Expert Discusses Robotic Surgery for Prostate Cancer

Robotic surgery can have a multitude of benefits for patients who are undergoing a prostatectomy, leading to fewer reports of pain and blood loss, as well as shorter hospital stays, compared with open surgery.

Can you discuss the role of robotic prostatectomy in treating patients with prostate cancer?

In an interview with CURE, David Albala, M.D., urologist and medical director with Associated Medical Professionals, discussed some of the benefits of robotic surgery and the impact it has had on the field of prostate cancer, as well as methods that larger urology groups can use to better achieve compliance.In 2016, robotic surgery does have a firm implant in urological surgery, especially in oncology with prostatectomy, partial nephrectomy, and cystectomy work. The real benefit of robotic surgery is that patients can leave the hospital—the recovery time is much, much quicker than open surgery. It’s a minimally invasive procedure so there is less pain, and there’s less blood loss associated with these procedures. Now, an experienced robotic surgeon can do these procedures in a timely fashion.

Obviously, there’s a learning curve that’s associated with robotics, but most of us have passed that learning curve. We now have done 1,000 to 3,000 prostatectomies. The learning curve has passed.

The time of surgery is equivalent to open surgery, and, really, the efficacy of the procedure, complication rates, impotence, and incontinence are the types of complications similar to what we see in open surgery.

The patient benefits because the recovery time is much quicker, they’re out of the hospital typically in 1 day, and a catheter is left in place for approximately one week, which is somewhat shorter than what we saw in open surgery.

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

In prostatectomy, there are clearly benefits. For partial nephrectomy — taking out kidney tumors — these patients in my practice typically stay in the hospital overnight and are able to leave the hospital the next day. Many of the same benefits we see with prostatectomy can be translated into partial nephrectomy and cystectomy.All patients who are surgical candidates for the procedure can have it be done robotically. If a patient is a candidate for a prostatectomy, whether you do it with a retropubic approach, perineal approach, or robotic approach. All of those patients can be done robotically.

Obese patients can be done robotically with the new da Vinci System. These have longer reaches for their instruments; these procedures can be done with greater ease. Those were difficult with some of the earlier prototypes of the robot but, as the evolution of the robot has taken place, we can now do this on the obese patient much better, and so we get better results.

What impact has robotic surgery had in the field of prostate cancer?

Really, anything we can do with an open procedure, we can do robotically. The real benefit has been the shorter recovery time. There’s good documentation in the literature about blood loss. The average blood loss for a robotic prostatectomy is about 150 cubic centimeters, which is a small amount compared with an open prostatectomy — which is 700 to 1,000 cubic centimeters — so there is quite a difference.

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

What were the key points regarding achieving compliance in a large urology group?

The efficacy of the procedure and the complication rates are comparable. Where robotics really help patients are with blood loss, length of stay and catheter drainage time.Compliance within large urology groups is really an important quality of a practice not only for reimbursement, but also to avoid penalties.

Dr. Carl Olsson and I essentially went through steps 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 two or three times per year of each individual physician. What that does is allow us to see where the physician is in his coding, where the documentation of that physician is. If it’s 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.

It’s simple things, such as filling out and signing off on charts in a timely fashion. Those have been problems in large urology groups. We have 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.

What we found is that physicians comply when you essentially put demands on them. If they are financial demands, physicians 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 two standard deviations in using ultrasound, that physician would get an audit to see if the indications were proper, how he is doing the test, why he is doing the ultrasound, what the proper indications are, and whether he 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.

Finally, there are certain hard decisions that have to be made. Rules need to be established; they need to be communicated to the physician. We have instituted educational programs going over all of the American Urological Association (AUA) guidelines. In a two-year period, all the AUA guidelines are reviewed by individual members of our group. Every two years, the physicians in our group have been educated on the most up-to-date guidelines. Those are some of the simple measures that can be done to ensure compliance within the groups.