Is robot prostate surgery best for quality of life?

NEW YORK (Reuters Health) - Despite the popularity of robot-assisted procedures for prostate cancer, when it comes to men’s long-term quality of life, patients with earlier stage cancers generally fare better with non-surgical approaches than with surgery, according to a new study.

Researchers say the findings, reported in the Journal of Urology, offer men more information to consider when deciding on treatment.

Men with earlier stage prostate cancer have a number of treatment options, from “watchful waiting” to radiation to surgical removal of the prostate gland.

When it comes to surgery, robot-assisted laparoscopic surgery -- where the surgeon sits at a console, operating robotic “arms” that extract the prostate gland through small cuts in the abdomen -- has become the dominant approach in the


After hospitals invest the roughly $1.5 million for the machines, plus the costs of surgeon training and annual service contracts, they often aggressively market robotic surgery. That may include claims that it carries lower risks of long-term incontinence and impotence than traditional open surgery. Actual study data to prove that, however, are lacking.

In the new study, researchers at the Sentara Health System/Eastern Virginia Medical School in Norfolk followed 785 men who received one of four types of treatment for localized prostate cancer (cancer confined to prostate gland) at their center between 2000 and 2008.

Overall, 135 men underwent traditional “open” surgery to remove the prostate gland, while 447 had robotic surgery. Another 122 patients had radioactive “seeds” implanted in the prostate gland to kill the cancer cells. The remaining 81 patients had cryotherapy, where the doctor uses thin metal rods inserted through the perineum to freeze prostate gland tissue and kill the resident cancer cells.

In general, the researchers found, men treated with radioactive seeds tended to fare best in terms of quality of life, based on standardized questionnaires they completed before treatment and periodically for three years afterward.

Patients who had received either radioactive seeds or cryotherapy had higher average scores when it came to urinary function, versus men who had either type of surgery. And together, men who had radioactive seed implants or cryotherapy were three times as likely as surgery patients to return to at least 90 percent of their pre-treatment score for urinary function.

When it came to sexual function, radioactive seed patients reported a greater quality of life than those who had received any of the other three treatments. Three years after treatment, radioactive seed patients’ scores for sexual function and “bother” -- the degree to which they thought their sexual side effects were a problem -- were higher than they were before treatment.

In contrast, scores remained below pre-treatment levels for men in each of the other treatment groups. Cryotherapy patients had the poorest scores long term.

However, there were no significant differences in quality of life between men who had undergone open surgery and those who’d had robot-assisted surgery.

“I think data like these give men more information to use in their decision-making,” Dr. Michael D. Fabrizio, one of the researchers on the study, said in an interview.

As for the lack of difference between open and robotic surgery, Fabrizio said that while there are advantages to the robot -- including far less blood loss during surgery and shorter hospital stays -- that may not necessarily translate into better long-term quality of life.

He noted that there is a “big push” to promote robotic surgery, and many patients “assume it’s the way to go.”

But the current findings, the researchers write in their report, “serve as a reminder that popular enthusiasm for robotic prostatectomy merits temperance.”

Nor do the findings come down in favor of any single therapy, however. “This study doesn’t tell patients what’s right for everyone,” said lead researcher Dr. John B. Malcolm, and men still have to talk with their doctors about which treatment might be best for them.

The study did not look at the four treatments’ effectiveness against the cancer, Malcolm told Reuters Health, but other research has suggested that surgery is more effective than radioactive seeds.

The study had a number of limitations as well, including a lack of information on any other patient health problems that might have been affecting their sexual or urinary function.

It was also not designed as a randomized, controlled clinical trial -- where patients are randomly assigned to receive a particular treatment, notes Dr. Stephan A. Boorjian, of Fox Chase Cancer Center in Philadelphia, in a commentary published with the study. Such trials are considered the gold standard for assessing a given treatment’s outcomes.

A second commentary says that the findings point to a broader issue: the general lack of randomized clinical trials comparing prostate cancer treatments with each other -- in terms of cancer control or quality of life.

“If the standard for evaluating all treatments for prostate cancer were raised,” writes Dr. Yair Lotan, of the University of Texas Southwestern Medical Center in Dallas, “then patients and physicians would be able to use more objective criteria in determining the optimal treatment.”

SOURCE: Journal of Urology, May 2010.