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Behind the Scenes of the Robotic Prostate Cancer Surgery Chosen by Dr. Drew

IMG_4757On his HLN show “Dr. Drew On Call,” Dr. Drew Pinsky, famous for sharing advice on sexual health, addiction, and other issues on his numerous TV shows, recently chronicled his journey with prostate cancer.

Drew’s story began with a prostate specific antigen (PSA) test, a urine check, and an ultrasound of his prostate.  His doctor diagnosed prostatitis, or prostate inflammation, and followed up with a biopsy that found a low-grade tumor. Drew and his doctor pursued a plan of active surveillance and closely monitored the tumor for a year. Two additional biopsies reported that the mass on Drew’s prostate spread significantly enough to pursue a radical robotic prostatectomy.

Drew now says on HLN that he is cancer free.

Similar prostate cancer cases are routine for Penn Medicine urologists David I. Lee, MD, chief of the division of Urology at Penn Presbyterian Medical Center, Phillip Mucksavage, MD, assistant professor at Pennsylvania Hospital, and Thomas J. Guzzo MD, MPH, assistant professor at the Hospital of the University of Pennsylvania, who perform this procedure and many other robotic surgery techniques for urological problems. Together, they comprise the Philadelphia area’s most experienced robotic urologic surgery team.

All prostate cancer patients are unique and have numerous treatment options – which, in addition to robotic prostatectomy, also include traditional open surgery, conventional radiation treatment or proton beam therapy, drug therapy, or even "watchful waiting," in which patients are monitored closely in lieu of undergoing any treatment.

I asked these experienced urologists how patients can sort through their options and decide what approach is best for them, especially as robotic surgery procedures proliferate and are offered by more hospitals.

When approached by a patient seeking a prostatectomy, the doctors say that a urologist should be comfortable sharing the difference between robotic and laparoscopic prostatectomy.

“The benefit of the robotic approach is the wristed instruments which allow for many degrees of freedom as opposed to the rigid laparoscopic instruments,” said Guzzo. “This is particularly advantageous in prostate surgery due to the space constraints of the pelvis. The wristed instruments allow the surgeon to maneuver in the pelvis much more effectively and efficiently.”

Experience using the robotic procedure should be a key quest for men interested in that option, Lee says.  

The more experience the surgeon has with their particular approach, the better the results are,” said Lee, who has performed more than 3,700 robotic prostatectomies. “However, once that criterion is met, then a discussion about the benefits of a particular approach is then appropriate.”

The benefits of robotic prostatectomy can include quicker recovery from surgery, including less pain, less blood loss, shorter hospital stay, shorter time with a urinary catheter and a quicker return to work and exercise.  But Lee adds that the primary outcomes, such as cancer cure percentages, recovery of urinary control and erection function are dependent not on use of the robot, but on the surgeon’s experience.

The procedure, like any surgery, can come with side effects, however.

“The two most noteworthy potential long term consequences of the operation include urinary leakage and erectile dysfunction,” Mucksavage says.  “It is rare, but some men will require a procedure in the future to improve their continence after surgery.”

Most men experience little to no leaking after the procedure, and some men who had urinary issues due to a large obstructing prostate before the operation may actually see an improvement after the surgery.

Patients also have choices for treating any possible erectile dysfunction after the surgery.

“A robotic prostatectomy won’t improve erections, but most men who could achieve an erection before should be able to do so after the surgery,” added Guzzo. “Patients have options to assist them in regaining this function, including oral medications. At Penn, we also have an aggressive post-surgical rehabilitation program focusing on quality of life after prostate surgery.”

The Penn team is continuing their work to improve outcomes associated with robotic surgery, including the recent completion of a pilot study with Penn Engineering that incorporates haptic, or a sense of touch, technology to robotic minimally invasive surgery.

Current robotic technology provides no audio or vibration feedback to the surgeon when touching rougher surfaces or specific body parts, which may impact efforts to spare nerves during these procedures. The new haptic feature – similar to that which is used on smart phone key boards – provides additional clues for what’s happening in the body during surgery, assists in training residents, improves surgeon awareness when operating, and gives feedback even when robotic arms are off camera.

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