To support the “con” position of the debate, Dr. Joniau noted marked differences in open prostatectomy (RRP) series compared to robotic prostectomy (RALP) series. The baseline characteristics are not consistently comparative and virtually all studies are observational and non-randomized in nature. Thus, there are inherent selection biases, inconsistent results reporting, and a lack of standardized definitions of continence/potency. In the highest level studies, there are few differences among positive surgical margin rates, erectile function, or continence between the two approaches.
Next Dr. Joniau considered the various learning curves of RRP versus RALP. It appears clear that good surgeons are made; it is likely the singer and not so much the song. Learning curves for RRP approximate 250 days; however, the learning curve for RALP is much higher at nearly 1500 cases. Given that 80% of surgeons are doing 10 or fewer cases per year, Dr. Joniau expressed concern that the plateau of the learning curve may never be met in one’s career. This is important because there is a 2-3-fold higher rate of avoidable compilations in the early adoption phase.
While there is evidence that pelvic lymphadenectomy can be performed safely and effectively in the robotic approach, there is evidence to support that it is performed less frequently in RALP compared to RRP. Based on a SEER analysis, lymphadenectomy was performed 5-times less frequently in RALP compared to RRP. This may have quality of care implications.
He closed the argument by pointing out that there are a lack of long term oncologic results, no differences in post-opeartive pain and narcotic use, higher rates of salvage therapy during the learning curve, and the fact that RALP patients tend to be less satisfied postoperative than their RRP compatriots. Thus, he argued that robotic surgery should be preferentially performed open.
Presented by: S. Joniau
Written by: Benjamin T. Ristau, MD, SUO Fellow, Fox Chase Cancer Center, Philadelphia, PA
at the #EAU17 -March 24-28, 2017- London, England