Risk for conversion from minimally invasive to open surgery for prostate cancer patients

A new paper in the Journal of Urology provides us with a detailed assessment of the likelihood of and the risks associated with the need to convert from a minimally invasive (e.g., robot-assisted) to an open surgical procedure during the course of a radical prostatectomy.

Sharma and Meeks base their analysis on data from the Nationwide Inpatient Sample for the years 2004 though 2010 (the most recent data available).

During this time frame there has been a major increase in the application of minimally invasive and robot-assisted forms of radical prostatectomy, but conversion from a minimally invasive to an open procedure may still occur as a result of surgical complications, surgeon inexperience, or failure of the initial surgery to progress.

The authors searched the National Inpatient Sample database specifically for patients who underwent radical prostatectomy to analyze the association of open conversion during minimally invasive radical prostatectomy with Clavien complications. Here is what they found for the study time period:

  • About 134,000 minimally invasive radical prostatectomies were performed (over the 7-year period).
  • There was a 1.8 percent rate of conversion to open surgery (i.e., about 2,360 conversions).
  • Compared to non-conversion cases, open conversion cases had, on average,
    • A longer length of stay (4.17 vs 1.71 days, p <0.001)
    • Higher hospital charges ($51,049 vs $37,418, p <0.001)
  • 45.2 percent of open conversion cases were associated with a definable complication (compared to 7.2 percent of unconverted minimally invasive and 12.9 percent of  unconverted open cases).
  • After adjusting for age and co-morbidities, open conversion was associated with significantly increased odds of a Clavien grade 1, 2, 3 and 4 complication compared to unconverted minimally invasive  and open cases.
  • Significant predictors of open conversion were
    • Obesity (odds ratio [OR] = 1.9)
    • Tissue adhesions (OR = 3.1)
    • Anemia (OR = 5.7)
    • Surgeon volume for minimally invasive radical prostatectomy < 25 cases per year (OR = 7.4).

From a patient perspective, if nothing else, this paper appears to confirm the importance of ensuring that one’s surgeon is appropriately trained and skilled and has had significant and frequent experience in the conduct and completion of minimally invasive radical prostatectomies: 25 cases a year clearly doesn’t seem to cut it!

Patients should be reminded that not all minimally invasive forms of radical prostatectomy are carried out using the daVinci robot. There is a small, but often highly skilled, subset of surgeons  who carry out laparoscopic radical prostatectomies without using the daVinci robot.

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