Raoul S. Concepcion, MD
Editor-in-Chief, Urologists in Cancer Care
Director of Clinical Research,
Urology Associates, PC
Mark S. Austenfeld, MD
Kansas City Urology Care
Saint Luke’s Hospital
Kansas City, Missouri
E. David Crawford, MD
Head, Urologic Oncology
University of Colorado
Neal D. Shore, MD
Director, Carolina Urologic
Grand Strand Urology/Atlantic
Myrtle Beach, South Carolina
Paul R. Sieber, MD
Urological Associates of Lancaster
In large integrated urology practices, robot-assisted radical prostatectomy (RARP) is only one of a range of treatment options clinicians may offer patients diagnosed with prostate cancer. But its adoption into medical practice has been swift and encompassing, even as questions remain about its efficacy, added costs, and perioperative and longer-term outcomes versus alternatives.
In a videotaped discussion for OncLive’s Peer Exchange program, Raoul S. Concepcion, MD, editor-in-chief of Urologists in Cancer Care
, discussed the status of RARP with colleagues, each a urologist in a large group practice.
“We started doing robotic prostatectomies early…and it has been growing ever since,” said panelist Mark S. Austenfeld, MD. Austenfeld is part of Kansas City Urology Care, a large group practice in Kansas City, Missouri, with over 20 healthcare professionals. “Today, we cover, I think, seven major hospitals and satellites.” Most of the hospitals have acquired their own robot, he said. As a result, urologists in Austenfeld’s group can rely on a sufficient number of individuals at each hospital with training in robotic procedures.
But this is not the best model of care, he said. A better model for urology practices is to identify one or more of its surgeons with the most training and experience in robotics, and to refer all robotic procedures to these individuals. “With a larger referral base, the surgeons perform more procedures on a weekly basis and quickly become more proficient.” Patient outcomes, in terms of recovery and perhaps cancer control, may be better as a result. And related costs, which have been reported to be higher with robotic versus traditional open or laparoscopic surgery, may be better contained.
The “Centers of Excellence” Model
In hospitals and healthcare systems across the country, a “centers of excellence” model is emerging with respect to radical prostatectomy and robotic prostatectomy in particular. According to a study that was based on data from the large Nationwide Inpatient Sample (n = 586,429), between the years 2000 to 2008, there was a 74% increase in the number of radical prostatectomies, and a 19% decline in the number of hospitals performing the procedure—with one exception. During the same time frame, radical prostatectomy volume increased significantly within hospitals with an urban location, teaching status, a large bed capacity, and an onsite robot (P
Is Robotic Prostatectomy Better Than the Alternatives?
The comparative effectiveness of robot-assisted versus laparoscopic (LRP) and open radical prostatectomy (ORP) is currently under scrutiny in many recent trials, as are its associated costs.
Post-surgery continence was the endpoint of a small (N = 120) randomized, controlled trial in Italy that compared LRP (n = 60) and RARP (n = 60). All procedures were performed by the same surgeon.2 Continence was assessed at the time of catheter removal and 48 hours later, and both continence and potency were then evaluated at 3, 6 ,and 12 months. At every time point, continence was better among patients undergoing RARP. At 3 months, continence in the RARP group was 80% versus 61.6% in the LRP group (P
= .044). After 1 year, continence reached 95% in the roboticallytreated group versus 83.3% in patients who were treated laparoscopically (P
= .042). RARP was also associated with a higher rate of recovery of erection—80% versus 54.2% with LRP—in patients who were potent preoperatively and treated with nerve-sparing techniques.2