A new study from Duke University Medical Center, led by Dr. Judd W. Moul, a prostate surgeon, suggests that men’s expectations of laparoscopic robot-assisted prostatectomy may be too high. The study found that of 171 men facing prostate cancer surgery, those having robotic surgery expected a shorter hospital stay and a quicker return to their usual physical activity and sex life. Dr. Moul points out that those hopes may not be realistic. I disagree with this observation.
In my nearly 40 years of practicing urology and participating in thousands of surgical operations for prostate cancer, I have seen no technique, piece of equipment, drug, imaging device, or surgical procedure that has been more innovative than the introduction of laparoscopic robot-assisted prostatectomy. It is certainly true that the experience and skill of the robotic surgeon is the key element to the success of this breakthrough procedure. But assuming that the procedure is performed by an experienced robotic surgeon, when comparing robotic surgery with open surgery in terms of the precise definition of surgical anatomy, field magnification, blood loss, and nerve and continence preservation, there is no contest!
Among many other advantages, the laparoscopic robot-assisted prostatectomy requires no large incision (resulting in less pain), the surgical field is magnified, the blood loss is negligible, and the natural tremor of the surgeon (who can often become fatigued) is eliminated. These advantages all allow a more exacting and anatomically correct attachment between the bladder neck and the urethra after the prostate has been removed.
In my experience at Tower Urology at Cedars-Sinai Medical Center in Los Angeles, the overwhelming majority of our patients experience essentially no postoperative pain, are discharged to moderate activity on the first postoperative day, need to wear a urinary catheter for about five days (much shorter than with open surgery), have nearly perfect continence from the start, and have an excellent return of sexual function (usually dependent on the degree, if any, of preoperative erectile dysfunction).
It is true that the robotic equipment is expensive and that many hospitals heavily promote this approach with aggressive marketing. But claims that robotic surgery is better than the old-fashioned way are true, based on my experience. Surgeons who still cling to the illusion that open surgery is better often say that, by using their hands, they get a tactile feel of the organs and nerve bundles, a benefit impossible with the robotic approach. Although there is no tactile feel using the robot, this loss is more than compensated by the magnification of the surgical field and the ability of the robotic arm to rotate 360 degrees and angulate in a manner much more efficient than the ability of any human wrist, hand, or arm.
No surgical procedure should be approached as a “walk in the park.” Since there are only two surgical approaches to removal of the prostate, laparoscopic robot-assisted prostatectomy and incisional prostatectomy, the choice seems obvious, assuming that the procedure is performed by an experienced robotic surgeon. Of course, many men with early-stage prostate cancer decide to hold off on treatment. Many prostate cancers are slow-growing and may never advance. More and more men are opting for watchful waiting or active surveillance as a modality of treatment. This decision is entirely justified.
However, if the patient and his urologist decide that prostatic surgery is the best course of action, robot-assisted laparoscopic prostatectomy by an experienced robotic team is both revolutionary in the annals of urologic surgery and unequaled in results.
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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