In my last blog post, I discussed why I believe surgical removal of the prostate is the best option for most men with prostate cancer. For those patients who agree, the next question is which way should the prostate be removed? There are three options_ open, laparoscopic, and robotic. I'll go over these three methods, listed in the order of their historical development, and their relative benefits.
1. Open radical prostatectomy. This is an operation that has been performed since the 19th century, involving an approximately 6 inch incision below the belly button. Because the prostate is located deep in the pelvis, the surgery needs to be performed with very long instruments. Perhaps the most critical portion of the surgery, sewing the bladder back to the urethra, can be challenging because of problems seeing the urethra and getting the long instruments into place. Most patients go home after a two to three day stay in the hospital and usually require a blood transfusion.
2. Laparoscopic prostatectomy. A newer form of prostatectomy, the laparoscopic approach offers several advantages to the open approach. The surgery is done through four or five small incisions, all less than an inch (although one needs to be extended to get the prostate out). As in open prostatectomy, the instruments are long and can be difficult to maneuver into the right places. One advantage is that there is much less blood loss, making it easier to see during the surgery and avoiding the need for blood transfusion. Most patients go home the next day.
3. Robotic prostatectomy. The newest form of prostatectomy, the robotic approach only begun in 2001. This is a form of laparoscopy where a robot is attached to the long laparoscopic instruments. Again, several small incisions are made for the robotic instruments to enter the body. Unlike robots in automobile factories, the robot does not do the surgery itself. Rather, the surgeon sits at a console nearby and manipulates the instruments. The instruments have very small hands and flexible wrists, making it easier to operate (and especially to sew) deep in the pelvis. Because the magnified camera is inside the body, it is easier to see places that would not be able to be seen with your eyes from outside the body.
I have been trained in all three methods, and believe that the robotic approach is the best option. Better vision, less blood loss and easier sewing enables me to perform the best operation for my patients. More than 80 percent of prostatectomies in the U.S. are now performed robotically, which shows that I'm not the only surgeon who feels this way.
All available studies show that patients go home sooner and have less blood loss following robotic prostatectomy, however, some have not shown significant improvement over the open approach. Very few have shown that patients do worse with robotics. This is likely because the robotic procedure is very new, and some of these reports comparing open to robotic prostatectomy are based on older information. But more important than which method of surgery you choose is the experience of your surgeon. Surgeons who have done more procedures tend to have better results, regardless of whether they do surgeries open, laparoscopically or robotically.
David B. Samadi, MD is the Vice Chairman of the Department of Urology and Chief of Robotics and Minimally Invasive Surgeryat Mount Sinai School of Medicine in New York City. As a board-certified urologist and an oncologist specializing in the diagnosis and treatment of urologic diseases, kidney cancer, bladder cancer, and prostate cancer, he also specializes in many advanced minimally invasive treatments for prostate cancer, including laparoscopic radical prostatectomy and laparoscopic robotic radical prostatectomy. His Web site, Robotic Oncology, has been translated into six different languages and is one of the most popular urology sites on the Internet.
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