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T.S.: Not at all. It is available mainly in
private practice. There are two or three public hospitals that have a robotic system right now.
Prof. Joseph A. Smith: You know, I keep mentioning that in the United States everybody has a robot. That's actually shameful in a sense, if you consider the amount of money that we have spent on overlapping robots and robots that sit at small hospitals that aren't used every day. I think that's actually a criticism of our health system.
But in places where you don't have the robot, then yes. Learn to be an excellent laparoscopic surgeon because there are clearly advantages compared to open surgery for many procedures.
T.S.: Radical prostatectomy has undergone significant transformation from a highly invasive procedure to a precise, predominantly robotic-assisted surgery. In your view, what have been the most critical developments in the evolution of this operation?
Prof. Joseph A. Smith: That’s a great question! I think there were several. Οne of them I have alluded to earlier is that the robot made it so most practitioners could perform the operation with good results. That wasn't true, at least in this country, with open radical prostatectomy. Yes, there was some excellent surgeons who did get good results, but the average urologist wasn't getting great results all the time. It could be a very bloody operation.
Bladder neck contracture could be a very difficult problem. I think nerve sparing in the hands of many people was almost a dream. It wasn't really something that was valid. So, I think the average urologist wasn’t getting very good results with open radical prostatectomy. The average urologist gets good results with the robotic surgery.
I can tell you we were doing robotic surgery almost routinely because there was less blood loss. But we were transfusing 2% or 3% of our open radical prostatectomy patients and it was not very common to have massive blood loss. Our bladder neck contracture rate was lower because we could get a more precise anastomosis. I think that there were enough advantages and I basically adopted the robotic procedure, even though, at least in my hands, the results were only a little bit better.
F.N.: Focal therapy has gained attention
in recent years as a less invasive option for treating prostate cancer. What are your thoughts on its future role in the management of prostate cancer? Do you believe it could eventually replace the surgical treatment
for certain patients?
Prof. Joseph A. Smith: Well, you just hit the nail on the head when you said “certain patients” - most patients no, certain patients yes. And the question is who are those certain patients, right? Willett Whitmore from Memorial Sloan Kettering back in the 70s had that famous statement that he made when it comes to prostate cancer: “Is cure possible? Is cure necessary? Is cure possible when it is necessary?” If you think about that, that's a really profound statement. I would tell you even today that when cure is necessary, it's probably not possible with surgery or focal therapy or radiation. So sadly, for most of the patients who are destined to die from prostate cancer, even if we catch them when we presume it’s early, we don't cure them. You know, the Gleason 9, the Gleason 10, the ISUP grade group 5, even some of the grade group 4, there are some of those that we detect and cure with local therapy, but it's not the majority.
So it's still true that most of the people on whom we operate, whether we're doing focal therapy or whether we're doing surgery, radical prostatectomy, are people who were not destined to die from their prostate cancer in the first place, no matter how careful we try to select them. I can look back at myself. I've truly tried never to operate on somebody that didn't need treatment. But the majority of the people actually didn't need treatment because they would have had a cancer that never progressed or they did have a bad one and, despite our treatment, we didn't cure them.
So, focal therapy is kind of lowering the bar a little bit, isn't it? Because if you believe what I just said, and I believe it, that to most of the people with bad cancers who are really going to get in trouble, our treatment is inadequate, then if we have someone with one of those cancers, focal therapy would be even less adequate. The good thing about focal therapy is that the morbidity that we impose on so many patients, who probably never benefit from treatment in the first place, is diminished. No one could argue that focal therapy has less morbidity than radical prostatectomy. I think we have to be very, very careful in whom we select.
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