RALP vs. LRP vs. open prostatectomy

An article by Hu et al. in the Journal of the American Medical Association this week is getting a lot of media visibility. (See for example the report from the Associated Press.) The “New” Prostate Cancer InfoLink thinks the article says more about the skills of individual surgeons than it does about the techniques and equipment that they use.

It is well known that the use of minimally invasive techniques to carry out radical prostatectomy has increased massively in recent years despite limited rigorous data on outcomes compared with the historically conventional open retropubic approach. According to Hu and his colleagues, compared with open retropubic radical prostatectomy, patients who underwent one of the minimally invasive procedures clearly did better in some areas and not so well in others:

  • They had had significantly shorter lengths of stay in the hospital, fewer respiratory and miscellaneous surgical complications, and fewer strictures after surgery
  • They had similar rates of use of additional cancer therapies post surgery.
  • They had more more genitourinary complications, erectile dysfunction, and incontinence.

However, what Hu and his colleagues actually did was to look at Medicare-linked data in the US Surveillance, Epidemiology, and End Results (SEER) database from 2003 through 2007. Among those data they were able to identify 8,837 men diagnosed with prostate cancer who underwent a radical prostatectomy, of whom 1,938 had had a minimally invasive procedure and 6,899 had had an open retropubic procedure.

During the period from 2003 to 2007, there was a major shift in the use of robotic surgery in the USA. Most urologic surgeons at that time would have been only starting to learn how to use a robot, and a tiny number might have been learning how to carry out LRP without a robot (which is generally considered to be a much more difficult procedure to learn). If we make the additional assumption that the majority of Medicare patients were unlikely to be getting their prostatectomies from surgeons with the highest skill levels, it makes perfect sense to us that (a) most of the surgeons doing the 1,938 minimally invasive procedures identified by Hu and his colleagues had done relatively few such procedures and (b) that the vast majority of these surgeons would have initially trained and had more time to develop their skills using open procedures.

The actual measures used by Hu et al. to compare outcomes were: postoperative 30-day complications; anastomotic stricture between 31 and 365 days post-surgery; long-term incontinence and erectile dysfunction (> 18 months post-surgery); and postoperative use of additional cancer therapies.

The results reported are as follows:

  • Use of minimally invasive techniques increased from 9.2 percent of cases in 2003 to 43.2 percent of cases in 2006-2007.
  • Men being treated with minimally invasive as opposed to open techniques were more likely to be Asian (6.1 vs 3.2 percent) and less likely to be black (6.2 vs 7.8 percent) or Hispanic (5.6 vs 7.9 percent).
  • Men being treated with minimally invasive as opposed to open techniques were more likely to live in areas with > 90 percent high school graduation rates (50.2 vs 41.0 percent) and with median annual incomes of at least $60 000 (35.8 vs 21.5 percent).
  • Actual differences in clinical outcome for minimally invasive (MIRP) as opposed to open techniques (RRP) were:
    • Median hospital stay — MIRP 2.0 days vs. RRP 3.0 days
    • Blood transfusion rates — MIRP 2.7 percent vs RRP 20.8 percent
    • Respiratory complications — MIRP 4.3 percent vs RRP 6.6 percent
    • Miscellaneous surgical complications — MIRP 4.3 percent vs RRP 5.6 percent
    • Anastomotic stricture — MIRP 5.8 percent vs RRP 14.0 percent
    • Genitourinary complications — MIRP 4.7 percent vs RRP 2.1 percent
    • Incontinence — MIRP 15.9  vs RRP 12.2 per 100 person-years
    • Erectile dysfunction — MIRP 26.8 vs 19.2 per 100 person-years
    • Use of additional cancer therapies — MIRP 8.2 vs RRP 6.9 per 100 person-years

It is easy to see that there were big benefits to the minimally invasive procedure in terms of less hospital time, fewer blood transfusions, and fewer strictures. There were smaller benefits related to respiratory and miscellaneous surgical complications. By comparison, the minimally invasive procedure was associated with a significant increase in the rate of genitourinary complications and long-term erectile dysfunction; a smaller increase in the rate of incontinence; and no significant change in the rate of additional cancer therapies.

The authors concluded that “Men undergoing MIRP vs RRP experienced shorter length of stay, fewer respiratory and miscellaneous surgical complications and strictures, and similar postoperative use of additional cancer therapies but experienced more genitourinary complications, incontinence, and erectile dysfunction.”

The “New” Prostate Cancer InfoLink concludes that the authors’ conclusion is accurate, but that without having detailed information on the level of training and skill of the surgeons involved, all we know is that on average there were some major benefits and some increase in complications that are well known to be dependent on the skill and experience of the surgeon. What’s the bottom line? Medicare patients should avoid being treated by “average” surgeons who are only just learning to use a robot!

2 Responses

  1. I just commented on this same report on the Us TOO Prostate Pointers support link. My reply drew these same conclusions:

    Interestingly the statistics for the … study were collected when the robotic daVinci system was in its somewhat “infancy,” with many urologists more in the learning stage of the appropriate manipulation and operation of the system that was breaking ground throughout the nation and world. With many urologists now having administered the procedure over a learning curve of 200 to 250 such procedures (several well over a thousand), and with improvements in the reconnection of the urethra to the bladder neck (anastomosis) and the intricacy of separating the neurovascular bundles from the gland, their expertise has improved tremendously since those earlier days; and time frame of return of continence as well as erectile function has similarly improved. I would venture to say that in another couple years, when statistics can be collected from 2007 to, say, 2010 or 2011, those statistics will be much different.

  2. A media release issued yesterday by Brigham and Women’s Hospital in Boston (where the study’s lead author, Dr. Hu, is a urologic surgeon) appears to endorse the perspective of The “New” Prostate Cancer InfoLink on the content of this article.

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