A case-mix-adjusted comparison of early
oncological outcomes of open and robotic
prostatectomy performed by experienced high
Jonathan L. Silberstein*, Daniel Su*, Leonard Glickman*, Matthew Kent†,
Gal Keren-Paz*, Andrew J. Vickers†, Jonathan A. Coleman*‡, James A. Eastham*‡,
Peter T. Scardino*‡and Vincent P. Laudone*‡
*Department of Surgery, Urology Service, and†Department of Epidemiology and Biostatistics, Memorial
Sloan-Kettering Cancer Center, and‡Department of Urology, Weill Cornell Medical Center, New York, NY, USA
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
• 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
• 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
• 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
• 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
© 2013 The Authors
BJU International © 2013 BJU International | 111, 206–212 | doi:10.1111/j.1464-410X.2012.11638.x
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Correspondence: Jonathan L. Silberstein, Urology Service,
Department of Surgery, Memorial Sloan-Kettering Cancer
Center, 1275 York Avenue, New York, NY 10065, USA.
Abbreviations: ORP, open radical prostatectomy; RALP,
robot-assisted laparoscopic prostatectomy; BCR,
biochemical recurrence; MSKCC, Memorial
Sloan-Kettering Cancer Center; BCRFS, BCR-free survival;
RP, radical prostatectomy; PLND, pelvic lymph node
dissection; NCCN, National Comprehensive Cancer
Silberstein et al.
© 2013 The Authors
BJU International © 2013 BJU International