Tag Archive for: LRP

You are here: / LRP

Posts

Article of the Week: Comparing LRP and RARP to ORP to treat PCa

/by

Every Week, the Editor-in-Chief selects an 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.

If you only have time to read one article this week, it should be this one.

Laparoscopic and robot‐assisted vs open radical prostatectomy for the treatment of localized prostate cancer: a Cochrane systematic review

 

Dragan Ilic*, Sue M. Evans†, Christie Ann Allan*, Jae Hung Jung‡§¶, Declan Murphy** and Mark Frydenberg††

 

*Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, †Centre of Research Excellence in Patient Safety, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia, ‡Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea, §Department of Urology, University of Minnesota, Urology Section, Minneapolis VA Health Care System, Minneapolis, MN, USA, **Cancer Surgery, Peter MacCallum Cancer Centre, and ††Department of Surgery, Monash University, Melbourne, Vic., Australia

 

Abstract

Objective

To determine the effects of laparoscopic radical prostatectomy (LRP), or robot‐assisted radical prostatectomy (RARP) compared with open radical prostatectomy (ORP) in men with localized prostate cancer.

Materials and Methods

We performed a comprehensive search using multiple databases (CENTRAL, MEDLINE, EMBASE) and abstract proceedings, with no restrictions on the language of publication or publication status, up until 9 June 2017. We included all randomized or pseudo‐randomized controlled trials that directly compared LRP and RARP with ORP. Two review authors independently examined full‐text reports, identified relevant studies, assessed the eligibility of studies for inclusion, extracted data and assessed risk of bias. We performed statistical analyses using a random‐effects model and assessed the quality of the evidence according to Grading of Recommendations Assessment, Development and Evaluation (GRADE). The primary outcomes were prostate cancer‐specific survival, urinary quality of life and sexual quality of life. Secondary outcomes were biochemical recurrence‐free survival, overall survival, overall surgical complications, serious postoperative surgical complications, postoperative pain, hospital stay and blood transfusions.

Results

We included two unique studies in a total of 446 randomized participants with clinically localized prostate cancer. All available outcome data were short‐term (up to 3 months). We found no study that addressed the outcome of prostate cancer‐specific survival. Based on one trial, RARP probably results in little to no difference in urinary quality of life (mean difference [MD] −1.30, 95% confidence interval [CI] −4.65 to 2.05; moderate quality of evidence) and sexual quality of life (MD 3.90, 95% CI: −1.84 to 9.64; moderate quality of evidence). No study addressed the outcomes of biochemical recurrence‐free survival or overall survival. Based on one trial, RARP may result in little to no difference in overall surgical complications (risk ratio [RR] 0.41, 95% CI: 0.16−1.04; low quality of evidence) or serious postoperative complications (RR 0.16, 95% CI: 0.02–1.32; low quality of evidence). Based on two studies, LRP or RARP may result in a small, possibly unimportant improvement in postoperative pain at 1 day (MD −1.05, 95% CI: −1.42 to −0.68; low quality of evidence) and up to 1 week (MD −0.78, 95% CI: −1.40 to −0.17; low quality of evidence). Based on one study, RARP probably results in little to no difference in postoperative pain at 12 weeks (MD 0.01, 95% CI: −0.32 to 0.34; moderate quality of evidence). Based on one study, RARP probably reduces the length of hospital stay (MD −1.72, 95% CI: −2.19 to −1.25; moderate quality of evidence). Based on two studies, LRP or RARP may reduce the frequency of blood transfusions (RR 0.24, 95% CI: 0.12–0.46; low quality of evidence). Assuming a baseline risk for a blood transfusion to be 8.9%, LRP or RARP would result in 68 fewer blood transfusions per 1,000 men (95% CI: 78–48 fewer).

Conclusions

There is no evidence to inform the comparative effectiveness of LRP or RARP compared with ORP for oncological outcomes. Urinary and sexual quality of life appear similar. Overall and serious postoperative complication rates appear similar. The difference in postoperative pain may be minimal. Men undergoing LRP or RARP may have a shorter hospital stay and receive fewer blood transfusions.

Read more articles of the week

Editorial: RARP and a Parachute

/by

Radical prostatectomy is probably the most scrutinized, debated and re‐invented procedure in the field of urology. This is with good reason. Dr Hugh Hampton Young gave the first formal account of a radical treatment for prostate cancer in 1905. It was a procedure performed perineally with the prime intention of total cancer extirpation. The oncological results were tremendous given the nascency of the procedure. Functional outcomes, however, were less so, with only ~25% of the patients achieving urinary continence and almost none achieving potency 1. Seminal studies undertaken by Drs Patrick C. Walsh and Pieter J. Donker in the 1980s led to the next major advance in technique: nerve‐sparing. It lead to dramatic improvements in sexual and urinary function preservation, with urinary continence achieved in upwards of 90% and potency in upwards of 60% of patients 2, 3. Nerve‐sparing retropubic radical prostatectomy was rapidly adopted by urologists across the world. No randomized trial was conducted as the operation ‘made sense’, and it would have been unethical to offer patients an alternative, inferior operation. Retropubic radical prostatectomy, however, remained a morbid operation that was difficult to master; 1 200 mL blood loss and 20% incontinence, 15% stricture and 60–90% erectile dysfunction rates were the norm. Robot‐assisted surgery changed much of this. This surgery was perfected and popularized by Dr Mani Menon and his team at the Henry Ford Hospital. Blood loss dropped to ~100 mL, and incontinence and stricture rates today are ~1–5% with potency rates between 70% and 80% 4.

In the systematic review by Ilic et al. 5 trials that compared open with minimally invasive radical prostatectomy were evaluated. The authors are commended for combing through vast quantities of data to arrive at the final sample of two clinical trials (one laparoscopic, one robot‐assisted). The authors found no data on oncological endpoints. With respect to functional outcomes, the data reported in their systematic review are essentially from the recent Yaxley trial. It is true that randomized controlled trials form the backbone of medical progress, but they must be interpreted with care. The Yaxley trial has been criticized for comparing surgeons of vastly varying surgical expertise (1 500‐case experience for open prostatectomies, 200‐case experience for robot‐assisted prostatectomies), having a small sample size (~150 patients in each arm) and having a limited follow‐up (3 months). In line with this, Dr Gordon Smith has eloquently argued about the judicious use of randomized trials in evidence‐based medicine in his classic paper on parachutes and gravitational challenge 6. It is our sincere belief that robot‐assisted radical prostatectomy is a procedure in the service of the patients, and we believe that anyone who has performed both an open radical prostatectomy and a robot‐assisted radical prostatectomy would agree. Operating deep in the pelvis and being able to visualize the anatomy up‐close with robotic assistance ‘makes sense’, much like the anatomical radical prostatectomy did in the 1980s 2, 3.

‘If it ain’t broke, don’t fix it’, the old saying goes. In case of radical prostatectomy, the converse has been true, for the most part. The procedure is still not perfect, and nuances need to be worked out. Nonetheless, over the last century, radicalprogress has been made in the surgery for prostate; the two issues that now remain to be solved are: improving potency and improving cost‐effectiveness. With the potential arrival of competing robotic systems and improvements in technology, the costs associated with robotic surgery may become less of an issue in the future. With regard to potency, focal therapies, whether surgical or otherwise, hold promise.

Akshay Sood, Firas Abdollah, and Mani Menon
Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA

 

 

References
  • 1 Young HH. The cure of cancer of the prostate by radical perineal prostatectomy (prostato‐seminal Vesiculectomy): History, Literature and Statistics of Young’s Operation1. J Urol 1945; 53: 188–252

 

 

 

  • 4 Menon M, Dalela D, Jamil M et al. Functional recovery, oncologic outcomes and postoperative complications after robot‐assisted radical prostatectomy: an evidence‐based analysis comparing the Retzius sparing and standard approaches. J Urol 2018; 199: 1210–7

 

  • 5 Ilic D, Evans SM, Allan CA, Jung JH, Murphy D, Frydenberg M. Laparoscopic and robot‐assisted vs open radical prostatectomy for the treatment of localized prostate cancer: a Cochrane systematic review. BJU Int 2018; 121: 845–53

 

  • 6 Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ 2003; 20: 1459–61

 

Article of the Week: Evaluating health resource use and secondary care costs for RP and partial nephrectomy

/2 Comments/by

Every Week the Editor-in-Chief selects an 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 from Mr. Jim Adshead, discussing his paper.

If you only have time to read one article this week, it should be this one.

Health resource use after robot-assisted surgery vs open and conventional laparoscopic techniques in oncology: analysis of English secondary care data for radical prostatectomy and partial nephrectomy

David Hughes*†, Charlotte Camp*, Jamie O’Hara*† and Jim Adshead‡

 

*HCD Economics, Daresbury, †Faculty of Health and Social Care, University of Chester, Chester, and ‡Hertfordshire and South Bedfordshire Urological Cancer Centre, Department of Urology, Lister Hospital, Stevenage, UK

 

Read the full article

Objectives

To evaluate postoperative health resource utilisation and secondary care costs for radical prostatectomy and partial nephrectomy in National Health Service (NHS) hospitals in England, via a comparison of robot-assisted, conventional laparoscopic and open surgical approaches.

Patients and Methods

We retrospectively analysed the secondary care records of 23 735 patients who underwent robot-assisted (RARP, n = 8 016), laparoscopic (LRP, n = 6 776) or open radical prostatectomy (ORP, n = 8 943). We further analysed 2 173 patients who underwent robot-assisted (RAPN,n = 365), laparoscopic (LPN, n = 792) or open partial nephrectomy (OPN, n = 1 016). Postoperative inpatient admissions, hospital bed-days, excess bed-days and outpatient appointments at 360 and 1 080 days after surgery were reviewed.

JUnAOTW2FI

Results

Patients in the RARP group required significantly fewer inpatient admissions, hospital bed-days and excess bed-days at 360 and 1 080 days than patients undergoing ORP. Patients undergoing ORP had a significantly higher number of outpatient appointments at 1 080 days. The corresponding total costs were significantly lower for patients in the RARP group at 360 days (£1679 vs £2031 for ORP; P < 0.001) and at 1 080 days (£3461 vs £4208 for ORP; P < 0.001). In partial nephrectomy, Patients in the RAPN group required significantly fewer inpatient admissions and hospital bed-days at 360 days compared with those in the OPN group; no significant differences were observed in outcomes at 1 080 days. The corresponding total costs were lower for patients in the RAPN group at 360 days (£779 vs £1242 for OPN,P = 0.843) and at 1 080 days (£2122 vs £2889 for ORP; P = 0.570). For both procedure types, resource utilisation and costs for laparoscopic surgeries lay at the approximate midpoint of those for robot-assisted and open surgeries.

Conclusion

Our analysis provides compelling evidence to suggest that RARP leads to reduced long-term health resource utilisation and downstream cost savings compared with traditional open and laparoscopic approaches. Furthermore, despite the limitations that arise from the inclusion of a small sample, these results also suggest that robot-assisted surgery may represent a cost-saving alternative to existing surgical options in partial nephrectomy. Further exploration of clinical cost drivers, as well as an extension of the analysis into subsequent years, could lend support to the wider commissioning of robot-assisted surgery within the NHS.

Read more articles of the week

Editorial: Cost-effectiveness of robotic surgery; what do we know?

/by

The introduction of the daVinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA) has led to a continuous discussion about the cost-effectiveness of its use. The capital costs and extra costs per procedure for robot-assisted procedures are well known, but there are limited data on healthcare consumption in the longer term. In this issue of BJUI, a retrospective study investigated the NHS-registered, relevant care activities up to three years after surgery comparing robot-assisted, conventional laparoscopic, and open surgical approaches to radical prostatectomy and partial nephrectomy [1].

The robotic system is particularly useful in difficult to perform laparoscopic surgeries, which are easier to perform with the daVinci system due to improved three-dimensional vision, ergonomics, and additional dexterity of the instruments. Because the use of the robotic system is more costly, to justify its use the outcomes for patients should be improved. Therefore, more detailed information about the clinical and oncological outcomes, as well as the incidence of complications after surgery with the daVinci system, is needed.

Lower rates of positive surgical margins for robot-assisted radical prostatectomy (RARP) vs open and laparoscopic RP have been reported [2]. There also is evidence of an earlier recovery of functional outcomes, such as continence. RARP is associated with improved surgical margin status compared with open RP and reduced use of androgen-deprivation therapy and radiotherapy after RP, which has important implications for quality of life and costs. Ramsay et al. [3] reported that RARP could be cost-effective in the UK with a minimum volume of 100–150 cases per year per robotic system.

Centralisation of complex procedures will not only result in better outcomes, but also facilitate optimal economical usage of expensive medical devices. Furthermore, the skills learned to perform the RARP procedure can be used during other procedures, such as robot-assisted partial nephrectomy (RAPN) and radical cystectomy (RARC). The recent report by Buse et al. [4] confirms that RAPN is cost-effective in preventing perioperative complications in a high-volume centre, when compared with the open procedure. Minimally invasive techniques for complex procedures, such as a RC, take more time to perform, but result in less blood loss. A systematic review by Novara et al. [5] showed a longer operation time for RARC, but fewer transfusions and fewer complications compared with open surgery. However, there is no solid evidence about the cost-effectiveness of this technique to date. The RAZOR trial (randomised trial of open versus robot assisted radical cystectomy, DOI: 10.1111/bju.12699) is likely to provide some answers about differences in cost, complications, and quality of life when the results of the study become available later this year.

Additionally, the robotic system has been shown to shorten the learning curve of complex laparoscopic procedures in simulation models [6]. Recently, a newly structured curriculum to teach RARP has been validated by the European Association of Urology-Robotic Urology Section [7]. The effect of the shorter learning curve on the cost of the procedures has not yet been well studied for cost-effectiveness. However, due to the shorter learning curves, patients have lower risks of complications, which from the patients’ perspective is more important than any increased costs.

The study reported in this issue [1]; however, does not include the ‘out of pocket’ expenses of patients, it does not report on the differences in patient and tumour characteristics, and outcomes such as complications and oncological safety. These issues are all challenges to be addressed in a thorough prospective (randomised) trial on the cost-effectiveness of the use of robot-assisted surgery, including quality-of-life measurements and complications of the surgical procedures. In the Netherlands the RACE trial (comparative effectiveness study open RC vs RARC, www.racestudie.nl) started in 2015 and the results are expected in 2018–2019.

Read the full article
Carl J. Wijburg
Department of Urology, Robotic Surgery , Rijnstate Hospital, Arnhem, The Netherlands

 

References

 

1 Hughes D, Camp C, O’Hara J, Adshead J. Health resource use after robot-assisted surgery vs open and conventional laparoscopic techniques in oncology: analysis of English secondary care data for radical prostatectomy and partial nephrectomy. BJU Int 2016; 117: 940–7

 

2 HuJC, Gandaglia G, Karakiewicz PI et al. Comparative effectiveness of robot-assisted versus open radical prostatectomy. Eur Urol 2014; 66: 666–72

 

3 Ramsay C, Pickard R , Soomro N et al. Systematic review and economic modelling of the relative clinical benefit and cost-effectiveness of laparoscopic surgery and robotic surgery for removal of the prostate in men with localised prostate cancer. Health Technol Assess 2012; 16: 1–313

 

4 Buse S, Hach CE, Klumpen P et al. Cost-effectiveness of robot-assisted partial nephrectomy for the prevention of perioperative complications. World J Urol 2015; [Epub ahead of print]. DOI:10.1007/s00345-015-1742-x

 

5 Novara G, Catto JW, Wilson T et al. Systematic review and cumulative analysis of perioperative outcomes and complications after robot-assisted radical cystectomy. Eur Urol 2015; 67: 376–401

 

6 Moore LJ, Wilson MR, Waine E, Masters RS, McGrath JS, Vine SJ. Robotic technology results in faster and more robust surgical skill acquisition than traditional laparoscopy. J Robot Surg 2015; 9: 67–73

 

7 Ahmed K, Khan R, Mottrie A et al. Development of a standardised training curriculum for robotic surgery: a consensus statement from an international multidisciplinary group of experts. BJU Int 2015; 116: 93–101

 

Video: Health resource use after robot-assisted surgery vs open and conventional laparoscopic techniques

/by

Health resource use after robot-assisted surgery vs open and conventional laparoscopic techniques in oncology: analysis of English secondary care data for radical prostatectomy and partial nephrectomy

David Hughes*† ,Charlotte Camp*, Jamie O’Hara*† and Jim Adshead‡

 

*HCD Economics, Daresbury, †Faculty of Health and Social Care, University of Chester, Chester, and ‡Hertfordshire and South Bedfordshire Urological Cancer Centre, Department of Urology, Lister Hospital, Stevenage, UK

 

Read the full article

Objectives

To evaluate postoperative health resource utilisation and secondary care costs for radical prostatectomy and partial nephrectomy in National Health Service (NHS) hospitals in England, via a comparison of robot-assisted, conventional laparoscopic and open surgical approaches.

Patients and Methods

We retrospectively analysed the secondary care records of 23 735 patients who underwent robot-assisted (RARP, n = 8 016), laparoscopic (LRP, n = 6 776) or open radical prostatectomy (ORP, n = 8 943). We further analysed 2 173 patients who underwent robot-assisted (RAPN,n = 365), laparoscopic (LPN, n = 792) or open partial nephrectomy (OPN, n = 1 016). Postoperative inpatient admissions, hospital bed-days, excess bed-days and outpatient appointments at 360 and 1 080 days after surgery were reviewed.

JUnAOTW2FI

Results

Patients in the RARP group required significantly fewer inpatient admissions, hospital bed-days and excess bed-days at 360 and 1 080 days than patients undergoing ORP. Patients undergoing ORP had a significantly higher number of outpatient appointments at 1 080 days. The corresponding total costs were significantly lower for patients in the RARP group at 360 days (£1679 vs £2031 for ORP; P < 0.001) and at 1 080 days (£3461 vs £4208 for ORP; P < 0.001). In partial nephrectomy, Patients in the RAPN group required significantly fewer inpatient admissions and hospital bed-days at 360 days compared with those in the OPN group; no significant differences were observed in outcomes at 1 080 days. The corresponding total costs were lower for patients in the RAPN group at 360 days (£779 vs £1242 for OPN,P = 0.843) and at 1 080 days (£2122 vs £2889 for ORP; P = 0.570). For both procedure types, resource utilisation and costs for laparoscopic surgeries lay at the approximate midpoint of those for robot-assisted and open surgeries.

Conclusion

Our analysis provides compelling evidence to suggest that RARP leads to reduced long-term health resource utilisation and downstream cost savings compared with traditional open and laparoscopic approaches. Furthermore, despite the limitations that arise from the inclusion of a small sample, these results also suggest that robot-assisted surgery may represent a cost-saving alternative to existing surgical options in partial nephrectomy. Further exploration of clinical cost drivers, as well as an extension of the analysis into subsequent years, could lend support to the wider commissioning of robot-assisted surgery within the NHS.

Read more articles of the week
© 2024 BJU International. All Rights Reserved.