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Open vs. Robotic Prostatectomy: What's Right for Me?

The decision to undergo radical prostatectomy, or any treatment for prostate cancer, is of course not an easy one. Patients are usually offered a tremendous amount of information from their doctors, friends and family members, as well as the internet. Most of this information is helpful and necessary, but some can also be misleading and inaccurate. The sheer amount of information can often make what is normally a difficult period in a patient's life even more challenging and stressful.

Dr. Drew Wagner, Director of Minimally Invasive Urologic Surgery at Beth Israel Deaconess Medical Center, provides some guidance if you are considering either robotic-assisted radical prostatectomy or traditional (otherwise known as "open") radical prostatectomy.

Q. What are the main differences between open and robotic-assisted laparoscopic surgery?

A. There are several important differences. First, robotic surgery is a minimally-invasive approach, so by its very nature, patients have less abdominal trauma due to smaller incisions and most will have less pain when compared to open surgery.

Additionally, our research shows that patients in general are more satisfied with their incisions after this procedure than after open surgery. This allows some patients to return to work rather quickly, some as quick as two weeks, but I tell most patients to expect to take three to four weeks off of work or heavy physical activity, as they will feel fatigued from the ordeal of surgery. Patients after open surgery tend to take a couple of extra weeks to recover physically, and sometimes require a longer time of catheterization.

The second main benefit of robotic surgery is that the blood loss during robotic surgery is far less than during open surgery, even open surgery done by an experienced surgeon. For example, our blood transfusion rate during robotic prostatectomy is less than 1 percent. Even in the hands of the most experienced open surgeons in the world, the blood transfusion rate varies from 8 to 40%. The lack of blood loss allows us to see the prostatic anatomy a bit more clearly than during open surgery. This visualization allows us to remove the cancer at an equally effective rate to open surgery, even for high-grade or advanced tumors.

With the magnification of the robotic system, sparing of the urethral sphincter muscle (important for urinary continence) and sparing of neurovascular bundles (important for erections) can be done in an extremely precise fashion. Several studies have shown the urethral scarring is less after robotic surgery, however, patients should know that long-term results of recovery for both urinary and sexual health are probably equivalent for robotic and open surgery as long as they are done by a highly trained surgeon.

Q. What should a patient consider when weighing either of these treatment options?

A. I see our goal as prostate cancer specialists to provide patients with accurate and unbiased information regarding each treatment option for prostate cancer, keeping in mind the many individual variables that each patient brings to the table. This is best done in a setting where patients can meet multiple specialists working on the same team towards the same goal: to provide the patient with the best care for their particular situation. Once they make that choice, they need to be confident that they will be receiving the very best treatment available by the best and most highly-trained physicians anywhere.

With that in mind, if a patient and their doctors decide on radical prostatectomy, they need to have extreme confidence in their surgeon and his or her team. This is an operation with countless technical nuances, and studies have shown that results can vary with both surgeon volume as well as inherent surgical skill. This procedure has much at stake: most importantly, cancer control, urinary function and sexual function. Achieving these goals involves high level of surgical skill that is best achieved with intense training and the performance of a steady volume of procedures.

Q. What questions should a patient ask his doctor?

A. Patients need to ask their surgeons what their personal experience is with laparoscopic or robotic surgery. This includes asking about cancer recurrence rates, as well as the typical rates of recovery for urinary and sexual function. Past results can't guarantee success for any one patient, but knowing what the typical recovery is, particularly when sorted by age group, can give a patient accurate and honest expectations for recovery.

Patients should also ask their surgeons if they can contact other patients who have had the surgery (performed by that particular surgeon). This can give patients a degree of confidence that other patients in their position have gone through the surgery and are happy with their overall cancer care. Additionally, this gives patients often anxious about an upcoming major surgery a chance to receive support from other men who have been through it all before.

Q. Are there any drawbacks to the robotic surgery?

A. Well, there are a few myths about robotic surgery that should be dispelled. First, the myth that robotic patients don't have pain or are able to return to normal activity in a day or so is not true. Although the procedure is done through small incisions, most patients do experience soreness, fatigue, and a slow return to energy level and appetite for a week or two following surgery. They need to plan to take it easy for a few weeks.

The second myth is that robotic patients have quicker and better recovery of urinary and sexual function than patients after open surgery. This just isn't true, despite some advertising to the contrary. We recently presented results of a study -- the largest to date -- to directly compare open, laparoscopic, and robotic surgery. We found that the recovery of urinary and sexual function was more related to the experience of the surgeon, not whether the procedure was done open or robotically. Again, this bears repeating: results are more dependent on surgeon and team experience, training and inherent skill, not surgical approach.

Overall, we have found robotic surgery to be an excellent approach for most patients with prostate cancer because of smaller incisions, better visualization of the prostate and surrounding structures, decreased blood loss, and a quicker physical recovery after surgery.

Above content provided by Beth Israel Deaconess Medical Center. For advice about your medical care, consult your doctor.

Posted October 2011

Contact Information

Prostate Cancer Center
Beth Israel Deaconess Medical Center
Shapiro Clincial Center
330 Brookline Avenue
Boston, MA 02215
Phone: 617-667-7777
Fax: 617-667-7292