Robotic Surgery Is Milestone Advancement for Prostate Cancer Treatment

David Albala, MD

Robotic surgery has had a significant impact on patients with prostate cancer undergoing a prostatectomy.

Compared with open surgery, “the recovery time is much quicker than open surgery,” said David Albala, MD, in an interview with OncLive. “It is a minimally invasive procedure so there is less pain and less blood loss.”

Robot-assisted radical prostatectomies increased from 13.6% in 2003 to 2004 to 72.6% in 2011 to 2012. This procedure has comparable cancer control and improved overall survival (OS) versus open surgery. Robotic surgery has also been associated with less use of additional treatment compared with open radical prostatectomy (HR, 0.78; 95% CI, 0.70-0.86).¹

OncLive: Can you explain the benefits of robotic urological surgery?

Albala, medical director, co-director of Research at Associated Medical Professionals and chief of Urology at Crouse Hospital, discusses the uses and benefits of robotic urological surgery in prostate cancer, as well as methods to achieve better physician compliance.Albala: Robotic surgery has a firm implant in urological surgery, especially oncology with prostatectomy, partial nephrectomy, and cystectomy work. The real benefit of robotic surgery is that patients can leave the hospital.

Now, an experienced robotic surgeon can do these procedures in a timely fashion. Obviously, there is a learning curve that is associated with robotics, but most of us have passed that learning curve. We now have done 1000 to 3000 prostatectomies. The learning curve has passed. The time of surgery is equivalent to open surgery and the efficacy of the procedure, complication rates, impotence, and incontinence are the types of complications that are very comparable to what we see with open surgery.

Are there certain patients who are better for robotic surgery than others?

The patient benefits because the recovery time is much quicker. They are out of the hospital typically in 1 day and a catheter is left in place for approximately 1 week, which is somewhat shorter than what we saw with open surgery. In partial nephrectomies for kidney tumors, patients in my practice typically stay in the hospital overnight and are able to leave the next day. Many of the same benefits that we see with prostatectomy can be translated in partial nephrectomy and cystectomy.All patients who are surgical candidates for the procedure that they're going to have can be done robotically. If a patient is a candidate for a prostatectomy—whether you do it with a retropubic, perineal, or a robotic approach—all of those patients can be operated on robotically.

What impact has robotic surgery had in prostate cancer?

Obese patients can be done robotically with the new da Vinci system. These have longer reaches for their instruments, and these procedures can be done with greater ease. Those were difficult with some of the earlier types of the prototypes of the robot but, as the evolution of the robots has taken place, we can now perform this procedure on obese patients much better and get better results. Anything that we can do with an open procedure we can do robotically.The real benefit has been the shorter recovery time. There is good documentation in the literature about blood loss. The average blood loss for a robotic prostatectomy is about 150 cubic centimeters, which is just a small amount compared with an open prostatectomy, which is 700 to 1000 cubic centimeters. There is quite a difference.

Clearly, the hospitalization time is shorter robotically, although lines get blurred. If you're a very experienced open surgeon, you can have tremendous outcomes, which are very comparable to what we see robotically.

At the 2016 LUGPA Annual Meeting, you spoke on achieving compliance. Can you give an overview of some of the key points?

The efficacy of the procedure and the complication rates are very comparable. Where robotics helps patients is with blood loss, length of stay, and catheter drainage time.Compliance within large urology groups is an important quality of a practice. Not only for reimbursement to ensure that you are reimbursed but also to avoid penalties. Carl Olsson, MD, and I essentially went through steps that we believe practices can institute relatively easily to avoid the penalties of the federal government coming in and creating penalties on these practices.

For example, we audit charts 2 to 3 times a year of each individual physician. What that does is allow us to see where the physician is in his coding and where the documentation of that physician is. If it is lacking certain measures, we can sit down and educate the physician and try to bring their standard up to a certain baseline level that we would expect the whole practice to do.

These are simple things, such as filling out and signing off on charts in a timely fashion. Those have been problems in large urology groups. We’ve tried a variety of different measures to bring compliance within the groups and found that, essentially, you have to draw boundaries. If physicians aren't compliant with certain rules of the practice, then those physicians need to be fined and have a penalty charged against them. We found that physicians comply when you essentially put demands on them and, if they are financial demands, they tend to react to those demands a little bit quicker.

Additionally, we found good documentation improvement by looking at bell-shaped curves on where physicians and individual groups stand with regards to utilization.

For example, if a physician is 2 standard deviations in using ultrasound, that physician would get an audit to see if the indications were proper, how he/she is doing the test, why he/she is doing the ultrasound, what the proper indications are, and whether he/she is reporting or coding it properly.

We do utilization reviews. The compliance committee is involved with that to make sure there are no outliers in the group. This is because it is the outliers that get us in trouble.

Is there anything else you would like to highlight?

Then, there are certain, hard decisions that have to be made and rules that need to be established and communicated to the physician. We have instituted educational programs going over the American Urological Association (AUA) guidelines. In a 2-year period, individual members in our group review all of the AUA guidelines and we meet 4 times a year. Every 2 years, physicians in our group have been educated on the guidelines. Those are some of the simple measures that can be done to ensure good compliance within the groups.The takeaway message is that education is extremely important. We don't just blindly fine people for not doing things. Once we identify a problem, we sit down with the physician, educate them, and do re-audits of their charts to make sure that they have learned and are compliant. It makes documentation better, improves coding, improves reimbursement, and improves communication among physicians. There is a very big upside to try to bring people into line with things.

Hu JC, O’Malley P, Chughtai B, et al. Comparative effectiveness of cancer control and survival after robot-assisted versus open radical prostatectomy. J Urol. 2017;197(1):115-121.