Platinum Priority – Prostate CancerEditorial by Mani Menon on pp. 7–9 of this issueA Prospective Trial Comparing Consecutive Series of Open Retropubic and Robot-Assisted Laparoscopic Radical Prostatectomy in a Centre with a Limited Caseload
Introduction
Prostate cancer (PCa) is the most frequently diagnosed cancer and cause of cancer-related death in men [1]. Since the introduction of Patrick Walsh’s technique, open radical prostatectomy (RP) is the standard surgical treatment for localised PCa [2]. Laparoscopic RP and, later, robot-assisted laparoscopic prostatectomy (RALP) were introduced with the intention of minimising perioperative and postoperative morbidities [3], [4], [5]. In particular, RALP is a rapidly evolving technique, becoming widely applied as an alternative treatment to open or laparoscopic prostatectomy. Unfortunately, randomised studies comparing retropubic RP (RRP) and RALP are not available and will probably never be performed [6]. Therefore, the next best scientific “comparison” consists of matched case studies or consecutive studies. Another problem concerning the comparison between RRP and RALP is the lack of equal measurement for outcome parameters (such as continence, potency, and complications) and the potential discrepancy between low- and high-caseload centres in terms of results.
This trial compares consecutive series of RRP with recently introduced RALP procedures with respect to safety and efficacy in our centre, which has a limited caseload. The advantage of our study is the use of the same inclusion criteria and outcome measurements in both groups.
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Patients and methods
Between November 2007 and December 2009, 150 consecutive patients underwent RP and pelvic lymph node dissection (PLND). The first 75 patients were recruited for the RRP group and the last 75 patients for the RALP group. No patients in the study had had preoperative radiation therapy and/or neoadjuvant androgen-deprivation therapy. The preoperative workup for both groups consisted of digital rectal examination, serum prostatic-specific antigen (PSA) measurement, 10–12 biopsies for cancer
Results
Preoperative characteristics such as age, PSA, D’Amico risk, continence, and potency are reported in Table 1. The two groups were comparable for all variables. Surgical data are provided in Table 2. Statistically significant differences between RRP and RALP were observed for the operative time (253 ± 41 min vs 330 ± 54 min; p = 0.020) and for the median number of dissected lymph nodes (18 [range: 12–23] vs 12 [range: 9–17]; p < 0.001).
For the RRP and RALP groups, catheter-free rates were 88% (66 of 75
Discussion
RRP is considered the gold-standard surgical treatment for localised PCa. Despite technical improvements, there is still associated morbidity, especially urinary incontinence and erectile dysfunction. Minimally invasive approaches are continuously being advanced, but they must at least equal RRP in terms of oncologic and functional outcomes; otherwise, they are not justified.
Since its introduction, the robotic approach has shown excellent if not slightly better outcomes than open and
Conclusions
In consecutive series, using the same inclusion and outcome measurement criteria, RALP showed slightly better results than RRP in terms of PSM rate, urinary continence, and maintenance of erectile function as well as major complication rates, even when all patients under the RALP learning curve are considered. Although RALP also has the self-explanatory advantage of being a minimally invasive procedure, it shows at least no inferiority compared with RRP in our limited caseload centre.
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