LRP vs Davinci?

[James]

<This posting is moved from the general site as requested>

 

I just came across this item

http://www.davinciprostatectomy.com/treatment-options/871407_rev_a_...

 

It lists outcomes post surgery for the two options.

 

It shows dramticly better outcomes for urinary and sexual function then LRP.

 

This is different then anything else I have seen on this topic - is this claim valid?

 

I realize this is an "Ad" for a device from a manufacturer - but the stats are still pretty impressive.

 

I was curious if anyone beleives them valid - or if they are viewed as pure fiction.

 

[James]

I am still curious if anyone else has looked at this and can offer an opinion.
The stats (which have refrences) all show that davinci has improved urinary and sexual outcomes from LAPRP.

Now since the publisher has a vested interest in this report (i.e. its on davinci web site) - I am curious if anyone has another source that is less biased.

[Arnon Krongrad, MD]

There are so many facets to this single question as it is posed that we could spend the next month just on this. They range from commercialism, conflict of interest, the nature of clinical trial design, retrospective vs. prospective data collection, standardization of functional definitions (see Erection Season), surgeon experience, the ills of an unrefereed information age (see Medicine Meet the Mouse) ... it's endless.

The question is not if anybody believes the presentation is valid. The question is if it is valid. And no, they are not pure fiction. They are under-characterized retrospective data, which are perfectly suitable for the generation of hypotheses. However, they do not test the hypothesis. In this case, because we know nothing about patient selection, selection and volunteer and other bias, data censoring due to death and/or drop-out, and surgeon exprience, the observations are essentially without any meaning. They should not have been used to support any health claim.

For some more perspective, you may with to review:

Surgical Robot Examined in Injuries

A Discussion About Robotic Surgery (audio)

It ain't the "clubs." It's the "Tiger Woods."

[James]

I like the analogy - and I appreciate its appropriateness.

I do not question that the surgical skill of the surgeon is the most importatant factor.

I just wonder - if you combine the best surgeons with the best tools will you not get the best outcomes on average?

And then - if yes - which tools are the best (LAPRP or Davinci or other).....just posing a question for consideration..not meaning to imply one technique is superior to another.

[Arnon Krongrad, MD]

Great question. So which tools are "best?"

The fact is that you cannot dissociate the tool from the surgeon and his experience in using that tool. So a surgeon who has done 4,000 open prostatectomies over 30 years would be expected to have spectacular results with open surgery, though not laparoscopic surgery.

One reason this surgeon will have spectacular results is that he will have learned which tools to use -- in his hands -- and how to use them. In other words, the great surgeons choose their tools; does this not seem obvious? Sadly, what we see today is commercially driven perversion: The tools choose the surgeon. This is called marketing pressure and as the WSJ article linked above illustrates, it can lead to surgical disaster and even death.

Having said that, I firmly believe that minimally invasive surgery is much less bloody and painful than open surgery. I am saying this from a perspective of 15 years of open surgery and now 11 years of minimally invasive surgery with a range of gizmos. This does not mean that one should always select minimally invasive surgery. Remember: The surgeon is what matters. So given a minimally invasive surgeon at at a hospital with a commercial conflict of interest or a very experienced open surgeon, the latter is the obvious choice.

Please understand that what you framed above as "LRP vs. Davinci" implies a false distinction, although I think I know what you meant. Indeed, "daVinci" is an LRP: laparoscopic radical prostatectomy:

1) Laparoscopic = minimally invasive
2) Radical = the whole organ is removed along with seminal vesicles and/or lymph nodes
3) Prostatectomy = we're talking about the prostate

So the only real question is which gizmo did the surgeon use in doing the LRP. To this there are many possible "robot" answers: none, AESOP, Raven, Viky, Freehand, daVinci, and others.

Having used AESOP and da Vinci, I'll say simply that my patients do the same no matter which I use. They take an average of 2 Tylenols in the first 24 hours, they don't get transfused, they leave the morning after. Not counting the fact that da Vinci requires an extra hole and bigger holes -- and costs the system a lot more money that goes to Wall Street -- the gizmo makes no difference.

Tiger Woods knows which clubs to use. Don't micromanage them on behalf of the club makers. That's conflict of interest. And in the case of surgery, it's left patients injured and dead.

[James]

Thank you for the thoughful response.
It is a topic that is hard to not think about in a culture or marketing.
Davinci is being sold and marketed hard - and it seems we (prospective patients) would be obligated to look at it - hence my original post. Your answer helps frame the discusion.

[Arnon Krongrad, MD]

Yes. Many things are marketed hard. Think about pomegranate juice. There are no data to support health claims. Has that mattered? Nope. At least with pomegranate juice the risks seem to be low. Not so with surgical devices.

In an age that combines snake oil salesmanship with an open internet, patients are more vulnerable than ever because they do not have the means to defend themselves against false claims that can come from a world away. This is why civil, interactive, and constructive forums like this one are so vital. They permit those with knowledge to share them. On our prostate cancer forum, which now numbers close to 2,000 members worldwide, we bring together patients, wives, surgeons, radiation oncologists, pathologists, scientists ... It is setting a very high standard for knowledge sharing, which depends on everyone, all the stakeholders, buying into the notion that we need to work together. I hope the same happens with this forum.

Read Medicine Meets the Mouse. We are living in transformational times and the implications are profound.

[James]

I read the wall street journal piece. That was very good. It does show the pressure of overmarketing something.

But it also does hit to my point a little - it mentions several of the doctors saying that while it may take hundreds of surgeries to master it (more then many do that actually use it daily) - it can provide supperior results in the hands of an experienced surgeon (so the Dr in the article says at least - and yes - I am paraphrasing).

That goes to my question about the best tools in the best hands ....and while I agree with the Tiger Woods comment - you have to admit - he ain't buying his clubs at walmart either.

So - it will be interesting to see if with all of the marketing pressure - will newer urologists be trained only with robotic lap removal techniques - or will traditional laproscopic be around for the long haul -

I am glad to hear that your results are not apprecitably different with either technique - I am glad that you provide that self evaluation.

Thanks again.

[Arnon Krongrad, MD]

LRP and what you call "da Vinci" are one the same. So my results are not the same with "either" technique. My results are the same with the same technique using either gizmo.

Of course Tiger's not buying the wrong clubs. If he did he wouldn't be Tiger. Likewise, great surgeons select the right clubs, or at least, relieved of marketing pressures, they should. Gizmo selection is not apart from great surgeons. Gizmo selection is part of being a great surgeon. That's the point. A great surgeon knows which clubs he needs. Find the great surgeon. Then don't micro-manage how he works.

Hundreds of cases to master? That shows their inexperience. A great surgeon never stops learning. And great surgeons have done thousands of cases.

It can provide "superior" results in the hands of an experienced surgeon. Is this a revelation? Is this not teleological and self evident? After all, an experienced surgeon is a superior surgeon, partly for having practiced and partly for having selected the right instruments that give the great results in his hands.

Nobody has a crystall ball. Nobody knows what happens when exuberant marketing meets financial limits. The fact is that da Vinci has saturated many markets and caused many hospitals to lose lots of money; and as the WSJ article showed, many surgeons to lose judgment and cause patients to do badly. The real issue is does it introduce a clinical advantage in the hands of experienced surgeons, the only kind of surgeons we care to deal with. On this point, the answer is obvious: No.