Short-term (perioperative) outcomes of RALP compared to open surgery in 2008-09

A new study available on line as a full-text article in European Urology has provided a retrospective analysis of the perioperative outcomes of men undergoing radical prostatectomy for localized prostate cancer in a 15-month period between October 2008 and December 2009 at 20 percent of the community hospitals in the USA (including public hospitals and academic medical centers).

Trinh et al. used data from the National Inpatient Sample to evaluate various criteria among men with localized prostate cancer being treated by robort-assisted laparoscopic prostatectomy (RALP, n = 11,889) and open radical prostatectomy (ORP, n = 7,389). Men treated with non-robotic forms of laparoscopic radical prostatectomy (LRP, n = 184) were identified but not evaluated for perioperative outcome data. The criteria evaluated and compared by Trinh and his colleagues included:

  • Rates of blood transfusions
  • Rates of intraoperative and postoperative complications
  • Rates of prolonged length of stay (pLOS)
  • In-hospital mortality rates

The study offers us no data at all on the comparative oncologic outcomes of men over time or on the outcomes as they relate to such factors as recovery of continence, recovery of sexual function, post-surgical strictures, Peyronie’s disease, penile shortening or any other of the well-identified but longer-term side effects and complications of radical prostatectomy. It is entirely focused on the immediate outcomes of surgery.

It is worth noting that the NIS data supposedly encompasses data from approximately 20 percent of all surgical procedures carried out in the USA. Based on these data, we can therefore immediately make a guesstimate that — during calendar year 2012 — there were about 78,000 radical prostatectomies carried out in the USA. This number does not suggest anything like the doubling in the number of radical prostatectomies between 2003 and 2009 proposed by Lowrance et al., in another recent article, but we really don’t know which of the two is more accurate.

According to Trinh et al., their analysis shows the following core results:

  • Men being treated with RALP as opposed to ORP were
    • Less likely to be given a blood transfusion (odds ratio [OR] = 0.34)
    • Less likely to have an intraoperative complication (OR = 0.47)
    • Less likely to have a short-term postoperative complication (OR = 0.86)
    • Less likely to experience a pLOS (OR = 0.28)
  • Limitations of this study include lack of adjustment for
    • Patients’ individual tumor characteristics
    • Surgeons’ patient volumes
    • The surgical learning curve effect
    • Longitudinal follow-up of patients (as noted above)

The lower likelihood of blood transfusions and the shorter length of hospital stays for men undergoing RALP as compared to ORP are not new. These findings are entirely to be expected and date back to the earliest use of non-robotic LRP in the late 1990s.

With regard to the reduction in likelihood of intraoperative complications, there were 71 such complications reported among the 7,389 men treated with an ORP (0.96 percent) and 33 such complications among the 11,889 men treated with RALP (o.28 percent). This is certainly a statistically significant difference, but the actual numbers of patients are small.

With regard to the postoperative complications, there were 823 such complications among the 7,389 men treated with an ORP (11.1 percent) and 975 such complications among the 11,889 men treated with RALP (8.2 percent). Trinh et al. note that cardiac, respiratory, and vascular complications were the ones less likely to occur in patients undergoing RALP as compared to patients undergoing ORP.

There is little doubt that minimally invasive forms of radical prostatectomy have had significant impact on the speed at which patients can be treated and released from hospital after radical prostatectomy, on the risk for blood tramnsfusions associated with this type of surgery, on post-surgical, and on general time to recovery (because of the less invasive nature of the treatment). Trinh et argue that these new data now confirm that RALP is also associated with a reduction in risk for intra- and postoperative complications of radical prostatectomy compared to the open form of the procedure. This appears to be the case, although the degree of benefit is smaller than one might have hoped for.

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