Robot-assisted and open radical prostatectomy have equivalent results

After 24 months of investigations and data analysis, researchers have concluded that robot-assisted laparoscopic prostatectomy and open radical retropubic prostatectomy have similar functional outcomes.

But first of all, let’s talk about what these two surgical techniques mean. Prostatectomy is a procedure that involves removing a man’s prostate gland. Laparoscopic refers to the way the surgery is done. In this traditional method of radical prostatectomy, the surgeon makes a vertical 8- to 10-inch incision below the belly button. Radical prostatectomy is performed through this incision. In robot-assisted laparoscopic prostatectomy (RALP), a surgeon controls an advanced robotic system of surgical tools from outside the body.

Robot-assisted radical prostatectomy (RARP) has been rapidly adopted despite the lack of evidence demonstrating superior oncological or functional outcomes compared with laparoscopic (LRP) or open retropubic radical prostatectomy (ORP).

Between Aug 23, 2010, and Nov 25, 2014, men aged between 35 years and 70 years who have recently been diagnosed with prostate cancer and have chosen surgery as their treatment approach were recruited from the Royal Brisbane and Women’s Hospital (Brisbane, QLD, Australia).

“Robot-assisted laparoscopic prostatectomy has been widely adopted as the preferred surgical technique for radical prostatectomy without previous validation of improved outcomes,” highlight Suzanne Chambers (Griffith University, Gold Coast, Queensland, Australia) and her colleagues.

According to the Lancet Oncology, 326 men were enrolled in this study, of whom 163 were randomly assigned to robot-assisted laparoscopic prostatectomy and 163 to open radical retropubic prostatectomy. 18 of them withdrew, thus, 151 were assigned to have radical retropubic prostatectomy surgery and 157 to the robot-assisted laparoscopic prostatectomy surgery.

In the final step, 150 men remained in the robot-assisted laparoscopic prostatectomy group and 146 remained in the open radical retropubic prostatectomy group. Also, they mailed a questionnaire 18 months after diagnosis.

Primary outcomes were urinary function and sexual function!

In the laparoscopic group, urinary function scores were 91.33 and 90.86 in the open prostatectomy group, while sexual function scores were 45.70 and 46.90, respectively. There was no significant difference in other measured functional parameters, including continence or HRQoL (health-related quality of life).

Over the years, various studies have been made in order to compare sexual and urinary function and HRQoL.  However, many of these studies recruited patients from a single surgeon, single institution, or from tertiary medical centers. In particular, robotic surgery entails less blood loss, shorter catheter times and hospital stays, all of which facilitate early mobilization and reduce postoperative morbidity.

The choice of type of surgery depends strongly on where a patient had his treatment rather than on his specific characteristics because most hospitals offer only one surgical technique at a given time. This further reduces the likelihood of patients being allocated to one treatment or another based on their individual risk characteristics at diagnosis.

Nowadays, robot-assisted radical prostatectomy has been rapidly adopted in many countries and has become the most common type of RP within the English NHS (The National Prostate Cancer Audit, 2016b; Aggarwal et al, 2017; Sujenthiran et al, 2017).  While RARP was associated with marginally better sexual function scores than LRP or ORP as reported by men 18 months after diagnosis, this difference is small and unlikely to be clinically significant.

Vidit Sharma and R Jeffrey Karnes (both from the Mayo Clinic, Rochester, Minnesota, USA) conclude: “The gold standard for prostate cancer surgery remains a high-quality radical prostatectomy, regardless of the approach.”

All the results presented must be interpreted with caution, and further high-quality studies controlling for selection, confounding, and selective reporting biases with longer-term follow-up are needed to determine the clinical efficacy and safety of these two surgical techniques.