How to choose between different types of prostate cancer surgery?

Mr Alan Doherty

I frequently see patients who have been diagnosed with prostate cancer, have decided on surgery, but are struggling with the choice of different types of surgery. Increasingly, there can be a choice, especially if patients seek opinions from two or three different urologists (which we certainly support). A common scenario might be: the patient sees a doctor who argues robotic prostate cancer surgery is superior to other approaches. He might see another specialist who argues that a laparoscopic (keyhole) prostatectomy remains the gold standard; the best minimally invasive approach. A third consultant might advise him that his best chance of maintaining his usual erections would be open surgery. Who to believe?

The only way to understand this variety of approaches and the marketing behind them is to look at how they each developed. In the UK, up until 2000, the only prostatectomy on offer was via open surgery. Thereafter, a small number of surgeons, myself included, started to carry out prostatectomies using a laparoscopic (keyhole) approach. The number of surgeons was relatively small because this is a technically difficult operation to perform. Compared with, for example, removing a gall bladder, reaching and safely removing a prostate laparoscopically is very challenging. However, I felt there were clear benefits of keyhole surgery for patients in terms of post-operative recovery and performed many hundreds of laparoscopic operations.

In 2007, robotic prostatectomy came to the UK and since then, its development has been rapid. Using a system called the Da Vinici surgical system, “the robot” works on the same principles as laparoscopic surgery – we reach the prostate via small incisions, through which the robotic arms work. This is called a minimally invasive approach because it avoids using a larger incision down from just below the belly button to avove the pubic area. The robot is designed to be easier for surgeons to accomplish, because it eradicates the possibility of hand tremor and provides enhanced and magnified images of the surgical area to guide the surgeon.

My own NHS hospital, the Queen Elizabeth Hospital, Birmingham, acquired the Da Vinci system at the end of 2013 and most medium to large hospitals within the region also have one. While only a small number of urological surgeons embarked on laparoscopic prostatectomy, the vast majority are now doing robotic operations wherever the technology is available. There is much debate on whether this is necessarily good or otherwise. But the maths are inescapable – there are far more surgeons carrying out a procedure whose overall volume will remain fairly level. This means robotic operations are being carried out by surgeons who will have not undertaken many such procedures before and who may not go on to do prostatectomies on a very regular basis.

I undertake robotic prostatectomies and can see the benefits of the system, particularly from the surgeon’s point of view, in terms of utility. I have built up one of the largest caseloads of laparoscopic prostatectomies in the UK, at more than 1,000 procedures. I also regularly carry out open prostatectomies- at more than 1,500 procedures – so perhaps uniquely, I can speak for and offer all three approaches as a large volume surgeon.

When I discuss all the advantages and disadvantages of the different approaches with patients, in many cases the decision is to choose open surgery. Why? Because the versatility and flexibility of having an open surgical field means this offers the best of the two outcomes with most variations – erectile function and continence. We will have a frank discussion about the relative differences – having an open procedure will mean a day or two longer in hospital compared with laparoscopic or robotic. But most patients do not see this immediate post-operative measure as the decisive priority. Having their best chance of full erectile and continence recovery is the greatest influencing factor for patients. Importantly, when I evidence recovery rates, I do so using my own audited and published data.

To return to the original question – how to choose surgery, if I could offer one piece of advice it would be: beware the enthusiast. If a surgeon is promoting one approach alone, it may be difficult to measuredly assess whether this is necessarily the right approach for you personally. Never feel afraid or reticent to ask the surgeon how many prostatectomies he or she has undertaken and to ask to see results (these should be the surgeon’s individual results, not national data or studies).