Robot-assisted surgery is not necessarily better than open surgery

As we regularly point out, outcomes after surgery for prostate cancer are massively impacted by the skill, the experience, and the focus of the surgeon. The tools he or she uses to carry out the surgery may or may not be a factor. We simply do not really know.

A new study just published by Barry et al. in the Journal of Clincial Oncology pretty much confirms what we do and don’t know. The authors sought to compare the risks of problems with continence and sexual function after robot-assisted laparoscopic prostatectomy (RALP) and open radical prostatectomy among Medicare-eligible men. They sent a mail survey to a random sample of men drawn from the 20% Medicare claims files for August 1, 2008, through December 31, 2008. All men sent the sample had hospital and physician claims for radical prostatectomy and diagnostic codes for prostate cancer and reported undergoing either a robotic or open surgery.

The results of the study showed the following:

  • The average (median) time period for distribution of the survey to participants was 14 months post-surgery.
  • Completed surveys were obtained from 685/797 eligible participants (86 percent) of 797 eligible participants.
    • 406 patients reported having  had a RALP.
    • 220 patinets reported having had open surgery.
  • 189/607 men (31.1 percent) reported having a moderate or big problem with continence.
  • 522/593 men (88.0 percent) reported having a moderate or big problem with sexual function.
  • RALP was associated with a non-significant trend toward greater problems with continence (odds ratio [OR] = 1.41).
  • RALP was not associated with greater problems with sexual function (OR, 0.87).

The authors conclude that, “Risks of problems with continence and sexual function are high after both [RALP and open surgery]. Medicare-age men should not expect fewer adverse effects following robotic prostatectomy.”

An accompanying editorial in the Journal of Clincial Oncology (not available on line unless you are a subscriber) does note that men may have higher expectation of the quality of their outcome after RALP, which implies that even if their outcome is, in fact, better with RALP than with an open procedure, one may not see any evidence of this. This observation is certainly accurate. However, there is no way to really assess this with any accuracy because the surgeon factor is still probably more important than the equipment factor. As we have stated before, “A poor surgeon with access to a robot is still a poor surgeon.” For more information we refer readers to the Reuters report on this article.

One Response

  1. What if patients selecting method A had more diabetes and smoking history? Or more cancer and thus fewer nerves preserved? The equivalence of erectile function compared with method B would imply that method A was superior. And away we go speculating.

    This a retrospective, patterns-of-care, non-randomized study that does not account for coexisting illness or surgeon experience. In other words, this study sets up a hypothesis about method equivalence, but it does not test it. It is impossible to interpret.

    That said, laparoscopic prostatectomy, with or without a “robot,” was never about continence or erections. It was always about pain, suffering, and bleeding.

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