Robotic Surgery for Prostate Cancer

Prostate cancer affects approximately 1 in 8 men and is the second-most common cause of cancer-related deaths among men in the United States, according to the American Cancer Society®. As the diagnosis and treatment of prostate cancer has advanced, so has the rate of patients choosing active surveillance. When active treatment is appropriate, radical prostatectomy is one of the leading therapeutic options. Robotic assistance helps ensure maximum efficacy and has led to increased utilization.

“Traditionally, radical prostatectomy has been associated with a high risk of postoperative complications and functional impairment, which makes active surveillance appealing for many men,” says Michael J. Whalen, MD, chief of urologic oncology at The George Washington University Hospital, director of genitourinary oncology multidisciplinary clinic. “By performing the procedure with the advanced da Vinci Xi®️ surgical system, there is less morbidity, less blood loss and a shorter hospital stay.”

As the first facility in the region to offer robot-assisted radical prostatectomy (RARP), GW Hospital has achieved superlative outcomes.

Robotic Prostatectomy, the Gold Standard

Radiation therapy in older patients is often a safe and effective option, given the age-dependent competing risk of mortality. For younger patients (those in their 50s and 60s), however, radiation therapy can cause rare but catastrophic complications in a delayed fashion (even a decade later), such as severe bleeding and even secondary cancers.

Surgical intervention is therefore preferred in this younger patient group. For these individuals, RARP is considered the gold standard of care for successful oncologic and functional outcomes.

“Minimally invasive surgery is one of the key components of ERAS (enhanced recovery after surgery) protocols that have become standard at many top institutions, and RARP fulfills that,” Dr. Whalen says.

With RARP, more patients are given access to minimally invasive procedures. According to Dr. Whalen, RARP allows surgeons to operate on more challenging patients and safely “push the envelope.” Obesity affects many men throughout the U.S. and can present many challenges during traditional open radical prostatectomy, based on the deep anatomy and risk of large blood loss.  Such patients may be well-served with robotic surgery. Dr. Whalen has performed successful RARP on patients with a BMI as high as 45 safely and effectively.

Some relative contraindications for RARP include an exceptionally large prostate, disease present at the junction between the prostate and bladder, or pre-existing pulmonary disease, which may present unique anesthetic challenges.

Outward-Facing Benefits

In many robotic-assisted surgery applications, patients experience reduced blood loss, smaller incisions, a reduced hospital stay and quicker recovery. Within the treatment of prostate cancer, the superior visualization offered by the robotic surgical approach allows for more precise identification of important anatomical landmarks, such as the internal urinary sphincter/bladder neck that aids in urinary continence and the cavernous nerves that control sexual function, permitting surgeons to prospectively identify and spare these structures to afford preservation of their function.

“The enhanced appreciation of the anatomy likely translates into shorter duration of urinary leakage after surgery and improved likelihood of returning sexual performance after surgery,” Dr. Whalen says. In Dr. Whalen’s practice, post-RARP incontinence levels are approximately 5 percent, 12 months post-intervention. These levels will likely decrease as new approaches, such as Retzius-sparing RARP, are developed and made more commonplace.

Cost-Reward Analysis

Prior to offering RARP, the cost of adoption had to be justified. Upfront updates, upgrades and ongoing maintenance were measured against benefits to the facility and patients, as well as the time necessary to gain proficiency.

RARP patients normally return home the day following surgery. At some centers, particularly healthy patients are discharged the day of the procedure.

“In addition to functional consideration, it’s important to take into account whether one will offer a better chance at a cure,” Dr. Whalen says. “In some ways, that can be envisioned as the most important metric of success.”

Presently, research has indicated no negative oncological impact of RARP. Dr. Whalen and others hope future research into innovative surgical approaches and techniques, such as the experitoneal approach, Retzius-sparing or single-port access, will determine whether RARP patients experience improved oncological and functional outcomes compared to open or laparoscopic approaches.

*Individual results may vary. There are risks associated with any surgical procedure. Talk with your doctor about these risks to find out if robotic surgery is right for you.