Apr 14, 2014
By Shira Klapper, Senior Writer/Editor
Ever since robot-assisted radical prostatectomy (RARP) appeared on the scene in 2000, the technology has been widely embraced by surgeons and patients alike, rapidly overtaking the traditional open radical prostatectomy (ORP) as a surgical modality. Whereas in 2003, RARP accounted for 9.3% of all prostatectomies (and ORP for 91.7%), by 2009 that number had shot up to 60%. As the technology grew in popularity, so did the controversy as physicians and medical reporters voiced differing opinions in the pages of the county’s leading medical journals, as well as the New York Times. At the heart of the debate is this question: How does RARP compare to ORP in terms of such variables as medical complications, need for additional cancer therapies, and cost?
In a 2009 study in the Journal of the American Medical Association, Hu et al. reported that men who underwent minimally invasive surgery—a term that includes RARP and laparoscopic surgery—had fewer transfusions, respiratory and miscellaneous complications, and anastomotic strictures. However, these men also had a greater likelihood of being diagnosed with genitourinary incontinence and erectile dysfunction, side effects that led the researchers to their conclusion: Insufficient data demonstrating RARP’s superiority at that time. Then, in 2011, Dr. Quoc-Dien Trinh, et al. published a study that found “superior adjusted perioperative outcomes in RARP in virtually all examined outcomes.” Most recently, a study from February, 2014 published in European Urology, reported no differences between RARP and ORP in terms of cancer control or health-related quality of life; however, that study reported that those undergoing RARP experienced shorter hospital stays, less blood loss, and lower rates of transfusions, compared to ORP.
|Quoc-Dien Trinh, MD, FRCSC|
Into this ongoing debate comes a Journal of Clinical Oncology (JCO) study (online ahead of print April 14, 2014), written by many of the same authors as the 2011 study, including Dr. Trinh of the Brigham and Women's Hospital and Dana-Farber Cancer Institute. The study, “Comparative Effectiveness of Robot-Assisted and Open Radical Prostatectomy in the ‘Post-Dissemination’ Era” found that for men 65 years and older, RARP and ORP have similar rates of complications.
In this newer study, the researchers sought to address several of the limitations within previous studies.
“The 2009 study used data from 2003 to 2006, soon after robotics was first introduced,” said Dr. Trinh, explaining that surgeons in those pre-dissemination years might not yet have developed expertise in using the new machines. In addition, in that earlier study, RARP and laparoscopic prostatectomy were both defined as “minimally invasive,” making it difficult to separate out outcomes for RARP specifically.
The 2011 Trinh et al. article also had a limitation in that it culled its data from the Nationwide Inpatient Sample (NIS). The NIS does not include two important pieces of information: cancer stage and grade characteristics (which allow researchers to see whether some effects are due to differences in cancer progression) and long-term data on complications.
To address these limitations, Trinh and his colleagues used U.S. Surveillance, Epidemiology and End Results Medicare (SEER) linked data for the current study. SEER Medicare collects data only on people 65 years and older, but it has the advantage of including stage, grades, and longitudinal data. These additional data points allowed the researchers to study such variables as post-hospitalization complications, readmissions, need for additional cancer therapies (a proxy for progression), and cost of care within the first year after surgery.
Dr. Trinh and his co-authors hypothesized that their new study would yield similar results to their 2011 study, which showed RARP to be superior to ORP in terms of outcomes.
But the data demonstrated equivocal results.
“The data suggests that in the post-dissemination era [i.e., contemporary patients], elderly patients over 65 undergoing robotic-assisted radical prostatectomy have the same risk of complications, readmissions, and additional cancer therapies as those who get open surgery,” said Dr. Trinh.
The study did find, however, that in terms of number of transfusions and rates of prolonged lengths of stay—which Dr. Trinh’s current study did not define as complications—RARP did show a benefit compared to ORP, confirming previous studies’ findings about the benefits of minimally invasive surgery. In terms of expenditures, ORP came out ahead; total first year charges for RARP patients were a median $1,400 more than charges for ORP patients.
The study did not look at comparative rates of erectile dysfunction and genitourinary incontinence.
In summing up the study’s findings from his perspective, Dr. Trinh stated, “Our hypothesis is that younger patients, who constitute the majority of patients undergoing radical prostatectomy, may derive greater benefit from robotic prostatectomy, as it was demonstrated in the Nationwide Inpatient Sample study. However, further studies are warranted.”
Quoc-Dien Trinh, MD, FRCSC, is an Associate Surgeon in the Division of Urologic Surgery at the Brigham and Women's Hospital, Dana-Farber Cancer Institute, and Harvard Medical School, in Boston, MA. He is a Core Faculty at the Brigham and Women’s Hospital Center for Surgery and Public Health. He also currently serves as the Associate Editor for Health Services at the British Journal of Urology (BJU) International.
Click here to read the abstract.
Click here to view a PDF of the full article.
Gandaglia, G, Sammon, JD, Chang, SL, et al. Comparative effectiveness of robot-assisted and open radical prostatectomy in the ‘post-dissemination’ era. J Clin Oncol. 2014; Published online ahead of print 3.14.2014.
The Exclusive Coverage series on ASCO.org highlights selected research from JCO with additional perspective provided by the lead or corresponding author.
@ 2014 American Society of Clinical Oncology