Myth #1: Prostate cancer is an emergency and I need to have my prostate removed immediately.
Prostate cancer is typically a very slow-growing form of malignancy. On average, it takes over 2 years for prostate cancer volumes to double in size. For those who die from prostate cancer, the median time to death is 12 years from the time of diagnosis. While it is important to make the diagnosis in its earliest stage when treatment for cure is most effective, it is not an emergency to treat. There is data to suggest that a delay in surgical treatment of 6 months from the time of diagnosis has no impact on the final pathology specimen (and presumably no impact on chances of ultimate cure). Decisions to wait longer than 6 months for definitive treatment, however, may be more risky in terms of final outcome. You are encouraged, therefore, to commit yourself to definitive management (even if it is active surveillance) within 6 months.
Myth #2: Robotic surgery is not a good method because you loose all ability to feel the tumor, and tumor may therefore be left behind.
True, robotic surgery results in loss in tactile sensation. However, the video telescopic system results in magnification 10 – 15 times normal. This plus a bloodless field lends to much better visualization than what is feasible with open surgical methods. The visual cues are entirely adequate to make a safe operation. Further, while prostate cancer is often diagnosed by a lump noticed on rectal examination, it is rare that you can actually feel these tumors during the course of surgery. The majority of prostate cancers being treated surgically today are microscopic – visual cues are the only means for ensuring good gross margins of resection. And finally, while initial reports on robotic prostatectomy discovered higher positive surgical margins (ie, cancer left behind), refinements in robotic surgical techniques have demonstrated better margin rates compared to what has been accomplished with open methods. Put simply, a robotic prostatectomy is at least as likely as open surgery to render you cured from prostate cancer, and maybe it’s even better.
Myth #3: Robotic surgery lacks long-term data and it is not known to be a good method for long-term cancer cure.
True, this robotic technology has been in clinical existence since 2000, and there is not sufficient data to demonstrate actual 20-year survival. However, the prostate gland is removed in its entirety, along with the seminal vesicles, just as in open surgery. Further, it has been well established that cancer margins (the presence or absence of cancer cells at the periphery of the surgical specimen), final Gleason’s score (microscopic scoring of cancer severity), and postoperative PSA levels strongly predict the chances for long-term cure. These points are routinely used as surrogates for the prediction of long-term outcomes of open surgery, and it is no different for robotic surgery. If anything, robotic surgery now yields better cancer margins than what has been achieved with open surgical methods to date, which indicates better chances of long-term cure.
Myth #4: Robotic surgery results in higher positive margin rates, which means worse cancer control.
At the dawn of laparoscopic prostate surgery, including robotics, positive margin rates were variably higher than what was seen in standard open surgery. As it stands now, however, the worst positive margin rates are seen in the open literature, and the best positive margin rates are seen in the robotic literature. At Morristown Memorial Hospital, where Dr. Kaynan operates, the positive margin rate for patients who underwent open radical prostate surgery in the two years prior to the advent of robotics there was 11%. Robotic surgery at MMH, in Dr. Kaynan’s experience, has reduced the positive margin rate to 6%. These figures are in line with rates noted at high-volume university programs, and indicate an improvement in cancer control.
Q. Why should I choose surgery of any kind over the other treatments for prostate cancer?
A. Surgery is considered the gold standard for treatment of prostate cancer. It has the longest track record for a disease that typically takes years to manifest in biochemical or symptomatic recurrence. It has been demonstrated to provide the best chance for cure, particularly for patients with intermediate or high-risk disease and who are rendered margin negative upon microscopic examination of the specimen. This includes patients with a PSA level of ten or more, a bump noted on rectal exam, or Gleason’s score of 7 or greater, and for whom no cancer cells are seen by microscopy at the periphery of the specimen after surgical removal. Recognize, too, that the preoperative assessment for risk of disease is far from perfect in that about 25% of patients are upgraded to a higher Gleason’s score after surgery compared with the preoperative biopsy score. A patient with seemingly low-risk disease may in fact have intermediate or high-risk disease, which could potentially be better treated and prognosticated by surgical removal of the gland.
Further, some patients with intermediate or high-risk disease might need more than one treatment method to cure them of prostate cancer. “Multi-modal therapy” is then needed. In general, from a logistical perspective, it is fairly easy to administer radiation therapy after surgery (for those who need it), however, it is very risky to perform surgery after radiation therapy. Again, virtually all candidates for open surgery are candidates for robotic surgery.
Q. What are the downsides to robotic prostatectomy?
A. Very little. Early on in the robotic experience, the risks of injury to the rectum or ureters were higher compared with open surgery (1.2% instead of 0.7%). With experience these robotic injury rates have declined. Nevertheless, certain safety policies aimed at reducing these risks have long been instituted for patients undergoing robotic prostatectomy at Morristown Medical Center ( click on this to see safety policies at MMC ).
There is a small chance of a urinary leak at the junction between the bladder and the urethra. In robotic surgery, access to the pelvis is made through the abdominal cavity. (In open surgery, the incision is made in such a way as to skip directly to the pelvis, excluding the abdominal contents). If urine leaks into the abdominal cavity in significant amounts you may become quite ill. A drain is therefore left in the pelvis (which exits your right lower abdomen) in order to draw away any urine which may collect there. The junction is checked for perfect water-tightness prior to exiting the operating room, and the drain is removed the next day if the drainage is deemed insignificant. An x-ray test called a cystogram is performed one week after surgery to verify that there is no urinary leak prior to removal of the urinary catheter from your penis.
Q. How long does it take to perform robotic prostatectomy?
A. In Dr. Kaynan’s hands, robotic surgery takes about 2 hours, similar to open surgery.
Q. Does the robot ever malfunction? Is a malfunction dangerous? Can the machine go haywire on me?
A. Despite routine maintenance of the robot, and routine checks of the robot immediately prior to surgery, on rare occasion, malfunctions occur during surgery and the robot cannot be used. There are multiple safety features, however, that prevent any malfunction from causing a direct injury: the instruments either lock in place, in which case they need to be unlocked; or the instruments “float” gently, but do not drive forcefully in any direction. If the robot critically malfunctions and cannot be used, Dr. Kaynan may complete the operation laparoscopically (as very few others world-wide can). If it appears unfeasible or impractical to complete the operation laparoscopically, then the operation may be converted to open and completed safely using traditional methods.
The term robot is really a misnomer. It is a master-slave relationship. All manipulations by the surgeon at the console get translated into actions by the robot arms in the patient. Unless the surgeon’s head is engaged by sensors in the viewfinder at the console, the console joy sticks can’t be manipulated. At the patient’s bedside, release buttons must be toggled in order to manually advance any of the arms. The robot cannot make any motions on its own.
