Article of the week: An open and shut case: outcomes similar for open and robotic prostatectomy
Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.
In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.
Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video of Jonathan Silberstein discussing his paper.
If you only have time to read one article this week, it should be this one.
A case-mix-adjusted comparison of early oncological outcomes of open and robotic prostatectomy performed by experienced high volume surgeons
Jonathan L. Silberstein*, Daniel Su*, Leonard Glickman*, Matthew Kent†, Gal Keren-Paz*, Andrew J. Vickers†, Jonathan A. Coleman*‡, James A. Eastham*‡, Peter T. Scardino*‡ and Vincent P. Laudone*‡
*Department of Surgery, Urology Service, and †Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, and ‡Department of Urology,Weill Cornell Medical Center, New York, NY, USA
OBJECTIVE
• To compare early oncological outcomes of robot assisted laparoscopic prostatectomy (RALP) and open radical prostatectomy (ORP) performed by high volume surgeons in a contemporary cohort.
METHODS
• We reviewed patients who underwent radical prostatectomy for prostate cancer by high volume surgeons performing RALP or ORP.
• Biochemical recurrence (BCR) was defined as PSA 0.1 ng/mL or PSA 0.05 ng/mL with receipt of additional therapy.
• A Cox regression model was used to evaluate the association between surgical approach and BCR using a predictive model (nomogram) based on preoperative stage, grade, volume of disease and PSA.
• To explore the impact of differences between surgeons, multivariable analyses were repeated using surgeon in place of approach.
RESULTS
• Of 1454 patients included, 961 (66%) underwent ORP and 493 (34%) RALP and there were no important differences in cancer characteristics by group.
• Overall, 68% of patients met National Comprehensive Cancer Network (NCCN) criteria for intermediate or high risk disease and 9% had lymph node involvement. Positive margin rates were 15% for both open and robotic groups.
• In a multivariate model adjusting for preoperative risk there was no significant difference in BCR rates for RALP compared with ORP (hazard ratio 0.88; 95% CI 0.56–1.39; P = 0.6). The interaction term between © 2013 The Authors 206 BJU International © 2013 BJU International | 111, 206–212 | doi:10.1111/j.1464-410X.2012.11638.x Urological Oncology nomogram risk and procedure type was not statistically significant.
• Using NCCN risk group as the covariate in a Cox model gave similar results (hazard ratio 0.74; 95% CI 0.47–1.17; P = 0.2). The interaction term between NCCN risk and procedure type was also non-significant.
• Differences in BCR rates between techniques (4.1% vs 3.3% adjusted risk at 2 years) were smaller than those between surgeons (2.5% to 4.8% adjusted risk at 2 years).
CONCLUSIONS
• In this relatively high risk cohort of patients undergoing radical prostatectomy we found no evidence to suggest that ORP resulted in better early oncological outcomes then RALP.
• Oncological outcome after radical prostatectomy may be driven more by surgeon factors than surgical approach.
But if your surgeon is good enough then there are plenty of advantages to robotic surgery in terms of recovery, pain, return to work, blood loss, transfusion, scar etc
Dr. Silberstein–again, very nice study and congratulations on article of the week for only the second issue from the new BJUI team.
Question–did you actually look at outcomes from the rest of the surgeons, i.e. beyond the 4 high volume?
An excellent paper – the data at our institution demonstrate similar findings. Two great approaches to treating localized prostate cancer. Congratulations to the authors.
The key on outcomes may indeed more be driven by the case volume of the surgeon. Moreover differences between high volume surgeons may be related to differences in technique used. Can you derive these data from the present work?
Agree with Dr Partin.
Nice work once again providing evidence that surgeon factors are most important in determining patient outcomes. The approaches as many suspect provide comparable outcomes.
Jonathan and MSKCC team,
Great work as usual. I think its interesting that both the robotic and open surgeons performed at least some nerve sparing in the vast majority of patients and they had low positive margin rates and low biochemical recurrence rates in both groups. The high volume surgeons have embraced at least partial nerve sparing with no apparent decrement in oncologic outcomes even for well selected higher risk patients.
Great Job. In my opinion, one of the most relevant aspects of this paper is the Lymph node count. 16 for open 15 for RALP with similar IQ range demonstrates once again that Robotics is oncologically adequate also for intermediate – high grade disease.