Is RALP potentially associated with fewer complications than open surgery?

A study from the prestigious Karolinska Institute in Sweden has provided some concrete evidence that — with an appropriately high caseload and experience — robot-assisted laparoscopic prostatectomy (RALP) may, in fact, be associated with a significant reduction in surgical complications by comparison with open, radical retropubic prostatecomy (RRP).

Now The “New” Prostate Cancer InfoLink wants to make it clear up front that it is the skill and experience of the individual surgeons involved that determines the results of retrospective data analyses like the one presented in this study, and it would not be wise to “generalize” this finding to every institution that wants to claim expertise in the use of da Vinci equipment to carry out RALPs (see below). However, …

Carlsson et al. have reported on the surgical complications of 1,738 consecutive patients with clinically localized prostate cancer who had a radical prostatectomy at their institution between January 2002 and August 2007. The results that they report are as follows:

  • 1,253 patients had a RALP and 485 had an RRP.
  • 170 patients required blood transfusions of whom 112 (23 percent) underwent an RRP and 58 (4.8 percent) underwent a RALP.
  • Infectious complications occurred in 44 RRP patients (9 percent) compared with 18 RALP patients (1 percent).
  • Bladder neck contractures was treated in 22 RRP patients (4.5 percent) compared with 3 RALP patients (0.2 percent).
  • Clavien grade IIIb-V complications were more common in RRP patients (n = 63; 12.9 percent) than in RALP patients (n = 46; 3.7 percent).

The authors conclude that the introduction of the RALP procedure at the Karolinksa Institute has reduced the numbers of patients who have Clavien grade IIIb-V complications (e.g., bladder neck contractures), who need blood transfusions during or immediately following surgery, and who have postoperative wound infections.

Despite the date presented above, and to follow up the point that we made at the beginning of this commentary, it is worth noting the findings of Murphy et al. in a forthcoming review to be published in European Urology. Having reviewed 68 papers that addressed the potential downsides of RALP, they list the following key points:

  • Device failure occurs in 0.2–0.4 percent of cases.
  • Assessment of functional outcome has been unsatisfactory to date because of non-standardized assessment techniques.
  • Overall complication rates of RALP are reported to be low, but higher rates are noted when complications are reported using a standardized system.
  • Long-term oncologic data and data on high-risk prostate cancer are limited.
  • There is a steep learning curve for surgeons, and although acceptable operative times can be achieved within <20 cases, individual surgeons may require experience with > 80 cases before a plateau level is achieved just for the incidence of positive surgical margins.
  • Robotic assistance does not reduce the difficulty associated with treatment of obese patients and those with large prostates, middle lobes, or previous surgery, in whom outcomes are less satisfactory than in patients without such factors.
  • Economic barriers prevent uniform dissemination of robotic technology.

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