Robot-assisted radical prostatectomy: Another Canadian experience

Abstract

O ver the past decade, robot-assisted radical prostatectomy (RARP) has been gaining acceptance among patients and urologists. It has become the dominant surgical approach in the United States and other countries. Despite a paucity of prospective, randomized trials supporting its oncological or functional superiority over open radical prostatectomy (ORP), 1 parameters of reduced blood loss and transfusion, shorter hospital stay, reduced re-admission, re-operation, ureteral and rectal injuries, lymphocele and anastomotic leak, as well as overall reduced surgical morbidity, have favoured adoption of RARP. 2In the current Canadian study, the authors present their retrospective, single institution review of perioperative, oncological and functional outcomes for both ORP and RARP. 3,4 Interestingly at this tertiary academic high volume centre (The Vancouver Prostate Centre BC), their findings contrast to previously published outcomes.5 More specifically, systemic reviews suggest that RARP is advantageous with regards to blood loss, transfusion rates and length of hospital stay. In the study by Gagnon and colleagues, ORP and RARP blood loss (402 vs. 287 mL), transfusion rate (1.5% vs. 3.5%) and length of stay (1.95 vs. 1.69 days) were not found to be statistically significant (all p > 0.05). Furthermore, no differences in 90-day non-descriptive Clavien complications were observed. Moreover, in our initial robotic experience at the University of Montreal Hospital Centre in 2012, we compared perioperative outcomes of the first 200 RARP cases to 83 ORP cases performed in the same year (unpublished data). RARP men demonstrated significantly less blood loss (625 vs. 237mL; p < 0.01), transfusion (16.5% vs. 1.8%; p < 0.01) and length of stay (3.1 days vs. 1.4 days; p < 0.01). The incidence of perioperative 30-day complications was also higher in the ORP group (39% vs. 9%, p < 0.01). Similarly, in a large meta-analysis by Tewari and colleagues 2 of 167 184 ORP and 62 309 RARP cases from 400 original publications, the mean blood loss (745 vs. 188 mL, p < 0.01), transfusion rate (16.5% vs. 1.8%, p < 0.01) and length of stay (3.1 vs. 1.4d, p < 0.01) were all more favourable in RARP. In addition, rates for re-admission, re-operation, nerve, ureteral and rectal injury, deep vein thrombosis, pneumonia, hematoma, lymphocele, anastomotic leak, fistula, and wound infection showed significant differences favouring RARP over ORP.Two factors that may explain the discrepancy are surgeon experience and learning curve. A single surgeon (SLG), who did not undergo formal robotic fellowship training, performed the 200 consecutive RARP cases. It is noteworthy to highlight that only 70 cases were conducted before the study period. As such, the oncological learning curve of 200 (n = 4) cases was not reached for this surgeon and therefore, the comparison to a high-volume expert ORP surgeon could be considered unfair. More specifically, the reader should be aware that the single ORP surgeon (MEG) was fellowshiptrained at the MD Anderson Center an...