Low quality of evidence for robot-assisted laparoscopic prostatectomy: what about the evidence for open?

In the United States, robot-assisted radical prostatectomy (RARP) is now the most common surgical procedure for the treatment of localized prostate cancer, accounting for >75% of all radical prostatectomies (RPs) currently performed [1]. This transition has occurred quite rapidly, in less than a decade since the introduction of the robotic technology. The speed of this change was initially attributed to ‘‘marketing of the robot’’; however, the test of time has shown significant advantages of this technology in the hands of experienced surgeons. This dramatic paradigm shift has been driven by the need for a less invasive surgical approach to RP and by the preference of surgeons and patients alike. Kang et al [2], in their article published in the current issue of European Urology, attempt to explore the paradigm shift and to discern the reasons for the change from open to robotic surgery as well as the validity of such a change. The article focuses on evaluating the methodology and presentation of published literature regarding the results of RARP. The conclusion of the analysis is quite obvious: improvements in the standards and the quality of reporting of clinical research are necessary. The authors imply that because the published robotic literature is imperfect, the clinical outcomes must also be suboptimal and that there is no reason for this paradigm shift. This conclusion is far fetched and without merit. What is woefully lacking from Kang et al’s study [2] is an evaluation of the level of evidence of the major open RP (ORP) studies, which this article implies are the reference standard. It is difficult to give credence to an article that chastises the lack of reporting quality in one field but fails to evaluate and validate the supposed reference standard. Over recent decades, the quality of scientific publications has improved as we have established criteria for evidencebased medicine [3]. What is published today is likely of a higher standard than previous research because the benchmarks of quality also have been set higher. Most of the larger ORP series, if analyzed, would also be found to be lacking validated questionnaires, randomization, and institutional review board or ethics committee approval. Therefore, to challenge the validity of a dramatic change in clinical practice patterns based solely on how the procedure is reported is somewhat meaningless. The authors have cited a few key articles to support their assumption that, based on the quality of the literature currently presented, the transition to robotics should not have occurred. These articles, however, also have some clear limitations. The publication by Ficarra et al [4], in 2009, evaluated the results of only comparative series for open, laparoscopic, and robotic prostatectomy. A small number of studies met their criteria, with the majority of the larger experienced series being excluded because they were not comparative analyses. These authors concluded that, based on comparative series, patients undergoing laparoscopic RP (LRP) or RARP had less blood loss and blood transfusion; however, the available data were not sufficient to prove the superiority of any surgical approach in terms of functional and oncologic outcomes. Additionally, in their analysis, the surgeons’ experience was found to be an important factor influencing patient outcomes. They clearly acknowledge that the literature for all three approaches was ‘‘not excellent’’ and that ‘‘due to the limitations of the currently available literature, further prospective, comparative studies are needed.’’ These authors have shown that the literature in all three approaches is limited to studies of low methodologic quality.