Clinical outcomes and costs of robotic surgery in prostate cancer: a multiinstitutional study in Korea

Background

This study compared the surgical, functional, and oncologic outcomes of robot-assisted laparoscopic radical prostatectomy (RALP), laparoscopic radical prostatectomy (LRP), and retropubic radical prostatectomy (RRP) in Korean men.

Methods

The study population included 864 patients who underwent radical prostatectomy for prostate cancer in the departments of urology of five tertiary hospitals between 2010 and 2011. RALP, LRP, and RRP perioperative, oncological, and functional outcomes as well as complications were assessed. Medical cost data were analyzed for 682 of 864 patients.

Results

No significant differences were found among the three groups regarding the length of stay, biochemical recurrence, complications, and metastasis. The RALP group had a significantly higher rate of pelvic lymph node dissection (64.6% vs. 35.3% or 53.3%, P value <0.0001) and bilateral nerve-sparing procedures (15.7% vs. 10.0% or 8.9%, P value <0.0001) and less blood loss (median 250 mL vs. 300 mL or 700 mL, P value <0.0001) than the LRP and RRP groups. The 12-month continence recovery rate was higher in the RALP group (92.1%) than in the LRP (86.5%) and RRP (84.4%) groups (P value <0.0001). Medical costs for RALP were approximately twofold to threefold higher than those for LRP or RRP.

Conclusions

Our findings suggest that surgical and functional outcomes are better with robot-assisted surgery than with laparoscopic or open surgery in terms of estimated blood loss and urinary continence; however, no differences were found among groups in terms of biochemical recurrence and the rate of complications.

Robot-assisted radical prostatectomy has lower biochemical recurrence than laparoscopic radical prostatectomy: Systematic review and meta-analysis

Purpose

To assess the effectiveness and safety of robot-assisted radical prostatectomy (RARP) versus laparoscopic radical prostatectomy (LRP) in the treatment of prostate cancer.

Materials and Methods

Existing systematic reviews were updated to investigate the effectiveness and safety of RARP. Electronic databases, including Ovid MEDLINE, Ovid Embase, the Cochrane Library, KoreaMed, Kmbase, and others, were searched through July 2014. The quality of the selected systematic reviews was assessed by using the revised assessment of multiple systematic reviews (R-Amstar) and the Cochrane Risk of Bias tool. Meta-analysis was performed by using Revman 5.2 (Cochrane Community) and Comprehensive Meta-Analysis 2.0 (CMA; Biostat). Cochrane Q and I2 statistics were used to assess heterogeneity.

Results

Two systematic reviews and 16 additional studies were selected from a search performed of existing systematic reviews. These included 2 randomized controlled clinical trials and 28 nonrandomized comparative studies. The risk of complications, such as injury to organs by the Clavien-Dindo classification, was lower with RARP than with LRP (relative risk [RR], 0.44; 95% confidence interval [CI], 1.23–0.85; p=0.01). The risk of urinary incontinence was lower (RR, 0.43; 95% CI, 0.31–0.60; p<0.000001) and the potency rate was significantly higher with RARP than with LRP (RR, 1.38; 95% CI, 1.11–1.70; I²=78%; p=0.003). Regarding positive surgical margins, no significant difference in risk between the 2 groups was observed; however, the biochemical recurrence rate was lower after RARP than after LRP (RR, 0.59; 95% CI, 0.48–0.73; I²=21%; p<0.00001).

Conclusions

RARP appears to be a safe and effective technique compared with LRP with a lower complication rate, better potency, a higher continence rate, and a decreased rate of biochemical recurrence.

Comparison of functional outcomes after retropubic, laparoscopic and robot-assisted radical prostatectomy: A meta-analysis

AIM: To assess the 6-mo and 12-mo functional outcomes after retropubic, laparoscopic and robot-assisted laparoscopic radical prostatectomy retropubic radical prostatectomy (RRP) laparoscopic radical prostatectomy (LRP); robot-assisted laparoscopic prostatectomy (RARP).

METHODS: A literature search was conducted using the PubMed, EMBASE, The Cochrane Library and the Web of Knowledge databases updated to March, 2014 for relevant published studies. After data extraction and quality assessment via the Newcastle-Ottawa Scale or the Cochrane collaboration’s tool for assessing risk of bias, meta-analysis was performed using RevMan 5.1. Either a random-effects model or a fixed-effects model was used. Potential publication bias was assessed using visual inspection of the funnel plots, and verified by the Egger linear regression test.

RESULTS: Thirty-seven studies were identified in total: 14 articles comparing LRP with RRP, 12 articles comparing RARP with RRP, and 11 articles comparing RARP with LRP. For urinary continence, a statistically significant advantage was observed in RARP compared with LRP or RRP both at 6 mo [odds ratio (OR) = 1.93; P < 0.01, OR = 2.23; P < 0.05, respectively] and 12 mo (OR = 1.47; P < 0.01, OR = 2.93; P < 0.01, respectively) postoperatively. The continence recovery rates after LRP and RRP, with obvious heterogeneity (6-mo: I² = 74%; 12-mo: I² = 75%), were equivalent (6-mo: P = 0.52; 12-mo: P = 0.75). In terms of potency recovery, for the first time, we ranked the three surgical approaches into a superiority level: RARP > LRP > RRP, with a statistically significant difference at 12 mo [RARP vs LRP (OR = 1.99; P < 0.01); RARP vs RRP (OR = 2.66; P < 0.01); LRP vs RRP (OR = 1.34; P < 0.05)], respectively. Meta-regression and subgroup analyses according to adjustment of the age, body mass index, prostate volume, Gleason score or prostate-specific antigen did not vary significantly.

CONCLUSION: Current evidence suggests that minimally invasive approaches (RARP or LRP) are effective procedures for functional recovery. However, more high-quality randomized control trials investigating the long-term functional outcomes are needed.

Experience of 100 laparoscopic radical prostatectomies performed by a single surgeon: an analysis of surgical and functional outcomes

PURPOSE

We analyzed the surgical and functional outcomes of 100 consecutive laparo-scopic radical prostatectomies (LRP) performed by a single surgeon.

MATERIALS AND METHODS

Between October 2007 and May 2010, a total of 100 consecutive patients underwent LRP for prostate cancer at our institution. We retrospectively reviewed the medical records of these patients to determine surgical and functional results. We compared surgical and functional outcomes between three groups divided on the basis of operation period (Group 1; first 40 cases; Group 2; next 30 cases; Group 3; last 30 cases).

RESULTS

The operative time decreased significantly as the surgeon's experience increased over time (P<0.01). The learning curve for operative time was surpassed after approximately 40 cases. The overall positive surgical margin (PSM) rate was 17.5% in Group 1, 16.7% in Group 2, and 10% in Group 3. For organ-confined disease, the PSM rate was 2.5%, 6.7%, and 3.3% in Groups 1, 2, and 3, respectively. The continence rate (absence of a pad) was 73.2% and the social continence rate was 94.7% at 12 months after surgery. There was a significant difference in continence (absence of pad) between the early (Group 1) and late group (Group 3) at 1, 3, and 6 months (P<0.0001). The continence rate was not affected by whether the pubic bone-anchoring procedure or the Rocco suture method was used. The overall potency rate was 16.7% and 48.6% at 6 and 12 months, respectively. For bilateral nerve-sparing cases, the potency rate was 20% and 57.1% at 6 and 12 months, respectively.

CONCLUSIONS

Our surgical and functional outcomes indicate that even in this 'robotic era', LRP is still an attractive treatment option for patients with localized prostate cancer, especially in areas with limited access to surgical robots.