Less invasive RP safer than open RP, large study finds

Nearly half of radical prostatectomies now involve a minimally invasive approach, according to a large study comparing minimally invasive radical prostatectomy (MIRP) with open retropubic radical prostatectomy from 2003 to 2007.

The study, which was published in European Urology (2012; 61:803-9), contains three other major findings, each deserving of a clinician’s further reading:

There were fewer complications with MIRP, regardless of complication type, with fewer blood transfusions and shorter hospital stays. Most MIRP complications decreased or remained stable over the study period, whereas open RP complications increased from 27.4% to 32%.
Open RP was associated with greater odds of perioperative mortality, including a significant increase in post-surgical death from 0.5% to 0.8% over the study period. Overall, MIRP had a 0.2% risk of post-surgical death versus a 0.6% risk in open RP.
Patients undergoing MIRP were younger and had fewer comorbidities.

MIRP utilization increased from under 5% in 2003 to 44.5% in 2007 with a concomitant decrease in open RP.

The study was conducted by researchers from Georgetown University Hospital, Washington; Harvard’s Brigham and Women’s Hospital, Boston; and the Centers for Medicare & Medicaid Services, Baltimore.

Previous studies were finding problems with MIRP, suggesting conclusions different from the European Urology study would result once MIRP could be reliably compared to open RP over a longer term. But as the authors noted, those previous studies were small or otherwise not representative, and most published MIRP outcomes originate from high-volume referral centers and may not be generalizable to community settings.

The current study used data from the 100% Medicare sample from 2003 to 2007 to assess temporal trends in the utilization and outcomes of 19,594 MIRPs using either laparoscopy or robotic technology and 58,638 open RP procedures in men aged 65 years and older.

Perioperative complications were characterized within 30 days of surgery and included potentially life-threatening cardiac, respiratory, or vascular events; genitourinary complications; bleeding; miscellaneous surgical and medical complications; wound infection; and death. Late complications included anastomotic stricture, urethral complications, rectourethral fistula, and lymphocele.

Two common long-term complications, erectile dysfunction and urinary incontinence, were not included because the outcomes are often subjective and might not be adequately assessed using Medicare data that relies on diagnosis codes rather than validated patient questionnaires, the most accurate methods to measure erectile function and continence.

"We expected to see fewer complications as surgeons got more comfortable with minimally invasive procedures like robotics, but it remains somewhat of a mystery why the complication rates rose in the open surgery group," said first author Keith Kowalczyk, MD, Georgetown University Hospital.

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