Prostate cancer is the most common non-skin cancer in American men, affecting 1/6 over his lifetime. In 2010, there will be roughly 200,000 men newly diagnosed with prostate cancer, and 20,000 will die of this, the second cause of cancer deaths in American men. Despite these staggering numbers, over two million men in U.S. live with prostate cancer, and 2/3 of the men diagnosed with it are over the age of 65. Today many patients with prostate cancer are found to have clinically organ confined disease at the time of diagnosis, thanks in great part to screening in the form of annual PSA and digital rectal exams.
However, the screening and treatment of prostate cancer has significantly changed in the past decade, and NOT without its controversies, some of which I will address here with a focus on changes in the surgical treatment of prostate cancer. Traditionally, prostate cancer has been regarded as “a disease of the older men,” and many still believe that “most patients will die with and not of prostate cancer.” This notion, is the basis for “watchful waiting,” where older patients with multiple co-morbidities and with life-expectancy of less than ten years, chose not to seek any further treatment. Regular checkups with their physician, allows close follow up and helps avoid some of the side effects of the treatment with the assumption that they would succumb to other diseases in their advanced age and never develop prostate cancer related sequelae.
Yet, in younger men diagnosed with this devastating disease, who are expected to live more than ten years, the choices of treatment were limited and not without significant side effects. These options included radical prostatectomy, radiation therapy (and its various iterations), more recently cryotherapy (freezing the prostate) and hormonal therapy. Radical prostatectomy, the gold standard of prostate cancer treatment where the organ is removed in its entirety, was initially described in the early 1900’s and underwent gradual evolution until its popularized form in the late 1970’s by world-renowned urologist Dr. Walsh . His contributions included steps to decrease bleeding, and preserve the important nerves and structures around the prostate which when damaged can cause the most dreaded side effects of the surgery, which are post-prostatectomy urinary incontinence and erectile dysfunction. This procedure is however difficult to master, and upwards of 200 cases are required for acquiring consistent results. Furthermore, it requires a large incision, and patients require significant time for recuperation post operatively.
With the advances in laparoscopic surgery, where small incisions allow for insertion of small instruments into the abdominal cavity, the operation was transformed, allowing the patient to have equivalent cancer control, yet decrease in post operative discomfort and convalescence, as the smaller incisions were far less painful. However, due to the position of the prostate in the pelvis, this operation is technically challenging and has a significant learning curve. Furthermore, it has several disadvantages including lack of tactile sensation for the surgeon. Moreover, in most centers traditional laparoscopy provides an image which is two-dimensional, and the handling of the instruments are difficult and counter intuitive (i.e. when the surgeon wishes to move the instrument in the body to the right, he/she has to move the instrument to the left outside the body) as the instruments are anchored at the skin level. Thus, laparoscopic prostatectomy did not enjoy widespread popularity in the U.S.
In early 2000’s however, new robotically assisted technologies led to the development of the da Vinci surgical platform, which propagated the paradigm shift for the treatment of prostate cancer in our era. These novel improvements for the surgeon include the capabilities to have a three dimensional view of the anatomy, the ability to move the instruments in an intuitive fashion (i.e. when the surgeon wishes to move an instrument to the right, he or she does so by moving his or her hand to the right) much like in open surgery. Furthermore, the tiny instruments of the robotic system, have all the degrees of freedom that the human hand has, unrivaled by traditional laparoscopic surgery.
Initially, the da Vinci robot was adopted by the laparoscopically trained surgeons as there was no formal training during most residency or fellowship programs, and as the anatomy and steps of the procedure were akin to that of laparoscopic prostatectomy. However, as these platforms became more ubiquitous, training has become more standardized and quickly reached the discipline enjoyed by its predecessor, the open radical prostatectomy.
The robotic approach affords many advantages for the patient as well, including decreased bleeding, shorter hospital stay, decreased pain, smaller incisions enabling faster recovery. Nonetheless, improved cancer control, urinary continence and erectile function have not materialized in the literature. Some however consider the comparison between mature surgeons performing open prostatectomies to novice surgeons negotiating their robotic “LEARNING CURVE” to be unfair, and one of the reasons why robotic prostatectomy has not “reached its true potential” in achieving these goals.
This illustrates the crucial importance of training. Studies indicate that the number of cases required during the learning curve is somewhere around 50 for individual surgeons; while some experts believe that is as high as 200, akin to the open surgical approach. It is also important to mention that the robotic approach is not without complications, especially as the surgeon is negotiating the learning curve. This is where formal fellowship training or years of experience with the procedure can secure an excellent outcome.
With the purchase of its dual console da Vinci Si robotic surgical platform, and recruitment of minimally invasive surgeons in urology and gyenocology, Glendale Adventist Medical Center has taken the next step to insure excellent service to its patients. There is a new air of innovation in the halls of the hospital, and with this new spirit of progress, our patients will have access to world-class technologies and expertise.