Robotic radical prostatectomy results help establish its credibility

New Orleans-Robot-assisted laparoscopic prostatectomy may have made its way into the clinical arena under heavy marketing, but its value has now become clear, according to James E. Montie, MD, professor of urology at the University of Michigan, Ann Arbor. Dr. Montie described the emergence of robot-assisted prostatectomy and its potential benefits, particularly among low- and moderate-volume surgeons, at the American College of Surgeons Clinical Congress here.

"Market pressures pushed others in Metro Detroit to invest in the robot, and the contest was on," he said. "This scenario was repeated countless times around the country, often with surgeons claiming in paid advertisements to have substantial superiority using the robot over conventional surgery, even when the surgeons had negligible experience."

"This hospital lost cases, even though they have very good urologists. In 2006, they got a robot," Dr. Montie said.

He told the audience that much of the marketing by hospitals was based on deceptive comparisons between robotic and conventional radical prostatectomy. For example, one hospital made comparisons with its own open surgery results and demonstrated substantial benefit to the robotic procedure. The hospital claimed that in its surgical center, robotic prostatectomy produced less pain, fewer complications, shorter hospital stays, faster recovery, earlier return of urinary control, improved sexual function, and less internal scarring.

"Yes, [those outcomes were accurate] compared to their open results," he argued. "Thus, this was technically true. The implication to patients was, 'if you do anything other than robotic laparoscopy, you are needlessly suffering.' "

Deconstructing the message

Differences in outcomes are less among high-volume hospitals and experienced surgeons, Dr. Montie pointed out. In a study by Wood et al comparing outcomes of robotic and conventional radical prostatectomy, length of stay was the same, narcotic use was similar, and in-hospital narcotic use was less with the robot (although clinically insignificant for a length of stay of just 1 day) (Urology 2007; 70:945-9). Time to normal activities was about 1 day shorter; time to 100% normal activity was 1 week less with the robot.

"But by both approaches, these are quick, short-term recoveries. How do you reconcile those claims?" Dr. Montie asked.

He contended that when both types of patients are given the same instructions for pain control and recovery and surveys use a validated instrument and third-party data acquisition, few differences between procedures can be found. By contrast, the hospital marketing the procedure reported poor outcomes with open prostatectomy, gave different instructions to patients regarding their recovery, and "told patients that robot-assisted prostatectomy was the new best thing." In other words, the comparator was not fair, Dr. Montie said.

"In my opinion, the way robotic surgery was introduced is a black mark on urology as a field, and I hope we never let it happen again," he declared.

Dr. Montie explained that short-term outcomes and long-term function with the robot might not be much better compared with open results from high-volume surgeons, but outcomes might be better for small- to moderate-volume surgeons because of less variability during the case and less risk of heavy bleeding, which can make the operation unpleasant, if not dangerous. That explains why robotic prostatectomy has flourished around the country.

"The surgeon experience during the operation is better," he said. "Almost everybody says that, particularly lower-volume surgeons. The robotic approach is popular for reasons other than just marketing or competition.

"Therefore, for a lower- or moderate-volume surgeon, the less variability in the robotic procedure makes the operation a less traumatic event for the surgeon may hasten slightly the recovery for the patient because blood loss is less, and may provide better outcomes because of fewer instances of blood loss interfering with the procedure," Dr. Montie concluded.

The need to optimize outcomes for patients by whatever means necessary is clear. At 1 year after open radical prostatectomy, only 30% of patients report optimal outcomes (ie, cancer free, potent, dry), and the rate rarely rises above 50% in any center, according to a study published by Saranchuk et al in the Journal of Clinical Oncology (2005; 23:4146-4151).

"These results are disappointing," Dr. Montie said. "Prostate cancer patients constitute 41% of all male cancer survivors. This is why our efforts to improve radical prostatectomy are worthwhile. Robot-assisted prostatectomy may well be improving overall quality of care. It's a shame it was introduced the way it was, but it may have sped implementation.

"Someday, we will have to think about the economic consequences of new technology, although apparently not yet."