Recent reviews, reports and research relating to radical prostatectomy

Comparative effectiveness of robotic-assisted radical prostatectomy Vs open surgery. In a pre-print online version of a Journal of Clinical Oncology article by Giorgio Gandaglia et al dated 14 April 2014 is reported a post-hoc analysis of data from a SEER-Medicare linked (USA) database. The study involved records for 5,915 patients whom had radical prostatectomies through either the robot-assisted (RARP) or the open surgery (ORP) procedures. The authors concluded that: “RARP and ORP have comparable rates of complications and additional cancer therapies, even in the post-dissemination era. ...RARP was associated with lower risk of blood transfusions and a slightly shorter length of stay...”

In the same source is a related opinion piece by Debasish Sundi and Misop Han entitled “Limitations of Assessing Value in Robotic Surgery for Prostate Cancer: What Data Should Patients and Physicians Use to Make the Best Decision?” Their views are worth noting. They conclude that: “Perhaps the more important message of this well- conducted study by Gandaglia et al is that overall complications between RARP and ORP are quite similar. In 2014, we are truly in the RARP post- dissemination era. Whether RARP will become widely adopted is no longer in question - despite increased costs, it already has. Our recommendation for patients considering surgical treatment of their prostate cancer is not to choose a technique, but to choose a surgeon who is an expert at a given technique, to minimize surgical complication risk.”
The Gandaglia article
can be read here or here: http://tinyurl.com/lfajyjd The Sundi article can be read here or here: http://tinyurl.com/lsoo75l

Positive surgical margin (PSM) rates amongst open surgery, laparoscopic surgery and robot-assisted surgery patients.
In a European Urology article dated 24 November 2013 written by P Sooriakumaran et al is reported a large-scale study of PSMs for 22,393 patients who had radical prostatectomies through one of the three surgical procedures. PSMs are a known risk factor for biochemical recurrence of prostate cancer after surgery. The authors state that: "In this study, we compared the effectiveness of different types of surgery for prostate cancer by looking at the rates of cancer cells left at the margins of what was removed in the operations. We compared open, keyhole, and robotic surgery from many centers across the globe and found that robotic and keyhole operations appeared to have lower margin rates than open surgeries. How many cases a [medical] center and surgeon do seems to affect this rate for both robotic and keyhole procedures." More details about the study can be read here: http://www.ncbi.nlm.nih.gov/pubmed/24290695 and the full article is here: http://tinyurl.com/l75yy63

Article by Menon, M et al: Biochemical recurrence following robot-assisted radical prostatectomy: analysis of 1,384 patients with a median 5-year follow-up. European Urology 58(6) pp e53-e62 December 2010. The authors provide this ‘take home message’: ‘We present biochemical recurrence–free survival (BCRFS) outcomes for 1384 men who underwent robot-assisted radical prostatectomy (RARP) between 2001 and 2005, with the longest follow-up to date for this surgical approach. With a 5-yr actuarial BCRFS of 86.6%, RARP appears to confer effective 5-yr prostate cancer control.’ Viewable and downloadable as a 367 KB PDF file from here.

Article by Barbashi G I and Glied S A on health care costs of robot-assisted laparoscopic surgery reported in the New England Journal of Medicine 363:701-704, August 19 2010. In reaching their conclusions the authors note that: ‘To date, there have been no large-scale randomized trials of robot-assisted surgery, and the limited observational evidence fails to show that the long-term outcomes of robot-assisted surgery are superior to those of conventional procedures.’ and ‘ Various nonsurgical treatment alternatives for localized prostate cancer exist, with similar long-term outcomes and varying side effects, such as incontinence and impotence. Existing analyses suggest that as compared with open surgery, robot-assisted surgery does not diminish the frequency of these adverse effects.’ and ‘...the substantial short-term benefits in terms of postoperative recovery ... associated with robot-assisted procedures...’

Study on the
comparative effectiveness of minimally-invasive radical prostatectomy (MIRP) Vs open retropubic radical prostatectomy (RRP) by Hu J C et al reported in JAMA 2009 Oct. 14; 302(14) pp 1557-64. An abstract of the article is here. It indicates that the authors observed that MIRP vs RRP was associated with shorter length of stay (median, 2.0 vs 3.0 days), lower rates of blood transfusions (2.7% vs 20.8%), postoperative respiratory complications (4.3% vs 6.6%), miscellaneous surgical complications (4.3% vs 5.6%), and anastomotic stricture (5.8% vs 14.0%). However, MIRP vs RRP was associated with an increased risk of genitourinary complications (4.7% vs 2.1%) and diagnoses of incontinence (15.9 vs 12.2 per 100 person-years) and erectile dysfunction (26.8 vs 19.2 per 100 person-years). Rates of use of additional cancer therapies did not differ by surgical procedure.