Diagnostic Center For Disease: Robotic Prostatectomy - A Race To Failure?

Main Category: Prostate / Prostate Cancer
Also Included In: IT / Internet / E-mail;  Urology / Nephrology
Article Date: 25 Jun 2008 - 2:00 PDT

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The following statement was issued by Diagnostic Center for Disease

"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."

Policy Statement from the American College of Preventive Medicine, published in the American Journal of Preventive Medicine, February 2008

There were an estimated 50,000 robotic prostatectomies performed in 2007(1). 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 supposition:

"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.

The increasingly aggressive search for cancer by repeated needle biopsies will inevitably lead to more and more unnecessary surgeries, more failures to cure and a growing number of men and their families suffering from the devastating side effects of incontinence and sexual dysfunction. There exists no compelling evidence at this time that robotic prostatectomy will deliver any improvement whatsoever over the current poor rate of cure for all other radical, curative treatments. What is truly alarming is that the effort to find more cancers by more than doubling the rate of biopsy, will only serve to increase the devastation that exists today. Ironically, increasing number of insignificant cancers included for treatment, will only serve to (falsely) indicate better cure rates for robotic prostatectomies. Of course, this will only incentivize urologists to treat even more cancers. Also of concern is the trend is to treat more aggressive cancers, Gleason 8 and above. In far too many cases, it is not confirmed prior to actual surgery that the cancer is organ-confined. The number of failures, exceeding 1,000,000 men, could easily double within the next few years. What of these men and these families? The only reasonable conclusion is to discontinue curative treatments such as robotic prostatectomy, for the majority of positively diagnosed men until proof exists that these treatments can successfully cure prostate cancer. There is a real concern that the cure may become more dangerous than the disease. To read the full article, "Robotic Prostatectomy - A Race to Failure?," go to http://www.mrisusa.com.

Reference

1. Minimally Invasive Surgery in Urology, Current Opinion in Urology. 18(2):173-179, March 2008, Box, Geoffrey N; Ahlering, Thomas E

2. Robot-Assisted Prostate Surgery Has Possible Benefits, Higher Costs, By Lisa Esposito, Editor, Health Behavior News Service, August 29, 2005

3. Clinically Insignificant T1 Stage Tumors Of The Prostate, Konstantinos Stamatiou, Vassilissa Karanassiou, Kavouras Nikolaos, Makris Vasilios, Lebren Fred, Emmanuel Agapitos: Clinically Insignificant T1 Stage Tumors Of The Prostate. The Internet Journal of Urology. 2007. Volume 4 Number 2.

Diagnostic Center for Disease
http://www.mrisusa.com

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