Minimally Invasive Open Retropubic Prostatectomy: In Experienced Hands-Still the Gold Standard

Judd W. Moul, MD, FACS

Over the last decade, robotic-assisted laparoscopic prostatectomy (RALP) has rapidly gained in popularity, primarily for three reasons: the enthusiasm of surgeons keen to try something new, medical marketing, and patients’ desire to avoid side effects from surgery. Early on, the promoters of RALP could essentially say anything they wanted, and there were no data to refute their inflated claims about the benefits of the robotic technique. As if this were not bad enough, some marketers even inflated the side effects and morbidity of the open technique. The most blatant web sites showed grossly exaggerated incisions for the open approach to scare patients into choosing RALP. There was even a billboard in the outfield of Fenway Park in Boston touting the skill set of a robotic maestro. Probably most major health systems in the United States have used robotic marketing over the last 5 years in some way or another to try to steer insured patients to their center. RALP was considered a “loss leader,” and the theory was that it would create downstream revenue and a halo effect. This is clearly seen from an examination of the typical RALP learning curve, in which positive margins, incontinence, and impotence led to greater use of adjuvant and salvage pelvic radiotherapy and treatments for incontinence and impotence. Amazingly, all this took place long before there were any quality comparative outcomes data.

In the first 5 years after the introduction of RALP, many thought I was crazy or foolish not to have switched from open to robotic surgery. However, there is now pretty compelling evidence that the results of radical prostatectomy (RP) are driven much more by the skill of the surgeon and far less by the choice of robotic or open technique.[1] For both patients and referring physicians, the way forward is now clear: pick an experienced surgeon first, and do not choose a surgeon solely on the basis of his or her being a robotic surgeon or an open surgeon. Experienced open surgeons who have mastered the open technique should stick with it. Similarly, master RALP surgeons who are achieving documented outstanding results should keep up the good work. However, low-volume surgeons should assess their outcomes, and most surgeons who dabble in both techniques may want to reassess the value of doing so and instead choose one approach in which to develop expertise.

Four Reasons That Open Surgery Should Remain the Gold Standard

Here are the reasons I believe the open retropubic approach should remain the gold standard, in experienced hands. First, the retropubic incision allows a surgeon to enter the retroperitoneal space where the prostate resides and completely obviates the need to enter the peritoneal cavity (intestinal cavity). Why risk even a small chance of bowel injury or future intraperitoneal adhesions if you don’t have to? If we are talking about “minimally invasive” in terms of number of body cavities entered, the open approach wins. With RALP, the surgeon generally enters two cavities: the peritoneal cavity and the retroperitoneum. With the open approach, only one space is entered-the retroperitoneum. While a few robotic surgeons have mastered the pure retroperitoneal robotic technique, this has never caught on because it is more difficult to do; thus, the vast majority of patients will not be offered this type of RALP.

Second, the open technique permits a hands-on approach. An experienced surgeon gains a lot from being able to feel the prostate and surrounding tissue. Furthermore, the surgeon can use his or her hands and fingers to help dissect both the neurovascular bundles and bladder neck, which may help ensure more rapid return to full urinary continence and capacity for erections. In fact, several recent papers have suggested that men who undergo open RP may have more rapid recovery of continence and a return of erections at least as good as is seen with RALP.[2,3]

Third, the open technique in experienced hands takes less time and is less expensive.[4-6] In the era of health reform, this fact alone may be enough to convince decision makers and payers to reexamine the open technique. Fourth, the touted and hyped advantages of RALP have not been proven in follow-up studies in broad practice or even in centers of excellence.[1-3]

A Few Robotic Boasts Debunked

I am not against RALP as long as patients are educated accurately and as long as the results of RALP are not over-hyped. In fact, RALP is likely generally as effective as open RP when very experienced open and robotic surgeons are compared. Robotic proponents point to the great visualization that is possible with RALP-and to the fact that they can see the structures very well due to the magnification and three-dimensional imaging. Although these things are true, most experienced open RP surgeons use surgical loop magnification glasses; moreover, the touted better visualization of RALP has not translated into superior results. RALP proponents also point to lower levels of blood loss with the robotic technique. There is no question that with less experienced surgeons, RALP will result in less blood loss. However, at centers of excellence where open RP surgeons are efficient and experienced, there is little difference in blood loss between the two approaches, and certainly no statistically significant difference in blood transfusions between open RP and RALP.

The Upside of the Advent of Robotic Approaches

There have been some good outcomes of the robotic era. First and foremost, it caused many academic prostate surgeons to focus on outcomes-and it especially pushed open surgeons to try to optimize their results and outcomes. In other words, the competition spurred on by the RALP craze made fans of the open technique reexamine all aspects of their care. Experienced open RP surgeons soon learned how to better manage postoperative pain and bladder spasms. We made smaller incisions and used long-acting local anesthesia to infiltrate the incisional area in order to improve our patients’ early postoperative quality of life. We paid closer attention to treating postoperative bladder spasms with suppositories and perioperative bladder relaxant medications. We developed more careful care pathways to allow most open RP patients to be discharged from the hospital on postoperative day one or two. We started to take Kegel training for our patients more seriously and did a better job with sexual function rehabilitation education and support. In other words, we were pushed by our robotic colleagues and their aggressive marketers to think about how to achieve maximal optimization of every facet of care. This has been good for our patients and has made the practice of radical prostatectomy, whether open or robotic, a highly specialized and careful endeavor.

When “High-Volume” Becomes Too High

Data have shown that high-volume surgeons tend to have better results. In my opinion, however, there is a limit to the extent to which volume confers an advantage. Instead, I believe there is likely a happy medium. For example, I generally do 120 to 150 open RPs per year. While I work with resident physicians, I am very hands-on and perform the majority of all my surgeries. At certain high-volume robotic centers, some surgeons are claiming to do more than 500 surgeries per year. However, most of these centers are flush with trainees in robotics, and it is sometimes unclear how much of all those operations are actually being performed by the celebrity high-volume surgeon.

Another issue seems to be embellishment of case experience. I will sometimes see patients for second opinions in situations in which the patient states that his prostate surgeon has done “hundreds” or even “thousands” of operations a year. While these claims may be true-and I do not want to second-guess fellow surgeons-is it fair to count surgeries done as a resident or fellow when the responsibility for those patients fell to an attending or other experienced surgeon?

In other words, I would want a surgeon who is high-volume but not too high-volume. As a patient, I would not want my surgeon to take me for granted or be too tired or bored to perform the majority of my operation. Patients and referring physicians also need to understand that at most centers there is only one robotic console, and that only one surgeon can be at the controls at a time. If a trainee is involved in a procedure, he or she is typically at the console for a third to half of the operation, and the surgeon of record may not have as much control as the open surgeon who is right there “hands-on” with a resident or fellow. While the experienced surgeon at the console may be very careful not to use any cautery or excess traction near the neurovascular bundles, what about when the trainee or less experienced partner is at the robotic console? These are difficult issues to discuss but likely play into global outcomes around the country.

When Experienced Open and Robotic Surgeons Are Compared

Our group at Duke has had the advantage of having high-volume open and robotic surgeons practicing at the same time, facilitating some interesting comparisons.[6-8] In addition to economic comparisons that highlight the cost disadvantages of RALP, we have received a lot of recognition for our work comparing levels of satisfaction and regret following open and robotic RP.[7] Robotic patients had more dissatisfaction and regret. This was likely due to patients having unrealistic expectations that were fueled by surgeons who were trying to work through their learning curve by overemphasizing the positive aspects of the robotic approach in order to build their volume. Later, when the realities of the surgery and its side effects sunk in, the patients were not educated or prepared, and they experienced more regret. Our recent follow-up work continues to show that RALP patients have unrealistic expectations, particularly about nerve-sparing and sexual recovery.[8] Whether this is still playing out around the country at other centers is not clear, but it does underscore the fact that honest and open preoperative counseling for both open and robotic procedures is the right thing to do and leads to better informed and more satisfied patients.

Putting aside the differences between the open and robotic approaches, RP, in general, remains a robust treatment for clinically localized prostate cancer. A recent comprehensive review by Boorjian et al shows that this cancer operation provides long-term cure rates and remains the gold standard for disease control in long-term follow-up.[9] The field will continue to evolve. Later generations of RALP equipment will likely allow for haptic feedback and offer other advances, and I am all for progress. Nonetheless, in 2012, my advice is to focus on finding an experienced surgeon who treats patients as individuals and with respect, and who has skill and a passion for the task. The robot will not deliver in and of itself, and if it sounds too good to be true, it probably is.

Financial Disclosure:The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

References

1. Murphy DG, Bjartell A, Ficarra V, et al. Downsides of robot-assisted laparoscopic radical prostatectomy: limitations and complications. Eur Urol. 2010;57:735-46.

2. Hu JC, Gu X, Lipsitz SR, et al. Comparative effectiveness of minimally invasive vs. open radical prostatectomy. JAMA. 2009;302:1557-64.

3. Barry MJ, Gallagher PM, Skinner JS, Fowler FJ Jr. Adverse effects of robotic-assisted laparoscopic versus open retropubic radical prostatectomy among a nationwide random sample of Medicare-age men. J Clin Oncol. 2012;30:513-8.

4. Yu HY, Hevelone ND, Lipsitz SR, et al. Use, costs and comparative effectiveness of robotic assisted, laparoscopic and open urological surgery. J Urol. 2012;187:1392-9.

5. Yu HY, Hevelone ND, Lipsitz SR, et al. Hospital volume, utilization, costs and outcomes of robot-assisted laparoscopic radical prostatectomy. J Urol. 2012 Mar 14. [Epub ahead of print]

6. Mouraviev V, Nosnik I, Sun L, et al. Financial comparative analysis of minimally invasive surgery to open surgery for localized prostate cancer: a single-institution experience. Urology. 2007;69:311-4.

7. Schroeck FR, Krupski TL, Sun L, et al. Satisfaction and regret after open retropubic or robot-assisted laparoscopic radical prostatectomy. Eur Urol. 2008;54:785-93.

8. Schroeck FR, Krupski TL, Stewart SB, et al. Pretreatment expectations of patients undergoing robotic assisted laparoscopic or open retropubic radical prostatectomy. J Urol. 2012;187:894-8.

9. Boorjian SA, Eastham JA, Graefen M, et al. A critical analysis of the long-term impact of radical prostatectomy on cancer control and function outcomes. Eur Urol. 2012;61:664-75.