BERKELEY, CA (UroToday.com) - Long-term outcomes of open radical retropubic prostatectomy for clinically localized prostate cancer in the prostate-specific antigen era
Robot assisted radical prostatectomy (RARP) has become the predominant surgical technique for treatment of clinically localized prostate cancer. This paradigm shift has occurred in the absence of quality evidence demonstrating either equivalent or superior oncologic outcomes when compared with open radical prostatectomy (ORP). In this setting, we present a large contemporary series of patients undergoing ORP with significant long-term follow-up. To date, several studies have sought to compare oncologic outcomes of these techniques, however, the majority are characterized by short-term follow-up insufficient for accurate 5 or 10 year biochemical recurrence-free survival (bRFS) estimates.[1-5] Additionally, none of these series have addressed long term freedom from clinical recurrence or overall survival. Though comparative studies have reported similar bRFS rates for RARP and ORP patients, they are confounded by significant differences in preoperative risk characteristics, with the ORP cohorts consistently composed of higher risk patients.[1, 5, 6] Though this selection bias is understandable in the development of a new procedure, it must be noted in order to make an effective comparison. Additionally, as data continues to accumulate supporting active surveillance for low-risk patients, it is probable that in the near future a significantly higher proportion of prostatectomy patients will be intermediate or high risk.
The largest long-term RARP series published to date, by Menon and colleagues, reports estimated 5- and 7-year bRFS rates of 87% and 81%, respectively. When stratified by D’ Amico risk groups, 7-year bRFS is estimated at 93%, 70%, and 67% for low-, intermediate-, and high-risk patients, respectively. Although positive surgical margin (PSM) rates and baseline patient characteristics were similar to our series, the 7-year bRFS rates among intermediate- and high-risk patients are lower than the 10-year bRFS rates in our series of ORP patients. The reason for this is unclear, but may relate to differences in the implementation of PLND. Several recent studies have suggested that the incidence of LN metastases is significantly underestimated by the most widely used nomograms, which are often used to justify the omission of PLND. In our series, PLND was performed in every patient as a matter of routine.
Though oncologic outcomes are not improved with the use of the robot, the primary advantages reported by proponents of RARP pertain to improved postoperative recovery and decreased complication rates. These assertions conflict with a large SEER database study reporting increased genitourinary complications in patients undergoing RARP. Proponents of RARP will emphasize that this broad study included very early experience RARP patients, and may prefer to reference a more recent population-based study pending publication, which compared complication rates and hospital stay between ORP and RARP patients from 2008-2009. The authors reported significantly lower transfusion rates and lower perioperative complication rates for patients undergoing RARP. This study’s conclusions were weakened by the absence of preoperative staging data, lack of follow up for oncologic and functional outcomes and significant differences in patient characteristics between the two arms, which was ostensibly mitigated through statistical corrections. Additionally, a significantly greater proportion of RARP patients underwent surgery at high-volume institutions. Though the results of this study are encouraging, convincing evidence for superior outcomes of RARP does not yet exist.
Our purpose in reporting outcomes of ORP in an era dominated by RARP is to re-focus attention on the standards for radical prostate surgery established by reports from large volume ORP centers, in which positive margin (20-30%) clinical recurrence- free survival (90-95%) and perioperative complication rates (2-9%) are relatively low.[10-12] The results of RARP should be compared to these standards, and the advancement of this technique should seek to improve upon these results.
- Barocas, D.A., et al., Robotic assisted laparoscopic prostatectomy versus radical retropubic prostatectomy for clinically localized prostate cancer: comparison of short-term biochemical recurrence-free survival. J Urol, 2010. 183(3): p. 990-6.
- Di Pierro, G.B., et al., A prospective trial comparing consecutive series of open retropubic and robot-assisted laparoscopic radical prostatectomy in a centre with a limited caseload. Eur Urol, 2011. 59(1): p. 1-6.
- Magheli, A., et al., Impact of surgical technique (open vs laparoscopic vs robotic-assisted) on pathological and biochemical outcomes following radical prostatectomy: an analysis using propensity score matching. BJU Int, 2011. 107(12): p. 1956-62.
- Murphy, D.G., et al., Operative details and oncological and functional outcome of robotic-assisted laparoscopic radical prostatectomy: 400 cases with a minimum of 12 months follow-up. Eur Urol, 2009. 55(6): p. 1358-66.
- Schroeck, F.R., et al., Comparison of prostate-specific antigen recurrence-free survival in a contemporary cohort of patients undergoing either radical retropubic or robot-assisted laparoscopic radical prostatectomy. BJU Int, 2008. 102(1): p. 28-32.
- Drouin, S.J., et al., Comparison of mid-term carcinologic control obtained after open, laparoscopic, and robot-assisted radical prostatectomy for localized prostate cancer. World J Urol, 2009. 27(5): p. 599-605.
- Menon M, et al., Biochemical recurrence following robot-assisted radical prostatectomy: analysis of 1384 patients with a median 5-year follow-up. Eur Urol. 2010 Dec;58(6):838-46. Epub 2010 Sep 17.
- Hu JC, et al. Comparative effectiveness of minimally invasive vs open radical prostatectomy. JAMA. 2009 Oct 14;302(14):1557-64.
- Trinh QD, et al. Perioperative Outcomes of Robot-Assisted Radical Prostatectomy Compared With Open Radical Prostatectomy: Results From the Nationwide Inpatient Sample. Eur Urol. 2011 Dec 22. [Epub ahead of print]
- Boorjian SA, Karnes RJ, Rangel L, et al., Mayo Clinic validation of the D'Amico risk group classification for predicting survival following radical prostatectomy. J Urol 179(4): 1354-60; discussion 1360-1, 2008.
- Yossepowitch O, Eggener SE, Bianco FJ, et al., Radical prostatectomy for clinically localized, high risk prostate cancer: critical analysis of risk assessment methods. J Urol 178(2): 493-9; discussion 499, 2007.
- Lepor H, Nieder AM, Ferrandino MN: Intraoperative and postoperative complications of radical retropubic prostatectomy in a consecutive series of 1,000 cases. J Urol 166(5): 1729-33, 2001.
Ryan Dorin, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.