Men with prostate cancer who undergo robot-assisted radical prostatectomy achieve equivalent urinary and sexual function outcomes relative to their counterparts managed with open surgery.
The study analyzed data from CaPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor), a large, prospective, longitudinal registry of men diagnosed and treated for prostate cancer at predominantly community-based practice sites. It included patients accrued between 2005 and 2007, and so represented a contemporary group of open radical prostatectomy patients and an early experience with robotic surgery during the period when the technology was becoming pervasive. There were 203 men in the robotic group and 608 who underwent open surgery.
In CaPSURE, health-related quality of life (HR-QOL) is assessed at baseline and every 6 to 12 months post-treatment using the self-administered, validated UCLA Prostate Cancer Index. Analyses based on 2 years of follow-up showed that whether plotting the index's data for urinary function, urinary bother, sexual function, or sexual bother, the curves for the open and robot-assisted groups were essentially superimposable. Statistical analyses using a repeated measures technique adjusting for age and other clinical characteristics showed that surgical approach was not predictive for any of the HR-QOL outcomes, reported first author Matthew Cooperberg, MD, MPH, assistant professor of urology at the University of California, San Francisco.
Dr. Cooperberg also observed that the robotic prostatectomy patients generally represent the relatively early experience of surgeons in the community with that technique.
"It is unclear to what extent the outcomes may improve as the surgeons' experience grows. Importantly, there is a need for analyses of QoL outcomes data from a larger population with longer follow-up, and particularly for formal cost-effectiveness studies that include hospital charges and indirect costs. We currently have such a project under way as a collaboration between CaPSURE and the PROST-QA [Prostate cancer Outcomes and Satisfaction with Treatment Quality Assessment] registry in Boston, and hope to report our initial findings in the near future," he said.
Data estimating that over 60,000 robotic prostatectomies were performed in the U.S. in 2009 highlight the rapid diffusion of this procedure. This phenomenon has occurred against a background of limited data comparing the effectiveness of robotic and open surgery in terms of long-term oncologic and QoL outcomes.
Dr. Cooperberg noted that a recent population-based observational cohort study, which received substantial lay media attention, reported the minimally invasive procedure was associated with significantly higher rates of incontinence and erectile dysfunction (JAMA 2009; 302:1557-64).
"However, the urinary and sexual function data were based on Medicare diagnosis codes, which are an unreliable measure of QoL outcomes," he pointed out.
Open surgery was performed at each of the 25 sites that contributed patients to the CaPSURE study, while only 14 sites contributed robotic surgery patients. The mean case volume per site was 24 cases for open and 14 for robotic surgery.
"These are not high-volume surgical centers, but the number of cases being performed is consistent with national averages, and at sites performing both procedures, there was a good correlation between the open and robot-assisted prostatectomy case volumes," Dr. Cooperberg noted.
Patients in the open and robotic groups had a similar risk profile based on mean CAPRA (Cancer of the Prostate Risk Assessment) score: 2.5 vs. 2.2, respectively. Positive margins were detected in 27.1% of open cases and 20.4% of the robotic patients, and those rates were not significantly different.
"In terms of this short-term oncologic outcome, the results in the robotic group were certainly no worse than for open prostatectomy," Dr. Cooperberg said.
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