Robotic Prostate Surgery is Overhyped

Robot-assisted surgery for prostate cancer has been heavily hyped, and a new study suggests that men's expectations of the surgery may be too high.

Researchers 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.

But those hopes may not be realistic.

Prostate removal is one treatment option for prostate cancer, and in the United States, a majority of those surgeries are now done with the help of a "robot."

During the procedure, the surgeon sits at a console, operating robotic "arms" that extract the prostate gland through small cuts in the abdomen.

The robotic approach is expensive. And after hospitals invest the roughly $1.5 million for the machines, plus the cost of surgeon training and annual service contracts, they often aggressively market the approach — as do the companies behind the technology.

And that may include claims that robotic surgery is better than the old-fashioned way.

"Since about the mid-2000s, people were thinking that robotic surgery was the greatest thing since sliced bread," said Dr. Judd W. Moul, a prostate surgeon at Duke University Medical Center who led the new study.

There was reason to believe that the better visualization with robotic surgery could lead to some better outcomes, Moul told Reuters Health.

On the other hand, he said, when surgeons actually use their hands, they get "tactile feedback" that's missing with the robotic approach.

And studies have suggested that while robotic surgery may have some short-term advantages — like a somewhat shorter hospital stay — there may be no clear difference in the most important outcomes.

So far, there's no good evidence that robotic-surgery patients fare any better as far as cancer recurrence or long-term side effects like urine leakage and erectile dysfunction.

And in an earlier study, Moul and his colleagues found that men who had the robotic procedure were actually less satisfied in the long run than those who had traditional surgery.

They guessed that patients' expectations going into surgery might have something to do with it.

More Optimism

So for the new study, they surveyed 171 men about their expectations heading into prostate cancer surgery. The majority of patients — 97 — had opted for robotic surgery, while 74 were going with the traditional route.

Overall, 89 percent of men having the robotic surgery expected to stay just one night in the hospital, versus 37 percent of men having traditional surgery.

The robotic-surgery group also thought they would be back to exercising sooner — typically predicting a five-week wait, versus six weeks in the other group. And they expected to have recovered their erectile function within five months of surgery.

Men having traditional surgery were much less optimistic. They typically assumed it would take nine months to regain their sex life.

On average, Moul said, men having robotic surgery do seem to get out of the hospital eight to 12 hours quicker.

But a small percentage, he noted, end up staying in the hospital for a few days because their bowel function does not return quickly.

As far as physical activity and long-term erectile function, it's not clear if there's any advantage to robotic surgery. At Duke, Moul noted, men are advised to avoid any heavy lifting for six weeks after surgery — robotic or not.

Ask Tough Questions

Where are men getting their expectations? Ads, the Internet, and the general belief that high-tech must be better may all play a role, according to Moul.

"But I think that probably physician counseling has a lot to do with it," Moul said.

He noted that surgeons do have an incentive to push men toward the new technology in order to "work through their learning curve" — that is, hone their skills by doing more procedures.

Increasingly, experts are saying that men should put more stock in their surgeon's experience than on the type of prostate surgery.

Moul agreed. That experience, he said, "is what drives the long-term outcomes of urinary and sexual recovery of function."

"Ask your surgeon the tough questions," Moul said. That means asking how many procedures he or she has ever done, and how many per year.

There's no hard-and-fast number that defines a "good" surgeon. But Moul suggested that a doctor who performs at least 40 to 75 procedures a year (of one specific kind — robot or traditional) would be considered experienced.

Of course, that all assumes a man has decided on having surgery.

Many men with early-stage prostate cancer can decide to hold off on treatment altogether. That's because prostate tumors are often slow-growing and may never advance to the point of threatening a man's life.

One study found that more than 120,000 American men diagnosed with prostate cancer every year are ideal candidates for "watchful waiting" — which means doctors keep an eye on the cancer to see if it's progressing.

In reality, though, the majority of those men end up having surgery, radiation, or other treatment instead.