Radical Prostatectomy by Open or Laparoscopic/Robotic Techniques: An Issue of Surgical Device or Surgical Expertise?

摘要

In the study reported by Hu et al 1 in this issue of the Journal, the authors identified 2,702 men who underwent radical prostatectomy from 2003 to 2005 from a national sample representing 5% of Medicare beneficiaries.During this time interval, the data showed a 30% increase in use of what is termed laparoscopic radical prostatectomy (LRP) and a 12% decrease in standard open technique, most likely due to the introduction of robotic-assisted radical prostatectomy (RARP).Although RARP is different from LRP, the authors are unable to separate LRP from RARP.Patient interest in RARP has been the result of a highly successful marketing campaign with resultant consumer demand.Patients have been led to believe that hospital and recovery times are shorter and outcomes are better, but study has shown this expectation not to be the case. 2 RARP is simply an alternative method to extract the prostate.In this study, patients undergoing LRP were found to have shorter lengths of stay (mean, 1.42 days v 4.35 days; P Ͻ .001),but were more likely to require salvage therapy (27.8% v 9.1%; P Ͻ .001) with radiation therapy plus androgen deprivation therapy for local relapse.Patients who underwent LRP/RARP appeared to have more anastomotic strictures than open surgery (15.2% v 12%; P ϭ .11).However, the authors did note that high-volume LRP/RARP surgeons were able to reduce these complication rates and the likelihood of local relapse, though both were still more frequent after LRP/RARP than after open technique.Obviously, in any analysis of the Medicare-age population, beneficiary claims data represent a 35,000-ft view of the practice since Medicare claims data cannot reliably be a surrogate for surgical outcome data.However, we believe the trends are more than likely true.The decrement in oncologic outcome (requiring more salvage therapy for local relapse) and increased incidence of anastomotic stricture may be related to do the steep initial learning curve for both LRP/RARP, though more analysis of detailed data would be required to determine this with certainty.Certainly, almost 30% of patients in the LRP/RARP group requiring salvage therapy compared with 9% in the open technique would imply greater oncologic efficacy in the latter.However, without multivariate analysis including clinical and pathologic data, one cannot reliably account for these differences.It is disconcerting that the anastomotic stricture rate is higher than, and not superior to, open technique.Good technique prevents strictures.Anastomotic stricture results in a significant decrease in urinary quality of life including difficult bladder emptying, recurrent urinary tract infection, and bleeding.Necessary repeated corrective procedures