Robotic surgery – the future for prostatectomy ?

Mr Alan Doherty

Since the start of 2014, I have been carrying out prostatectomies using the robotic da Vinci system at the Queen Elizabeth Hospital. Robot-assisted surgery is the norm in America and in the UK, where a growing number of hospitals are investing in the da Vinci, many see it as the future and “gold standard”.

My viewpoint, at this point in time, is that I am impressed with the technology and pleased of the opportunity to use it. I am one of very few surgeons currently undertaking prostatectomies using all three established techniques – open, laparoscopic and robotic. Indeed, when I carried out my first robotic operation, I had the privilege of being able to introduce the patient having that surgery to the first patient I operated on laparoscopically a decade earlier (read more here).

Published results

What is also unusual is that I have a long-established, transparent system for publishing the results of the prostatectomies I undertake, focusing on the two major known complications: erectile dysfunction and incontinence.

The results of patients having robotic surgery will be included in this system, so there will be a clear and accessible means of measuring and comparing the results of different approaches. If a surgeon is only carrying out one surgical approach, inevitably there is a danger that the surgeon will become an enthusiastic advocate for that approach; proclaiming it to be better than others, but without comparative data.

Although the surgeon may compare his or her data with studies or national statistics, this neglects a key factor: outcomes from surgery are at least as dependent upon the skill of the individual surgeon, rather than the approach (in fact, probably more so). The best way of accurately assessing the benefits of robotic surgery is by the same surgeon comparing his results using the same measures.

Surgical experience

Am I now an enthusiast for robotic surgery? I like the way the da Vinci Surgical System translates the surgeon’s hand movements into movements of the instruments inside the body and the highly magnified 3D vision system, producing images of the surgical field to guide the surgeon. I would certainly conclude that for a junior surgeon at the start of his or her learning curve, they will more quickly become competent in robotic surgery than laparoscopic surgery, which is technically more challenging. But the fact that a young surgeon can more quickly become competent in an approach does not mean the approach itself is, in all cases and with all surgeons, necessarily superior.

For several years, I have been convinced that open surgery has clear benefits when nerve-sparing surgery is the priority. I am keen to see how the results data for robotic surgery measures up to open surgery data. Equally, I am able to compare the recovery for patients having robotic surgery compared with open surgery, as I have for many years compared the recovery after laparoscopic versus open surgery.

If I am an “enthusiast”, it is primarily for the process of recording, reflecting on and publishing results, rather than one particular surgical approach over another. I am pleased to have the opportunity to work with the da Vinci Robotic System and being able to accurately evaluate the benefits it brings for patients. As the outcomes data grows, I look forward to being able to properly assess the robotic approach using clear benchmarks, so we can accurately judge whether there are benefits and exactly what those benefits are