Mani Menon, MD, is a urologist and Director of the Vattikuti Institute at Henry Ford Hospital in Detroit. Dr. Menon is a pioneer in the development of robotic surgery, especially the robotic prostatectomy. He and his group at the Vattikuti Institute have performed the largest number of robotic prostatectomies in the world (more than 6,000) and have the longest follow-up (up to 11 years).
In an interview with Renal & Urology News, he discusses the place of this procedure in the treatment of localized prostate cancer.
What role does robotic prostatectomy today have in the surgical treatment localized prostate cancer?
Dr. Menon: It has become the preferred surgical treatment for localized prostate cancer in the United States. Up to 85% of patients undergoing surgery for localized prostate cancer choose robotic prostatectomy. It is a better way of doing surgery because there is less bleeding and fewer complications, and surgeons can see better.
This results in better outcomes. For the vast majority of urology residents who are training today, open radical prostatectomy will become a historical footnote because they are trained to do robotic surgery.
Most patients want a noninvasive approach, whether to remove their gall bladder or prostate. They don’t want to have an operation where they might lose 20% or 30% of their blood volume and have impaired urinary control.
Given a choice between radiation and open surgery, many patients will choose radiation therapy, If the choice is between radiation therapy, and robotic surgery, though, many will tend to choose robotic surgery because they prefer to have their cancer removed. So they’re getting the benefit of having the cancer out and easier recuperation and less side effects.
Your institute has performed robotic prostatectomies on more than 6,000, with up to 11 years of follow-up. What can you say about outcomes and complications?
Dr. Menon: In our series of patients with a minimum follow-up of five years, 31 patients developed a PSA recurrence, three had distant spread, and one died of prostate cancer, for every 1000 patient-years of follow up. The cure rates are comparable to the best reports from open surgery.
The complication rate drops by about 90% with robotics. Blood loss for robotic surgery is about 100 cc compared with 1000 cc for open surgery. With open surgery, most surgeons ask the patient to donate two units of blood, a month before surgery. This blood is then transfused back to the patient during the operation. We don’t do that for robotics, because we don’t need to. The cost savings is about $750 per unit of blood.
Because we can see better and there’s less bleeding in robotic prostatectomies, we’ve been able to fine-tune the operation. As a result, 50% of patients are continent when the catheter comes out. One of the newer refinements is not draining the bladder with a Foley catheter coming from the penis. Perhaps because there is nothing irritating the urethra, healing is more natural, and urinary control comes back sooner. We’ve done more than 1,500 robotic prostatectomies using this technique and patients really like this approach.
We’ve also developed new nerve-sparing techniques that have resulted in faster return of erectile function compared with open techniques. Some of these techniques have been duplicated by open surgeons. In more ways than one, robotics has raised the bar and allows everybody to get to be better at what they do.
How many robotic prostatectomies does a urologist need to perform to become proficient in the procedure?
Dr. Menon: How does one define“proficiency”? Anybody who goes through residency training these days is going to be good at robotic surgery because most training programs incorporate robotics into their curriculum. When you talk about people in practice, the situation may be a bit different.
Some people are better at it than others. If someone has been out in practice for 10 years, and they do one radical prostatectomy every two months—which is what the average urologist does—it will be more difficult for them to be proficient in robotic surgery. But if a urologist works in a big group that does several hundred prostatectomies a year, he or she can become quite good in two or three months.
How does the cost of robotic prostatectomy compared with that of other treatments?
Dr. Menon: Robotic surgery is a couple of thousand dollars more expensive than open surgery, but much less expensive than radiation treatment, hormones, or chemotherapy. At our institution, an international patient, who has no health insurance, is charged about $80,000 for radiation treatment and about $40,000 for surgery, whether it is open or robotic. Now this is just for the acute treatment.
Over a five-year period, patients who undergo radiation therapy may need additional testing such as MRI and CT scans, and the costs add up quickly. The least expensive treatment by far for patients with localized prostate cancer is surgery. The cost of buying a robot, in most instances, is less than that of a radiation machine.
Do you think hospitals oversell robotic surgery?
Dr. Menon: Any time hospitals develop a new program, they will market it. And there is a strong suggestion that they make claims about robotics without collecting their own data