Low Rates of Regret After Prostatectomy When Outcomes Are Good

Overall rates of regret were low for men who underwent prostatectomy for localized prostate cancer, and there was no difference in regret between men who underwent open radical prostatectomy (ORP) and those who underwent robot-assisted radical prostatectomy (RARP), investigators report.

These results come from a large German observational study, which the authors believe is the ﬁrst study of decision regret in a large and moderately selected cohort of patients who underwent routine care. The follow-up period was 6 years.

The study was published online September 13, 2019, in the Journal of Urology.

No Regret Provided Outcomes Are Good

Low rates of regret were associated with good outcomes, which included erectile function, urinary continence, and freedom from cancer recurrence. Low rates were also associated with the patient's having had an active role in decision making, report Martin Baunacke, MD, Technische Universitat, Dresden, Germany, and colleagues.

"Predictably, [the authors] confirmed that patients with complications such as incontinence or impotence were more likely to regret the choice of having a radical prostatectomy compared with patients who had excellent results," Peter Albertsen, MD, University of Connecticut Health Center, Farmington, comments in a related editorial.

Ultimately, satisfaction depended on the functional outcome, not on the surgical technique, he adds.

"The take home message: excellent results, no matter how they are achieved, led to the happiest patients," Albertsen concludes.

In an additional editorial, Thomas Polascik, MD, Duke University Medical Center, Durham, North Carolina, agrees with Albertsen. "Not surprisingly, patients with good functional and cancer outcomes maintain low regret regardless of the surgical approach," he writes.

"Being proactive with one's treatment choice was also associated with low remorse," he noted. Taking personal responsibility for one's own treatment decisions can promote greater patient satisfaction with treatment outcomes, he commented.

HAROW Study

The data for the current study came from the Hormonal Therapy, Active Surveillance, Radiation, Operation, Watchful Waiting (HAROW) study, which ran from 2008 to 2013. Ofﬁce urologists throughout Germany enrolled 3169 patients, of whom 572 underwent RARP and 798 underwent ORP.

In Germany, ofﬁce urologists diagnose and advise most patients who have prostate cancer and then refer them to hospitals for inpatient treatment, the authors explain.

For their study on decision making and regret, the team mailed questionnaires to participants in February 2017. The response rate was 76.8% (936 of 1218 patients).

Among those who responded to the questionnaire, 404 had undergone RARP, and 532 had undergone ORP.

Decision regret was evaluated using the Decision Regret Scale.

At a median follow-up of 6.3 years, the overall level of decision regret was low. The mean score was 14 on a scale of 0 to 100 in which 0 indicated no regret and 100 indicated high regret.

"There was no difference in decision regret between the 2 surgical approaches," the authors note.

However, patients who chose the robot-assisted approach more actively engaged in decision making than those who chose the open approach, they note.

For example, patients who chose the robot-assisted procedure displayed more active information-seeking behavior than the patients in the open-approach group.

"They chose the treating hospital more often based on an information search," the authors add — 25% of the men who received RARP chose the treating hospital, vs only 11% of those opting for an ORP approach (P < .001).

Men who chose RARP also used the Internet more often than patients who chose ORP (87% vs 72%; P < .001).

"Patients treated with RARP more often chose high volume hospitals (P < .001)," the authors observe.

"[P]atients who underwent RARP traveled a longer distance to the treating hospital than patients who underwent ORP... (63 vs 42 km, p < .001)," they add.

In his editorial, Polascik notes that the current study was conducted at a time when the RARP approach was already widely in use. This may explain why the findings differ from those of earlier studies, conducted when RARP was still new. Those earlier studies showed less satisfaction with RARP in comparison with standard open surgery. He suspects that at that time, when the RARP approach was just being introduced, practitioners may have painted an "overly optimistic picture" of the advantages of robotic procedures, which in turn could have led to patient disappointment.

"As many urologists are now beyond the learning curve, RARP is currently regarded as routine care rather than as an engineering novelty…. [T]he enthusiastic expectations of robotic surgery have become tempered with a more grounded assessment of outcomes by patients and physicians," Polascik suggests.

Baunacke, Albertsen, and Polascik have disclosed no relevant financial relationships.

J Urol. Published online September 13, 2019. Full text; Albertsen editorial; Polascik editorial

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