ORLANDO, FL USA (UroToday.com) - This reboot of the debate on robotic versus open radical prostatectomy (RP), proclaimed the “pterodactyls” (open debaters) versus the “hucksters” (robotics debaters) by moderator Dr. Joseph Smith, featured a face-off between Drs. Ashutosh Tewari and Mani Menon on the pro-side, for the robot, versus Drs. Joel Nelson and Herbert Lepor on the con-side.
Dr. Tewari outlined his case for robotic RP. He cited several published reviews of retrospective studies comparing open to robotic RP which found a 4-fold increased risk of complications with open RP, including an 8-fold risk of need for transfusion. Dr. Tewari discussed a recently published European Urology study (Sooriakumaran P, et al., Eur Urol, 2013) which looked at over 22 000 RP patients and found that positive surgical margins were experienced by 23% of open RP patients compared to 14% of robotic RP patients. In a review of functional outcomes, he conceded that continence outcomes were similar between the approaches but implied that early continence rates were better with robotic RP. With regards to potency, however, Dr. Tewari argued that the literature showed a clear improvement in outcomes with a robotic approach. He concluded with the presentation of a single surgeon series where experienced open surgeons compared their open and robotic outcomes and found better functional outcomes and decreased positive surgical margin status with robotic RP.
Dr. Lepor began his argument for open RP by discussing the way in which robotic RP was first adopted and then widely disseminated. He argued that the adoption of the robot was not evidence-driven and instead was highly market-driven. He then focused on comparative outcomes between the two techniques and emphasized that outcomes have been shown to be highly influenced by surgeon experience. Dr. Lepor presented several series which demonstrated data completely opposite to the papers presented by Dr. Tewari. His studies showed robotic RP resulted in a higher positive margin rate, as well as longer hospital length of stay, and complication rates. He presented a study from Duke University (Schroeck et al. Eur Urol (2008) 54:785) which found that men undergoing robotic RP were 3 times more likely to regret undergoing RP given unrealistic preoperative expectations. Dr. Lepor then presented a study that showed that robotic RP resulted in about $1500 greater costs to Medicare over the first 12 months due to higher complication rates. Dr. Lepor concluded that robotic RP was more expensive with no better outcomes.
Dr. Menon addressed the cost and marketing concerns with regards to robotic RP. He started by pointing out the IMRT comprises over 40% of prostate cancer treatment and costs $15000 more, on average, than open RP, compared to just $300 more for robotic RP compared to open RP according to one study presented. He argued that reducing costs in prostate cancer treatment should focus instead on the reduction of the use of IMRT. He argued that robotic RP does not cost the patient or the insurer more as payments are identical, but does cut margins for the hospital. Despite the acknowledged increased cost, he questioned how much extra people in the audience would pay for improved outcomes, including decreased complications and earlier return to normal activity, and argued that with time and experience, the costs may lessen. With regards to marketing for robotic RP, he tried to debunk the notion of over-marketing of the robot leading to its dissemination by pointing out that over 80% of hospital marketing is targeted towards name branding, and at Henry Ford only 0.01% of the budget is spent marketing robotic surgery.
Dr. Nelson finished up the debate by pointing out flaws in the articles initially presented by Dr. Tewari. He highlighted the fact that one of the reviews used included authors affiliated with Intuitive Surgical. He stated that the bulk of the open RP cohorts used for comparison to robotic RP cohorts were primarily from the pre-PSA era and thus represented a completely different population of patients. Other study flaws he discussed ranged from the methodological to statistical. He pointed out that the best metric for assessing surgical technique with regards to RP was BCR rates after RP in a patient with Gleason 3+3=6 disease. He pointed out that in his open RP series, as well as Dr. Lepor’s, PSA failure rates for patients with Gleason 6 disease were between 1-2% at 5 years. In robotic RP series, including that of Dr. Menon, PSA failure rates for patients with Gleason 6 disease were an order of magnitude greater, ranging from 6-12.5%. Dr. Nelson concluded that robotic RP has not been demonstrated adequately to improve outcomes, and given the concerns with rising health care costs, he questioned its role in the future “pay to play” system.
Overall the discussion was lively and both sides highlighted why we are not yet at a point where a definitive answer can be given regarding whether open or robotic RP should be favored. Both sides agreed that this debate will continue to rage on 5 years from now.
Moderated by Joseph A. Smith, Jr, MD at the American Urological Association (AUA) Annual Meeting - May 16 - 21, 2014 - Orlando, Florida USA
Debater - Pro: Mani Menon, MD
Debater - Pro: Ashutosh K. Tewari, MD, MCh
Debater - Con: Herbert Lepor, MD
Debater - Con: Joel B. Nelson, MD
Written by Timothy Ito, MD, medical writer for UroToday.com