I was going to share with you an opinion piece in which several doctors from the Mayo Clinic comment on a study by Dr. Hu of Harvard, which compared outcomes for laparascopic (which includes robotic) and traditional open surgery for prostate cancer. I had some resistance to posting this information because I know it’s not what people want to hear and I thought they might not listen. But today in the NY Times there is an article about the Hu study called, “Mixed Outcomes in Laparoscapy for Prostates“. If the NYT thinks this is an important enough health issue to highlight, I will take a chance on it.
The Hu study showed that despite a track record of lower complications during and immediately after surgery, laparascopic surgery proved deficient in a number of other ways. There was more scarring, potentially necessitating more surgery. And the rate of anastomic strictures, or as they put it, “urinary quality of life”, was worse in laparoscopic patients. Worst of all, the oncologic outcomes (successfully removing the cancer) were significantly worse in men who had minimally invasive surgery. Other studies have shown the same.
The number of laparoscopic surgeries performed in the U.S. has skyrocketed in recent recent years. At present, one in 3 prostate surgery patients will undergo minimally invasive surgery. Consider that the number of laparascopic prostatectomies done increased by 20% between 2003 and 2005. This, unfortunately, is not because of merit, but because laparascopic prostate surgery, especially robotic, has been heavily marketed to doctors and patients. And don’t forget the profit motive: American doctors are far more likely to recommend surgery in general, because, unlike European doctors, they are paid per procedure. And a doctor who invests in a da Vinci robot will also want to make a profit from that investment.
So what kind of defects did the Hu study find in laparascopic surgery? I’m quoting from the Times:
“But the men who had laparoscopies had a 40% increase in scarring that interferes with organ function, a complication that requires additional surgery. And within 6 months of their operations, more than one-quarter needed additional hormone or drug therapy compared with 1 in 10 of those who had conventional surgery.”
This last sentence is sobering: it says that laparoscopic surgery failed to remove the cancer in significantly more cases than did open surgery. Therefore, additional treatment was required. Ultimately, removal of the cancer is the only thing that matters.
I will add some information from the Hu article that was not in the Times. Fortunately, when you look deeper into the results, you find that the rate of success with laparoscopy compares with that of open surgery in cases where the surgeon is more experienced. Unfortunately, there are a lot of urologists who are performing minimally invasive prostate surgery who are not qualified, according to the study.
Experience is critical when it comes to outcomes in surgery. The more the better, obviously. As Dr. Krongrad, a laparoscopic surgeon,wrote here, the important thing when considering surgery is to choose a person, not a gizmo. As he put it, “You need a Tiger Woods, not a good set of golf clubs”. So if you have are in a situation, for example, where you have a choice of a more experienced conventional surgeon and a less experienced laparoscopic surgeon, you should choose the former. A robot can’t turn a so-so surgeon into a master.
So how much experience is enough for a laparascopic surgeon? I read about this recently in two sources. The answer really jolted me. A British doctor wrote that in order to achieve a “trifecta”, that is, continency, potency and removal of the cancer, a doctor would have had to perform *700* operations. He recommends that patients wanting to have minimally invasive prostate surgery should not hire any doctor who is not a member of this high-volume, elite click of surgeons. Specifically:
“Christopher Eden, of the Royal Surrey County Hospital in Guildford, said that surgeons needed to carry out hundreds of operations before perfecting their technique for the complete removal of the prostate. Writing in the British Journal of Urology, Mr Eden, who has completed a thousand such operations, said: “The learning curves demonstrate that it takes 100 to 150 cases to achieve proficiency. It takes 200 to 250 cases for complications and continence but 700 cases for potency. Given that most surgeons will not do 700 prostatectomies in their entire career, this makes a powerful argument for limiting complex surgery to high-volume surgeons.”
A study done at MSK also stresses the importance of experience. But the authors set the bar quite a bit lower. They recommend that candidates for laparoscopic prostate surgery reject any doctor who has not completed 250 operations. (SOURCE: Andrew Vickers, Ph.D., Memorial Sloan-Kettering Cancer Center, New York City; Anthony D’Amico, M.D., Ph.D., chief, radiation oncology, Brigham and Women’s Hospital, Boston; July 24, 2007,Journal of the National Cancer Institute.) Here are some key points from the MSK study:
“Your chance of being cancer-free after surgery for prostate cancer are strongly influenced by the amount of experience that your surgeon has,” said lead researcher Andrew Vickers, from Memorial Sloan-Kettering Cancer Center in New York City.
“Improvement in patient outcome dramatically increased for doctors once they had done at least 250 operations. For example, patients whose doctor had done only 10 operations had a 70 percent increase in having their cancer return within five years compared with surgeons who had performed 250 or more prostatectomies. With inexperienced surgeons, 17.9 percent of patients had a recurrence of cancer, compared with 10.7 percent of patients whose surgeons had performed 250 or more prostatectomies, the researchers found.”
What this all means is that if you are going to have minimally invasive prostate surgery, you have to forego the local doctor and go to a center of excellence to be operated on by a top surgeon. What is at stake here is not potential side effects, but the removal of the cancer itself.
I am going to post the entire editorial on the Hu Study written by members of the Urology Department at the Mayo Clinic. The authors strongly prefer open surgery to laparascopic. They write:
“Currently, open technique is the state-of-the-art procedure in experienced hands, as the long-term results for LRP/RARP do not exist. The published literature fails to answer whether LRP/RARP meets “quality standards.”
There is no need to panic if you have had or are having minimally invasive surgery. Chances are you chose an experienced surgeon who is up to the job. Even the Mayo Clinic editorial acknowledges that with experienced surgeons, short-term oncological outcomes (removal of the cancer) are equal with open and laparascopic procedures.