Wondering how robotic prostate surgery works? Since it is the latest, is it the best treatment for prostate cancer? Is it better than cryosurgery? I wanted an expert on robotic prostatectomy to give you the answers so I interviewed Dr. David B. Samadi, one of the very few urologic surgeons in the United States.
Dr. David B. Samadi has successfully done robotic prostatectomy on more than 4000 patients. He is a well-known and a highly respected surgeon trained in the latest treatment. He is currently based in New York City.
Dr. Samadi is such a generous man that he is more than willing to share his knowledge and expertise on the new prostate cancer treatment, his views on whether robotic prostate surgery is the best treatment and his thoughts on other treatment options that are available and other issues regarding this type of tumor.
Prevention Guide: What surgical procedures have you prescribed to your patients with prostate cancer as their treatment options?
Dr. Samadi: When it comes to discussing prostate surgery with my patients, there are three prostate cancer treatment options that they need to be aware of:
1. OPEN PROSTATECTOMY: The incision for open surgery runs from the navel to the pubic bone. This large opening allows the surgeon to see the entire site at once, and to reach into the prostate with his hands to remove the gland and sew the bladder back to the urethra.
This one-time procedure may cure prostate cancer in the early stages of development. The risks of open surgery are bleeding, nerve damage, a longer healing time, and possible infection along the large incision. Loss of sexual function and incontinence can also result from the invasive nature of this procedure.
2. LAPAROSCOPIC PROSTATECTOMY: This relatively new surgical procedure uses several small abdominal incisions as opposed to the longer midline cut used in open surgery. The surgeon’s hands remain outside of the patient and are controlled with extensions coming from the fine surgical instruments.
Advantages to this approach are less pain and quicker recovery time. The scars are hardly noticeable and the risk of infection is reduced. The disadvantage of this procedure is its steep learning curve and two-dimensional imagery which makes it more difficult for the surgeon to achieve optimal visualization.
3. SAMADI MODIFIED ADVANCED ROBOTIC TECHNIQUE (SMART): Using the da Vinci surgical system, this procedure -- also known as robotic prostate surgery -- is the latest treatment in minimally invasive surgery and offers the most recent advances in robotics and computer technology. This permits three-dimensional visualization and small, wristed hands that facilitate sewing deep in the pelvis.
We prefer robotic prostate surgery over all others because it has the most advantages for patients. The benefits include low risk of bleeding and infection, shorter hospital stays, reduced postoperative pain, quick healing, small scars, and minimal risk of becoming impotent or incontinent. This technique allows the surgeon to be even more precise with dissecting the nerves that control erections off the prostate.
Prevention Guide: You advocate robotic prostate surgery, the latest treatment option right now. Do you think it is the best treatment for prostate cancer so far? If yes, why do you think so?
Dr. Samadi: Robotic prostatectomy has the same advantages associated with laparoscopic prostatectomy -- such as small incisions, minimum blood loss, fast recovery, and minimal catheter use — but the new technology uses robotic instrumentation and two cameras for better visualization.
Using two cameras enables us to ascertain a three-dimensional view of the anatomy with greater magnification. And unlike laparoscopic prostatectomy, the robotic instrumentation provides surgeons with a full range of motion, and is associated with significantly less blood loss.
For this reason, robotic assisted prostate surgery is sometimes called bloodless prostate surgery. In addition, sexual dysfunction and incontinence risks are reduced because the surgeon has a clear view of the anatomy; we can more accurately navigate around the nerves and structures responsible for these problems.
Prevention Guide: What about cryosurgery instead of robotic prostate surgery? It is also a new prostate cancer treatment that is less invasive and ensures quicker recovery of the patient.
Dr. Samadi: Cryosurgery essentially freezes the prostate gland thereby destroying the tumor, and yes, it is less invasive than other forms of treatment. But while minimally invasive is a great way to go (thatís one of the reasons I advocate robotic prostatectomy), cryotherapy may not be invasive enough.
Although cryosurgery is technically an option for some patients, it has major drawbacks for the following reasons: Prostate gland volume is a factor; the larger the prostate, the more difficult to achieve a uniformly cold temperature throughout the gland which could lead to cancer recurrence. During total gland cryosurgery, the ice ball extends outside the prostate capsule and in most cases encompasses both sets of nerves that are responsible for erections, commonly resulting in erectile dysfunction.
The incidence of erectile dysfunction among cryotherapy patients ranges from 49% to 93% at one year. Todayís elderly population wants to live longer and maintain a high quality of life throughout. For this reason cryotherapy is more often considered in men who are not concerned with erectile function or who cannot undergo radiation due to inflammatory bowel disease, or rectal disorders.
Prevention Guide: Will robotic prostate surgery work for all patients regardless of their age, health condition and stage of the tumor?
Dr. Samadi: No treatment is perfect for everyone, and especially with prostate cancer. It is crucial to look at each patientís unique situation. That being said, if a patient has a >10 year life expectancy, and is a good surgical candidate, robotic prostatectomy is an excellent treatment choice. Whether a patient has low risk or aggressive disease, prostatectomy is the only way to remove all of the cancer, and provide a definitive cure.
Prevention Guide: What about radiation therapy? Is it still required after a robotic prostate surgery?
Dr. Samadi: Radiation therapy is sometimes suggested in place of surgery if the cancer is localized or if it has spread to the surrounding tissue. Radiation has its own set of side effects such as bowel dysfunction.
In some cases, if surgery is unsuccessful, the physician may suggest radiation as a potential treatment choice. In the vast majority of robotic prostatectomies, however, the cancer is removed. Thus the patient remains disease-free and radiation, with its harmful side effects, is avoided.
Prevention Guide: According to a recent study in the Journal of NCI, PSA testing is found to be "excessive and it leads to over diagnosis" that some patients are operated on unnecessarily. What is your opinion on this?
Dr. Samadi: PSA stands for Prostate-specific antigen. The PSA test analyzes the blood for PSA, a substance produced by the prostate gland. If higher-than-normal levels of PSA are detected, above a level of 4.0g/ml, it may indicate prostate infection or enlargement of the prostate gland, or cancer.
In my opinion, itís always better to be on the safe side when it comes to screening, especially when dealing with cancer. But this isnít just my own personal opinion. The American Urologic Association recently released their guidelines for PSA testing, which recommends a baseline PSA in well-informed men starting at age 40, and re-screening either yearly or every 3-5 years depending on that first baseline value.
The logic behind this is understandable; PSA is a simple blood test that can help detect prostate cancer before it spreads. Trends in PSA scores over time can also provide valuable information for urologists when they counsel their patients.
That being said, we donít want to unnecessarily subject patients to more tests and procedures than they actually need, so the decision to use PSA must be made with a full understanding of the patientís family history, overall health, and previous test results.
Prevention Guide: One of my readers emailed me with this question - Are lymph nodes supposed to be removed during a robotic prostate surgery?
Dr. Samadi: Lymph nodes are part of a vast system of channels that course throughout the body eliminating excess fluid from tissues. Removing lymph nodes that are adjacent to the prostate gland during prostatectomy helps your surgeon be certain that the cancer hasnít spread to other areas of the body, and that the entire tumor has been removed.
Lymph node removal is considered a standard part of radical prostatectomy, and the robot allows us to remove these nodes with precision, and without damage to surrounding tissues.
Prevention Guide: You're trained in conventional medicine as a surgeon/urologist/oncologist. What do you think about the use of curcumin or turmeric as prevention against and even as part of a natural treatment for prostate cancer?
Dr. Samadi: While some laboratory studies have shown that turmeric may possess anti-cancer and anti-inflammatory properties, the gold standard for medical evidence is a randomized clinical trial of which few, if any, have been performed.
Itís important to remember that “anti-cancer” agents may show promise in the laboratory, but that often doesnít translate into successful treatments when administered to real patients. No studies have conclusively shown that turmeric prevents prostate cancer, and while there may be some benefit to this herb, more investigation is needed in this area.
In general, there are many herbs and botanicals out there that may one day show promising results for patients who are ill, and thatís why itís so important to continue pursuing research in these areas.