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Impotence, Incontinence Risk Casts Doubt on High-Tech Prostate Surgery

TUESDAY Oct. 13, 2009 -- Heightened risks for post-operative incontinence and impotence may outweigh any benefits from minimally invasive "keyhole" surgery for prostate cancer, a new study suggests.

The presumed good stemming from the robotic technique are being oversold to a public that is all too willing to believe, said Dr. Jim C. Hu, a genitourinary surgeon at Brigham and Women's Hospital in Boston who led the study.

"Given the expense of the procedure and the hype around it, expectations are being raised that are too high," said Hu, whose team published the findings in the Oct. 14 Journal of the American Medical Association.

Men who have the prostate-removing surgery, which requires only a small incision and is helped along by robotic technology, do get out of the hospital faster than those who have the older operation, according to the report. Patients who underwent the more high-tech surgery spent an average of two days hospitalized rather than the three-days seen with traditional procedure. They were also less likely to require blood transfusions or suffer respiratory or surgical complications, researchers found.

But the study of more than 8,800 men also found a higher incidence of genitourinary complications, including impotence and incontinence, among those having the keyhole procedure (4.7 percent) versus those who got traditional surgery (2.1 percent).

And yet the popularity of minimally invasive prostatectomy, especially when done with robotic assistance, continues to grow. It accounted for more than 40 percent of all prostate operations in 2006, up from 1 percent in 2001, the report said.

That growth has been fueled by "widespread direct-to-consumer advertising," according to the report.

The minimally invasive technique is especially popular among patients in high-income areas, the research team said. This may be the result of a "highly successful robotic-assistant MIRP [minimally invasive radical prostatectomy] marketing campaign disseminated via the Internet, radio and print media channels, likely to be frequented by men of higher socioeconomic status," they wrote.

"Patients are demanding it," agreed Dr. Stephen J. Freedland, associate professor of urology and pathology at Duke University Medical Center, who performs prostate surgery but does not do the minimally invasive version. "In many cases, if the surgeon is not offering it, the patient will not come to you. So you have no choice. You do robotic surgery, or you don't do surgery."

Men who have been diagnosed with prostate cancer usually go directly to the Internet for information, and what they usually find are reports about the benefits of minimally invasive robotic surgery, Freedland said.

"But we are learning more and more that there are not all the benefits that have been touted," he said. "There are some benefits. But for long-term outcomes, there is no benefit and perhaps some detriment."

The numbers in the new study "are really worrisome," Freedland said. "They are finding an incontinence rate that is 30 percent higher and an erectile dysfunction rate that is 40 percent higher, and those are really important."

And the robotic technique is not readily mastered by surgeons, he said. "The learning curve is 150 to 200 patients, so the first 150 you do, you're practicing on them," Freedland said.

Men who are considering minimally invasive prostate surgery should first check carefully about the training of the surgeons doing the procedure, Hu said.

"They should go online to see how long the procedure has been available [at the clinic]," he said. "They should ask about how surgeons have been trained to do it, whether they have extensive training or just a standard three-day course."

Minimally invasive robotic surgery for prostate cancer is in an early stage of evolution, Hu said, and the surgical techniques needed to preserve urological function and prevent incontinence and impotence still have not been perfected.

More information

There's more on prostate cancer surgeries at the U.S. National Library of Medicine.

Posted: October 2009


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