Its an art

The only way to cure prostate cancer, if detected early, is to undergo an operation called radical prostatectomy. Before the advent of robotic surgery with the Da Vinci Robotic System, the operation was performed through a sizeable incision in the abdomen. With the availability of robotic surgery, the same operation can be achieved through smaller incisions leading to shorter hospital stay, quicker recovery and less incidence of erectile dysfunction. According to urologists, it is not too difficult to become proficient at the technique of robotic surgery as the robot makes the surgery ’easier’ to perform as compared to an open prostatectomy. Does this equate to similar recurrence rate (or cancer control) as achieved with open prostatectomy?

Researchers from Memorial Sloan-Kettering Cancer Center reported their analysis of 7765 open radical prostatectomy cases carried out in 4 major US academic medical centres (J Natl Cancer Inst 2007; 99: 1171 – 1177). The study showed that the learning curve for prostate cancer recurrence after open radical prostatectomy was steep. The predicted probabilities of cancer recurrence at 5 years were 17.9% for patients treated by surgeons with 10 prior operations and 10.7% if performed by surgeons with 250 prior operations.

The same researchers just published their analysis of 4702 patients with prostate cancer treated laparoscopically (robotic surgery) at 7 centres in Europe and North America between January 1998 and June 2007 (Lancet Oncol epub; 2009 March 31). The 5 years risk for recurrence in patients treated by surgeons who had performed 10 laparoscopic prostatectomies was 17%. The rate became 16% when the surgeon had performed 250 laparoscopic prostatectomies. By the time the surgeon had performed 750 laparoscopic prostatectomies, the 5 years risk for recurrence had reached 9%. In other words, surgeons had to perform approximately 750 laparoscopic prostatectomies before they achieved the same low level of disease recurrence (10.7%) as surgeons who had performed 250 open prostatectomies. The study shows that the learning curve was even longer for those who perform laparoscopic radical prostatectomy. Interestingly, the study also found that surgeons with previous experience of open radical prostatectomy had significantly poorer results than those whose first operation was laparoscopic.

If medicine were pure science, then once a doctor has learnt the science of how to perform robotic surgery, his or her results should be consistent. To me, medicine is indeed not just science, it is a mixture of science and art. Hence the term - the art of medicine.