Outcomes from use of a robot to assist surgeons in removal of a cancerous prostate are at least as good, if not better, than the other two techniques used for a radical prostatectomy -- open or laparoscopic surgery -- according to a large meta analysis led by researchers at NewYork-Presbyterian/Weill Cornell.
The study, published February 24 online in European Urology, should help resolve some of the controversy regarding use of the robotic option, known as robot assisted laparoscopic radical prostatectomy (RALP), says the study's lead author, Dr. Ashutosh Tewari, director of the Lefrak Center for Robotic Surgery and director of the Prostate Cancer Institute at New York-Presbyterian Hospital/Weill Cornell Medical Center.
"There is a lot of debate about the best way to remove a cancerous prostate gland," says Dr. Tewari, who is also the Ronald P. Lynch Professor of Urologic Oncology and professor of urology and public health at Weill Cornell Medical College. "Since the robotic technology is expensive, the patient benefits often get intertwined with the societal costs. It is clear, however, that robotic surgery is the most popular surgical modality today. This study represents the largest ever systematic review of patient outcomes comparing robotic-assisted, laparoscopic and open radical prostatectomy.
By analyzing 400 original research articles -- all that have been published to date on the three methods -- Dr. Tewari and his colleagues concluded that RALP is more effective than a pure laparoscopic approach and comparable to an open surgical approach in completely removing cancer from the body. Positive surgical margins, a measure of oncological efficacy, were lower in patients receiving robotic radical prostatectomy as compared to those undergoing laparoscopic prostatectomy.
The researchers also found that robot assisted surgery had fewer intraoperative and perioperative complication rates when compared to both laparoscopic and open approaches. In addition, robotic showed both less intraoperative blood loss and less blood transfusions as compared to open surgery.
The meta analysis included treatment information on 286,876 patients, representing the largest compilation of radical prostatectomy patients to date.
"Understanding the best method to remove the prostate matters," Dr. Tewari says, "because prostate cancer is the most common diagnosed cancer and the second most common cause of cancer death for men in developed countries."
But given the nature of the study, Dr. Tewari says he cannot recommend one surgical approach over another. He emphasizes that surgical approaches need to be adjusted for the technique and experience of the surgeon. Many studies have shown that surgical experience is an independent predictor for outcomes, far beyond the approach alone.
"This paper is innovative in its attempt to unpack the outcomes data, in a systematic way, surrounding the three surgical modalities for prostate cancer treatment, but the data we used were not standardized -- outcome measures differed between studies," he says. "Still I believe the results are meaningful in that it shows RALP has at least as good outcomes as the other methods."
Challenges of Randomized Studies for Prostate Surgery
The three forms of surgery studied are "open radical" in which the prostate is removed via an abdominal incision in the belly button or pubic bone; laparoscopic prostatectomy that requires several small minimally invasive "keyhole" incisions in the abdomen, and robotic surgery, which is a form of laparoscopic surgery. RALP is done through keyholes with the aid of robotic arms that eliminate hand tremor as well as advanced optics that magnify the prostate and surrounding nerves in three-dimensions.
"It is hard to accrue patients for randomized studies. We have an ongoing study open at our institution, investigating the quality of life differences between robotic and open radical prostatectomy. This is designed as a randomized controlled study," he says. "But no one has enrolled because they did not want to be randomized to a treatment they don't prefer. Patients often come, especially to prostate cancer specialists, self-selecting for a particular treatment modality."
So Dr. Tewari and Peter Wiklund, M.D., of Sweden's Karolinska University Hospital, developed a study that examined all of the peer-reviewed studies published on any of the three techniques.
This ambitious effort was aimed at understanding the short-term (30 day) outcomes of the three surgical techniques. Given the short time frame, the meta analysis did not compare outcomes for urinary continence or sexual potency.
The researchers determined that complications and mortality were low for all three methods, suggesting that radical prostatectomy is a safe procedure.
Significant differences found were in the lower positive surgical margin (PSM) rates for RALP compared with laparoscopic surgery and lower intra operative and perioperative complications for RALP in comparison to other modalities. "PSM rates are important because they represent the effectiveness by which cancer is removed," Dr. Tewari says. "The RALP PSM rate was as good as open surgery," he adds.
The researchers also found that both laparoscopic and robotic surgery patients experienced lower rates of blood loss and transfusions and a shorter hospital stay compared with patients who had traditional surgery. Other measures, such as rates of readmission, reoperation, and complications, seemed to favor RALP, the researchers say.
"We would love to be able to directly compare the three prostatectomy surgical techniques, but that may not happen," Dr. Tewari says. "This study is the first to provide an important -- and much needed -- analysis of the short term benefits and risks between curative surgeries that many men rely on."
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