Open vs Robotic Prostatectomy: An Evidence-Based Analysis

From Medscape...
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*Conclusions and Recommendations*

While laparoscopic robotic prostatectomy is appealing to patients for its
cutting-edge technology and for being less invasive than the open approach,
the evidence to date shows that, in many respects, outcomes following the
robotic procedure are quite similar to those following open surgery. From
the patient's point of view, robotic prostatectomy offers quicker time to
full recovery, a reduced risk for blood loss, and slightly less
postoperative pain. However, it does not offer any advantage in functional
outcomes, nor does it result in better cancer control. Although some
authors claim that outcomes with robotic surgery will improve as
practitioners gain experience, studies indicate that the learning curve
plateaus after roughly 100-200 cases and that subsequent improvement is
minimal at best. In summary, we must expect that results from high-volume
centers represent the state of the art and that, while equivalent outcomes
can be achieved with robotic surgery, it is unlikely that they will be
superior.

These considerations must be set alongside the potential disadvantages of
robotic surgery. Although not discussed in this article, the costs to the
healthcare system of this approach are greater, given the fixed cost of the
da Vinci system and the costs of disposable and reposable equipment. These
factors, while not of concern to the patient, should certainly be a factor
in decision-making for institutions considering the acquisition of the da
Vinci system. Of course, the primary concern is cancer control and cure.
Given the observation that patients with pT3 tumors likely require a more
extended lymph node dissection and may also have higher margin-positive
rates with robotic surgery, we must decide whether the recovery benefits of
the laparoscopic approach outweigh the oncologic risks of the procedure.
This author does not believe that this is the case in patients with
high-risk disease and does not routinely offer robotic surgery to patients.

The following evidence-based guidelines for use of robotic prostatectomy in
localized prostate cancer are suggested:

* "Low-risk" patients: Gleason 6 pts, PSA < 10 ng/mL, cT1 or cT2a:

o Either open or robotic approach is reasonable

* "High-risk patients": Gleason 8-10 pts, PSA > 10 ng/mL, cT2b or higher

o Open approach is preferred

* "Moderate-risk" patients: Gleason 7 pts:

o Optimal approach is unclear and depends upon the surgeon's and
patient's preferences. Surgeon should use the approach that he/she is most
comfortable with. Another possible approach is to use a nomogram to
segregate moderate-risk patients on the basis of 3+4 vs 4+3 disease and
risk for pT3 disease.