Robot Prostate Surgery: More ED, Incontinence

Oct. 13, 2009 - Minimally invasive prostate surgery -- often performed using a high-tech robot -- carries a higher risk of incontinence and erectile dysfunction than does open surgery.

However, the newer technique cuts patients' hospital stays, requires far fewer blood transfusions, and carries less than half the risk of leaving behind scar tissue necessitating a second surgery.

The findings come from an analysis of outcomes for men with prostate cancer who chose treatment with radical prostatectomy -- surgery to remove the prostate. There are two basic kinds of prostatectomy: the tried-and-true open surgery improved over 20 years or minimally invasive surgery, a much newer technique.

Today, as many as 70% of minimally invasive prostatectomies are performed using a surgeon-controlled robot, Brigham and Women's Hospital urologist Jim C. Hu, MD, MPH, said at a news conference. This appears to be driven by direct-to-consumer marketing by hospitals that have purchased the robots, which cost up to $2 million.

But does minimally invasive prostatectomy really work as well as open surgery? To find out, Hu and colleagues analyzed prostate surgery outcomes for nearly 9,000 men whose records are in the Medicare-linked SEER database.

Importantly, open and minimally invasive surgery (both manual and robotic) were equally excellent at ridding men of prostate cancer.

But there were big differences between the two surgical choices in other outcomes. Minimally invasive surgery had several important advantages over open surgery:

• One day shorter hospital stay (two days vs. three days).
• Far less need for blood transfusion.
• Much less likely to leave scar tissue (anastomotic stricture), which often requires surgical correction.
• Fewer surgical complications.

But minimally invasive surgery also had several important drawbacks compared with open surgery:

• 18 months after surgery, a higher rate of incontinence.
• 18 months after surgery, a higher rate of erectile dysfunction.
• Nearly twice as many urinary and genital complications.

"Outcomes of minimally invasive prostatectomy are not uniformly superior to the open approach," Hu said.

He said the technique has been oversold to patients. But he noted that doctors have had decades to learn the best techniques for open prostate surgery.

"Dissemination of surgical technique takes years to unfold," Hu said. "Our study needs to be repeated in the future when teaching of proper minimally invasive technique has had time to diffuse."

The Hu study appears in the Oct. 14 issue of The Journal of the American Medical Association.