Year : 2010 | Volume
: 26 | Issue : 4 | Page : 601--602
Limitations and complications of robot-assisted laparoscopic radical prostatectomy: The other side of the coin
D Ananda Kumar, K Sairam, V Srinivasan
Department of Urology, Glan Clwyd Hospital, Rhyl, United Kingdom
D Ananda Kumar
Department of Urology, Glan Clwyd Hospital, Rhyl
|How to cite this article:|
Kumar D A, Sairam K, Srinivasan V. Limitations and complications of robot-assisted laparoscopic radical prostatectomy: The other side of the coin.Indian J Urol 2010;26:601-602
|How to cite this URL:|
Kumar D A, Sairam K, Srinivasan V. Limitations and complications of robot-assisted laparoscopic radical prostatectomy: The other side of the coin. Indian J Urol [serial online] 2010 [cited 2020 Oct 1 ];26:601-602
Available from: http://www.indianjurol.com/text.asp?2010/26/4/601/74480
Robot-assisted laparoscopic radical prostatectomy (RALP) is now well-established in the United States but the uptake is increasing globally. Although several reports have established the feasibility, safety and early functional and oncological efficacy of RALP, few have highlighted its limitations. In this review, the authors evaluate the current status of RALP, with a particular focus on its limitations and complications. A Medline search of English literature was performed in September 2009. In total, 412 articles were reviewed and 68 papers selected for the final review.
Instrument and Patient Issues
Device failure is rare, occurring in only 34 of 8240 cases (0.4%). Most of the adverse events relate to either broken instrument tips or failure of electrocautery elements of the da Vinci instruments. Robotic surgery does not diminish the deleterious effect of obesity or larger prostates on surgical outcome. Post-TURP patients had a significantly higher PSM rate usually at the bladder neck. Satisfactory reports of salvage RALP following failed external-beam RT (EBRT), brachytherapy, high-intensity focused ultrasound treatment (HIFU) or cryotherapy have been reported in small case series.
Complications of Robot-Assisted Radical Prostatectomy
Using standardized Martin criteria,  an overall complication rate of 21.6% was demonstrated, with Clavien I-II complications  accounting for 18.6%. From an anesthetic perspective, the steep Trendelenburg position in RALP is well-tolerated.
Oncological and Functional Outcomes
Overall, although there is no level 1 evidence to provide conclusive data, PSM rates for RALP compare favorably to those for ORP and laparoscopic radical prostatectomy (LRP). The authors suggest that the learning curve for RALP is about 30 cases, but one could suggest that as PSMs continued to improve in the latter third of series, a figure of 60 cases might be more appropriate. Extracapsular disease was the most powerful predictor of overall, posterolateral and multiple PSM, while perineural invasion was predictive of PSM in organ-confined disease. In the short term, overall survival and biochemical recurrence-free survival rates are encouraging and compare favorably to ORP and LRP. As of now there is no increased indication or referral for early adjuvant RT or salvage therapy in the RALP group. Despite excellent continence rates (using the ICIQ-UI questionnaire, 88% ORP versus 97% RALP), patients reported less satisfaction with RALP. Miller et al , only demonstrated a 1-week difference in return-to-baseline scores in the physical domain in favor of RALP and no difference in the mental domain.
The Learning Curve
One of the claimed benefits of the robot-assisted approach is that it reduces the difficulty associated with conventional LRP, reducing the learning curve to as few as 12 cases.
At the time of writing, the da Vinci Si is the latest incarnation being marketed by Intuitive Surgical. Despite a phenomenal increase in the number of robots globally, costs for installation and maintenance remain prohibitively high due to lack of a competitor in this arena.
Proponents of RALP and those with vested interests often claim that it leads to shorter hospitalization, faster return to work and other benefits that justify the expense of the robot-assisted approach. However, these claims are usually unsubstantiated and are often limited by the great variation in health economies from one country to another. Scales et al , demonstrated cost-equivalence of RALP with ORP based on 10 cases per week and cost superiority based on 14 cases per week in the United States. However, this is purely an economic model, and achieving 14 cases per week on a single robot is unlikely in the majority of facilities.
There is little doubt that Intuitive Surgical's acquisition of Computer Motion Inc. (manufacturers of the Zeus master-slave system) in 2003 effectively wiped out the only potential competitor in this market. Intuitive Surgical retain a monopoly, with no significant competition on the horizon. One really wonders whether EndoWrist instruments have to be discarded after 10 or so uses, especially when EndoWrist training instruments often work very well for 50 sessions. A competitor in the field of robotic instrumentation would be most welcome as a stimulus to an otherwise monopolized market.
In this era where the robot is idolized, this article attracted our interest as it discussed the limitations of RALP. We appreciate the authors' attempt to look at the other side of the coin. Frequently, the introduction of an innovative surgical technique is characterized by a non-virtuosic process, starting with a promising report and finishing with a standard procedure. 
One important area of interest in promotion of RALP is that surgeons doing ORP can directly adapt to RALP. The authors identified an important drawback in it. In review of the MAUDE database 2006-07, 32 procedures were converted to open surgery, which reflects the lack of experience with conventional LRP in the United States.  In future once RALP becomes de rigueur in training programs, the lack of training in ORP or LRP techniques may pose a potential problem when dealing with the consequences of instrument or device failure.
RALP does not seem to offer any particular advantage either with patient related comorbidities like obesity or previous failed treatments like EBRT, brachytherapy, HIFU or cryotherapy.
The goals of treating prostate cancer are cancer control, continence, coitus and acceptable co-morbidity - 4 Cs.  Even though the first robotic prostatectomy was performed in May 2000, long-term results are still lacking. Oncological and functional results must always be correlated because PSM rates will rise as one dissects closer to the prostate.  The authors have clearly identified the limitations of the non-standardized reporting system which makes comparison with other modalities virtually impossible. There are standard methodologies available for RALP series like:
Martin criteria  for recording and Clavien  classification for reporting complications.Stanford protocol  for prostate specimen processing and PSM reporting.Validated questionnaires to assess functional outcome such as International Index of Erectile Function (IIEF), ICIQ-UI, UCLA-PCI and compliance with the Mulhall criteria  for series reporting detailed potency data.
Non-standardized reporting makes it impossible to have a head-to-head comparison of RALP with other modalities. Based on the available literature there is no statistically significant advantage for RALP in both oncological (like PSM) and functional (like continence and potency) outcomes.
Finally, the authors have boldly discussed the monopoly by the manufacturers, resulting in exorbitant cost of the procedure, making it virtually impossible for the third world countries to use the robot. The point about the EndoWrist instruments programmed to work for a finite number of cases, brings into sharp focus the strategy utilized by many companies, that serves as a deterrent for all but the richest. Programming an instrument to work for a finite number of procedures, even though it can be used for more procedures safely, for the sake of improving sales is not only unaffordable for developing countries, but is a blatant waste of resources.
A competitor in the field of robotic instrumentation or a different pricing structure of the currently available robot for the developing countries would be the way forward for better uptake of robotics in urology on a global scale.
|1||Martin RC, Brennan MF, Jaques DP. Quality of complication reporting in the surgical literature. Ann Surg 2002;235:803-13.|
|2||Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-13.|
|3||McKinlay JB. From "promising report" to "standard procedure": Seven stages in the career of a medical innovation. Milbank Mem Fund Q Health Soc 1981;59:374-411.|
|4||Murphy D, Challacombe B, Elhage O, Dasgupta P. Complications in robotic urological surgery. Minerva Urol Nefrol 2007;59:191-8.|
|5||Mottrie AM. The introduction of robot-assisted surgery in urologic practice: Why is it so difficult? Eur Urol 2010;57:747-9.|
|6||Zorn KC, Gofrit ON, Orvieto MA, Mikhail AA, Zagaja GP, Shalhav AL. Robotic-assisted laparoscopic prostatectomy: Functional and pathologic outcomes with interfascial nerve preservation. Eur Urol 2007;51:755-63.|
|7||True LD. Surgical pathology examination of the prostate gland: Practice survey by American Society of Clinical Pathologists. Am J Clin Pathol 1994;102:572-9.|
|8||Mulhall JP. Defining and reporting erectile function outcomes after radical prostatectomy: Challenges and misconceptions. J Urol 2009;181:462-71.|