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Imaging technologies reshape prostate cancer treatment


Chicago-Although open radical prostatectomy remains the gold standard of treatment for clinically localized prostate cancer, laparoscopic prostatectomy and, more recently, robot-assisted laparoscopic prostatectomy are rapidly increasing in popularity as alternatives to traditional open prostatectomy techniques.

According to Inderbir S. Gill, MD, MCH, vice chairman and professor, Glickman Urologic Institute, Cleveland Clinic, intraoperative use of such imaging modalities as transrectal ultrasound of the prostate have made these new surgical approaches more sophisticated and precise.

"The ability of modern TRUS imaging is significant," Dr. Gill explained, "and we should be able to use that to our advantage during surgery."

However, Michael S. Cookson, MD, associate professor of urologic surgery, Vanderbilt University Medical Center, Nashville, TN, pointed out that the use of intraoperative TRUS should be considered investigational and not yet ready for routine clinical use.

"Most of the tumors I treat are not visible on TRUS, and, furthermore, are non-palpable. I would not think this would be useful for actually viewing the tumor," Dr. Cookson said. "However, it might assist in identification of the neurovascular bundle, and it is certainly worthy of continued clinical investigation."

For Dr. Cookson, a more useful tool may be augmented reality visualization (ARV), which he said "may be most useful as a tool for teaching the next generation of laparoscopic prostatectomists."

According to Dr. Gill, this new approach, refined by his team, allows surgeons to determine 3-D structures in real time. Although ARV has been used for some time in neurosurgery, it is more difficult to use in a less-fixed organ like the prostate, he said.

Dr. Gill feels that robotics offers some future benefits.

"The main advantage of robotics is a digital platform that hopefully will extend the surgeon's ability beyond what is humanly possible," he said.

"Robot-assisted laparoscopic prostatectomy is the most rapidly increasing treatment for clinically localized prostate cancer in the United States," Dr. Cookson added. "As many as 35% to 45% of patients undergoing radical prostatectomy will be treated with RALP [in 2006], while less than 2% will be treated with a pure laparoscopic approach."

Both Dr. Gill and Dr. Cookson agree, however, that regardless of treatment approach, surgical skill remains the most important factor influencing outcomes.

"I agree with Dr. Gill that no matter which surgical approach is utilized, surgeon skill and experience are the most important factors impacting cancer control and functional outcomes after radical prostatectomy," said Dr. Cookson.

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