Approach To Radical Prostatectomy

Main Category: Prostate / Prostate Cancer
Also Included In: Urology / Nephrology;  Cancer / Oncology
Article Date: 07 Aug 2008 - 2:00 PDT

email to a friend   printer friendly   view / write opinions   rate article

UroToday.com - There are 4 major surgical approaches to radical prostatectomy. This presentation will compare and contrast open radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP), and robotic assisted radical prostatectomy (RALP).

Operative time is shortest with RRP (124 minutes) compared to 164 minutes for robotic and 227 for LRP. Webster reported similar pain outcomes for RRP and RALP. Although patient reported pain on post-operative day 0 was lower for RALP, it was statistically the same on POD#1 and 14. The weighted mean of complications in 54 studies was overall 6.6 for RALP, 10.3 for RRP and 15.6 for LRP. Estimated blood loss is clearly lower for RALP at 152cc, compared to 405cc for LRP and 697cc for RRP. Length of hospital stay in combined series is shorted for LRP and RALP, but in single surgeon series RALP at 1.2 (Tewari) and RRP at 1.25 (Nelson) are comparable.

Menon has presented data comparing the medical (not surgical) complications of prostatectomies. He compared large analyses by Begg and Lu-Yao with his own RALP data. The RRP data has medical complications in the 20% range, compared to 11% for LRP and 0.9% for RALP. The statistical justification in his analysis is that if a relative risk difference is in the 20-fold range, then comparison between studies is acceptable.

Urinary continence for LRP and RALP are above 89% at 6 months, which may exceed RRP by 10%, although no randomized trials assess this. Sexual function is comparable among techniques, although Menon's data for percent of men achieving intercourse is higher than that of LRP or RRP by 15-20%. In the analysis of 54 studies by Berryhill, RALP had a positive SM rate of 12.5%, compared to 19.6% for LRP and 23.5% for RRP. Single surgeon series, however are comparable.

In the US, RALP is now the most common treatment for clinically localized prostate cancer. RALP has 60% of the prostatectomy market share with 54,000 RALPs performed in 2007. Yet only 15% of available hospitals are performing RALP. The learning curve for RALP is about 150 procedures. A reasonable approach is to set up a dedicated OR team, observed an establish RALP surgeon and then have a mentor for 5-6 cases. Biochemical recurrence rates during the first 10 RALPs are 17.9%, compared to 10.7% when a surgeon has 250 prior RALPs (Vickers). A robotic approach is a reasonable undertaking for a urologist in a competitive market environment who has a substantial practice in radical prostatectomies, at least 5-7 years of career remaining and who has the ability to set up a team dedicated to RALP.

References:

Berryhill R, et al., 2008, J Urol
Webster TM, et al., 2005, J Urol
Tewari A, et al., 2003, BJU Int
Nelson et al., 2005, J Urol
Begg et al , 2002, NEJM,346:1138
Lu-Yao et al, 1999, Urology, 54: 301
Vickers AJ, et al., 2007, J Natl Cancer Inst

Presented by: Christopher P. Evans, MD, at the Masters in Urology Meeting - July 31, 2008 - August 2, 2008, Elbow Beach, Bermuda

UroToday - the only urology website with original content written by global urology key opinion leaders actively engaged in clinical practice.

To access the latest urology news releases from UroToday, go to: www.urotoday.com

Copyright © 2008 - UroToday