Robotic vs. open RP: Equivocal results (again)

A new study has found that for men 65 years of age and older, robot-assisted radical prostatectomy (RARP) and open prostatectomy have similar rates of complications, providing further evidence that outcomes between the two procedures are not significantly different.

In this study, which was published online ahead of print in the Journal of Clinical Oncology (April 14, 2014), the authors sought to address several of the limitations of previous studies of the open-versus-robotic-surgery debate. In 2009, researchers reported that men who underwent minimally invasive surgery had fewer transfusions, respiratory complications, miscellaneous complications, and anastomotic strictures (JAMA 2009; 302:1557-64). However, these men also had a greater likelihood of being diagnosed with urinary incontinence and erectile dysfunction, side effects that led the authors to conclude that the data demonstrating RARP’s superiority at that time was insufficient.

Then, in 2012, a study was published that found “superior adjusted perioperative outcomes in RARP in virtually all examined outcomes” (Eur Urol 2012; 61:679-85).

“The 2009 study used data from 2003 to 2006, soon after robotics was first introduced,” said Quoc-Dien Trinh, MD, a study author on both the current and 2012 studies, explaining that surgeons in those pre-dissemination years might not yet have developed expertise in using robots. In addition, in that earlier study, RARP and laparoscopic prostatectomy were both defined as “minimally invasive,” making it difficult to separate out outcomes for RARP specifically.

The 2012 study also had a limitation in that it culled its data from the Nationwide Inpatient Sample (NIS). The NIS does not include cancer stage and grade characteristics and long-term data on complications.

To address these limitations in the current study, Dr. Trinh and colleagues used U.S. Surveillance, Epidemiology, and End Results Medicare (SEER)-linked data, which has the advantage of including stage, grades, and longitudinal data. These additional data points allowed the authors to study such variables as post-hospitalization complications, readmissions, need for additional cancer therapies, and cost of care within the first year after surgery.

Dr. Trinh and his co-authors hypothesized that their new study would yield similar results to their 2012 study, which showed RARP to be superior to open prostatectomy in terms of outcomes.

But the data demonstrated equivocal results.

“The data suggests that in the post-dissemination era [ie, contemporary patients], elderly patients over 65 undergoing robotic-assisted radical prostatectomy have the same risk of complications, readmissions, and additional cancer therapies as those who get open surgery,” said Dr. Trinh, of Brigham and Women’s Hospital and Dana-Farber Cancer Institute, Boston.

The study did find, however, that in terms of number of transfusions and rates of prolonged lengths of stay-which the current study did not define as complications-RARP did show a benefit compared to open surgery, confirming previous studies’ findings about the benefits of minimally invasive surgery. In terms of expenditures, the open procedure came out ahead; total first year charges for RARP patients were a median $1,400 more than charges for patients undergoing open surgery.

“Our hypothesis is that younger patients, who constitute the majority of patients undergoing radical prostatectomy, may derive greater benefit from robotic prostatectomy, as it was demonstrated in the Nationwide Inpatient Sample study,” Dr. Trinh said. “However, further studies are warranted.”

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