Urologists Abandon Good Old Procedure for Flashier, Costlier Ones: Study

May 17, 2011

By Gabriel Miller

NEW YORK (Reuters Health) May 16 - Perineal radical prostatectomy (PRP) is just as effective, and less costly, than newer retropubic (RRP) and minimally invasive radical prostatectomy (MIRP) approaches, researchers reported Saturday at the American Urological Association's annual meeting in Washington DC.

"The increased adoption of MIRP over the past decade has been controversial," said Dr. Sandip Prasad, the study's lead author and a urologic oncology fellow at the University of Chicago, in an email to Reuters Health.

According to Dr. Prasad, the rise in minimally invasive surgeries has been driven not by data, but by marketing efforts of surgical robotics companies, the perception of quicker recovery for the patient, and improved visualization and dexterity in robot-assisted procedures.

"No randomized controlled trial has been performed to study the various surgical approaches," he said.

The study's senior author, Dr. Jim Hu, a genitourinary surgeon at Brigham and Women's Hospital, cited an example. He told Reuters Health that marketing on some web sites touts better cancer control, continence and potency outcomes with robotic surgery, although there is no firm data to support these claims.

In a retrospective study, Dr. Hu and Dr. Prasad and colleagues used the Surveillance, Epidemiology and End Results (SEER) Program database to study 452 prostate cancer patients who underwent PRP, 1,938 who had MIRP, and 6,899 who had RRP between 2003 and 2005.

The study compared postoperative, 30-day, and anastomotic stricture complications, incontinence and erectile dysfunction, and adjuvant cancer therapy use.

PRP, formerly the dominant approach, comprised just 4.9% of operations in the study period. However, in an adjusted analysis, the PRP group had a shorter mean hospitalization (median 2 vs. 3 days, p<0.001) and lower rates of heterologous transfusions (7.2% vs. 20.8%, p<0.001) and additional cancer therapy (4.9% vs. 6.9%, p=0.020) compared to those who underwent RRP.

Compared to MIRP, men who had PRP had fewer miscellaneous medical complications (5.3% vs. 10.0%, p=0.045) and fewer procedures for erectile dysfunction (1.4 vs. 2.3 per 100 person-years, p=0.008). They did have a higher number of heterologous transfusions, however (7.2% vs. 2.7%, p=0.018).

The average costs for PRP in the first six months post-operatively were $1,500 less than either RRP or MIRP (p<0.001).

Even though the outcomes are "not demonstrably different" between the older perineal and newer, more minimally invasive approaches, "aggressive, no-holds barred marketing" by the companies that produce surgical robots will likely wipe-out the older approach, said Dr. Mark Litwin, a urologist and health services researcher at UCLA in Los Angeles.

Dr. Litwin, who was not involved in the study, told Reuters Health he thinks surgeons also find robot-assisted procedures more enjoyable and are training their fellows and residents based on this preference.

The investigators' "final conclusion, or recommendation, which is that maybe we are abandoning a time-honored approach that has some advantages, is true," Dr. Litwin said, "but it is just not the future."


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