Transition from open to robotic-assisted radical prostatectomy is associated with a reduction of positive surgical margins amongst private-practice-based urologists

Abstract

Several recent studies have suggested that thought leaders in radical prostatectomy have decreased their own positive margin rates by switching from open to robot-assisted radical prostatectomy. Theoretically, this improvement is largely attributed to enhanced visualization of the deep pelvis and precision of dissection afforded by the instrumentation. To date, it has not been determined if this phenomenon exists amongst non-fellowship-trained urologists in private practice. Herein, we describe the positive margin rates of two non-fellowship-trained private-practice urologists who converted from open radical retropubic prostatectomy to robot-assisted radical prostatectomy. The margin positivity data from two non-fellowship-trained private-practice urologists (surgeon 1 and surgeon 2) were reviewed retrospectively. The last 50 cases of open radical retropubic prostatectomy from each surgeon were compared with the first 50 robotic prostatectomy cases of surgeons 1 and 2, respectively. A positive surgical margin was defined as tumor present at the inked margin of the prostate. There was a significant decrease in the overall and pT2 positive margin rates for both surgeons. The overall positive margin rate and pT2 positive margin rate for surgeon 1 dropped from 44 to 20% and from 37 to 5.7%, respectively, after changing from open to robotic prostatectomy. For surgeon 2, the overall positive margin rate changed from 26 to 18% and the pT2 positive margin rate changed from 27.5 to 7% after converting. Changing from open to robotic-assisted radical prostatectomy may improve the ability of urologists to obtain negative surgical margins. With proper training this phenomenon does seem to apply to non-fellowship-trained urologists in private practice and can be realized within the first 50 cases performed.

The Impact of Robotics on Treatment of Localized Prostate Cancer and Resident Education in Rochester, New York

“…If one uses positive margins as a surrogate marker for a higher likelihood of prostate cancer recurrence, one can imagine that the lower positive margin rate previously described in this community after the transition to RARP may translate into lower rates of adjuvant pelvic radiation therapy, androgen blockade, imaging, and other ancillary cost, thus reaping greater savings in the future. 7 With regard to surgical training, we have had to modify our training techniques significantly so that residents can learn to perform robot-assisted surgery while maintaining patient safety. The exact techniques used to accomplish this have been previously reported.…”

“…We now, however, have up to 7-year follow-up data for several mature series showing equivalent, and in some cases improved, oncologic and functional results in addition to lower complication rates. 7,23,24 For better or for worse, we predict that at some point in the future, many surgeons will not be able to perform open radical prostatectomy when robot-assisted surgery is inappropriate or impossible because of adhesions from previous surgery. These patients may need referral to an open surgical specialist to have an open prostatectomy performed.…”

“…3 As with many other urologic procedures, a minimally invasive approach for radical prostatectomy was developed, but the procedure had a steep learning curve, a higher complication rate, and was limited to academic centers that had highly trained laparoscopic surgeons. [4][5][6][7][8][9][10] Compared with the generally slow, deliberate adoption of other technology and methods for performing urologic procedures, the adoption of robotics and robot-assisted prostatectomy has been rapid. After relatively few years of clinical use, numerous manuscripts from academic and community-based centers reported comparable, and in some cases better, shortterm outcomes and lower complication rates.…”

“…After relatively few years of clinical use, numerous manuscripts from academic and community-based centers reported comparable, and in some cases better, shortterm outcomes and lower complication rates. 4,[6][7][8][9][10][11][12][13][14][15] Robotassisted surgery was adopted in Rochester, NY, in 2003. There are currently five robotic systems operating in three hospitals that are located within a 5-mile radius of one another.…”

The “halo effect” in Korea: change in practice patterns since the introduction of robot-assisted laparoscopic radical prostatectomy

“…There was a statistically signiWcant lower incidence PSM in patients undergoing RALP; the most common location of a PSM in both RALP and ORP cases was the apex. Madeb et al [10] also reported that the transition from open to robot-assisted radical prostatectomy was associated with a reduction in PSM rates amongst privatepractice-based urologists; they suggested that the improvement is largely attributed to enhanced visualization of the deep pelvis and increased precision of dissection aVorded by the instrumentation.…”