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In discussions and advice given for and against robot-assisted laparoscopic prostatectomy (commonly referred to as Da Vinci) one point raised is that in normal open surgery, the surgeon can feel the presence of a tumour better than the laparoscopic surgeon can see such tumours. The small study below compares the incidence of positive surgical margins obtained using robot-assisted laparoscopic prostatectomy, during the initiation of a robotics program, with that from a similarly matched cohort of open radical retropubic prostatectomy cases as performed by a single surgeon.
The point of this study was to try and establish if there was evidence that either of the methods was better than the other at removing the entire tumour. Evidence of positive margins meaning that this might not have happened, so the lower the percentage of positive margins the better.
The conclusion of the authors of the study is that significantly lower positive margin rates can be achieved in laparoscopic patients even during the learning period.
Because this is a small study involving only one surgeon it is not possible to say that any other surgeon will produce similar (or better) results; it may demonstrate what is theoretically possible.
Urology. 2009 Mar;73(3):567-71 Comparative Analysis of Surgical Margins Between Radical Retropubic Prostatectomy and RALP: Are Patients Sacrificed During Initiation of Robotics Program?
White MA, De Haan AP, Stephens DD, Maatman TK, Maatman TJ.
Urologic Consortium, Metro Health, Michigan State University College of Osteopathic Medicine, Wyoming, Michigan.
OBJECTIVES: To compare the incidence of positive surgical margins obtained with robotic-assisted laparoscopic prostatectomy (RALP), during the initiation of a robotics program, with that from a similarly matched cohort of open radical retropubic prostatectomy (RRP) cases as performed by a single surgeon.
METHODS: From December 2005 to March 2008, 63 patients underwent RRP and another 50 underwent RALP by a single urologist. The records were retrospectively reviewed, and 50 RRP patients were selected from the RRP group whose records were similar to the records of the 50 patients who had undergone RALP. We compared the incidence of positive surgical margins and the location of positive margins among the 2 groups. Additional variables evaluated included the preoperative prostate-specific antigen level, preoperative Gleason score, clinical stage, postoperative Gleason score, tumor volume, and pathologic stage. RESULTS: The positive margin rate for the RRP group was 36% compared with 22% for the RALP group (P = .007). The incidence of positive margins for pathologic Stage pT2c disease in the RALP group was 22.8% compared with 42.8% in the RRP group, a statistically significant difference (P = .006). Fewer positive margins were found in the RALP Gleason score 7 group than in the RRP group, 29% vs 60%, again a statistically significant difference (P = .003).
CONCLUSIONS: We present our series comparing a single urologist's positive margin rates during the learning curve of a robotics program with his experience of a similarly matched cohort of RRP patients. A statistically significant lower positive margin rate can be achieved in RALP patients even during the learning period.
Thanks for the interesting article. Certainly bodes well for the future of robotic surgery as it makes inroads into some of the other avenues of other cancer treatments as well.
The less invasive nature of robotics is certainly easier on the patient, and lets face it most patients dealing with cancer are "older" and have a much more difficult time with any type of surgery. Robotics opens the door a little wider for choosing surgery as an option, not only in Prostate cancer but other types of cancer where surgery is the only treatment available.
Clearly, from my bad experience, I cannot recommend the DaVinci. I'm one of three men in my small support group who have had tissue left behind after this surgery. Since they only get one shot at it, I'd suggest an open. Even the Chief of Urology at my hospital agrees.
Like Paul A, the robot didn't get all mine out either. But given the advantages of the smaller intervention (keyhole surgery), I think that IF there are no other presenting problems, then probably as surgery it will be the best way to go. The problem seems to be the presence of pre-exisitng scar tissue from either injury to the pelvic area or operations like earlier TURP.
I am told that it was the thoroughness of my TURP that caused my (eminent and world famous surgeon Roger Kirby of the UK Prostate Centre) to lose his bearings.
Yet I asked repeatedly BEFORE surgery if this TURP would cause problems. Both he and another uro said that although it made it more difficult it was all do-able. Well it wasn't was it!
I subsequently asked him if I would have been better off with open and he said it has been so loong since he did one he wasn't sure if he remembered how. ( I'm sure this was an exagerration,but the point is that the robot guys are developing their skills on the robot and probably losing them on the old ways).
Anyway, my advise would be to think extra carefully about having robotic if you have any hint of a complication such as previous injury or scar tissue.
