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Removal of the prostate using a surgical robot (Da Vinci method) does not lead to a lower incontinence and impotence rate after treatment. On the contrary: low case numbers can even jeopardize the quality of the therapy and increase the risk of complications. At the same time, patients with a localized prostate carcinoma are often unnecessarily subjected to a stressful operation.
Less pain, shorter hospital stay, more precise incisions: Radical removal of the prostate (prostatectomy) using the Da Vinci robot is becoming increasingly popular. Today, numerous clinics and prostate centers have the robot technology at their disposal. Despite the high acquisition costs of almost 2 million euros plus the annual maintenance costs, more than 30 percent of prostate operations in Germany are currently performed using robotic assistance.
As with prostate removal using keyhole surgery (laparoscopic prostatectomy), access for robotic surgery is via incisions in the lower abdomen measuring just a few millimetres. The "surgical robot" essentially consists of 2 components. The control console, which is operated by the surgeon, and the multi-armed surgical assistant, which is positioned on the patient. A high-resolution three-dimensional view, a large magnification of the surgical field and improved movement of the instruments allow the surgeon to guide the instruments very precisely. This procedure is called robot-assisted radical prostatectomy or prostate removal with the Da Vinci system. Proponents of this method promise patients with prostate cancer fewer complications such as incontinence and impotence, as well as better recovery rates.
Although the system has been on the market for almost 20 years, the number of scientific studies is surprisingly low. To date, there is only one study that directly compares the two surgical techniques. From August 2010 to November 2014, a total of 308 patients with localized prostate cancer were randomly assigned to a robot-assisted laparoscopic prostatectomy or a conventional radical prostatectomy using an abdominal incision (retropubic prostatectomy). The Australian study was published in the renowned journal "The Lancet" in 20181. The results show that the surgical robot does not perform better in terms of the main postoperative risks of prostate removal: After 6, 12 and 24 months, the same number of patients complained of incontinence and impotence in each case - regardless of whether they underwent minimally invasive surgery with the Da Vinci robot or open surgery using the conventional method. A review published in 20172 shows a similar result, in which both methods were compared in a total of 446 men with prostate cancer. Here too, the study authors found no improvement in the men's quality of life in terms of their continence and sexual function after undergoing robot-assisted surgery.
The results of a recent study by the Memorial Sloan Kettering Cancer Center in New York, which was recently published in the renowned journal "European Urology", are also sobering3. The scientists investigated the question of whether an improvement in erectile dysfunction could be achieved over the last ten years through the use of modern surgical techniques in radical prostatectomy. In more than 2,000 open or minimally invasive prostatectomies performed by experienced surgeons over a ten-year period, no improvement in erectile function after surgery was observed.
Numerous clinics also advertise a better oncological outcome with robot-assisted surgery, arguing that surgeons are more likely to completely remove the cancer during da Vinci surgery compared to open prostatectomies. However, to date there has been no major scientific study to support this assumption. Neither of the above-mentioned studies found a higher PSA-free survival rate (a measure of cancer recurrence) with the use of the da Vinci robot.
A US study4 even came to the conclusion that the survival rate after da Vinci surgery was worse than after the conventional surgical technique. The survey of 2700 prostate cancer patients showed that within the first six months after robot-assisted surgery, the rate of further treatment (e.g. radiotherapy), known as salvage therapy, was three times higher (27.8% vs. 9.1%) and the probability of anastomotic strictures (narrowing of the urethra due to increased scarring) was 1.4 times higher than with conventional prostate surgery. This clearly shows that, in addition to the advertised advantages such as less blood loss and shorter hospital stays, there may also be disadvantages in the medium term.
The experience and expertise of the respective surgical team always have a significant influence on the surgical outcome, regardless of the surgical procedure. Every surgeon has to perform a certain number of operations (the so-called learning curve) before he or she masters the procedure perfectly and the result is optimal. This also applies to the removal of the prostate in the case of localized prostate carcinoma, regardless of whether the procedure is performed using robotic technology or not.
The surgeon needs between 40 and 250 procedures to optimally master the Da Vinci robot. This is the result of a review in which 44 studies were evaluated in which the learning curve for robot-assisted prostate removal was determined. The authors of the study emphasize that the learning curve for Da Vinci surgery is not as short as is often stated. However, the Da Vinci boom has led to many hospitals now having a surgical robot without having enough patients available. In many places, it is therefore becoming difficult for surgeons to acquire the routine required for the operation.
In addition, according to an investigation by the US FDA, the number of reported incidents involving the Da Vinci robotic system is said to have increased. The Da Vinci market leader Intuitive Surgical is also accused in a lawsuit in the US state of Washington of urging hospitals to allow doctors to operate using the robots without sufficient training.
However, it should not primarily be a question of Da Vinci "yes" or "no", but rather whether all detected tumors actually require invasive therapy, such as radical prostate removal. Despite the scientific consensus, many urologists still hold on to the conviction that only radical removal of the prostate can lead to tumor healing. To this end, they sometimes accept severe side effects, whether robot-assisted or not. According to a study by Barmer GEK, 70 percent of those who underwent surgery complained of potency problems, 53 percent of sexual disinterest and around 16 percent of urinary incontinence (loss of urine). One in five also confirmed surgery-related complications such as heavy bleeding or bowel injuries. However, the aim should be to achieve the best possible recovery with minimal side effects.
Large comparative studies6/7 conducted in recent years provide evidence that radiotherapeutic procedures such as brachytherapy (internal radiation) are often equivalent or even superior to surgery in terms of their effectiveness for localized prostate cancer. This applies both to cure rates and to side effects such as incontinence and impotence.
Long-term studies, including a recent US study6, show that erectile dysfunction occurs in 70 percent after radical surgery and in 14 percent after seed implantation6. Urinary incontinence, which is up to 50 percent after radical removal of the prostate, is also negligible at 0.3 to 3 percent after seed implantation and actually only occurs after previous prostate resection (TURP).
Rather, treatment considerations should therefore include whether radiotherapy is preferable to radical surgery. Despite the excellent long-term results of brachytherapy, many patients have high expectations of robotic technology and are prepared to undergo treatment using the Da Vinci method without the actual benefits having been proven.
1 Coughlin GD, Yaxley JW, Chambers SK, Occhipinti S, Samaratunga H, Zajdlewicz L, Teloken P, Dunglison N, Williams S, Lavin MF, Gardiner RA.: Robot assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: 24-month outcomes from a randomized controlled study. Lancet Oncol. 2018 Aug;19(8):1051-1060.
2 Ilic D1, Evans SM, Allan CA, Jung JH, Murphy D, Frydenberg M : Laparoscopic and robotic-assisted versus open radical prostatectomy for the treatment of localized prostate cancer. Cochrane Database Syst Rev. 2017 Sep 12; BJU Int. 2018 Jun;121(6):845-853
3 Capogrosso P et al: Are We Improving Erectile Function Recovery After Radical Prostatectomy? Analysis of Patients Treated over the Last Decade. Eur Urol. 2019 Feb; 75(2): 221-22
4 Hu JC, gold KF, Pashos CL et al: Utilization and outcomes of minimally invasive vs open radical prostatectomy. J Clin Oncol 2008 26(14):2278-2284
5 Abboudi H, Khan MS, Guru KA, Froghi S et al: Learning curves for urological procedures: a systematic review.BJU Int. 2014 Oct;114(4):617-29. doi: 10.1111/bju.12315. Epub 2013 Oct 24.
6 Grimm P, Ignace Billiet I, Bostwick D et al. Comparative analysis of prostate-specific antigen free survival outcomes for patients with low, intermediate and high risk prostate cancer treatment by radical therapy. Results from the Prostate Cancer Results Study Group. BJUI 109, Suppl. 1, 22-29, 2012
7 Comparative cost / QALY of guideline-recommended prostate cancer treatments: a UK cost perspective. PD 0371; 2nd ESTRO Forum, Geneva, Switzerland 2013.
8 Chen R.C., Clark J.A.; Talcott J.A.: Individualizing Quality-of-Life Outcomes Reporting: How localized prostate cancer treatments affect patients with different levels of baseline urinary, bowel and sexual function; Journal of Clinical Oncology, 2009; 27 (24), 3916 - 3922.
