Robotic Prostate Surgery Offers Good Long-Term Results

Robot-assisted radical prostatectomy (RARP) confers excellent long-term biochemical control of prostate cancer (PCa), according to a study of what researchers believe is the largest series to date to look at oncologic outcomes after RARP.

The study, by investigators at the Henry Ford Health System's Vattikuti Urology Institute in Detroit, included 4,803 of 5,152 patients who underwent RARP at the institute from 2001 to 2010. After a median follow-up of 26.4 months, biochemical recurrence (BCR) occurred in 470 patients (9.8%) and metastatic disease developed in 31 patients (0.7%); 13 patients died from prostate cancer (0.3%). 

Results also showed that the actuarial 8-year BCR-free survival (BCRFS), metastasis-free survival (MFS), and cancer-specific survival (CSS) rates were 81%, 98.5%, and 99.1%, respectively, the investigators reported in BJU International (2014;114:824–831). Among men with node-positive disease, the actuarial 5-year BCRFS, MFS, and CSS rates were 26%, 82%, and 97%, respectively.

“This evaluation represents the largest of its kind and conclusively establishes that the long-term oncological outcomes following RARP are at par with the outcomes following other modalities of radical prostatectomy,” lead investigator Akshay Sood, MD, told Renal & Urology News.

The study cohort had a mean age of 60 years and a preoperative PSA level of 6.1 ng/mL. Dr. Sood's group defined BCR as a post-operative serum PSA level of 0.2 ng/mL or higher with a confirmatory value.

The investigators also identified predictors of BCR, which included preoperative PSA level, surgical margin status, and pathologic primary Gleason score. For example, among patients with organ-confined disease, patients with a preoperative PSA level of 10–20 ng/mL had a significant 2.4 times increased likelihood of BCR than those with a level of 10 ng/mL or less. Patients with a positive surgical margin (PSM) had a significant 3.8 times increased likelihood of BCR compared with those who had a negative surgical margin. Compared with patients who had a pathologic primary Gleason score of 3, those with a score of 5 had a significant 5.5 times increased likelihood of BCR.

RARP has become the most commonly used radical surgery approach for PCa. For the surgeon, RARP offers better ergonomics, precise dissection, and better visualization in narrow cavities such as the pelvis, Dr. Sood observed. For patients, RARP offers a lower rate of complications, better urinary and sexual functional outcomes, and improved cosmesis. In addition, patients have much less post-operative pain and require less pain medication.

He pointed out that several considerations must be kept in mind when comparing outcomes among various RP approaches, with the foremost being the effect of surgeon volume. It appears that high-volume surgeons have better or equivalent outcomes regardless of surgical approach.

According to a prospective observational study published recently in European Urology (2014;65:521–531), RARP requires a long learning curve and may be best suited to high-volume surgeons. Australian researchers studied 1,552 consecutive patients who underwent either RARP (866 patients) or open radical prostatectomy (ORP, 686 patients) by a single high-volume surgeon who had performed more than 3,000 prior ORPs. They administered the Expanded Prostate Cancer Index Composite quality of life questionnaire at baseline, 1.5, 3, 6, 12, and 24 months after surgery.

RARP sexual function scores surpassed ORP scores after 99 RARPs and increased to a mean difference of 11 points at the 861st case, plateauing at around 600–700 RARPs, the researchers reported. Early urinary incontinence scores for RARP surpassed ORP after 182 RARPs and rose to a mean difference of 8.4 points, plateauing at around 700–800 RARPs. In addition the odds of a pT2 PSM were initially higher for RARP but became lower after 108 RARPs and were 55% lower by the 866th RARP, according to the investigators.

“In this single-surgeon analysis, RARP had a long learning curve with inferior outcomes initially but then progressively superior sexual, early urinary, and pT2 PSM outcomes, and equivalent pT3 PSM and late urinary outcomes,” the researchers concluded.

Although learning RARP was worthwhile for the high-volume surgeon, the learning curve may not be justifiable for late-career or low-volume surgeons, the researchers observed.

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