In August, 2006, I served as a faculty member for the 2006 "Advanced Robotics Techniques" ("ART") of Prostatectomy Symposium hosted by Ash Tewari, M.D. at Weill Cornell School of Medicine in New York City. The meeting was a comprehensive course for practicing urologists that focused on the surgical treatment of prostate cancer and management of post-operative morbidities. This year's speakers included leaders in the field of prostate cancer therapy, including Peter Scardino, Louis Kavoussi, Robert Myers, Michael Koch, Jay Smith, Inderbir Gill, Vip Patel, and myself.

During my presentation, I described the criteria I use at the Texas Prostate Center when counseling patients regarding the best choice of therapy for each individual patient. Through careful study and analysis of the 759 consecutive patients treated surgically by me since 2000, certain key points have become apparent:

1. The majority of patients who undergo PSA-based screening for prostate cancer as part of their routine healthcare, and in whom prostate cancer is eventually diagnosed, have early stage, clinically localized prostate cancer.
2. Many of those patients who have very small tumors (< 3mm total) in a properly performed 10- or 12- core biopsy, that are Gleason 6 or lower, can often be followed on an active surveillance program rather than undergoing immediate treatment. Active surveillance at the Texas Prostate Center always includes at least one additional set of prostate biopsies obtained by me, within 6 months of the first biopsy or sometimes sooner, depending on the quality of the original biopsy.
3. Patients with significant, curable prostate cancer, e.g. those with at least 3 mm of Gleason 6 cancer, or any amount of Gleason 7 or greater tumors are probably best treated rather than deferring treatment with active surveillance.  Treatment options include surgery, image guided radiation therapy, brachytherapy, cryotherapy as well as other non-FDA approved therapies like high-intensity focused ultrasound (HIFU).
4. Patients with Gleason 6 tumor or less extensive Gleason 7 tumors are excellent candidates for Robotic Assisted Laparoscopic Prostatectomy (RALP). Patients treated with RALP can expect an excellent outcome, with low, "best in class" positive margin rates, a shorter hospital stay, lower blood loss, and a more rapid and complete return of both continence and potency after surgery, compared to standard, open RP techniques.
5. Continuing advancements in our technique for performing RALP, most dramatically when we began to include perform both anterior and posterior reconstruction of the urinary rhabdosphincter during the robotic prostatectomy procedure, have dramatically improved the recovery of continence in much the same way that a similar technical change in the technique for open RP, instituted in 1990 by Dr. Peter Scardino, had a dramatically positive effect on the recovery of continence after open RP.
6. Patients with larger Gleason 7 tumors, or those with high grade, Gleason 8 - 10, are most effectively treated when a careful, extended lymph node dissection, that includes the removal of all lymph nodes situated in the iliac, hypogastric, and obturator regions, is performed as part of the prostatectomy procedure. This type of lymph node dissection is more difficult when performed robotically and requires a surgeon skilled in this technique to achieve optimal outcomes.  Remarkably high cure rates, even when a single lymph node is found to be involved with prostate cancer, have been achieved by applying this advanced technique in lymph node dissection for these selected, higher risk patients.
7. Patients with larger Gleason 7 - 10 tumors, situated primarily at the base of the prostate, who have a high risk of seminal vesicle invasion, can achieve a lower positive margin rate and higher cure rates than those with similar tumors treated with standard techniques, either open or robotic, when treated with an advanced open surgical approach to surgery, called "en bloc" resection of the prostate.  Again, this more complicated technique requires a surgeons skilled in this modification of the standard technique.
8. Tailoring the approach for each individual patient depending on his circumstances, rather than applying a one size fits all approach allows the surgeon to individualize the best available therapies, maximizing cancer cure and quality of life outcomes, depending on each patient's unique set of circumstances.

    

This presentation sparked a thoughtful dialogue amongst the physicians and experts present regarding the proper role of surgery, including open and robotic techniques, in the treatment of clinically localized prostate cancer, and surprising consensus was reached on many key issues. We continue to study comprehensively every patient treated at the Texas Prostate Center to keep our outcomes data as up-to-date as possible so patients can be counseled using the best available data regarding the choices available to them