Study Finds Pro and Cons to Prostate Surgeries

By RONI CARYN RABIN
Published: October 13, 2009

Prostate cancer patients who chose minimally invasive surgery rather than more extensive operations to remove the prostate were less likely to experience complications like pneumonia, but reported higher rates of long-term problems, including impotence and incontinence, according to one of the largest studies to compare outcomes to date.

Patients achieved similar rates of cancer control regardless of which surgery they had, the analysis found.

The study, in Wednesday’s Journal of the American Medical Association, is not considered the last word on the subject, several experts agreed. But it raises questions about claims of superiority of minimally invasive laparoscopic and robotic-assisted surgeries, which have led to a surge in their popularity.

“People intuitively think that a minimally invasive approach has fewer complications, even in the absence of data,” said Dr. Jim C. Hu, the study’s lead author, who is director of urologic robotic and minimally invasive surgery at Brigham and Women’s Hospital in Boston. “Men who were well educated and had higher incomes were actually more likely to embrace this approach, often due to aggressive marketing by hospitals that had spent $1.5 million to acquire the robots. I think the technology has been oversold.”

In one version of prostate removal, called open surgery, a surgeon makes an incision that is several inches long. With minimally invasive surgery, also called laparoscopic surgery, the surgeon operates through a series of small incisions using tools and a camera for the operation. With robotic surgery the surgeon sits at a computer and manipulates a robot to do the operation through the small openings.

In 2003, minimally invasive radical prostatectomies, which include robotic surgeries, made up fewer than 10 percent of prostate removal surgeries. By 2006-7, they constituted 43 percent of procedures.

The Harvard researchers who did the study assessed the outcomes of 1,938 men who had minimally invasive prostate surgery from 2003 to 2007 and 6,899 men who had open surgery. They used Surveillance, Epidemiology and End Results, or SEER, data from the National Cancer Institute representing 26 percent of the American population, linking it with Medicare data.

The men in the study — all of them 65 or older — who underwent minimally invasive surgery had shorter hospital stays, fewer respiratory complications and other surgical complications, and were far less likely to receive a blood transfusion. But they had more complications involving the genital and urinary organs immediately after surgery, with 4.7 percent having those complications, compared with 2.1 percent of open surgery patients.

When the researchers looked at lasting complications more than 18 months later, they found that men who had minimally invasive surgery were at greater risk of suffering from incontinence and erectile dysfunction than those who had open surgery.

For each 100 men who had minimally invasive surgery, some 15.9 percent were at risk of being incontinent each year, while 26.8 percent experienced erectile dysfunction, compared with 12.2 percent and 19.2 percent, respectively, each year for every 100 men who had open surgery, the study calculated.

Several surgeons who specialize in robot-assisted procedures said the study was limited because it was unable to distinguish between those using robot technologies and older minimally invasive techniques.

Many experts said the outcomes of experienced surgeons were better than those reported in the study.

“I almost exclusively do robotic prostatectomy now because I think that, despite this manuscript, there is clear evidence that it is comparable, in terms of continence, potency and tumor control,” said Dr. Joseph Smith, the chairman of urologic surgery at Vanderbilt University School of Medicine.

But Dr. Smith added, “I don’t think there’s anything demonstrating it to be superior.”

Dr. Peter Scardino, chief of surgery at Memorial Sloan-Kettering, said the study was important because it reported on data that did not come just from one medical center or one region.

“At the end of the day,” Dr. Scardino said, “what all the studies will show is that it’s not the tools the doctor uses, but the experience and skill of the surgeon. There’s nothing magical about the laparoscopic or robotic.”