Elsevier

European Urology

Volume 59, Issue 1, January 2011, Pages 1-6
European Urology

Platinum Priority – Prostate Cancer
Editorial by Mani Menon on pp. 7–9 of this issue
A Prospective Trial Comparing Consecutive Series of Open Retropubic and Robot-Assisted Laparoscopic Radical Prostatectomy in a Centre with a Limited Caseload

https://doi.org/10.1016/j.eururo.2010.10.026Get rights and content

Abstract

Background

Robot-assisted radical prostatectomy (RALP) is performed worldwide, even in institutions with limited caseloads. However, although the results of large RALP series are available, oncologic and functional outcomes as well as complications from low-caseload centres are lacking.

Objective

To compare perioperative, oncologic, and functional outcomes from two consecutive series of patients with localised prostate cancer treated by retropubic radical prostatectomy (RRP) or recently established RALP in our hospital, which has a limited caseload.

Design, setting, and participants

One hundred fifty consecutive patients were enrolled. Their data and outcomes were collected and extensively evaluated.

Intervention

Seventy-five consecutive patients underwent RRP, and 75 consecutive patients underwent RALP, including all patients of the learning curve.

Measurements

Patient baseline characteristics, perioperative and postoperative outcomes, and complications were evaluated. End points were oncologic data (positive margins, prostate-specific antigen [PSA]), perioperative complications, urinary continence, and erectile function at 3- and 12-mo follow-up.

Results and limitations

The preoperative parameters from the two groups were comparable. The positive surgical margin (PSM) rates were 32% for RRP and 16% for RALP (p = 0.002). For RRP and RALP, the PSA value was <0.2 ng/ml in 91% and 88% of patients 3 mo postoperatively (p = 0.708) and in 87% and 89% of patients 12 mo postoperatively (p = 0.36), respectively. Continence rates for RRP and RALP were 83% and 95% at 3-mo follow-up (p = 0.003) and 80% and 89% after 12-mo follow-up (p = 0.092), respectively. Among patients who were potent without phosphodiesterase type 5 inhibitors (PDE5-I) before RRP and RALP, recovery of erectile function with and without PDE5-Is was achieved in 25% (12 of 49 patients) and 68% (25 of 37 patients) 3 mo postoperatively (p = 0.009) and in 26% (12 of 47 patients) and 55% (12 of 22 patients) 12 mo postoperatively (p = 0.009), respectively. Minimal follow-up for RRP was 12 mo; median follow-up for the RALP group was 12 mo (range: 3–12). According to the modified Clavien system, major complication rates for RRP and RALP were 28% and 7% (p = 0.025), respectively; minor complication rates were 24% and 35% (p = 0.744), respectively.

Conclusions

Despite a limited caseload and including the learning curve, RALP offers slightly better results than RRP in terms of PSM, major complications, urinary continence, and erectile function.

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.

Section snippets

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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