First Large Meta-Analysis to Examine Differences Between Three Types of Curative Prostate Surgeries
Apr 25, 2012
Outcomes from use of a robot to assist surgeons in removal of a cancerous prostate are at least as good, if not better, than the other two techniques used for a radical prostatectomy — open or laparoscopic surgery — according to a large meta analysis led by researchers at NewYork-Presbyterian/Weill Cornell.
The study, published February 24 online in European Urology, should help resolve some of the controversy regarding use of the robotic option, known as robot assisted laparoscopic radical prostatectomy (RALP), says the study's lead author, Dr. Ashutosh Tewari, director of the Lefrak Center for Robotic Surgery and director of the Prostate Cancer Institute at New York-Presbyterian Hospital/Weill Cornell Medical Center.
"There is a lot of debate about the best way to remove a cancerous prostate gland," says Dr. Tewari, who is also the Ronald P. Lynch Professor of Urologic Oncology and professor of urology and public health at Weill Cornell Medical College. "Since the robotic technology is expensive, the patient benefits often get intertwined with the societal costs. It is clear, however, that robotic surgery is the most popular surgical modality today. This study represents the largest ever systematic review of patient outcomes comparing robotic-assisted, laparoscopic and open radical prostatectomy.
By analyzing 400 original research articles — all that have been published to date on the three methods — Dr. Tewari and his colleagues concluded that RALP is more effective than a pure laparoscopic approach and comparable to an open surgical approach in completely removing cancer from the body. Positive surgical margins, a measure of oncological efficacy, were lower in patients receiving robotic radical prostatectomy as compared to those undergoing laparoscopic prostatectomy.
The researchers also found that robot assisted surgery had fewer intraoperative and perioperative complication rates when compared to both laparoscopic and open approaches. In addition, robotic showed both less intraoperative blood loss and less blood transfusions as compared to open surgery.
The meta analysis included treatment information on 286,876 patients, representing the largest compilation of radical prostatectomy patients to date.
"Understanding the best method to remove the prostate matters," Dr. Tewari says, "because prostate cancer is the most common diagnosed cancer and the second most common cause of cancer death for men in developed countries."
But given the nature of the study, Dr. Tewari says he cannot recommend one surgical approach over another. He emphasizes that surgical approaches need to be adjusted for the technique and experience of the surgeon. Many studies have shown that surgical experience is an independent predictor for outcomes, far beyond the approach alone.
"This paper is innovative in its attempt to unpack the outcomes data, in a systematic way, surrounding the three surgical modalities for prostate cancer treatment, but the data we used were not standardized — outcome measures differed between studies," he says. "Still I believe the results are meaningful in that it shows RALP has at least as good outcomes as the other methods."
Challenges of Randomized Studies for Prostate Surgery
The three forms of surgery studied are "open radical" in which the prostate is removed via an abdominal incision in the belly button or pubic bone; laparoscopic prostatectomy that requires several small minimally invasive "keyhole" incisions in the abdomen, and robotic surgery, which is a form of laparoscopic surgery. RALP is done through keyholes with the aid of robotic arms that eliminate hand tremor as well as advanced optics that magnify the prostate and surrounding nerves in three-dimensions.
"It is hard to accrue patients for randomized studies. We have an ongoing study open at our institution, investigating the quality of life differences between robotic and open radical prostatectomy. This is designed as a randomized controlled study," he says. "But no one has enrolled because they did not want to be randomized to a treatment they don't prefer. Patients often come, especially to prostate cancer specialists, self-selecting for a particular treatment modality."
So Dr. Tewari and Peter Wiklund, M.D., of Sweden's Karolinska University Hospital, developed a study that examined all of the peer-reviewed studies published on any of the three techniques.
This ambitious effort was aimed at understanding the short-term (30 day) outcomes of the three surgical techniques. Given the short time frame, the meta analysis did not compare outcomes for urinary continence or sexual potency.
The researchers determined that complications and mortality were low for all three methods, suggesting that radical prostatectomy is a safe procedure.
Significant differences found were in the lower positive surgical margin (PSM) rates for RALP compared with laparoscopic surgery and lower intra operative and perioperative complications for RALP in comparison to other modalities. "PSM rates are important because they represent the effectiveness by which cancer is removed," Dr. Tewari says. "The RALP PSM rate was as good as open surgery," he adds.
The researchers also found that both laparoscopic and robotic surgery patients experienced lower rates of blood loss and transfusions and a shorter hospital stay compared with patients who had traditional surgery. Other measures, such as rates of readmission, reoperation, and complications, seemed to favor RALP, the researchers say.
"We would love to be able to directly compare the three prostatectomy surgical techniques, but that may not happen," Dr. Tewari says. "This study is the first to provide an important — and much needed — analysis of the short term benefits and risks between curative surgeries that many men rely on."
While the current research was not funded, Dr. Tewari has received research grants from Intuitive Surgical Inc., manufacturers of da Vinci robotic surgery system, in past and is funded from NIH, the Prostate Cancer Foundation and Lefrak Foundation.
Co-authors include Dr. Prasanna Sooriakumarana, of Weill Cornell Medical Center and Peter Wiklund, of Karolinska University Hospital, Daniel A. Bloch from Stanford University School of Medicine, Usha Seshadri-Kreadend and April E. Hebert, from Intuitive Surgical Inc. For more information, patients may call 866-NYP-NEWS.
Lefrak Center for Robotic Surgery and Institute of Prostate Cancer
The Lefrak Center for Robotic Surgery is dedicated to the care of patients with prostate cancer using innovative MRI based diagnostic and staging approach and provides comprehensive care involving active surveillance, focal therapy, robotic prostatectomy, radiation and medical therapy. The Center has performed over 3500 robotic procedures and its faculty have published extensively about their outcomes in peer reviewed literature. For more information visit www.cornellurology.com/about/treatment-centers/lefrak/.
NewYork-Presbyterian Hospital/Weill Cornell Medical Center
NewYork-Presbyterian Hospital/Weill Cornell Medical Center, located in New York City, is one of the leading academic medical centers in the world, comprising the teaching hospital NewYork-Presbyterian and Weill Cornell Medical College, the medical school of Cornell University. NewYork-Presbyterian/Weill Cornell provides state-of-the-art inpatient, ambulatory and preventive care in all areas of medicine, and is committed to excellence in patient care, education, research and community service. Weill Cornell physician-scientists have been responsible for many medical advances — including the development of the Pap test for cervical cancer; the synthesis of penicillin; the first successful embryo-biopsy pregnancy and birth in the U.S.; the first clinical trial for gene therapy for Parkinson's disease; the first indication of bone marrow's critical role in tumor growth; and, most recently, the world's first successful use of deep brain stimulation to treat a minimally conscious brain-injured patient. NewYork-Presbyterian Hospital also comprises NewYork-Presbyterian Hospital/Columbia University Medical Center, NewYork-Presbyterian/Morgan Stanley Children's Hospital, NewYork-Presbyterian Hospital/Westchester Division and NewYork-Presbyterian/The Allen Hospital. NewYork-Presbyterian is the #1 hospital in the New York metropolitan area and is consistently ranked among the best academic medical institutions in the nation, according to U.S.News & World Report. Weill Cornell Medical College is the first U.S. medical college to offer a medical degree overseas and maintains a strong global presence in Austria, Brazil, Haiti, Tanzania, Turkey and Qatar. For more information, visit www.nyp.org and weill.cornell.edu.