Tuesday, October 23, 2007

Robotic Radical Prostatectomy: Is it the new TURP?

It is my great privilege to have a guest blogger today, Dr Robert Batler. Robert Batler MD is a urologist in Indiana who specializes in robotic radical prostatectomies. Dr Batler has performed hundreds of robotic radical prostatectomies with exceptional success rates. and has become an internation leader in the field. Last week, Bob and I were discussing BPH, or benign prosate enlargement, when he made a comment that I found, to say the least, controversial.
Bob has agreed to publish his thoughts here, on Dr Schoor's Urology Blog. So here it is.

From Dr Batler's Blog:

Increasingly, patients are being diagnosed with early organ confined and in some circumstances incidental prostate cancer. Prostate screening programs have led to what some would say is an overly aggressive campaign in which we are diagnosing insignificant prostate cancers. Without a doubt this may be true in some circumstances. Conversely, we are diagnosing aggressive disease earlier and we have observed a stage migration. Ultimatley this should lead to less morbidity and lower death rates from prostate cancer within the screening population.However, what is the morbidity of treating incidently discovered prostate cancer? Any form of treatment carries the risk for potential urinary incontinence, lower urinary tract symptoms and erectile dysfunction. Could there be a hidden benefit?An interesting thought recently occurred to me. Do patients whom have had a laparoscopic robotic radical prostatectomy have fewer urinary complaints than most of our patients that are being treated medically for BPH or who have undergone a transurethral prostatectomy (TURP)? Without having done a prospective randomized trial, I would say my personal experience is that most patients undergoing robotic radical prostatectomy on the whole have far fewer urinary complaints and thus lower AUA (urinary complaint) scores than our average patient who is being medically treated or previously undergone a TURP.Am I suggesting we perform robotic radical prostatectomy in our patients with bladder outlet obstruction secondary to BPH? Certainly, I am not making that recommendation. However, I am intrigued by the question. Is incidently discovered prostate cancer treated with radical prostatectomy (particularly in the often impotent male) any more morbid than a TURP? Is there greater risk?Would urinary outcomes be better?We may never have the answer to these questions. As ridiculous as it may seem, there may be a day when laparoscopic robotic prostatectomy replaces TURP. In many circumstances, in practice, is already has replaced the TURP.

Thanks Bob.

I think it is an interesting question that you pose, though I am not sure that I agree with you. In my view, you are using a "big gun" to treat a "little" problem. Advances in BPH treatment have largely made invasive therapies, like TURP and open prostatectomy, a thing of the past. The average urologist does less than 10 TURP's per year and and instead treats BPH with other methods. Outcomes with other modalities, such as HOLAP and Greenlight Laser Therapy are excellent with minimal morbidity. In addition, medical treatments with alpha blockers and 5-alpha-reductase inhibitors often prevent progression of disease to the point of surgical intervention. Finally, when surgical intervention is needed, the cost of robotic radical prostatectomy outweighs the cost of a HOLAP, Greenlight, or even a TURP, by multiples of 10. Perhaps when the technology becomes more readily available and less expensive, robotic radical prostatectomy will be adopted for benign disease. Until then, I believe that standard BPH therapies will prevail.

Again, I thank you for this provocative post and for "stirring the pot."

The IU.