4 Questions With a Prostate Cancer Expert: In Defense of Prostatectomy


Gregory Zagaja discusses the benefits of surgery for prostate cancer, as well as recent updates in the field.

Patients with prostate cancer could significantly benefit from either two types of prostatectomy — laparoscopic or — according to Gregory Zagaja.

In an interview with CURE, Zagaja, professor of Surgery, director of the Prostate Cancer Center at the University of Chicago Medicine, discussed the benefits of radical prostatectomy and other ongoing developments with surgery in prostate cancer.

What are some of the latest developments in terms of surgery for prostate cancer?

The merits of prostatectomy have been questioned recently, as a result of the US Preventative Task Force’s D-rating regarding screening for prostate cancer, as well as the treatment of prostate cancer. I would like to basically de-buff some of those [incorrect] notions about prostatectomy and the potential for significant surgical outcomes preoperatively, postoperatively and then long term—especially having to do with quality of life for men.

There are data from multiple institutions — some single-surgeon studies, some multi-institutional studies — looking at outcomes. Basically, the data show that whether a prostatectomy is done as a laparoscopic procedure (which is not done that often here in the United States) or robotically (the more common way in the United States), the outcomes are fairly comparable as long as the surgery is being performed by a high-volume surgeon.

The robotic studies have basically shown slight improvements with regard to continence and potency in the early postoperative period. However, by one year, potency and incontinence rates are quite comparable.

How have you seen robotic prostatectomies make an impact on patients?

Surprisingly, over time, the oncologic data suggest that positive surgical-margin rates are lower with robotic prostatectomy, and biochemical recurrence-free survival is also improved with robotic prostatectomy. In general, the data support that robotic prostatectomy is a viable option. It is a surgical option that is here to stay, and, in the correct hands, patients get excellent outcomes.The major advantage is that it probably has forced us, as surgeons and care providers, to critically look at outcomes, and to analyze how we deliver medical care and how we can do it better. It basically brought competition to the surgical arena of treating prostate cancer. Naysayers of the robotic procedure have adapted techniques, as well as critical pathways that have helped to better expedite the recovery of patients and, at the end of the day, the procedures have become more comparable.

How can these techniques be further improved?

At the onset of robotic prostatectomy, it seemed like there were these significant, huge advantages. Personally, I think that the advantages are minimal. They have to do with quality of life, but it is more with regard to perhaps less postoperative pain and quicker return to full functional activity on a day-to-day basis. Again, if we look at continence, potency rates, and cancer control rates, they are fairly comparable across the spectrum of surgical treatment options. The major advantages that we are seeing, and were reported recently by the American Neurologic Association (ANA), are the developing technology through research and development at Intuitive Surgical with regard to the utilization and fusing of radiographic imaging with the robot. Therefore, we might better be able to see areas of cancer on an MRI, for example, at the same time that we are doing surgery. Additionally, there is work with some radiotracers that might be helpful, as well, in identifying tumors, helping to assess for positive margins, or avoiding positive margins when we are trying to spare nerves for sexual function, for example.

Lastly, haptics — the ability to feel — is also undergoing significant technologic advancements. The one downside with robotic technology is that we do not have tactile feedback, and, for some, that has limited their progress in adapting the skillset. This will be, especially for the novice haptics, a tremendous advantage. I would also look to see what it would do for me, having been an experienced robotic surgeon, as well.

Can you speak to the USPSTF recommendations?

The comments from the USPSTF were that both screening as well as treatment for prostate cancer, whether it is surgical or radiation, cryotherapy, etc., have more risks than benefits for the patients. Particularly, when it comes to survival advantage, the Task Force felt that the data at the time these studies were conducted did not support the utilization of screening and, more specifically, treatment of prostate cancer, because most men develop it late in life, and they probably do not need to be treated, or perhaps not as aggressively, and in a more conservative manner.

ANA has taken heed to that initially, and there is a much greater interest in active surveillance and treating men with less morbid procedures, such as focal therapy, which is undergoing significant investigation in the United States. Focal therapy can be performed as thermal therapy, cryotherapy, radiation seeds, utilization of a cyber knife, but really trying to pinpoint therapy toward localized lesions within the prostate.

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