Role for Robotic and Open Approaches in Treating Prostate Tumors

Minimally invasive urologic robotic surgery applications received approval from the U.S. Food and Drug Administration in 2000. At many centers, robotic radical prostatectomy has become the preferred alternative to both conventional open surgery and minimally invasive laparoscopic surgery for prostate removal.

The open approach retains a valid role, however, because intermediate- to high-risk patients benefit from the surgeon's palpable intraoperative feedback performed during the open procedure. Centers of urologic surgical excellence such as Mayo Clinic offer prostate patients the full spectrum of surgical options. Each approach has its advantages, depending on the patient and his unique cancer features.

In robotic surgery, the surgeon manipulates controls from inside a workstation console several feet from the operating table. While looking through binoculars equipped with a high-resolution 3-D stereoscopic imaging system, the surgeon guides the robotic endoscopic instruments inserted through 5 to 6 small incisions to create ports for cameras and the arms of robotic instruments.

Open Approach Still Indicated

Despite the rise in robotic prostatectomy, it is important to note that because of its relative newness, the robotic approach has not yet been fully accepted as the standard of care for prostatectomy, pending the availability of long-term outcome data. This may be of concern to younger patients (those in their 50s), who place a priority on evidence for durable surgical benefits when making health care decisions.

Published data show that in the hands of experienced urologic surgeons, equivalent outcomes are obtained with open radical retropubic prostatectomy and robotic approaches in terms of pain control, length of hospital stay, level of catheterization, and return to activities—and long-term outcome data are available that support the durable benefits of the open approach. A key advantage of the open approach is the surgeon's ability to palpate tumors and intimately assess extent of the disease.

Patients for whom an open retropubic prostatectomy should be considered include those with intermediate-grade or high-risk tumors that benefit from surgical palpation, high-volume tumors, and the need for extensive node dissection.

Growth and research

There are compelling clinical circumstances for selecting open surgery. The use of robotic prostatectomy has increased greatly, however, and urologic surgeons must be familiar with its strengths and limits to fully serve their patients' best interests. As an example, the robotic approach was used in 9 percent of prostatectomies at Mayo Clinic's Minnesota campus in 2003. By 2006 the percentage had increased to 16 percent and by 2008 it was up to 39 percent. Mayo physicians in Minnesota expect that by 2010 more than 50 percent of prostatectomies will be performed with a robotic device.

At Mayo Clinic, prostatectomy remains the most frequently performed urologic robotic surgery. The volume of Mayo's robotic prostate surgical procedures is among the highest in the country. A total of 848 robotic prostatectomies were performed at the three Mayo Clinic campuses. There are five robotic devices in clinical use on the Minnesota campus, one at Mayo Clinic in Florida, and two at Mayo Clinic in Arizona.

Mayo Clinic prostatectomy registry

The Department of Urology at Mayo Clinic in Minnesota has been tracking the short- and long-term results of prostate cancer surgery since 1966. The data registry is continually updated, following patients over time. The database currently includes more than 20,000 men. Analysis of these data shows changing trends in both the early diagnosis of prostate cancer and the long-term survival of patients: both are improving. Outcomes derived from these data help guide the treatment choices of Mayo Clinic's urologic surgeons and their patients.