Robotic Prostatectomy – A Race to Failure?

“There is currently no convincing evidence that early screening, detection, and treatment improve mortality. Limitations in prostate cancer screening include potential adverse health effects associated with false-positive and negative results, and treatment side effects.”
ACPM Policy Statement, American Journal of Preventive Medicine, February 2008

There were an estimated 50,000 robotic prostatectomies performed in 20071. It is projected that the number could double in 2008. Robot assisted laparoscopic prostatectomy (RALP) is now generally accepted by Urology as the “gold standard” of curative treatment for Prostate Cancer. Like conventional laparoscopic surgery to remove the prostate gland, “robotic” prostatectomy is presented and described as a “minimally invasive” procedure. Robotic surgery is possible due to some amazing technology. One excellent example is the “da Vinci” system manufactured by Intuitive Medical, Inc. The device is remotely operated by the surgeon. Television cameras inserted into the abdomen provide multiple views and simulate three-dimensional vision. The robot consists of small, articulating arms which can perform multiple tasks. Operating tools include suture, scalpel, cauterizing tool, etc. This is a laparoscopic surgical process and is considered to be minimally invasive. Promoters of robotic prostatectomy routinely use the term “promising” in their expectation that this device and procedure will eventually demonstrate improvement in the cure rate for prostate cancer. Their enthusiasm is generated by the awareness that other curative treatments have a poor track record to cure prostate cancer. This procedure is also accompanied in far too many cases, by other negative side effects such as incontinence and permanent erectile dysfunction. Robotic surgical technology and the procedure is still fairly new. There is as yet nothing dramatically different in performing the procedure or the results compared to traditional laparoscopic surgery. However, armed with hope for improved results, the urology community has increased the rate of these surgeries, and their search for cancer at alarming rates. In 2000, there were 1500 robotic prostatectomies performed. Last year, 2007, it is estimated that 50,000 robotic prostatectomies were performed.1 The rate of procedures is still climbing, with projected 80,000 or more robotic prostatectomy procedures in 2008. The number is staggering when you add robotic surgeries to all other curative procedures performed which include open prostatectomy, conventional laparoscopic prostatectomy, radiation in all forms , radiation seed implantation, cryosurgery, thermometry, focused ultrasound ablation, etc. The significant cost of the robotic system may be driving the search for new cancers in addition to an increase in the number of surgeries. A typical robotic surgery device costs $1.2M with annual maintenance of approximately $120,000.00 per year.2 In spite of the popularity of this procedure, robotic prostatectomy has yet to deliver any results or evidence that it will provide any improvement over other treatments to cure prostate cancer.

A great number of urologists and academic centers promote early detection and early curative treatment, citing a better cure rate.

“These technical improvements would lead one to believe that improved results with continence, potency and oncologic outcomes should logically follow. Ultimately, long-term outcomes and possibly financial impact will determine the role of robotic-assisted laparoscopic prostatectomy.”1

Published results of several studies simply do not support this…
“Cancer cure rate, measured by presence of cancerous cells at the surface of the removed prostate, and by PSA levels following surgery, was nearly identical for all three procedures (open, laparoscopic and robotic prostatectomy).” 2

Concurrently, the leadership in Urology and academic institutions have for several years expressed concern regarding “over treatment” of prostate cancer. Retrospective studies have revealed that a very high percentage, exceeding 30%, of surgeries were performed for “insignificant” cancers.3 In addition, physicians promote cure rates for robotic prostatectomy using statistics with only five years of data. The failure rates for treatments of all prostate cancers become quite significant by 7 to 10 years. Without any evidence for improvement in the rate of cure, surgeons are wagering on the hope that this new approach will deliver better results. As the numbers of treatments escalates, so will increased numbers of treatment failures and the devastating side effects that accompany them. A seemingly incongruous announcement in a policy statement released by the American College of Preventive Medicine last year recommended against routine prostate screening. Does this announcement have any connection to the alarming escalation of treatment? Their policy statement details concern regarding the PSA blood test as cause for false positive and false negative diagnoses. However, it also recognizes concern over the inability to improve outcomes, to cure cancer predictably, or improve upon the negative side effects.

Based upon an average 15 year life expectancy, a conservative estimate is that 1,000,000 men are currently living as treatment failures. A much greater number of men and their families suffer from debilitating side effects from the surgery and/or exploratory needle biopsy. Side effects include incontinence, erectile dysfunction, diseases of the bowel, bleeding, infection, etc. At the current escalating rates of treatment and exporatory needle biopsies, this number could easily double within a few years. The sensationalism associated with robotic technology is the driving force behind the escalation of treatment.

Quality of Care

At what point does treatment go beyond quality of care and begin to cause greater harm than the disease itself? Studies have already concluded that curative (radical) treatment of prostate cancer has provided no improvement in rate of cure and life expectancy when compared to doing nothing. How can physicians not know this, understand the implications and increase the rate of radical, curative treatments? Many surgeons now report that they “treat all cancers,” even though a high percentage of cancers are classified as insignificant or too aggressive to merit radical treatment. Urologists diagnose, stage and grade the cancer according to location, extent and aggressiveness (Gleason Score) of the cancer. Failure rates for Gleason 8 and above are very high within the first 7 years. Unfortunately, alternatives are presented to the patient in fewer and fewer cases leaving prostatectomy as the only option. The objective, “to cure cancer,” is given priority over a discussion of risk and outcomes. In some cases, urologists present only one alternative, “watchful waiting,” to radical treatment (surgery). Watchful waiting as it suggests, is monitoring PSA as it rises without treating the patient. Watchful waiting is a legitimate alternative, only because all treatment approaches, including robotic prostatectomy, have yet to significantly improve upon doing nothing. Of course, a great majority of patients want to act, to have any chance to remove the cancer from their body before it has an opportunity to spread outside the prostate. Are urologists using this alternative as a “selling tool,” to influence the patient to accept the physician’s attempt at curative treatment? Curative treatments, driven by robotic prostatectomy, can potentially double in 2008. The rate of needle biopsy already has doubled and more. 4 It is documented that needle biopsy and surgery spreads cancer cells from the prostate into the blood stream. Prostate tumors have been discovered outside the prostate capsule years later at the exact location of the needle biopsy.4

“Our results suggest that tumor cell spillage and less frequently hematogenous dissemination may be associated with operative manipulation of the prostate during radical retropubic prostatectomy and may potentially represent mechanisms of failure after radical retropubic prostatectomy.” 5

The patient and his urologist need to know that high PSA is driven primarily by non-bacterial prostatitis. Non-bacterial prostatitis is treatable and should be ruled out prior to any potentially harmful diagnostic testing. A patient with an elevated PSA is typically referred by his general practitioner to a urologist. In almost every case, the urologist recommends exploratory needle biopsy. In 2007, the number of tissue “cores” taken from the prostate for an initial needle biopsy averaged between 6 to 8 cores. In 2008, the number of tissue samples taken in the initial biopsy has more than doubled, from 12 to 20 cores. Exploratory needle biopsy is an extremely inefficient diagnostic procedure. Only 20-30% of needle cores return positive for prostate cancer, a failure rate of 70-80%. Patients intuitively are suspicious of the invasive nature of needle biopsies. It is well documented, but rarely accepted by urologists, that needle biopsy spreads prostate cancer cells outside the prostate, a phenomenon termed “needle tracking.” Additionally, needle biopsy inflicts trauma causing inflammation in prostate tumors. Inflammation has been documented to lead to prostate cancer and may cause prostate cancer tumors to metastasize. There is only one common denominator to all treatment methods that uniformly fail. It is prostate needle biopsy. To read more about needle tracking, review our article, “Prostate Biopsy Spreads Prostate Cancer Cells.4

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