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Approaches to radical prostatectomy
“There is a continuing controversy on the actual advantages of this new technology.” Keywords: approaches • blood loss • continence • costs • open surgery • potency • radical prostatectomy • robot-assisted surgery • surgical margins
Radical prostatectomy is one of the most frequently performed procedures in genitourinary surgery. In the recent years, the robot-assisted minimally invasive approach gained great popularity both in the USA and Europe [1] . There is a continuing controversy on the actual advantages of this new technology. Although some authors consider robotassisted radical prostatectomy as the new standard of care [2] , others call any advantage of the costly robotic approach except from a lower blood loss into question [3–5] . Besides the robot-assisted technique, the conventionally laparoscopic transperitoneal or extra peritoneal approaches and the open retropubic or perineal approaches to the prostate are currently in use. Performing valid comparisons between the surgical approaches in radical prostatectomy is challenging. In nonrandomized studies, selection bias may meaningfully influence the results. More advanced tumors are more likely to be assigned to open surgery [6–8] . Moreover, compared with open radical prostatectomy, robot-assisted surgery is more often performed in patients who are young, white, healthy and live in higher income areas [7–10]. Technology-driven superspecialization (doing only one procedure on a daily basis) is another possible factor that may improve surgical outcome independent of which tool or approach is used [11] . Also with randomization, differences in skills and
10.2217/CER.14.45 © 2014 Future Medicine Ltd
preferences of the involved surgeons might have a greater impact than the putative intrinsic differences between the approaches. Considerable outcome differences exist between radical prostatectomy surgeons even within the same high-volume academic institution [12] . Concerning perioperative complications and additional cancer therapies – even in the postdissemination era of robot-assisted surgery – no differences other than lower transfusion rates and a shorter hospital stay in patients who underwent robot-assisted radical prostatectomy with, however, significantly higher costs, were found [13] . Several studies suggested an advantage for robotassisted surgery compared with the open retropubic approach concerning continence [14] or potency recovery [9] and surgical margin rates [15,16] , respectively. Considering the potential for meaningful bias due to selection and super-specialization effects, comparisons between open and robot-assisted radical prostatectomy should be interpreted with caution. It is conceivable that hidden biases and incomplete controlling for overt confounders may pretend or level off differences. The possibility of under-reporting adverse outcomes of robot-assisted surgery or overinterpretation of favorable data are further aspects worth being taken into consideration since the high investment costs need
J. Comp. Eff. Res. (2014) 3(5), 451–453
Michael Froehner Author for correspondence: Department of Urology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany Tel.: +49 351 458 2447 Fax: +49 351 458 4333 [email protected]
Manfred P Wirth Department of Urology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
part of
ISSN 2042-6305
451
Editorial Froehner & Wirth justification and favorable outcomes of the application of the new technology might be more attractive to journal editors than reporting negative results. In one meta-analysis suggesting a higher continence recovery rate after robot-assisted radical prostatectomy [14] in contrast to the findings of other meta-analyses [17,18] , two population-based studies revealing opposite results and comprising a multitude of patients compared with the number eventually included in the meta-analysis were excluded for methodological reasons [14] .
“
Currently, there is no conclusive evidence to favor any approach to radical prostatectomy with the exception of the criteria blood loss and possibly hospital stay (favoring robotic surgery) and costs (favoring open surgery).
”
Robot-assisted radical prostatectomy is associated with higher costs than open surgery due to the amortization of the robot, expensive disposable instruments, maintenance contracts and (depending on the procedures performed and the experience of the surgical team) longer times of operation theater use. If in all procedures for which cost analyses were performed robotic surgery would completely replace the conventional approaches, the additional costs have been estimated to account for US$2.5 billion per year in the USA [4] . If the application of robotic technology would lead to a case-volume increase – as suggested for
radical prostatectomy in the USA – this cost increase would be even higher [4] . Currently, the high costs (a difference approximately of US$2500 per case [19] which may even be superseded with interdisciplinary sharing of a single robot) are an obstacle hindering a general application of robots particularly outside of specialized centers in most parts of the world. Altogether, the skills and the experience of the surgeon are probably more important for outcome than the approach to radical prostatectomy. Currently, there is no conclusive evidence to favor any approach to radical prostatectomy with the exception of the criteria blood loss and possibly hospital stay (favoring robotic surgery) and costs (favoring open surgery). This could, however, change in the future given that the promising functional recovery results of highly specialized robotbased techniques like the Retzius sparing approach [20] will be confirmed with wider distribution. Financial & competing interests disclosure The authors perform radical prostatectomy both via the open retropubic approach and with the da Vinci® robot (Intuitive Surgical Systems, Inc.) and attended the console training offered by Intuitive Surgical Systems, Inc. (CA, USA). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript.
References 1
2
3
4
5
452
Huang KH, Carter SC, Shih YC et al. Robotic and standard open radical prostatectomy: oncological and quality-of-life outcomes. J. Comp. Eff. Res. 2(3), 293–299 (2013).
versus robot-assisted laparoscopic approach. Urol. Int. 90(1), 36–40 (2013). 8
Froehner M, Novotny V, Koch R et al. Perioperative complications after radical prostatectomy: open versus robot-assisted laparoscopic approach. Urol. Int. 90(3), 312–315 (2013).
9
Kim SC, Song C, Kim W et al. Factors determining functional outcomes after radical prostatectomy: robotassisted versus retropubic. Eur. Urol. 60(3), 413–419 (2011).
10
Barbash GI, Glied SA. New technology and health care costs – the case of robot-assisted surgery. N. Engl. J. Med. 363(8), 701–704 (2010).
Parsons JK, Messer K, Palazzi K et al. Diffusion of surgical innovations, patient safety and minimally invasive radical prostatectomy. JAMA Surg. doi:10.1001/ jamasurg.31 (2014) (Epub ahead of print).
11
Healy KA, Gomella LG. Retropubic, laparoscopic or robotic radical prostatectomy: is there any real difference? Semin. Oncol. 40(3), 286–296 (2013).
Wirth MP, Froehner M. Radical prostatectomy only centers – the future in genitourinary surgery? Eur. Urol. 57(6), 953–954 (2010).
12
Vickers A, Savage C, Bianco F et al. Cancer control and functional outcomes after radical prostatectomy as markers of surgical quality: analysis of heterogeneity between surgeons at a single cancer center. Eur. Urol. 59(3), 317–322 (2011).
13
Gandaglia G, Sammon JD, Chang SL et al. Comparative effectiveness of robot-assisted and open radical
Hatiboglu G, Teber D, Hohenfellner M. Robot-assisted prostatectomy: the new standard of care. Langenbecks Arch. Surg. 397(3), 343–352 (2012). Kang DC, Hardee MJ, Fesperman SF et al. Low quality of evidence for robot-assisted laparoscopic prostatectomy: results of a systematic review of the published literature. Eur. Urol. 57(6), 930–937 (2010).
6
Minniti D, Chiadò Piat S, Di Novi C. Robot-assisted versus open radical prostatectomy: an evidence-based comparison. Technol. Health Care 19(5), 331–339 (2011).
7
Froehner M, Koch R, Leike S et al. Urinary tract-related quality of life after radical prostatectomy: open retropubic
J. Comp. Eff. Res. (2014) 3(5)
future science group
Approaches to radical prostatectomy
prostatectomy in the postdissemination era. J. Clin. Oncol. 32(14), 1419–1426 (2014). 14
15
16
Ficarra V, Novara G, Rosen RC et al. Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur. Urol. 62(3), 405–417 (2012). Sooriakumaran P, Srivastava A, Shariat SF et al. A multinational, multi-institutional study comparing positive surgical margin rates among 22393 open, laparoscopic and robot-assisted radical prostatectomy patients. Eur. Urol. doi:10.1016j.eururo.11.018 (2013) (Epub ahead of print). Hu JC, Gandaglia G, Karakiewicz PI et al. Comparative effectiveness of robot-assisted versus open radical prostatectomy cancer control. Eur. Urol. doi:10.1016j. eururo.02.015 (2014) (Epub ahead of print).
future science group
17
Parsons JK, Bennett JL. Outcomes of retropubic, laparoscopic and robotic-assisted prostatectomy. Urology 72(2), 412–416 (2008).
18
Ferronha F, Barros F, Santos VV et al. Is there any evidence of superiority between retropubic, laparoscopic or robot-assisted radical prostatectomy? Int. Braz. J. Urol. 37(2), 146–158 (2011).
19
Kim SP, Shah ND, Karnes RJ et al. Hospitalization costs for radical prostatectomy attributable to robotic surgery. Eur. Urol. 64(1), 11–16 (2013).
20
Galfano A, Di Trapani D, Sozzi F et al. Beyond the learning curve of the Retzius-sparing approach for robotassisted laparoscopic radical prostatectomy: oncologic and functional results of the first 200 patients with ≥1 year of follow-up. Eur. Urol. 64(6), 974–980 (2013).
www.futuremedicine.com
Editorial
453
Approaches to radical prostatectomy
“There is a continuing controversy on the actual advantages of this new technology.” Keywords: approaches • blood loss • continence • costs • open surgery • potency • radical prostatectomy • robot-assisted surgery • surgical margins
Radical prostatectomy is one of the most frequently performed procedures in genitourinary surgery. In the recent years, the robot-assisted minimally invasive approach gained great popularity both in the USA and Europe [1] . There is a continuing controversy on the actual advantages of this new technology. Although some authors consider robotassisted radical prostatectomy as the new standard of care [2] , others call any advantage of the costly robotic approach except from a lower blood loss into question [3–5] . Besides the robot-assisted technique, the conventionally laparoscopic transperitoneal or extra peritoneal approaches and the open retropubic or perineal approaches to the prostate are currently in use. Performing valid comparisons between the surgical approaches in radical prostatectomy is challenging. In nonrandomized studies, selection bias may meaningfully influence the results. More advanced tumors are more likely to be assigned to open surgery [6–8] . Moreover, compared with open radical prostatectomy, robot-assisted surgery is more often performed in patients who are young, white, healthy and live in higher income areas [7–10]. Technology-driven superspecialization (doing only one procedure on a daily basis) is another possible factor that may improve surgical outcome independent of which tool or approach is used [11] . Also with randomization, differences in skills and
10.2217/CER.14.45 © 2014 Future Medicine Ltd
preferences of the involved surgeons might have a greater impact than the putative intrinsic differences between the approaches. Considerable outcome differences exist between radical prostatectomy surgeons even within the same high-volume academic institution [12] . Concerning perioperative complications and additional cancer therapies – even in the postdissemination era of robot-assisted surgery – no differences other than lower transfusion rates and a shorter hospital stay in patients who underwent robot-assisted radical prostatectomy with, however, significantly higher costs, were found [13] . Several studies suggested an advantage for robotassisted surgery compared with the open retropubic approach concerning continence [14] or potency recovery [9] and surgical margin rates [15,16] , respectively. Considering the potential for meaningful bias due to selection and super-specialization effects, comparisons between open and robot-assisted radical prostatectomy should be interpreted with caution. It is conceivable that hidden biases and incomplete controlling for overt confounders may pretend or level off differences. The possibility of under-reporting adverse outcomes of robot-assisted surgery or overinterpretation of favorable data are further aspects worth being taken into consideration since the high investment costs need
J. Comp. Eff. Res. (2014) 3(5), 451–453
Michael Froehner Author for correspondence: Department of Urology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany Tel.: +49 351 458 2447 Fax: +49 351 458 4333 [email protected]
Manfred P Wirth Department of Urology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
part of
ISSN 2042-6305
451
Editorial Froehner & Wirth justification and favorable outcomes of the application of the new technology might be more attractive to journal editors than reporting negative results. In one meta-analysis suggesting a higher continence recovery rate after robot-assisted radical prostatectomy [14] in contrast to the findings of other meta-analyses [17,18] , two population-based studies revealing opposite results and comprising a multitude of patients compared with the number eventually included in the meta-analysis were excluded for methodological reasons [14] .
“
Currently, there is no conclusive evidence to favor any approach to radical prostatectomy with the exception of the criteria blood loss and possibly hospital stay (favoring robotic surgery) and costs (favoring open surgery).
”
Robot-assisted radical prostatectomy is associated with higher costs than open surgery due to the amortization of the robot, expensive disposable instruments, maintenance contracts and (depending on the procedures performed and the experience of the surgical team) longer times of operation theater use. If in all procedures for which cost analyses were performed robotic surgery would completely replace the conventional approaches, the additional costs have been estimated to account for US$2.5 billion per year in the USA [4] . If the application of robotic technology would lead to a case-volume increase – as suggested for
radical prostatectomy in the USA – this cost increase would be even higher [4] . Currently, the high costs (a difference approximately of US$2500 per case [19] which may even be superseded with interdisciplinary sharing of a single robot) are an obstacle hindering a general application of robots particularly outside of specialized centers in most parts of the world. Altogether, the skills and the experience of the surgeon are probably more important for outcome than the approach to radical prostatectomy. Currently, there is no conclusive evidence to favor any approach to radical prostatectomy with the exception of the criteria blood loss and possibly hospital stay (favoring robotic surgery) and costs (favoring open surgery). This could, however, change in the future given that the promising functional recovery results of highly specialized robotbased techniques like the Retzius sparing approach [20] will be confirmed with wider distribution. Financial & competing interests disclosure The authors perform radical prostatectomy both via the open retropubic approach and with the da Vinci® robot (Intuitive Surgical Systems, Inc.) and attended the console training offered by Intuitive Surgical Systems, Inc. (CA, USA). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript.
References 1
2
3
4
5
452
Huang KH, Carter SC, Shih YC et al. Robotic and standard open radical prostatectomy: oncological and quality-of-life outcomes. J. Comp. Eff. Res. 2(3), 293–299 (2013).
versus robot-assisted laparoscopic approach. Urol. Int. 90(1), 36–40 (2013). 8
Froehner M, Novotny V, Koch R et al. Perioperative complications after radical prostatectomy: open versus robot-assisted laparoscopic approach. Urol. Int. 90(3), 312–315 (2013).
9
Kim SC, Song C, Kim W et al. Factors determining functional outcomes after radical prostatectomy: robotassisted versus retropubic. Eur. Urol. 60(3), 413–419 (2011).
10
Barbash GI, Glied SA. New technology and health care costs – the case of robot-assisted surgery. N. Engl. J. Med. 363(8), 701–704 (2010).
Parsons JK, Messer K, Palazzi K et al. Diffusion of surgical innovations, patient safety and minimally invasive radical prostatectomy. JAMA Surg. doi:10.1001/ jamasurg.31 (2014) (Epub ahead of print).
11
Healy KA, Gomella LG. Retropubic, laparoscopic or robotic radical prostatectomy: is there any real difference? Semin. Oncol. 40(3), 286–296 (2013).
Wirth MP, Froehner M. Radical prostatectomy only centers – the future in genitourinary surgery? Eur. Urol. 57(6), 953–954 (2010).
12
Vickers A, Savage C, Bianco F et al. Cancer control and functional outcomes after radical prostatectomy as markers of surgical quality: analysis of heterogeneity between surgeons at a single cancer center. Eur. Urol. 59(3), 317–322 (2011).
13
Gandaglia G, Sammon JD, Chang SL et al. Comparative effectiveness of robot-assisted and open radical
Hatiboglu G, Teber D, Hohenfellner M. Robot-assisted prostatectomy: the new standard of care. Langenbecks Arch. Surg. 397(3), 343–352 (2012). Kang DC, Hardee MJ, Fesperman SF et al. Low quality of evidence for robot-assisted laparoscopic prostatectomy: results of a systematic review of the published literature. Eur. Urol. 57(6), 930–937 (2010).
6
Minniti D, Chiadò Piat S, Di Novi C. Robot-assisted versus open radical prostatectomy: an evidence-based comparison. Technol. Health Care 19(5), 331–339 (2011).
7
Froehner M, Koch R, Leike S et al. Urinary tract-related quality of life after radical prostatectomy: open retropubic
J. Comp. Eff. Res. (2014) 3(5)
future science group
Approaches to radical prostatectomy
prostatectomy in the postdissemination era. J. Clin. Oncol. 32(14), 1419–1426 (2014). 14
15
16
Ficarra V, Novara G, Rosen RC et al. Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur. Urol. 62(3), 405–417 (2012). Sooriakumaran P, Srivastava A, Shariat SF et al. A multinational, multi-institutional study comparing positive surgical margin rates among 22393 open, laparoscopic and robot-assisted radical prostatectomy patients. Eur. Urol. doi:10.1016j.eururo.11.018 (2013) (Epub ahead of print). Hu JC, Gandaglia G, Karakiewicz PI et al. Comparative effectiveness of robot-assisted versus open radical prostatectomy cancer control. Eur. Urol. doi:10.1016j. eururo.02.015 (2014) (Epub ahead of print).
future science group
17
Parsons JK, Bennett JL. Outcomes of retropubic, laparoscopic and robotic-assisted prostatectomy. Urology 72(2), 412–416 (2008).
18
Ferronha F, Barros F, Santos VV et al. Is there any evidence of superiority between retropubic, laparoscopic or robot-assisted radical prostatectomy? Int. Braz. J. Urol. 37(2), 146–158 (2011).
19
Kim SP, Shah ND, Karnes RJ et al. Hospitalization costs for radical prostatectomy attributable to robotic surgery. Eur. Urol. 64(1), 11–16 (2013).
20
Galfano A, Di Trapani D, Sozzi F et al. Beyond the learning curve of the Retzius-sparing approach for robotassisted laparoscopic radical prostatectomy: oncologic and functional results of the first 200 patients with ≥1 year of follow-up. Eur. Urol. 64(6), 974–980 (2013).
www.futuremedicine.com
Editorial
453
