Minimally invasive robotic prostatectomy has been advertised to men as a far easier surgery to undergo than traditional open prostatectomy, with a much shorter recovery and fewer complications during and after surgery. If you add to that equivalent cancer control, it seems like a worthwhile advance. However, one of the biggest worries that men have going in for a prostatectomy is whether or not, they will end up with erectile dysfunction and urinary incontinence in the long-term.
A new study in the Journal of the American Medical Association questioned the superiority of the minimally invasive surgery, finding that 18 months after surgery, men had a higher rate of erectile dysfunction (ED), incontinence, and within the first month after surgery, it was associated with a twofold increase in urinary and genital complications, such as infection.
The good news is that robotic prostatectomy worked as well as open prostatectomy in controlling prostate cancer. Also, the robotic technique went more smoothly in the operating room. Men were much less likely to need blood transfusions, had fewer surgical complications, and they went home one day sooner.
A big question remains, according to the John Hu, MD, the study's lead investigator, and a genitourinary surgeon at Brigham and Women's Hospital, Boston, MA. That question concerns whether robotic surgery has been oversold to the public. How much do men care about short-term advantages during and immediately after surgery if they must live with ED and incontinence?
My 88-year-old father has been trying for several years to avoid a prostatectomy, because of these problems (ED and urinary incontinence). I also saw that article about higher complication rates in patients undergoing a robotic prostatectomy. I think the complications have more to do with the experience of the surgeon than anything else. Patients need to ask their urologic surgeons how many procedures they’ve performed and the success rates with these procedures.
I always advise people to ask urologists and surgeons about their patients’ outcomes and numbers of procedures done (click on “top 10 questions” on upper left of this site.)
This was a large national database study. I think it would be hard to figure out surgeon experience. The other issue is that impotence and incontinence often become problems as you age.
Ahmed in the NEJM 361:1704 mentioned in passing that surgery and radiation cause impotence in 50% of cases, urinary incontinence in 5-10%, and rectal toxic effects such as diarrhea, bleeding and proctitis in 5-20% (rectal complications are more of a problem with radiation). Ahmed said that screening prevents the death of 1 man for every 48 men who are treated.
So a man with prostate cancer has to choose between a 50% probability of impotence and a 2% probability of death.