At last, there is guidance for men contemplating surgery for prostate cancer.
It has been provided by Queensland researchers who, in a world first, have just published a high-level comparison of traditional open surgery and robotic surgery.
Published in the Lancet Oncology, it is a comparison in which people can have confidence.
It found that over two years both forms of surgery produced equivalent results for preserving erectile function and urinary continence – two big concerns for men contemplating a radical prostatectomy.
The results were equal at 12 weeks and remained so at six, 12 and 24 months.
Surgical results were equivalent too with the same rates of positive margins (cancer at the edge of the removed tissue) and follow-up scans for cancer showed no visible differences.
But despite these equivalences, the researchers say robotic surgery is a safer option. As it is minimally invasive it causes less physiological distress during the operation and recovery in the short term is faster.
Funded by Cancer Council Queensland, the study was led by the Royal Brisbane and Women’s Hospital and Menzies Health Institute Queensland.
Dr Nigel Dunglison, chairman of urology at the Royal Brisbane, says the results shows that a new technology can be introduced that maintains a standard that was previously considered good.
It can do this while adding benefits, such as less blood loss which means a lower risk of transfusion, which was required in just 1 per cent of the robotic group.
Another benefit is less pain afterwards which means less morphine is required. Mobilisation is faster and because there is no large cut through muscle, men recover more quickly, have less inflammation and “get better, better”.
He urges doctors, health care institutions and funding organisations to embrace robotic surgery because it is minimally invasive.
The trial made some unexpected findings. One related to PSA, prostate specific antigen, which is a blood marker for prostate cancer.
If PSA is present in the blood after surgery, it means there is still some prostate cancer in the body.
While only 3 per cent of men in the robotic surgery group had a PSA recurrence, the number in the open group was 9 per cent.
But the authors emphasise this PSA finding should be taken with caution, saying it is crude and still needs to be explained.
“The reasons can’t be teased out from this study because the management of patients after surgery was not standardised, “says Dr Dunglison.
A second surprise was that 20 per cent of men in the trial, in both surgical groups, suffered continual and enduring psychological distress.
“This is as important as other aspects,” says Dr Dunglison. “It is all well and good to cure the cancer but to have a patient who will contribute much less to society again, defeats the process.”
Professor Suzanne Chambers, a psycho-oncologist and co-author of the study, says as the men’s overall results were good she expected a lower level of psychological distress.
“This is an important reminder to us all that the experience of localised prostate cancer is a psychologically challenging event and we need to provide routine screening for distress and psychological care long after treatment ends.”
Professor Chambers, director of the Menzies at Griffith University, says issues such as sexual dysfunction, urinary and bowel changes, and fear of recurrence can all lead to elevated distress.
“For optimal care, there needs to be evidence-based psychological intervention that is responsive to masculinity and how men prefer to receive support.”
She is in discussion with the Prostate Cancer Foundation of Australia and Urological Society of Australia and NZ to develop a screening tool.
When robotic surgery was introduced this century, it came in on a wave of marketing with little, if any, good evidence.
It is now the most-widely used surgical approach for a radical prostatectomy.
Studies comparing it with open surgery have been done before, but not with such scientific rigour over the long term.
This trial involved 300 men, randomised to open or robotic surgery. Dr Geoff Coughlin performed the robotic operations and Dr John Yaxley performed the open operations.
All the data was independently collected and both surgeons achieved results as good as the best published so far.
It is estimated that 18,300 Australian men will be diagnosed with prostate cancer this year and about 3200 will die from the disease.