Best Practices in Robot-assisted Radical Prostatectomy: Recommendations of the Pasadena Consensus Panel

Abstract

Context

Radical retropubic prostatectomy (RRP) has long been the most common surgical technique used to treat clinically localized prostate cancer (PCa). More recently, robot-assisted radical prostatectomy (RARP) has been gaining increasing acceptance among patients and urologists, and it has become the dominant technique in the United States despite a paucity of prospective studies or randomized trials supporting its superiority over RRP.

Objective

A 2-d consensus conference of 17 world leaders in prostate cancer and radical prostatectomy was organized in Pasadena, California, and at the City of Hope Cancer Center, Duarte, California, under the auspices of the European Association of Urology Robotic Urology Section to systematically review the currently available data on RARP, to critically assess current surgical techniques, and to generate best practice recommendations to guide clinicians and related medical personnel. No commercial support was obtained for the conference.

Evidence acquisition

A systematic review of the literature was performed in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement.

Evidence synthesis

The results of the systematic literature review were reviewed, discussed, and refined over the 2-d conference. Key recommendations were generated using a Delphi consensus approach. RARP is associated with less blood loss and transfusion rates compared with RRP, and there appear to be minimal differences between the two approaches in terms of overall postoperative complications. Positive surgical margin rates are at least equivalent with RARP, but firm conclusions about biochemical recurrence and other oncologic end points are difficult to draw because the follow-up in existing studies is relatively short and the overall experience with RARP in locally advanced PCa is still limited. RARP may offer advantages in postoperative recovery of urinary continence and erectile function, although there are methodological limitations in most studies to date and a need for well-controlled comparative outcomes studies of radical prostatectomy surgery following best practice guidelines. Surgeon experience and institutional volume of procedures strongly predict better outcomes in all relevant domains.

Conclusions

Available evidence suggests that RARP is a valuable therapeutic option for clinically localized PCa. Further research is needed to clarify the actual role of RARP in patients with locally advanced disease.

Introduction

Radical retropubic prostatectomy (RRP) has long been the most commonly used surgical approach for patients with localized prostate cancer (PCa) and a long life expectancy. In an effort to reduce the morbidity of the procedure, surgeons have developed new surgical techniques such as laparoscopic radical prostatectomy (LRP) and, more recently, robot-assisted radical prostatectomy (RARP) [1], [2], [3], [4], [5].

A systematic literature review published in 2009 showed that laparoscopic techniques were associated with advantages in terms of blood loss and transfusion rates compared with RRP [6]. At that time, the limited number of studies comparing RARP with RRP prevented the authors from drawing any conclusions about the superiority of one or the other of these techniques in terms of oncologic and functional outcomes.

In this context, and in the absence of any prospective randomized trial comparing RARP with either RRP or LRP, RARP has become the leading option for treating patients with clinically localized PCa in the United States, and it has been progressively expanding in other countries.

The systematic reviews presented in this issue of European Urology suggest that RARP is advantageous in terms of perioperative outcomes and both urinary continence and potency recovery in comparison with RRP [7], [8], [9], [10]. However, there are a lack of well-controlled prospective studies of functional outcomes of RARP compared with RRP. The Pasadena Consensus Panel (PCP) recognized that recovery of sexual function and continence following surgery is influenced by multiple factors including surgical experience and institutional volume of surgery, level of premorbid function in patients, postsurgical rehabilitation, and outcome assessment methods. These factors have not been sufficiently controlled in most studies. Although the available evidence is still limited, RARP has shown an impact on cancer control equivalent to RRP.

As a complement to the systematic reviews just mentioned, a consensus conference of world leaders in prostate cancer and radical prostatectomy (RP) was convened in Pasadena, California, and at the City of Hope Cancer Center, Duarte, California, in September 2011 under the auspices of the European Association of Urology (EAU) Robotic Urology Section. This paper presents the recommendations of that conference.