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Year : 2010  |  Volume : 26  |  Issue : 2  |  Page : 318-319
 

Minimally invasive radical prostatectomy: Perception vs. Reality


Department of Urology, Christian Medical College, Vellore, India

Date of Web Publication12-Jul-2010

Correspondence Address:
T J Nirmal
Department of Urology, Christian Medical College, Vellore
India
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How to cite this article:
Nirmal T J, Kekre N S. Minimally invasive radical prostatectomy: Perception vs. Reality. Indian J Urol 2010;26:318-9

How to cite this URL:
Nirmal T J, Kekre N S. Minimally invasive radical prostatectomy: Perception vs. Reality. Indian J Urol [serial online] 2010 [cited 2014 Jul 30];26:318-9. Available from: http://www.indianjurol.com/text.asp?2010/26/2/318/65419

Hu JC, Gu X, Lipsitz SR, Barry MJ, D′Amico AV, Weinberg AC, et al. Comparative Effectiveness of Minimally Invasive vs Open Radical Prostatectomy. JAMA 2009;302:1557-64.



   Summary Top


This population-based observational cohort study assesses the outcomes of minimally invasive radical prostatectomy (MIRP) vs. open radical retropubic prostatectomy (RRP). [1] Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare data base, 8837 men aged 65 years or older, who underwent radical prostatectomy for prostate cancer from 2003 to 2007, were identified. Of the total, 6899 men underwent RRP and 1938 MIRP. Men with other cancers and those who underwent an open perineal radical prostatectomy were excluded. The study compared postoperative 30-day complications, anastomotic stricture 31 to 365 days postoperatively, long-term incontinence and erectile dysfunction more than 18 months postoperatively; postoperative use of additional cancer therapies, a surrogate for cancer control. Over the study period, MIRP use went up by nearly five-fold, from 9.2% in 2003 to 43.2% in 2006-07. Asians were more likely (6.1% vs. 3.2%) to undergo MIRP vs. RRP (P < 0.001) compared to black or hispanics. Men undergoing MIRP were more likely to be from metropolitan areas (95.3% vs 91.2%; P = 0.007) with at least 90% high school graduation rates (50.2% vs 41.0%) and a median household income of ≥ $60, 000 (35.8% vs. 21.5%) (P < 0.001). In propensity score-adjusted analyses, MIRP vs. RRP was associated with shorter length of stay (median, 2.0 vs 3.0 days; P < 0.001) and lower rates of blood transfusions (2.7% vs. 20.8%; P < 0.001), postoperative respiratory complications (4.3% vs 6.6%; P = 0.004), miscellaneous surgical complications (4.3% vs. 5.6%; P = 0.03), and anastomotic stricture (5.8% vs 14.0%; P < 0.001). However, MIRP vs. RRP was associated with an increased risk of genitourinary complications (4.7% vs. 2.1%; P = 0.001) and diagnoses of incontinence (15.9 vs. 12.2 per 100 person-years; P = 0.02) and erectile dysfunction (26.8 vs. 19.2 per 100 person-years; P = 0.009). MIRP vs. RRP was more likely to have organ-confined disease (68.3% vs 60.8%; P < 0.001). Mortality rates and need for additional cancer therapies were similar for both groups. Based on these findings, the authors concluded that the marketed or potential benefits of MIRP were yet to be realized and its superiority over the gold standard RRP yet to be established.


   Comments Top


Ever since the first report on Robotic-assisted laparoscopic radical prostatectomy, [2] there has been a near exponential rise in the popularity and acceptance of MIRP. [3] Although MIRP techniques have been available for over two decades, their potential benefits over RRP are yet to be substantiated due to lack of randomized trials in literature. Until then, the debate on MIRP vs. RRP will continue to be fuelled by single center experiences, case series and observational studies such as the one by Hu et al.

This study is commendable as it makes an honest attempt to put MIRP into perspective, with evidence based outcomes that go beyond mere speculation, promise and marketing. The strength of the study lies in the high degree of validity of the SEER-Medicare database used for analysis which covered 26% of the U.S population and also on the meticulous analysis using measures like propensity weighted scores to account for all possible confounders. Apart from the observational study design, a significant drawback of this study is the fact that Medicare data lacked detailed clinical information and could not differentiate between laparoscopic procedures performed with and without robotic assistance.

The most interesting outcome of this study was the socioeconomic and demographic variation in the use of MIRP favoring the rich and educated who have both access and means to afford the latest, increasing their vulnerability to propaganda. This study corroborates the positive perioperative and short term outcomes of MIRP reported in several large case series [4] like shorter hospital stay, lower transfusion rates. However, MIRP failed to match RRP when it came to long term oncologic outcomes and quality of life issues like continence and potency. This may be attributable to steeper learning curves and unavailability of long term follow up data.

A recent study revealed that patients undergoing RRP were 4.4 times more likely to be dissatisfied, especially with urinary control [5] and it was important for urologists to disseminate realistic expectations to reduce subsequent regret. Finally, robotic-assisted radical prostatectomy can become relevant in a developing nation like ours only if it is cost effective. At present, RRP has a cost advantage of nearly $1726 [6] and robotic prostatectomy requires 75 cases per year at an average operative time of three hours per case to be cost-effective. [7] Hence MIRP may be best suited for high volume centers where the steep learning curve may be rapidly overcome.

To conclude, there is insufficient evidence to prove superiority of MIRP over the gold standard RRP despite successful marketing. The future is destined to bring improvement in technology and shall probably help us realize its potential benefits.

 
   References Top

1.Hu JC, Gu X, Lipsitz SR, Barry MJ, D'Amico AV, Weinberg AC, et al. Comparative effectiveness of minimally invasive vs open radical prostatectomy. JAMA 2009;302:1557-64.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Binder J, Kramer W. Robotically-assisted laparoscopic radical prostatectomy. BJU Int 2001;87:408-10.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Hu JC, Wang Q, Pachos CL, Lipsitz SR, Keating NL. Utilization and outcomes of minimally invasive radical prostatectomy. J Clin Oncol 2008;28:2278-84.  Back to cited text no. 3      
4.Badani KK, Kaul S, Menon M. Evolution of robotic radical prostatectomy: Assessment after 2766 procedures. Cancer 2007;110:1951-8.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Schroeck FR, Krupski TL, Sun L, Albala DM, Price MM, Polascik TJ, et  al. Satisfaction and regret after open retropubic or robot-assisted laparoscopic radical prostatectomy. Eur Urol 2008;54:785-93.  Back to cited text no. 5      
6.Lotan Y, Cadeddu JA, Gettman MT. The new economics of radical prostatectomy cost comparison of open, laparoscopic and robot assisted techniques. J Urol 2004;172:1431-5.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Menon M, Shrivastava A, Tewari A. Laparoscopic radical prostatectomy: Conventional and robotic. Urology 2005;66:101-4.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  




 

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