A human operates, not a robot

Prostate cancer is the most common cancer among men in Poland and Europe. What’s worse, in Poland, in the years 2015-2020, this cancer was characterized by the highest rate of increase in incidence in oncology…

The most common malignant tumor in men is not yet the main cause of death, but we can certainly talk about an epidemic of prostate cancer. Unfortunately, this cancer will remain with us, because the factors that cause its high incidence – genetic and age-related – will not disappear. This is a growing problem for the male part of society.

Do you see this epidemic in your office?

Unfortunately yes. Additionally, recently I have noticed that patients with cancer at an increasingly advanced stage come to me.

Prostate cancer does not cause symptoms for a long time. What to do to detect it at an early stage, when the possibility of cure is greatest?

This cancer is an insidious disease. Prostate cancer, not only in the early stage, but also in the intermediate stage and sometimes also in the late stage, may not cause symptoms. This makes it difficult to detect and treat this cancer. Testing and determining the PSA (Prostate Specific Antigen) value is the only way of prevention. Full diagnostics are complemented by a fusion biopsy and magnetic resonance imaging of the prostate and the assessment of their results by a radiologist and urologist.

The surgery performed in case of prostate cancer is the so-called radical prostatectomy. What is it?

Removal of cancer and the entire prostate. We want to free the patient completely from cancer, and in the case of prostate cancer, this involves removing the entire gland.

Do all patients require surgical intervention?

Detailed medical criteria are used. The basic exclusion criterion is numerous metastases. This means that if a patient presents with an advanced disease, with multiple cancer foci, prostatectomy surgery may no longer bring him sufficient benefits.

Sometimes, in the early stages of prostate cancer, the so-called active observation. Personally, I am critical of this method. Observing – what I see every day in my office – leads to cancer developing in these patients, becoming more malignant and often incurable. Although this action is in line with the guidelines, I warn you: you must be very careful and do not delay so that the situation does not end badly for the patient.

What kind of patients come for prostate cancer surgery using a robot?

The patients who come to me can be divided into two main groups. The first are patients with advanced cancer, difficult anatomical situation, and comorbidities, e.g. obesity, who were refused surgery in centers with less experience.

The second group are conscious, well-read patients who know how risky such an operation is if it is performed unprofessionally. These are patients who want to get the best possible result and for this purpose they are looking for an experienced operator with many years of practice and a well-coordinated team. This is the recipe for the greatest chance of avoiding diapers (urinary incontinence) and erection problems.

What constitutes a good result of robotic surgery in prostate cancer?

There are three elements that allow you to assess a fully satisfactory medical effect. First, complete removal of the cancer. Secondly, maintaining urological functions, i.e. urinary continence. And third, maintaining an erection. So what’s really important is normal functioning after surgery and the ability to remain active professionally or with family. Otherwise, a 50-year-old man is cured of prostate cancer, but is forced to use diapers or sanitary pads every day, which is crippling and frustrating for the man.

Conscious patients know that they have the best chance of achieving full results by choosing a procedure performed by an experienced operator. And an experienced operator, according to research published in professional medical literature, i.e. in the world’s best urological journals, is one who has personally and completely performed at least 500-1000 operations with the robot.

There are more and more centers in Poland where robot-assisted prostate surgery is performed. How to choose the right one?

Indeed, patients who are looking for a doctor to perform prostate cancer surgery have many choices. There are already about 40 robots in Poland – that is, about 40 centers that perform these operations. The choice of a center is a life-changing decision for the patient, because if after surgery the patient has complications such as constant urinary incontinence, it is practically impossible to reverse the situation. Such complications are not corrected using the da Vinci method.

Can urinary incontinence or erectile dysfunction be cured in such cases?

Unfortunately, it is often too late or very difficult to do so.

What can the patient do to minimize the risk of complications?

I will suggest a few questions that the patient should ask when going for a pre-operative interview; you should not be embarrassed or afraid to ask them, the results depend on the answers. If the answers are not satisfactory and comprehensive, please find another center and ask again. And after two or three conversations, make an informed decision, because – as I said – there is no going back from the results of the surgery.

First of all: since when has a given center had a robotic system?

Not only the operator is important, the entire team counts. If the center has had the robot for a month, the team is inexperienced.

Second: is the robotic system authorized? Does it come from the official manufacturer and distributor of this machine in Poland?

It is known that some robots are unauthorized and are not serviced by an authorized distributor of the equipment manufacturer. It is difficult to trust such equipment and a center that decides to make such savings.

And thirdly – and this is the key question: how many prostate cancer surgeries with the da Vinci robot were performed by the doctor personally, entirely?

As I have already said, according to professional medical literature, to be considered an expert, a minimum of 500-1000 operations are needed.

Does previous experience with other methods count?

It’s not about someone having previously performed 300 open surgeries and thinking they have enough skills. No, an operator who switches to a robot learns again.

And what do you need to learn?

All. From a technical point of view, performing this operation is a complete change, a completely different operating philosophy. The steps you need to take are completely different.

The good result of surgery using a robot depends on how we treat the anatomical structures, which are one-millimeter membranes. They are responsible for urinary continence and erection. If we cut the membrane, this function will be lost. And the preservation of these structures is a condition for the patient’s normal functioning after surgery. During open surgery, the operator is often unable to keep them, and when operating with the assistance of a robot, a lot of time and attention must be devoted to carefully separating these millimeter-sized membranes from the prostate, fiber by fiber, without damaging them.

Does this mean that a human operates?

100 percent a human operates, and the robot is just a tool. And the result of the operation depends on the person’s experience. Da Vinci is called a robot – but this is a wrong name, because he is actually a telemanipulator. It transfers the operator’s movements inside the human body in a miniaturized way, enabling precise operation. This is the technically complex, high-repetition activity we talked about. Additionally, the robot allows you to see the operating field at ten or even twenty times magnification. Among other things, this allows operations to be performed with precision down to a fraction of a millimeter.

And where did you gain experience?

I have been dealing with robotics since 2012. Before I started performing procedures in Poland, I worked in Germany for seven years in the largest robotics clinic in Europe. There, I followed the entire career path from resident doctor to head physician (German: Oberarzt). We have been performing them in the hospital since 2018, and the team of urologists operating the da Vinci method consists of three people. I made over 2,000 in total. treatments.

You operate with the assistance of a robot, but there are other techniques for performing prostate cancer surgery, e.g. laparoscopic or classic procedures. What are the differences between these methods?

If we were to conduct academic reflections on this topic, such a comparison is difficult because many criteria must be taken into account. From a practical point of view, the differences in the results obtained are fundamental, because if we compare a well-performed da Vinci operation, performed by an experienced operator in an experienced team, it is associated with a much lower risk of complications than a laparoscopic procedure or an open, i.e. classic, operation performed by experienced operators. The precision enabled by the robot allows this operation to be performed more effectively.

It concerns all aspects of the patient’s functioning after surgery – removal of the tumor as the main reason for treatment, but with simultaneous preservation of urinary continence and sexual function.

That’s why I appeal: Patients, ask! Before every surgery.

Interview by: Dorota Bardzińska