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Tuesday, March 27, 2007

RP vs. LRP vs. RLRP - Part 4. What Surgeons and Others Say

[Updated November 29, 2007]

This is part 4 of a 4 part series comparing 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

What Surgeons & Others Say

  • Dr. Kevin Slawin (papers) of Baylor College of Medicine. On his web site Dr. Kevin Slawin recommends that Gleason 6 and less extensive Gleason 7 can have laparascopic surgery while patients with more extensive Gleason 7 disease and Gleason 8-10 patients have open surgery and "are most effectively treated when a careful, extended lymph node dissection, that includes the removal of all lymph nodes situated in the iliac, hypogastric, and obturator regions, is performed as part of the prostatectomy procedure. This type of lymph node dissection can only be best performed using an open, rather than robotic-assisted, approach.

    Patients with larger Gleason 7 - 10 tumors, situated primarily at the base of the prostate, who have a high risk of seminal vesicle invasion, can achieve a lower positive margin rate and higher cure rates than those with similar tumors treated with standard techniques, either open or robotic, when treated with "en bloc" resection of the prostate, SVs and bladder neck."

  • David F. Person in Open vs Robotic Prostatectomy: An Evidence-Based Analysis (Feb 7, 2007) concludes that for low risk patients (all of: GS 6, PSA < 10, cT1 or cT2a) either open or robotic is reasonable, for high risk patients (any one of: GS 8 or higher, PSA > 10, cT2b or higher) open surgery is preferred. For Intermediate risk patients (GS 7) the proper approach is unclear.

  • Dr. William Catalona (papers), an open surgeon says this in answer to question 17 at his web site: "Laparoscopic radical prostatectomy is feasible. It is performed at several centers throughout the US, including my institution. It is now considered to be in its “infancy.” However, I do not believe there are any material advantages for the patient compared with open radical prostatectomy.

    In my opinion, it is far more difficult to get consistently good results because it does not afford the surgeon as much control as with the traditional operation. Also, it does not provide tactile feedback, and it is more difficult to suture laparoscopically.

    With robotic surgery, suturing is less difficult, but it still has limitations of access and lack of tactile feedback. The surgeon cannot tell how hard the robot is grasping tissue, or, if the angle of the needle is wrong and if the needle does not pass through the tissues easily, the robot continues to “muscle” its way through.

    With tactile feedback afforded by open surgery, the surgeon would “feel” the mistake and make the necessary adjustment.

    At present, information is insufficient to determine whether long-term results will be as good as with standard nerve-sparing radical prostatectomy, especially in terms of preserving sexual potency and obtaining cancer-free surgical margins.

    Having seen laparoscopic and robotic surgery performed by most of the world’s most experienced experts, I don’t believe it allows nerve-sparing to be performed with the same degree of fine control without risking thermal damage to the neurovascular bundles, and I do not believe removal of the cancer is as consistently complete."

  • Dr. Krongrad (papers), a laparascopic surgeon, says "In contrast to open radical prostatectomy, the LRP does not require an abdominal incision and relies instead on tiny entry sites, most of which are no longer than five millimeters. ... In making use of good lighting, modern optics, magnification, single operative views, and finer instruments, LRP is a relatively bloodless, controlled, coordinated, and elegant operation." This is from the response to the question "How is LRP different from open radical prostatectomy?" here.

  • Robotic.

    • Dr. Domenico Savatta, a robotic surgeon in New Jersey. Here is a summary of treatment choices (all treatment choices, not just open and laparascpic) from the blog of Dr. Domenico Savatta: [Savatta document on treatment choices] and also available on Google docs.

    • Dr. Ash Tewari (papers), robotic surgeon, provides his viewoint on page 2 and following of this November 2007 PCRI newsletter and another article is available here. Also see the end of Part 3 where a number of older similar Tewari articles are listed.

    • University of Michigan Health System has a comparison table focusing on recovery time here.

  • Some of the reduced blood loss and recovery time benefits attributed to laparascopic and robotic surgery may actually be due to the intensive training that can be involved. One open surgeon who had retrained in laparascopic techniques said his open surgeries improved after laparascopic training too. (Although see [PMID: 16813706] which suggests that its far from true that all laparascopic surgeons receive such intensive training.)

The points made in this series of articles are elaborated in the following reviews. The authors tended to be very cautious in their conclusions so the readers may wish to focus more on the details in the reports themselves than the conclusions. All these links point to the full text:
  • Speight & Roach, 2006

  • Lepor, Rev Urol 2005;7(3):115-127

  • Rassweiler et al, 2006

  • Touijer & Guillonneau, 2006

  • Boccon-Gibod, 2006. Comment on the last two papers.

  • Maurice Anidjar (papers) provides the following table (slightly abbreviated here) in Our Voice vol. 14 No. 1 pg. 10 (2009):
    IncisionMideline abdominal opening from pubic bone to navel4-5 tiny incisions in the lower abdomen5-6 small lower abdominal incisions
    Blood LossAbout 700 mlAverage 400 ml150 ml
    Duration of procedure2.5 hours2 hours2 hours
    Recoverybladder catheter in place for at least 2 weeks; in-hospital recovery usually 4 days; convalescence up to 6 weeksCatheter removed after 4-7 days; less pain; shorter hospital stay (2 days) and convalescence (4 weeks)Catheter usually removed after 7 days; shortest hospital stay (1 day)
    ContinenceAs high as 90% at 1 yearLong-term results at least equivalent to those reported with open surgeryRecovery of urinary control appears to be earlier than with open surgery
    PotencyDepending on nerve-sparing, can be up to 85%; takes 18 months or longerLong-term results at least equivalent to those reported with open surgeryResults at least equivalent to best results from open and laparascopic approaches
    Surgeon skills involvedMeasured by ability to eliminate the entire tumor and preserve patient's continence and potencyMajor learning curve reuired for surgeon to master the techniqueShorter learning curve than with laparascopic surgery


The statistical comparisons of open, laparascopic and robotic surgery may be problematic due to:
  1. Surgeon Effect. The effect of which particular surgeon is being compared may overshadow the treatment type (i.e. if the surgeon doing a particular treatment is more experienced or more experienced in that treatment that may be more influential than the treatment itself).

  2. Time. Changes in technique over time (e.g. transfusion using current open techniques is unlikely whereas once it was quite likely. Another example is that robotic surgery has been around for only 5 years so comparisons from just 5 yeas ago necessarily involved much less specific robotic experience than surgeries by surgeons who have used it since then.)

  3. Selection Bias. For example, if more difficult cases are being directed to open surgery then results from open surgery might show worse even if open were better.

  4. Length of Followup. As robotic surgery is only 5 years old the focus of comparisons has been largely on recovery issues and not enough time has elapsed for true follow up comparisons of cancer control.

Thus one has to be careful about relying on the statistics but rather its better to use them just to get an overall sense, i.e. the treatments are roughly comparable.

Using surgeon and others' observations seems important and from that it seems clear that laparascopic and robotic surgery have reduced recovery time and cosmetic results (externally visible scarring) are better.

Also, robotic requires less surgeon training than freehand laparascopic which assumes more importance the less experience your surgeon has. Although robotic equipment malfunction is unlikely, the reader may wish to discuss with the surgeon what his strategy would be in that event.

Open surgery likely has better cancer control if there is involvement in the apex (the side of the prostate furthest from the bladder where the urethra exits the prostate) or if extensive lymph node dissection (LND) is required. This point gains significance when one considers that [PMID: 17296375] (and discussed in the LND post) suggests that, contrary to standard practice, extensive LND or sentinel LND should always be done. Open surgery is more effective in simultaneously repairing (possibly subclinical) inguinal hernia (IH) in which case subsequent IH would be unlikely.

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

1 comment:

j&j said...

Good summary, however, one suggestion: read and add as references papers on RLRP by Dr. Mani Menon, Vattikuti Urology Institute, Henry Ford, Detroit:

Dr. Menon was recruited from France to be one of the pioneers in introducing DaVinci RLRP to the US and has trained many of the current RLRP practitioners.

Like all documentions of RLRP 'success' in diminishing side effects such as incontenance compared to traditional RP, one must take into account that Dr. Menon's best results are from a subset of patients with the best prognostics. However, this doesn't seem much differnt than the 'success' statistics quoted by Dr. Walsh and other noted RP surgeons.

Jon Nowlin