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Tuesday, March 20, 2007

RP vs. LRP vs. RLRP - Part 1. Open Surgery (RP)

[Updated January 5, 2009]

This is part 1 of a 4 part series comparing Radical Prostatectomy or Open Surgery (RP), Laparascopic Surgery (LRP) and Robotic Laparascopic Surgery (RLRP).

RP vs. LRP vs. RLRP - Part 1. Open Surgery (RP)
RP vs. LRP vs. RLRP - Part 2. Laparascopic Surgery (LRP)
RP vs. LRP vs. RLRP - Part 3. Robotic Surgery (RLRP)
RP vs. LRP vs. RLRP - Part 4. What Surgeons and Others Say

Advantages of Open Surgery (RP)

  1. A key advantage of open surgery is the availability of tactile feedback (also called haptics) which gives the surgeon superior ability to avoid damaging the nerves. See answer to question 17 in:

  2. Another advantage is the ability to examine specimen prior to completion of the surgery.

  3. Also open surgery takes less time to learn which means that with laparascopic one would need a more experienced surgeon just to get same level of surgical margins and complication rates.

  4. Referring to laparascopic surgery Touijer et al (2005) says "eradicating positive margins at the distal prostatic apex remains a challenge." In such cases open surgery would presumably have better chance of negative margins.

  5. Toujier, 2007 found that after adjusting for other clinical and pathologic variables in prostate volumes less than 30gm, laproscopic RP was associated with a positive surgical margin rate of 44%, while there was no difference between surgical margin rates and prostate volume in open RP. Six of 8 positive margins in this under 30 gram prostate size range were found at the apex of the prostate which suggests that in conjunction with the prior point that a small prostate and apex involvement when combined particularly favor open surgery.

  6. In a study of 517 patients surgery patients performed over a 30 month period (3/03 - 10/05) the rate of complications was comparable for surgery, laparascopic and robotic suggesting that laparascopic and robotic are just as good although open surgery did have a lower fraction of positive margins though not sufficiently many to be statistically significant. (Note that the authors felt that there could be selection bias which limit the generalizability of the results. For example, if the difficult tend to be directed to open surgery then any advantage in open surgery might not come to light in the comparison.)
    Event Occurrence (%) RRPLRPRAPp value
    Heterologous Transfusion6000.07
    Wound or UTI11890.88
    Thromboemoblic event3520.77
    Urinary retention108150.52
    Unplanned admit or ER visit41020.14
    Positive surgical margins1820260.28
    [abstract and table]

    Another comparison [PMID: 17919694] did find that there was faster recovery, less pain and quicker back to 100% functioning time with robotic surgery but that the differences were nevertheless quite small.

  7. In this usenet post one patient discusses why he believes open surgery is better:

  8. one of the advantages of open surgery is that it has been established for a longer period of time. Here is a 25 year study on open surgery:
    At 25 years less than 19% of patients had died from prostate cancer and at an average of 12 years 31% developed an increase in PSA, 8.4% experienced a cancer recurrence and 11% experienced a cancer recurrence in distant areas of the body: [Reference: Porter C, Kodama K, Gibbons R, et al. 25-Year Prostate
    Cancer Control and Survival Outcomes: A 40-Year Radical Prostatectomy
    Single Institution Series. Journal of Urology. 2006; 176: 569-574.]

  9. surgery takes less time than laparascopic

  10. instrument handling is more intuitive than laparascopic

  11. According to:
    problems with laparascopic RP are "lack of 3-dimensional visualization" and "loss of some freedom of motion because of use of rigid instruments".

  12. Because the cavity is under pressure in laparascopic surgery there is a greater danger of complications in the case of a hernia and that may include subclinical hernias which were not previously identified prior to choosing the method of surgery. See this post for more on inguinal hernias and prostatectomy.

  13. open surgery is more conducive to extensive lymph node dissection

  14. Response to Robotic. A November 2009 survey of about 80 open surgeons found that (1) caseloads of open surgery were declining due to a shift to robotic surgery and (2) the existence of robotic surgery has influenced open surgeons "to modify their surgical technique, reduce convalescence, and alter follow-up recommendations". This includes reducing the incision length, steps to reduce operative time, steps to reduce blood loss and transfusion rate, adoption of new instruments, modification of the dissection technique, increasing use of hemostatic agents and other measures. [PMID: 19630483].

Other Parts of this Series

RP vs. LRP vs. RLRP - Part 1. Open Surgery (RP)
RP vs. LRP vs. RLRP - Part 2. Laparascopic Surgery (LRP)
RP vs. LRP vs. RLRP - Part 3. Robotic Surgery (RLRP)
RP vs. LRP vs. RLRP - Part 4. What Surgeons and Others Say

Other Surgery Posts

Choosing a Surgeon - Part 1. Considerations
Choosing a Surgeon - Part 2. Finding a Surgeon

Lymph Node Dissection

Inguinal Hernia and Prostatectomy

Seminal Vesicle Ablation

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