Prostate News

Robot Versus Surgeon: No Clear Winner

Categories: Medical

Robot-assisted radical prostatectomy (RARP) led to complication rates, readmission rates, and rates of additional cancer therapy similar to those of conventional surgical prostatectomy, a review of almost 6,000 cases showed.

Patients who underwent RARP had significantly higher complications rates at 30 and 90 days, but blood loss and transfusion rates were lower, as was the risk of a prolonged hospital stay. After adjustment, the overall complication rates did not differ.

Total hospital reimbursement in the first year after surgery was significantly higher in the RARP patients, as reported online in the Journal of Clinical Oncology.

“RARP and open radical prostatectomy have comparable rates of complications and additional cancer therapies, even in the post-dissemination era,” Quoc-Dien Trinh, MD, of Dana-Farber Cancer Institute in Boston, and co-authors concluded. “Although RARP was associated with lower risk of blood transfusions and a slightly shorter length of stay, these benefits do not translate to a decrease in expenditures.”

A urologic oncologist with extensive clinical experience with open radical prostatectomy could not agree more.

“What I always tell patients [is that]I believe that the most important factor that can determine your outcome is the experience of a surgeon,” Herbert Lepor, MD, of NYU Langone Medical Center in New York City, told MedPage Today. “Obviously, the only way that you benefit from the experience of the surgeon is if they are in fact doing the operation.”

“I tell them, you don’t want [just] a technician during your operation,” he added. “You want a very competent technician but you also really want someone who understands this disease because understanding the disease has an impact on some of the decisions that you’re going to make about the operation beyond just the technical exercise.”

The argument that robotics can make a bad surgeon better doesn’t hold water with Lepor. “A bad surgeon shouldn’t be doing this in the first place.”

Introduced a decade ago, robot-assisted prostatectomy has become the dominant surgical technique for patients with localized prostate cancer. Investigators in some studies have suggested that robotic prostatectomy has driven the overall prostatectomy rate to a level beyond what would have been expected given current demographic and clinical trends.

One point of agreement is the higher cost associated with RARP, attributed at least in part to use of disposable materials and maintenance costs.

In the absence of randomized trials, proponents and opponents of RARP have relied on retrospective and observational or population-based studies to compare outcomes with RARP versus conventional open surgery. Many of the studies relied on results from early in the robotic period. Whether results would differ with more contemporary data remained unclear.

In an effort to provide an updated perspective outcomes with RARP, Trinh and colleagues analyzed data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results program for men with localized prostate cancer treated by prostatectomy from October 2008 through December 2009. Investigators used Medicare-linked data to examine costs.

The analysis comprised 5,915 patients with surgically treated localized prostate cancer, 2,439 by open prostatectomy and 3,476 by RARP.

Outcomes of interest included postoperative complications and blood transfusions at 30 and 90 days after surgery, postoperative complications, prolonged length of stay (beyond the median of 2 days), readmission at 30 and 90 days, administration of additional cancer therapies, and total expenditures in the first 12 months after surgery (versus expenditures in the 12 months before surgery).

Using data from the Nationwide Inpatient Sample, the authors found that use of RARP increased from 47.9% to 59.7% during the study period (P=0.001). Limiting the analysis to Medicare-eligible men yielded an increase from 46.% to 57.8% (P=0.004).

Complications were categorized as cardiac, respiratory, genitourinary, vascular, wound, and miscellaneous surgical and medical. In a bivariate analysis, the 30-day overall complication rate did not differ significantly between the groups. The PARP group had higher rates of genitourinary complications (P=0.001) but fewer miscellaneous complications (P=0.01).

Analysis of 90-day complication rates showed that the RARP group had fewer respiratory, wound, and miscellaneous complications, as well as a lower overall complication rate (P≤0.04 for all comparisons). The RARP group had a lower transfusion rate and shorter length of stay (P<0.001). Readmission rates did not differ significantly between the groups at 30 or 90 days.

Multivariate analyses showed no difference in 30- or 90-day complication rates. The RARP group still had higher rates of genitourinary and miscellaneous complications at both 30 and 90 days (P≤0.02). The odds of blood transfusion and prolonged length of stay were lower in patients who underwent RARP (P<0.001).

Use of adjuvant cancer therapies did not differ significantly between groups.

In the bivariate analysis, RARP was associated with a median first-year total charges of $13,394.40 versus $11,970.40 (P<0.001). In the multivariate analysis, 1-year charges remained significantly higher in the RARP group (OR 1.52, 95% CI 1.28-1.81, P<0.001).

“Although the benefits associated with the adoption of the minimally invasive approach are represented by lower risk of blood transfusion and by a slight reduction in length of hospital stay, these advantages do not translate into decreased charges relative to open surgery,” the authors concluded.

The authors of an accompanying editorial found the results “intriguing,” but noted the challenges inherent to measurement of complications and oncologic outcomes after radical prostatectomy. Postoperative complications, in particular, are closely related to a patient’s baseline comorbidities, said Misop Han, MD, and Debasish Sundi, MD, of Johns Hopkins.

Selection bias also might have influenced the results, as the patients in the study had a mean age of 69, 7 to 8 years older than men undergoing radical prostatectomy today in the U.S. Finally, the study does not permit inferences related to cancer control.

“Do the results of this study prove superiority or safety of one technique over another?” Han and Sundi asked. “The simple answer is no. Studies so far have provided conflicting results.”

The key finding, in their estimation, is that RARP and open prostatectomy led to similar overall complication rates. At the end of the day, the choice of technique is not as important as the choice of surgeon.

“Our recommendation for patients considering surgical treatment of their prostate cancer is not to choose a technique but to choose a surgeon is an expert at a given technique, to minimize surgical complication risk,” Han and Sundi concluded.

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