Is a robot really better at prostate surgery?

CAMPING in Somerset with his grandchildren, David Forrester felt an urgent need for the loo in the early hours. Normally a sound sleeper, he put it down to the night-time chill and a little too much tea.

But that night he went so many times he ended up falling asleep on the loo, he recalls four years later.

He went to his GP as soon as he got home a few days later.

He had a PSA test (which checks for prostate specific antigen: raised levels of this protein can indicate a problem, including cancer).

It had gone from his normal reading of three to 6.27, says David, who is married to Lynn, 62, and has three children and three grandchildren.

A biopsy confirmed he had prostate cancer. David says: ‘It was a shock. I’ve worked as an operating theatre manager in the NHS and Lynn is a nurse, so we are pretty resilient.

‘But even so, the first question I asked the doctor was: “Am I going to die?” He said: “Yes, but not from prostate cancer.” ’

David’s cancer had been caught early and he had a choice of treatment. One option was prostatectomy, removal of his prostate.

He knew that surgery, while potentially more likely to wipe out the cancer than radiotherapy, could have serious consequences.

Due to nerve damage, around 50 per cent of men are unable to achieve erections afterwards, while up to 30 per cent suffer urinary incontinence.

Meanwhile, radiotherapy, was less likely to cause such damage, but there was a chance cancer cells might escape.

It was a difficult choice — but there was one deciding factor.

The Freeman Hospital in Newcastle, where David was treated, had recently installed a robotic surgery machine, called Da Vinci.

This surgical robot, which has three arms and is operated by a trained surgeon sitting at a console at the back of the operating theatre, is spearheading a quiet revolution in hospitals across the UK.

More and more NHS trusts are using them for delicate procedures such as prostate removal, hysterectomies and gall bladder removal.

THE surgeon operates the robot using 3D images of the patient’s organs magnified up to ten times. The robot is positioned over the abdomen with cameras, cutting instruments and a telescope.

Using hand and foot controls, the surgeon manipulates the camera system and miniature instruments, allowing precise and delicate surgery to be done through tiny incisions.

Crucially, as well as magnified 3D imaging, the robot remains completely stable, cancelling out the risk of a surgeon’s hand tremor.

The first Da Vinci was installed in September 2000 at St Mary’s Hospital in London.

Initially, it was seen as highly experimental and take-up by other hospitals was slow.

But in the past five years, there has been an explosion in use, with 60 Da Vinci operating systems across the UK, with a third in NHS hospitals.

They cost £1.5 million each, plus £100,000 a year to service, though the majority of NHS machines are funded by charitable donations. ‘I read up about the Da Vinci robot and I knew it was right for me,’ says David.

‘Preserving my sexual function and preventing incontinence was immensely important.’

Following the four- hour operation, he spent two nights in hospital, then returned home — thankfully to a healthy sex life and only minor incontinence.

Around 1,000 prostate operations are carried out by robots in the UK every year.

But do they really deliver the clinical and financial benefits that justify the millions of pounds being invested?

Or has the NHS allowed their use to go ahead without demanding the exhaustive evidence needed for the approval of new drugs?

Last week, a study published in The Lancet found robots made little or no major difference for men having their prostates removed. In short, humans are just as effective.

Researchers from the University of Queensland in Brisbane, Australia, studied 326 men, half of whom had prostate tumours removed with ordinary surgery, the other half with robots.

Men who’d had robot surgery were in less pain immediately afterwards and had a better quality of life at six weeks, but after 12 weeks, there were no differences between the two.

One of the country’s top consultant urological surgeons is Alan Doherty, of University Hospitals Birmingham NHS Trust. He pioneered keyhole surgery for prostate removal more than a decade ago, then began using the Da Vinci robot system in 2014.

Now he has abandoned both and gone back to old-fashioned ‘open surgery’, where an incision is made in the lower abdomen and the prostate removed.

‘Why? Because it gives me better results than robot surgery or keyhole surgery,’ says Mr Doherty. ‘I did more than 1,000 keyhole operations and could not get the same good results as with open surgery. ‘When I look at my own results, in terms of men being able to get an erection, they were far more likely to be able to when I used open surgery. ‘ But robots are so in favour that few people are even doing open surgery. ‘I had a recent referral from London as no one there is doing open surgery any more. ‘With very little evidence, the robotic technique has taken off. That’s surprising and I think people are not being sceptical enough. ‘I’m not anti-technology, but the question is — is our money being well spent here?’ He says robots and keyhole instruments also deprive a skilled surgeon of a vital asset — touch. This can be crucial as cancerous tissue tends to be hard while healthy tissue is soft. ‘With open surgery, I can feel things,’ he says.

PROSTATE Cancer UK says only 13 per cent of prostate removals are done with open surgery — the rest are keyhole or robotic procedures (around 30 per cent are robotic).

The charity’s head of research funding Simon Grieveson says: ‘We need longer-term results before we can say whether one form of surgery leads to better outcomes than the other.’

But Marc Laniado, a consultant urological surgeon at the NHS Wexham Park Hospital in Berkshire and the private Windsor Urology Clinic, says that the beauty of the Da Vinci system is that it overrides the risk of human error, such as cutting a nerve.

He is convinced robotic surgery offers benefits, even though the latest study found no significant difference.

‘I’ve been using the Da Vinci system since 2008,’ he says.

‘It allows you to operate more consistently and reliably. A robot gives you a 3D perspective and you can record your procedures and go back and analyse what you did well and what you could improve on.’