Robotic Prostatectomy: The Rise of the Machines or Judgment Day

Abstract

Utilization of robotic prostatectomy has increased since its introduction in 2000 [1]. Trinh et al provide a national snapshot of the current trends in surgical treatment of prostate cancer (PCa) [2]. Although the enthusiasm for robotic prostatectomy is driven by surgeons, consumers, and the robotmanufacturer, the size of the shift is presented clearly in this manuscript. In 2008 and 2009, >60% of all prostatectomies were performed using robotics, with substantial growth from 2003 (9.3%) to 2007 (43%) [3]. The trend toward robot-assisted surgery for PCa is obvious, but the benefits for patients are not as clear cut. One of themajor issues in PCa today is the potential harm associated with the diagnosis and treatment of men who may not benefit from that treatment. In 2010, 217 000 men in the United States were diagnosed with PCa [4]; however, with PCa-specific mortality ranging from 3% to 10% [5], not all men diagnosed with PCa will benefit from surgery. With the proliferation of robotic surgery, are we any closer to decreasing PCa-specific mortality by removing aggressive cancers? Unfortunately, it is difficult to answer this question by analyzing the Nationwide Inpatient Sample (NIS), as Trinh et al did [2], because it does not provide information on grade and stage of cancers treated. The proportion of these men who would be candidates for active surveillance cannot be assessed. Trinh and colleagues confirm that the introduction and proliferation of robotics has hastened the centralization of delivery of PCa surgery [2]. Robotic surgery was more likely to occur in urban hospitals (98%) and teaching hospitals (72%), with a median hospital caseload of 159 procedures a year—more than double of the median caseload of the hospitals where patients who received open prostatectomy (64 cases) were treated. Simply by purchasing a robot, a hospital increases its prostatectomy volume by 12 cases per year [6]. The introduction of robotics resulted in the