Radical prostatectomy by open or laparoscopic/robotic techniques: an issue of surgical device or surgical expertise?

In the study reported by Hu et al in this issue of the Journal, the authors identified 2,702 men who underwent radical prostatectomy from 2003 to 2005 from a national sample representing 5% of Medicare beneficiaries. During this time interval, the data showed a 30% increase in use of what is termed laparoscopic radical prostatectomy (LRP) and a 12% decrease in standard open technique, most likely due to the introduction of robotic-assisted radical prostatectomy (RARP). Although RARP is different from LRP, the authors are unable to separate LRP from RARP. Patient interest in RARP has been the result of a highly successful marketing campaign with resultant consumer demand. Patients have been led to believe that hospital and recovery times are shorter and outcomes are better, but study has shown this expectation not to be the case. RARP is simply an alternative method to extract the prostate. In this study, patients undergoing LRP were found to have shorter lengths of stay (mean, 1.42 days v 4.35 days; P .001), but were more likely to require salvage therapy (27.8% v 9.1%; P .001) with radiation therapy plus androgen deprivation therapy for local relapse. Patients who underwent LRP/RARP appeared to have more anastomotic strictures than open surgery (15.2% v 12%; P .11). However, the authors did note that high-volume LRP/RARP surgeons were able to reduce these complication rates and the likelihood of local relapse, though both were still more frequent after LRP/RARP than after open technique. Obviously, in any analysis of the Medicare-age population, beneficiary claims data represent a 35,000-ft view of the practice since Medicare claims data cannot reliably be a surrogate for surgical outcome data. However, we believe the trends are more than likely true. The decrement in oncologic outcome (requiring more salvage therapy for local relapse) and increased incidence of anastomotic stricture may be related to do the steep initial learning curve for both LRP/RARP, though more analysis of detailed data would be required to determine this with certainty. Certainly, almost 30% of patients in the LRP/RARP group requiring salvage therapy compared with 9% in the open technique would imply greater oncologic efficacy in the latter. However, without multivariate analysis including clinical and pathologic data, one cannot reliably account for these differences. It is disconcerting that the anastomotic stricture rate is higher than, and not superior to, open technique. Good technique prevents strictures. Anastomotic stricture results in a significant decrease in urinary quality of life including difficult bladder emptying, recurrent urinary tract infection, and bleeding. Necessary repeated corrective procedures may result in progressive incontinence. One of the major touted features of both LRP/RARP is improved anastomosis based on wristing (a technical term relating to the robot’s ability for greater than 360 degrees rotation for suturing) and magnification. Once again, this may speak to the volume issue; that is, an inadequate period of training with too rapid adoption of LRP/RARP and high initial complication rates. It is particularly noteworthy that men undergoing LRP/RARP appeared to have fewer perioperative complications than open prostatectomy, while at the same time the patients were statistically significantly older with more comorbid conditions. The data in this study indicate that the complication rates to open surgery may not be consistent with that reported for optimal open surgery. The reported rates of cardiac (6.6%), respiratory (11.7%), vascular (6.5%), wound/ bleeding (3.6%), and genitourinary complications (8.0%) are not what are being achieved by most high-volume, open radical prostatectomy surgeons in this country. Cardiovascular perioperative complications should be 1% or less in centers at which a high volume of open radical prostatectomy is performed. Certainly, the length of stay experienced by patients who undergo open radical prostatectomy by most high-volume surgeons is consistently less than 48 hours and not over 4 days as reported in this analysis. Similarly, anastomotic stricture rates are more likely in the 2% to 4% range after open techniques rather than the 12% reported herein. Men treated by either LRP/ RARP or open radical prostatectomy can follow the same care pathway, so length of stay should not be an issue. The data strongly suggest that documentation of the surgical expertise of the surgeons performing both open and LRP/RARP surgery should be required by specialty societies and training programs as a prerequisite for board certification. Open surgery has its own learning curve. Importantly, as an obvious downside, LRP/RARP provides minimal or limited access to the prostate without helpful assistance of direct manipulation or tactile feedback. When LRP/ RARP surgeons are in trouble, they may need to convert emergently to an open procedure to control life-threatening bleeding. To be unfamiliar with, incompetent, or inexperienced in open surgery would constitute a grievous error in training. We note that the authors did not perform an analysis of the prostatectomy volume by surgeon in terms of complication rates in the open series, and this would be noteworthy. Would not the same improvement in complication trend be expected for high-volume open surgeons? Moreover, we are in an JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 26 NUMBER 14 MAY 1