In less experienced hands, robotic radical prostatectomy has the edge

Washington-In the hands of less experienced surgeons, robot-assisted laparoscopic radical prostatectomy has a lower perioperative morbidity rate and sound early oncologic outcomes compared to other surgical interventions, say researchers from Weill Cornell Medical College, New York. In the hands of high-volume surgeons, all things appear equal.

The authors arrived at that conclusion after an exhaustive meta-analysis of the literature. The study encompassed papers reporting outcomes on 110,016 patients who underwent open, pure laparoscopic, or robotic prostatectomy. The researchers analyzed 251 research papers incorporating reviews of 65,552 open procedures, 23,687 laparoscopic procedures, and 20,777 robotic procedures.

"The robot has been around only since the beginning of this millennium, but its popularity has increased exponentially in the last 5 or so years. We can't really say what the 10-year outcomes are because it hasn't been around that long," first author Prasanna Sooriakumaran, MD, PhD, told UrologyTimes.

Robotic surgery has the same advantages of laparoscopy but with the additional virtue of being a less demanding approach to learn.

"The perceived advantage is that it has a much shorter learning curve. It is easier to learn and get good outcomes. It has long been known that open prostatectomy has more blood loss and longer recovery. These are not associated with laparoscopy, but laparoscopy has a long learning curve and not everyone can master it," said Dr. Sooriakumaran, a fellow in robotic prostatectomy at Weill Cornell Medical College, working with Ashutosh Tewari, MD, and colleagues. He estimated that a surgeon would have to conduct several hundred open or laparoscopic procedures before being considered proficient but that a robot allowed the same level of proficiency to be reached in as few as 50 procedures.

"The disadvantage is cost. The robot is very expensive," Dr. Sooriakumaran added. Other disadvantages are that, like laparoscopy, the robotic procedures may be excluded by patient comorbidities such as cardiac or pulmonary disease.

"This is why we feel this analysis is important. It identifies the benefits of robotic procedures," said Dr. Sooriakumaran, who presented the results at the AUA annual meeting in Washington. Cost was not an issue addressed in the study, but it is an issue that cannot be ignored.

Both the robotic and laparoscopic approaches showed significantly lower estimated blood loss and rate of blood transfusions, and the length of hospital stay was shorter when compared to open surgery. The use of robotic assistance further decreased these parameters. Total complication rates were highest for the open approach, intermediate for the laparoscopic group, and lowest for the robotic group. The two minimally invasive surgical groups had similar overall positive surgical margin rates, with the robotic group having lower rates.

Volume appeared to be a distinguishing factor. Subgroup analysis of procedures found that those surgeons who had performed the greatest number of procedures, perhaps in excess of 1,000, also tended to have the best outcomes, regardless of the procedure applied.

The study's authors concluded that further work was needed to establish long-term functional and oncologic outcomes for robot-assisted prostatectomy and that cost/benefit comparisons would be required before any recommendations could be made.