Meta-Analysis: Robotic Prostatectomy Fares Well in Short Term

Nick Mulcahy

May 02, 2012

May 2, 2012 — Robot-assisted laparoscopic radical prostatectomy (RALP) is at least equivalent to other surgical approaches in terms of outcome in the short term, and might provide advantages such as decreased adverse events, according to a meta-analysis.

However, the study, published online February 24 in European Urology, did not include 2 important measures — urinary continence and sexual potency — because the outcomes data were limited to events occurring 30 days after surgery.

Nevertheless, it looked at 400 original research articles. It adds to the literature on surgery for prostate cancer because the approaches "have rarely been compared with regard to margin and perioperative complication rates," write the authors, led by Ashutosh Tewari, MD, director of the Prostate Cancer Institute at New York-Presbyterian Hospital/Weill Cornell Medical Center in New York City.

"I believe the results are meaningful, in that they show that RALP has at least as good outcomes as the other methods," he said in a press statement.

RALP was compared with open radical prostatectomy (ORP) and laparoscopic radical prostatectomy (LRP).

A total of 37 studies (only 1 a randomized controlled trial) have compared one approach with another. The other studies in the meta-analysis were not comparative. No study to date has looked at all 3 approaches together, say the authors.

There is "no good evidence of an overall benefit for one modality over another, and it is uncertain whether minimally invasive surgery, especially robotics, justifies its increased costs and training requirements," the authors explain.

The primary outcomes were positive surgical margin (PSM) rates and total intra- and perioperative complication rates.

The overall PSM rates were 24.2% for ORP, 20.4% for LRP, and 16.2% for RALP. For prostate cancer confined to the gland (pT2), the PSM rates were 16.6% for ORP, 13.0% for LRP, and 10.7% for RALP.

However, the researchers found that for overall and pT2 rates, only comparisons of RALP and LRP attained significance after statistical adjustment (propensity score matching and Hochberg correction) (overall PSM, P = .002; pT2 PSM, P = .01). The adjustments are necessary to compensate for differences between the treatment cohorts, the authors report.

The rates for cancers beyond the prostate (pT3) — 42.6% for ORP, 39.7% for LRP, and 37.2% for RALP — were not significantly different after statistical adjustment.

Total intraoperative complication rates were significantly higher for ORP than for RALP (1.5% vs 0.4%; P < .0001) and for LRP than for RALP (1.6% vs 0.4%; P < .0001).

For total perioperative complication rates — 17.9% for ORP, 11.1% for LRP, and 7.8% for RALP — the differences between RALP and ORP (P < .0001) and between RALF and LRP (P = .002) were significant.

The study also looked at a variety of secondary outcomes, including blood loss, transfusions, conversions, length of hospital stay, and specific individual complications.

There was less blood loss, fewer transfusions, and shorter hospital stays with LRP and RALP than with ORP. Total perioperative complication rates were higher for ORP and LRP than for RALP. "Total intraoperative complication rates were low for all modalities, but lowest for RALP," write the authors.

Rates for readmission, reoperation, deep vein thrombosis, pneumonia, hematoma, lymphocele, anastomotic leak, fistula, wound infection, and nerve, ureteral, and rectal injury were significantly different between groups, "generally favoring" RALP, they note.

Dr. Tewari said that on the basis of these findings, he cannot recommend one surgical approach over another, in part, because the technique and experience of the surgeon might be more important than the approach alone.

Still, "this paper is innovative in its attempt to unpack the outcomes data, in a systematic way, surrounding the 3 surgical modalities for prostate cancer treatment, but the data we used were not standardized; outcome measures differed between studies," he said.

Limitations

The study has a number of limitations, the authors admit. These include the above-mentioned lack of randomized controlled trials, uncertainty about the use of margin status as an indicator of oncologic control, and the inability to perform cost comparisons.

In their discussion of the limitations, the authors do not mention any patient-reported outcomes with the 3 surgical approaches, which reflects the 30-day postsurgery window of the study.

However, an earlier study, also published in European Urology (2008;54:785-793), has suggested that patient satisfaction is a wild card in terms of outcomes with the removal of the prostate. That study found that patients who underwent RALP were more likely to be regretful and dissatisfied than patients who underwent radical retropubic prostatectomy.

The authors of that earlier study — one of whom was Dr. Tewari — write that these feelings might be "because of higher expectation of an 'innovative' procedure'." They "suggest that urologists carefully portray the risks and benefits of new technologies during preoperative counseling to minimize regret and maximize satisfaction."

Dr. Tewari reports receiving research grants from Intuitive Surgical Inc., the manufacturers of the da Vinci Robotic Surgery System. Two coauthors report being employees of Intuitive Surgical.

Eur Urol. Published online February 24, 2012. Abstract

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