Open vs Robotic Radical Prostatectomy: Is This the Final Word?

Gerald Chodak, MD


August 23, 2016

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Hello, I'm Dr Gerald Chodak from Medscape. Today I want to talk about open vs robotic radical prostatectomy for men with clinically localized prostate cancer, based on a study by Pearce and coworkers that recently appeared in the Journal of Urology.[1] They looked at the National Cancer Database and extracted more than 100,000 patients—about 23,000 men who had undergone an open prostatectomy and 73,000 men who had a robotic prostatectomy. This cohort was matched to another from the entire population to end up with about 13,000 men in each group.

They found a statistically significant difference in positive surgical margin rates and the need for postoperative radiation in the men who had open prostatectomy compared with those who received the robotic method.

Of note, this study was not prospective or randomized, and I'll mention some of the other difficulties with it. The authors did an excellent job with their analysis, but the problem is that the absolute difference in the positive surgical margin rate was only 2.3% and the absolute difference in the radiation rate was 1.4%. Although there was a slightly higher risk for 30-day mortality with the open method, it was not statistically significant.

What are the concerns with this paper? First, the investigators made no effort to analyze the data in terms of the experience level of the different surgeons, and that can create a problem. It has been shown in the past that surgeons who do fewer than a certain number of prostatectomies annually have higher complication rates and worse overall outcomes. This study involved many different surgeons, and we have no way of knowing whether their expertise played a role in these small but measurable differences.

Another issue has to do with long-term outcomes, which this study did not address.

At the end of the day, we are left with another study that differs from past reports that suggested that robotic prostatectomy was not better, and may even be inferior in some ways. Without a randomized study, which would be difficult to do, it will be very hard to make a true determination of whether the differences are great. We do know, however, that blood loss and length of stay on average are lower, but experts around the country who specialize in radical prostatectomy (including many of the "older guard" of surgeons who still use the open method) also have excellent results. If we try to match the study's findings with outcomes among the general population of urologists who are using the robotic method, it's unclear what we would find.

For now, it is not so much the method of performing the prostatectomy, but the expertise of the surgeon doing the procedure that determines outcomes. Clearly, patients looking for the best outcomes should seek out well-experienced surgeons, perhaps even surgeons who specialize in prostate cancer surgery. Is the general urologist going to be as good as the expert? It doesn't mean they can't be, but on average, experience really counts. For now, patients who are considering the operation, the best thing they can do is find out how experienced their surgeon is, and ask specifically about outcomes, complication rates, cure rates, and the need for additional treatment.

I look forward to your comments. Thank you.


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