Better Continence Rate Gives Robotic Prostatectomy the Edge

Sara Freeman

August 05, 2020

Higher continence rates were seen after robot-assisted radical prostatectomy (RARP) than after laparoscopic radical prostatectomy (LRP) in the first large-scale, prospective, multicenter, randomized trial to compare the two surgical approaches.

At 3 months, 54.3% of prostate cancer patients who underwent RARP and 45.6% of those who had LRP were continent after catheter removal (P = .027).

"We did use a very strong definition for continence, meaning no pad or safety pad; patients wearing one pad per day we're not classified as continent," said study investigator Jens-Uwe Stolzenburg, MD, PhD, professor and head of urology at the University of Leipzig Hospital in Germany.

Dr. Stolzenburg presented these findings at the European Association of Urology virtual annual congress.

The findings fit with previous research showing higher continence rates with RARP (69%-80%) than with LRP (62%–63%), although those studies did not always find the difference to be statistically significant, and higher quality evidence was needed (J Sex Med. 2011 May;8[5]:1503-12; Eur Urol. 2013 Apr;63[4]:606-14). "Up to now, there are only two randomized studies published in the literature comparing robotic and classical laparoscopic prostatectomy, and my point of view is that there are strong limitations of both studies," Dr. Stolzenburg said.

"First of all, both studies are based on the single experience of surgeons, so only one surgeon has performed surgery. The second limitation is the limited numbers of patients included," he observed. One study had 64 patients in each arm, and the other had 60 patients in each arm.

Providing Higher Quality Evidence

Dr. Stolzenburg presented results of the LAP-01 study, which was designed to close the knowledge gap and determine if there really was an advantage for RARP over LRP for preserving continence.

The trial was conducted at three academic centers and one public hospital in Germany. The final analysis included 718 patients with prostate cancer referred for prostate surgery. They were randomized, in a ratio of three to one, to undergo RARP (n = 530) or LRP (n = 188), being unaware themselves of which surgery they would be having until the 3-month primary endpoint.

In addition to improved continence over LRP, RARP was associated with significantly better erectile function at 3 months (P = .016), as measured by the International Index of Erectile Function (IIEF).

That said, erectile function was still severely affected by both surgical procedures. Total IIEF scores were 6.0 with RARP and 4.7 with LRP, compared with 15.9 and 16.2, respectively, at baseline.

A higher percentage of men who had nerve-sparing procedures reported having an erection suitable for sexual intercourse at 2 months in the RARP group than in the LRP group (17.7% vs. 6.7%, P = .007).

The complication rate was "a little bit higher" in the LRP group than in the RARP group, "but the difference was not statistically significant," Dr. Stolzenburg said. He added that "the most frequent complication was anastomotic leakage, and most complications overall were low-grade complications in both groups."

Multicenter Experience

The potential for prostatectomy to have effects on urinary continence and sexual function are important issues that need to be discussed upfront with patients, observed Alexandre de la Taille, MD, PhD, who was invited to discuss the study.

Current European guidance says "there is no surgical approach — open, laparoscopic, or robotic radical prostatectomy — that has proven superiority in terms of functional or oncological results," he said. However, the LAP-01 study "found that the continence rate was better when we use a robotic approach compared to a laparoscopic approach."

Dr. de la Taille, who is professor and chair of the urology service at CHU Mondor in Cretéil, France, also highlighted that this result was achieved with no increase in the morbidity profile or compromise of cancer control.

"My very first impression is that we are missing a little bit, some granularity of the data in terms of one key question, which is volume of surgery," said the chair of the session Alberto Briganti, MD, PhD, associate professor of urology at Università Vita-Salute San Raffaele, and deputy director of the Urological Research Institute of IRCCS Ospedale San Raffaele, both in Milan.

"We know that recovery of outcomes is volume-dependent, both in the laparoscopic and robotic setting," Dr. Briganti added.

"This is really a multicenter study including a lot of surgeons," Dr. de la Taille countered, agreeing that the volume of surgeries might be something the LAP-01 study investigators could look at in a sub-analysis.

"Of course, some of them have a huge experience in the robotic approach and some of them a lower experience of the robotic approach, but when you put all together, there is a better continence recovery at 3 months when compared to the laparoscopic approach," Dr. de la Taille said.

Calling the study a "real-life practice study," he noted that urinary continence at 12 months might be a stronger endpoint, and the difference between the two surgical approaches may become less with time.

"But for the patient, again, daily practice, it's better to have early urinary continence recovery compared to a late recovery," Dr. de la Taille said.

This study was funded by the University of Leipzig via a German Cancer Aid grant. All speakers declared no conflicts of interest.

European Association of Urology (EAU) 2020 Congress: Presented July 17, 2020. Abstract

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