Robotic Surgery Most Common for Prostate Cancer in the US

Becky McCall

March 01, 2012

March 1, 2012 (Paris, France) — Robot-assisted radical prostatectomies are now the most common surgical treatment for prostate cancer in the United States, supplanting open radical prostatectomies. Robot-assisted surgery also has better perioperative outcomes than open surgery.

Quoc-Dien Trinh, MD, from the Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan, reported the results of a comparative study of robotic and open prostatectomy here at the European Association of Urology 27th Annual Congress.

Using data from the Nationwide Inpatient Sample (NIS), the researchers compared patients who underwent robot-assisted radical prostatectomy with those who underwent open radical prostatectomy from October 2008 to December 2009. A robot-assisted modifier code was introduced in October 2008 to identify robot-assisted procedures.

Dr. Trinh noted that there were 2 important findings from the analysis. First, it provides the first objective data to show that robot-assisted prostatectomy has taken over as the standard surgical care for prostate cancer; 61% of prostatectomies were done robotically in the United States during that time period, Dr. Trinh told Medscape Medical News.

Second, robot-assisted prostatectomy was associated with better perioperative outcomes than open prostatectomy. "There were fewer intraoperative complications, fewer postoperative complications, fewer transfusions, and shorter hospital stays," he reported.

A breakdown of intraoperative and postoperative complications shows that the odds ratio (OR) strongly favored robot-assisted surgery over with open surgery for such things as homologous blood transfusion (OR, 0.34; P < .001), intraoperative complications (OR, 0.47; P < .001), and overall postoperative complications (OR, 0.86; P = .007).

"If you do less of an incision, the body isn't as open; there is an attenuated inflammatory and immune response [compared with open surgery], and consequently, fewer complications," Dr. Trinh explained.

Dr. Trinh said his team's work addresses a debate that has been ongoing for years. In 2009, Jim Hu, MD, who is currently director of minimally invasive surgery in the Department of Urology at the David Geffen School of Medicine at University of California at Los Angeles, and colleagues compared outcomes associated with minimally invasive and open prostatectomy in Medicare patients (JAMA. 2009;302:1557-1564).

Early on, the complication rate was higher with robotic-assisted than with open surgery. Over time, the complication rate dropped for minimally invasive prostatectomies but remained the same for open surgery. In the most recent years studied, there was no difference in postoperative complication rates between the 2 approaches.

Dr. Trinh noted that the study by Dr. Hu's team was conducted on data from 2003 to 2007, and did not take into account the fact that the robot-assisted radical prostatectomy was still developing. That laid the foundation for the investigation by Dr. Trinh's team, the results of which are due to be published in the April issue of European Urology.

Dr. Hu noted that "Dr. Trinh's work is important and timely. It is similar to our work, in 2009 and more recently with NIS data, looking at all robotic versus open and laparoscopic surgeries. [We demonstrated] shorter lengths of stay, fewer transfusions, and fewer perioperative complications for most robotic...surgeries, at a greater financial cost."

"I'd argue that better outcomes are worth more. Athletes are willing to pay more for better equipment (shoes, golf clubs, tennis rackets), and with greater experience (i.e., practice), outcomes are better. However, better shoes don't make everyone Kobe Bryant," he cautioned.

In the United States, the proportion of surgeons using robot-assisted surgery has changed dramatically. In 2002, only a handful of surgeons were using robotics; now, according to Dr. Trinh's results, 61% of cases are being conducted robotically. There has been a learning curve for robot-assisted prostatectomy, and this is reflected in the results, Dr Hu said.

"Open prostatectomy has been around for a long time, so everybody has been trained in the procedure.... However, in recent years, robotic prostatectomy has been a procedure in development. With gradual changes to technique, it follows that the procedure is growing and, therefore, we see fewer complications with time," said Dr. Trinh.

Rafael Sanchez-Salas, MD, from the Institut Mutualiste Montsouris, Paris, France, who moderated the session, noted that Dr. Trinh's study is very timely. "It provides evidence that robotic prostatectomy has been exposed to a disciplined evaluation; that's probably not the same case for open prostatectomy. I think Dr. Trinh has nicely done the work, and it is welcome."

He added that "we need to define the real situation with robotic prostatectomy. Perhaps Dr. Trinh's situation is very specific to the United States...but we know that in time, these results are probably going to be reproduced."

Joshua J. Meeks, MD, from the Department of Surgery at the Memorial Sloan-Kettering Cancer Center in New York City, explained that "the most important finding is that this is a true snapshot of the rapid rise in the rate of robotic prostatectomy, from 9% in 2003 to more than 60% of cases in 2008. With such a rise in any surgical modality in a short period of time, the major concern is that technology is utilized with good oncologic technique in patients who will benefit from treatment."

"An limitation of the National Inpatient Sample is that data are limited to a single hospital admission," Dr. Meeks told Medscape Medical News. "With 87% of robotic admissions staying in the hospital less than 2 days, the true rate of complications — from patients discharged and readmitted — is not captured by this database. The complication rates in Trinh et al. are about half those of previous reports comparing open and robotic surgery. The authors describe superior outcomes after robotic prostatectomy, but the most important outcomes of prostatectomy — margin status, erectile function, and continence — are simply not addressed...and remain an important question of prostate cancer treatment."

"Robotic prostatectomy has becomes the most common method for surgical treatment of prostate cancer. At an added cost of $2000 to $4000 per procedure, we will need to determine if these added costs are truly justified," Dr. Meeks explained.

Dr. Trinh, Dr. Sanchez Salas, Dr. Hu, and Dr. Meeks have disclosed no relevant financial relationships.

European Association of Urology (EAU) 27th Annual Congress. Presented February 26, 2012.

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