A case-mix-adjusted comparison of early oncological outcomes of open and robotic prostatectomy performed by experienced high volume surgeons

Department of Surgery, Urology Service, New York, NY, USA.
BJU International (Impact Factor: 3.53). 02/2013; 111(2):206-12. DOI: 10.1111/j.1464-410X.2012.11638.x
Source: PubMed


WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Radical prostatectomy provides local-regional control of prostate cancer and is the most common treatment for prostate cancer in the United States. Over the past decade there has been a shift in the surgical approach used to treat this disease, moving from open retropubic approach to robot-assisted laparoscopic prostatectomy. While robotic prostatectomy has been demonstrated to result in less blood loss, fewer transfusions and shorter hospital duration, it has never been demonstrated in a meaningful prospective manner to result in improved or even equivalent oncological outcomes. Prior attempts to address this question have been hampered by methodological issues with study design, differences in case mix, or differences in surgical learning curve between surgeons. In this retrospective study we compared the oncological outcomes of open radical prostatectomy and robotic prostatectomy limiting our analysis to expert surgeons in their respective surgical approaches. Importantly, the patient cohort contained a majority of patients with intermediate- and high-risk features and all surgeons attempted to adhere to strict oncological principles, including performing complete pelvic lymph node dissections in almost all of the patients in the study. The results demonstrate that oncological outcomes show no significant difference with respect to surgical approach, even for patients with higher risk features, and that there is more variation between individual surgeons than between surgical approaches.
To compare early oncological outcomes of robot assisted laparoscopic prostatectomy (RALP) and open radical prostatectomy (ORP) performed by high volume surgeons in a contemporary cohort.
We reviewed patients who underwent radical prostatectomy for prostate cancer by high volume surgeons performing RALP or ORP. Biochemical recurrence (BCR) was defined as PSA ≥ 0.1 ng/mL or PSA ≥ 0.05 ng/mL with receipt of additional therapy. A Cox regression model was used to evaluate the association between surgical approach and BCR using a predictive model (nomogram) based on preoperative stage, grade, volume of disease and PSA. To explore the impact of differences between surgeons, multivariable analyses were repeated using surgeon in place of approach.
Of 1454 patients included, 961 (66%) underwent ORP and 493 (34%) RALP and there were no important differences in cancer characteristics by group. Overall, 68% of patients met National Comprehensive Cancer Network (NCCN) criteria for intermediate or high risk disease and 9% had lymph node involvement. Positive margin rates were 15% for both open and robotic groups. In a multivariate model adjusting for preoperative risk there was no significant difference in BCR rates for RALP compared with ORP (hazard ratio 0.88; 95% CI 0.56-1.39; P = 0.6). The interaction term between nomogram risk and procedure type was not statistically significant. Using NCCN risk group as the covariate in a Cox model gave similar results (hazard ratio 0.74; 95% CI 0.47-1.17; P = 0.2). The interaction term between NCCN risk and procedure type was also non-significant. Differences in BCR rates between techniques (4.1% vs 3.3% adjusted risk at 2 years) were smaller than those between surgeons (2.5% to 4.8% adjusted risk at 2 years).
In this relatively high risk cohort of patients undergoing radical prostatectomy we found no evidence to suggest that ORP resulted in better early oncological outcomes then RALP. Oncological outcome after radical prostatectomy may be driven more by surgeon factors than surgical approach.

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    • "The introduction of prostate specific antigen (PSA) assays means that more patients now undergo radical prostatectomy at earlier stages. However, pT3 disease still occurs in 25–58% of clinical T1 and T2 prostate cancer patients [1-4]. Although the management of patients with pT3 prostate cancer remains controversial, some reports recommend the use of adjuvant therapies in these patients [5-9]. "
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    ABSTRACT: Radical prostatectomy is used to treat patients with clinically localized prostate cancer, but there have been few reports of its use in locally advanced disease. We evaluated the long-term results of radical prostatectomy and immediate adjuvant androgen deprivation therapy in Japanese patients with pT3N0M0 prostate cancer. We retrospectively reviewed 128 patients with pT3N0M0 prostate cancer who underwent radical prostatectomy at our institute from 2000 to 2006. All pT3N0 patients were treated with adjuvant androgen deprivation therapy shortly after radical prostatectomy. Immediate adjuvant androgen deprivation therapy was continued for at least 5 years. Twenty-three were excluded because of preoperative hormonal therapy, missing data, or others. Death from any cause, death from prostate cancer, clinical recurrence and hormone-refractory biochemical progression were analyzed by Kaplan-Meier graphs. Relative risks of progression were estimated using Cox proportional hazards models with 95% confidence intervals. The 10-year hormone-refractory biochemical progression-free survival rate was 88.3% and the cancer-specific survival rate was 96.3% after a median follow-up period of 8.2 years (range 25.6-155.6 months). Higher clinical stage (p = 0.013), higher Gleason score at biopsy (p = 0.001), seminal vesicle invasion (p = 0.003) and microlymphatic invasion (p = 0.006) were predictive factors for hormone-refractory biochemical progression by univariate analyses. Multivariate analyses identified Gleason score at biopsy (p = 0.027) and seminal vesicle invasion (p = 0.030) as independent prognostic factors for hormone-refractory biochemical progression. None of the patients with clinical T1 cancers (n = 20), negative surgical margin (n = 12), or negative perineural invasion (n = 11) experienced hormone-refractory biochemical progression. Radical prostatectomy with immediate adjuvant androgen deprivation therapy may be a valid treatment option for patients with pT3N0M0 prostate cancer.
    Full-text · Article · Jan 2014 · BMC Urology
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    • "Despite a short follow-up (1 year), they found that RARP was not associated with lower rates of BCR-free survival or higher rates of PSMs. The same findings were confirmed for higher-risk patients receiving RARP when emphasis is placed on strict adherence to oncological surgical principles [21]. "
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    ABSTRACT: Since the first procedure performed in 2000, robotic-assisted radical prostatectomy (RARP) has been rapidly gaining increasing acceptance from both urologists and patients. Today, RARP is the dominant treatment option for localised prostate cancer (PCa) in the United States, despite the absence of any prospective randomised trial comparing RARP with other procedures. Robotic systems have been introduced in an attempt to reduce the difficulty involved in performing complex laparoscopic procedures and the related steep learning curve. The recognised advantages of this kind of minimally invasive surgery are three-dimensional (3D) vision, ten-fold magnification, Endowrist technology with seven degrees of freedom, and tremor filtration. In this article, we examine this technique and report its functional (in terms of urinary continence and potency) and oncologic results. We also evaluate the potential advantages of RARP in comparison with open and laparoscopic procedures.
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