| RE:
COMPARISON OF RADICAL PROSTATECTOMY TECHNIQUES: OPEN, LAPAROSCOPIC AND
ROBOTIC ASSISTED
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RODRIGO FROTA,
BURAK TURNA, RODRIGO BARROS, INDERBIR S. GILL
Section of
Laparoscopic and Robotic Surgery, Glickman Urological Institute, Cleveland
Clinic Foundation, Cleveland, Ohio, USA
Int
Braz J Urol. 2008; 34: 259-69
To the Editor:
This
timely paper reviews the current status and respective roles of laparoscopic,
robotically-assisted and open radical prostatectomy in the management
of localized prostate cancer. While open radical prostatectomy remains
the gold standard of treatment, a minimally-invasive approach has been
available since 1997 in the form of laparoscopic radical prostatectomy.
Minimally-invasive approaches to radical prostatectomy hope to duplicate
the benefits of this approach seen with other procedures, including decreased
patient blood loss and post-operative recovery time. The increased visualization,
through digitally enhanced images that both magnify and illuminate the
operative field, contributes greatly to the performance of this technically
challenging procedure. However, laparoscopic surgery requires the acquisition
of new anatomical perspectives, hand-eye coordination and the capacity
to operate with limited tactile feedback and lack of 3-dimensional vision,
all of which contributes to its undeniably steep learning curve. More
recently, robotic systems have been used as an additional tool for the
laparoscopic approach, with the hypothesis that they might improve the
precision and accuracy of the anatomical dissection for the reasons outlined
in the introduction of the current paper.
The authors concisely summarize the available
contemporary literature, paying most attention to larger series from centers
with established reputations in this field and with longer term follow-up.
Criteria for comparison include operative, oncological and functional
outcomes, as well as a pertinent discussion of financial considerations.
Advantages of the minimally-invasive approaches are seen in generally
lower operative blood loss, marginally decreased complication rates and
shorter duration of catheterization. Analgesia requirements appear to
be comparable and length of hospital stay often depends on more than simply
the operative technique involved. Data concerning functional outcomes
appears to be similar across the different techniques, but the authors
rightly point out the difficulties comparing like with like in these studies,
in terms of definitions of continence and potency and the use of validated
questionnaires. The long term oncological efficacy of RRP is well studied
but as yet limited long-term follow up is available for the minimally-invasive
approaches. PSA progression-free survival appears comparable in the short
to medium term, and what comparative studies exist show no significant
differences in positive margin rates.
Our own unit recently published a direct
comparison of robotic-assisted versus pure laparoscopic radical prostatectomy
(1). No significant differences were observed between the pure laparoscopic
and the robotic-assisted procedure with regard to operative time, operative
blood loss, length of hospital stay or bladder catheterization. A higher
transfusion rate was seen in the robotic-assisted group (9.8%) compared
to the pure laparoscopic group, though this finding has not been borne
out in other similar studies (2,3). No significant differences were seen
in the rate of major complications between the 2 groups. The rate of margin
positivity did not significantly differ between pure laparosocopy (15.8%)
and the robotic-assisted procedure (19.5%). Our conclusion was that pure
laparoscopic extra-peritoneal radical prostatectomy is equivalent to the
robotic-assisted procedure in a centre experienced in laparoscopic techniques.
The current review is a welcome addition
to the comparative literature regarding the status of minimally-invasive
techniques against the well-established gold standard of open surgery.
Tooher et al., in their comprehensive review of this topic, concluded
that any conclusions that can be drawn from these comparisons are limited
by the nature of the available data (4). Well performed, randomized, controlled
trials are urgently required to provide stronger evidence when comparing
these techniques. Sufficient follow-up and the use of internationally
validated measures of functional outcomes are essential.
REFERENCES
1. Rozet F, Jaffe J, Braud G, Harmon J, Cathelineau X,
Barret E, et al.: A direct comparison of robotic assisted versus pure
laparoscopic radical prostatectomy: a single institution experience. J
Urol. 2007; 178: 478-82.
2. Menon M, Shrivastava A, Tewari A: Laparoscopic radical prostatectomy:
conventional and robotic. Urology. 2005; 66 (5 Suppl): 101-4.
3. Joseph JV, Vicente I, Madeb R, Erturk E, Patel HR: Robot-assisted vs
pure laparoscopic radical prostatectomy: are there any differences? BJU
Int. 2005; 96: 39-42.
4. Tooher R, Swindle P, Woo H, Miller J, Maddern G: Laparoscopic radical
prostatectomy for localized prostate cancer: a systematic review of comparative
studies. J Urol. 2006; 175: 2011-7.
Dr.
François Rozet &
Dr. Gordon P. Smith
Department of Urology, Institut Montsouris
Université Paris Descartes
42, Bd Jourdan, 75014
Paris, France
E-mail: francois.rozet@imm.fr
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