NEW PROCEDURE IS LESS INVASIVE
U.S. doctors still getting experience in laparoscopic prostate-cancer surgery frequently used in France
By Dennis Fiely
THE COLUMBUS [OHIO] DISPATCH
Monday, July 15, 2002
A new wave of prostate-cancer surgery in France is only a ripple in the United States.
Surgeons in this country still are trying to perfect laparoscopic prostatectomies, pioneered by Drs. Guy Vallancien, Bertrand Guillonneau and colleagues at Institut Monsouris in Paris.
Former Mayor Greg Lashutka decided to fly to Paris last year for the procedure.
The surgery "is technically difficult and only a handful of surgeons in the world have enough experience to do it well," said Riverside Methodist Hospitals urologist Dr. John Burgers, a prostate-cancer specialist.
"If I wanted to have it done now, I'd go to France," Burgers said.
"I sent one of my patients there. Vallancien has probably done 1,000 of these."
Prostate Cancer Minimally Invasive Surgery, a patient-education center in Newton, Mass., lists 12 U.S. surgeons who perform the procedure.
The Cleveland Clinic and Henry Ford Hospital in Detroit are two of the leading centers in the approach.
Dr. Indebir S. Gill of the Cleveland Clinic has performed 180 of the operations during the past two years and is scheduling three to five a week.
"It will be a long time before the laparoscopic prostatectomy becomes a strong option in the hands of the average urologist," Gill said. "It is not worth it right now for the community urologist to get into this."
Dr. Michael Gong has performed four of the procedures at the James Cancer Hospital at Ohio State University Medical Center.
"He is a skillful, energetic young surgeon, but it is not unfair to say he is inexperienced," said Dr. Robert Bahnson, OSU's chief of urologic surgery. "We want one person doing them to build experience."
Instead of working through a large incision in the lower abdomen, surgeons remove the prostate by inserting slender tubes topped with tiny cameras, scalpels and tweezers through five holes in the abdomen.
Surgeons sometimes operate with a robotic instrument, controlled with a joystick like a video game, for increased maneuverability and precision.
"The public needs to know this is a challenging operation that requires someone with dedication, skill and experience," Bahnson said.
Laparoscopic procedures generally shorten hospital stays and speed recovery. Cleveland patients typically spend one night in the hospital and return to normal activity in two weeks, Gill said.
Surgeons hope that laparoscopic prostatectomies will spare nerve damage that causes incontinence and impotence.
The returns from Paris are promising.
Of 1,000 patients who received the surgery, more than 90 percent remained cancer-free after three years; 86 percent did not wear incontinence pads after one year; and 70 percent retained potency after six months.
Gill reports similar outcomes in Cleveland.
But the 5-year-old surgery is too new to definitively demonstrate more positive results than conventional "open" surgery.
"Even in centers where laparoscopy is performed, open surgery is the gold standard," Gill said.
Theoretically, laparoscopy enables surgeons to operate more carefully. The instruments improve a surgeon's view of the pelvic organs by providing better lighting and magnification, and cause less bleeding, which reduces the risk of damage to surrounding muscles and nerves.
Patients, however, spend at least one hour longer in the operating room and most insurance carriers are reluctant to pay for the more expensive procedure.
"The biggest disadvantage is the learning curve," Burgers said. "Until you have done a couple of hundred of these, you are not going to be very good at it."
Although nonsurgical treatments for prostate cancer are available, removal of the walnut-sized gland usually offers the best chance of survival.
Earlier diagnoses and technical improvements have combined to improve the outcomes from conventional surgery, surgeons noted.
"Just because an operation is laparoscopic does not mean it is better," Burgers said.
The James Cancer Hospital has had success with more than 400 nonsurgical procedures that kill tumors with radioactive-seed implants.
"The recurrence rates are similar to surgery and there seems to be less disruption of sexual function," Bahnson said.
All procedures risk impotency and incontinence, but the degree of risk varies from one procedure to another.
Laparoscopy "still has some bugs to be worked out," Burgers said. "And you still have to prove to me that it controls the cancer and the outcomes are just as good as open surgery.
"It may develop into the gold standard. Who knows? But right now patients are better off not being guinea pigs."
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