Functional outcomes for patients after differing types of radical prostatectomy

A newly published paper in the British Journal of Cancer has reported on  patient-reported functional outcomes following robot-assisted laparoscopic (RALP), non-robot-assisted laparoscopic (LRP), and open (ORP) forms of radical prostatectomy.

We are not at all surprised by the findings and the conclusions of this new paper by Nossiter et al. that included > 2,000 men who underwent a radical prostatectomy for first-line treatment of prostate cancer in England in 2014.

The authors state, basically, that:

While RALP was associated with marginally better sexual function scores than LRP or ORP as reported by men 18 months after diagnosis, this difference is small and unlikely to be clinically significant.

The full text of this paper is available on line and available to anyone, so we encourage interested individuals to read it for themselves.

The paper is interesting for a number of reasons, not least because the authors were able to invite (effectively) every single patient diagnosed with prostate cancer in England between April 1, 2014, and September 30, 2014, to participate in this study. Questionnaires were mailed to the homes of all identified men 18 months after they were diagnosed. Two reminders were sent to non-responders at 3 and 6 weeks after the first mailing of the questionnaire.

Out of a total of 2,883 eligible men who underwent a radical prostatectomy at 55 different centers in England and who received a questionnaire, 2,219 (77.0 percent) responded. That’s a remarkably high response rate, and means that the study’s findings come with a high degree of credibility.

So here are the basic findings reported by Nossiter et al. at 18 months post-diagnosis:

  • Of the 2,219 responders
    • 1,310 (59.0 percent) had been given a RALP.
    • 487 (21.9 percent) had been given an LRP,
    • 422 (19.0 percent) had been given an ORP.
  • Men treated by RALP reported slightly higher adjusted mean EPIC-26 sexual function scores compared with LRP (3·5 point difference) and ORP (4.0 point difference).
  • These differences (which were statistically significant) did not meet the threshold for a minimal clinically important difference (10 to 12 points).
  • There were no significant differences in other EPIC-26 domain scores or in health-related quality of life.

Now it should be emphasized that there are other benefits that have been associated with the use of RALP and LRP compared to ORP (such as less blood loss during surgery, shorter hospital stays, and faster recovery of full mobility post-surgery). However, it needs to be understood that the ability to gain such benefits from RALP has made the surgeons who use LRP and ORP techniques improve their own surgical techniques to an extent that has, to a considerable extent, made the initial benefits of RALP or LRP less evident.

In  their conclusions, Nossiter et al. make a number of key points that are important to understanding the implications of their findings:

  • That the rapid adoption of RALP across the National Health Service is not likely to lead to substantial improvements in functional outcomes for patients
  • That continued, long-term monitoring of patient-reported outcomes will be necessary if we are going to be able to determine whether the benefits of RALP will emerge in the future (after urologists have gained further experience with this particular type of radical prostatectomy)
  • That the expertise and skill of each individual surgeon, and the comparative performance of each specific surgical center, should drive patients’ treatment decisions (as opposed to the technique the surgeon chooses to apply)
  • That robust provider-level functional outcome measures are going to be necessary to support the best possible decision making by patients

As The “New” Prostate Cancer InfoLink has been pointing out for years, the outcomes of all forms of first-line treatment for localized prostate cancer are dependent on two very distinct sets of data:

  • The precise type of treatment being applied (and the tools used to apply it)
  • The skill, expertise, and experience of the clinical team that is carrying out the specific procedure using the available and appropriate tools

Given the variety of techniques available today for the first-line treatment of prostate cancer, the selection of exactly who is going to treat your prostate cancer is at least as important as which technique the physician may specialize in practicing. This is not a new idea!

3 Responses

  1. As time moves on the RALP will be the predominant procedure and the pool of physicians will be larger. The skill, expertise, and experience of the clinical teams will likely be greater with RALP due to volume. I think we are already seeing that.

  2. Dear Tony:

    Oh I think that’s probably true … and the costs for a radical prostatectomy will have risen significantly as a consequence. :O)

  3. Great article. Highlights both the importance of RALP and why more research is needed to be adopted as the primary technique for treating first line prostate cancer. It may not have significant benefits as compared to LRP or ORP but whatever little benefits it has over these two are crucial for patients.

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