clinical superiority,” I can assure the reader that, from my clinical experience over thousands of cases, there is!
Dr. Makary has made the case that the robot is more of a marketing tool to attract patients than a medical one to improve their care. Although it might be true that the term robot is marketable, its superiority in both surgical technique and patient outcome is undeniable.
The critics of da Vinci prostatectomy, including Dr. Makary, say that the sensory feedback upon which surgeons rely is gone and that the da Vinci cannot tell whether the body parts are firm, squishy, bony, soft, delicate, or hard. Given that scenario, it might be easier for a surgeon to accidentally cut the wrong body part.
But an experienced robotic surgeon does, in fact, get a tactile feel, by a combination of the movement of the robotic wrist and the 3-D visualization of the wrist in action, associated with an enhanced depth perception. The argument that there is loss of tactile or sensory feedback always seems to come from those who are not experienced with the da Vinci.
More than 4,000 published studies on the da Vinci show that, when compared with open surgery, da Vinci surgery resulted in fewer complications, less blood loss, and faster recovery.
There is some debate in urologic circles about whether there is a significant difference between traditional laparoscopic prostatectomy and da Vinci robot-assisted laparoscopic prostatectomy. The greatest advantages of the da Vinci technique are the magnification, the flexibility of the operating wrist, and the 3-D visualization of the operating field. It is certainly true that, in terms of pain, scarring, and length of hospitalization, the laparoscopic approach and the da Vinci robotic technique are about equal.
The Institute for Clinical and Economic Review examined da Vinci surgery as part of a 2009 report on prostate cancer treatment. Dan Ollendorf, the institute’s chief review officer, states, “There was no evidence of major benefit from the robot compared with open surgery.” This conclusion does not match my experience. Mr. Ollendorf further states, “What matters most is the experience of the surgeon, not the chosen tools.” I certainly agree that the experience of the surgeon carries significant weight, but given surgeons of equal experience, the da Vinci will win every time.
Performing surgery with the da Vinci system adds about $1,600 to the cost, an increase of about 6 percent, according to a 2010 analysis in the New England Journal of Medicine. The da Vinci system itself costs between $1.2 and $2.2 million. In most centers, it is used in a wide range of specialties, including gynecology, orthopedics, and cardiology. Of course, the more the robot is used, the lower the per-use cost becomes.
Viewing the entire landscape of surgical approaches to prostate cancer surgery, I have no doubt that the da Vinci technique, when used at a well-equipped medical center by an experienced surgical team, is, indeed, a better mousetrap.
Dudley S. Danoff, MD, FACS is the attending urologic surgeon and founder/president of the Cedars-Sinai Medical Center Tower Urology Group in Los Angeles, California. He is the author of Penis Power: The Ultimate Guide To Male Sexual Health (Del Monaco Press, 2011) and Superpotency (Warner Books).
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