Robot-assisted radical prostatectomy 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.
Raoul S. Concepcion, MD
Editor-in-Chief, Urologists in Cancer Care
Director of Clinical Research,
Urology Associates, PC
Nashville, TennesseeMark 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.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 <.001).1The 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
When perioperative outcomes were compared between RARP, ORP, and LRP, the robotic approach proved to be superior in a populationbased study utilizing data from the Nationwide Inpatient Sample (N = 19,462). Patients undergoing robotic prostatectomy were less likely to receive a blood transfusion, to experience an intra-operative or postoperative complication, or to require prolonged lengths of hospital stays versus the alternative procedures.3The cost-effectiveness of RARP versus surgical alternatives is currently an open question awaiting longer-term follow-up. But, according to findings from a 2012 literature review of articles assessing the direct costs of various approaches, RARP may not be cost-effective “from a healthcare, economic standpoint,” mainly due to the added costs of surgical instrumentation. However, of 1218 articles the authors initially screened for their analysis, only 11 detailed direct costs, and of these, only seven compared costs of different surgical approaches. For minimally invasive (laparoscopic and robotic) radical prostatectomy, cost totals in US dollars ranged from $5058 to $11,806. For radical retropubic prostatectomy, total costs ranged from $4075 to $6296.4
Total hospitalization costs were higher for patients undergoing RARP in a 2012 populationbased study conducted by investigators at the Mayo Clinic, but patients had fewer complications and shorter lengths of stay.5 Using a merged database from the Nationwide Inpatient Sample and the American Hospital Association survey from 2006 to 2008, the authors identified 29,837 patients with prostate cancer who had undergone radical prostatectomy. Of these, about 69% underwent RARP, and the remainder underwent the open surgical procedure. Median length of stay was shorter with the robotic procedure (1 vs 2 days), and postoperative complications were significantly less with the robot (8.2% with robotic prostatectomy vs 11.3% with ORP (P <.001). But overall median hospitalization costs were significantly higher with RARP, at $10,409 versus $8862 (P <.001).5
Evidence suggests that costs may be moderated when the robotic procedure is performed in a high-volume hospital. This was the finding from an assessment of outcomes by hospital volume using the Nationwide Inpatient Sample for the last quarter of 2008.6 Patients who were treated in hospitals performing RARPs at above the 50th volume percentile had shorter lengths of stay (1.6 vs 1.9 days) than patients who were treated in a low-volume hospital, and incurred lower median costs ($8623 vs $12,754; each P <.01). In a high-volume hospital, patients were also significantly less likely to experience complications (P = .01).6Since the FDA approved the first da Vinci Surgical System in 2000, its use has grown to the extent that an estimated 4 out of 5 radical prostatectomies are now performed robotically.
âœ“ Recent studies suggest that robotic surgery is comparable to traditional laparoscopic surgery in terms of blood loss, and superior to open surgery in terms of blood loss and length of hospital stay. Recovery time may be shorter following robotic surgery than open surgery.
âœ“ There is currently no definitive answer as to which approach to radical prostatectomy is superior in terms of cancer control, urinary control, and sexual function.
âœ“ Answering these questions via a large, randomized clinical trial comparing approaches to radical prostatectomy may not be feasible, experts suggest, because too few patients may be willing to risk randomization to surgery without the robot.
Over the past decade, a robot- related generation gap may have been developing among physicians. One study examining case logs from American Board of Urology certifications between 2004 and 2010, focusing on urologist age and use of RARP, suggests that this is the case. Of 4709 urologists who submitted case logs for urology certification during this seven-year period, 3374 included one or more radical prostatectomy cases. Only 8% of patient cases were treated robotically by urologists who were certified in 2004 (and submitted cases). But among urologists seeking certification in 2010 and who submitted cases, 67% of radical prostatectomies were reportedly performed using the robot. Urologist age was a significant discriminator. The median age of urologists who exclusively performed ORPs was 43 years. The median age of urologists who performed only RARPs was 41 years.7
Most academic institutions are emphasizing RARP in medical surgical training. “The expectation today with new residents is that they want to use the robot to take prostates out,” said Austenfeld in the Peer Exchange urology panel discussion. “Most academic institutions are emphasizing robotic prostatectomy, and most residents in training are doing it that way.”
Some urologists think this is shortsighted. “I think it’s a little concerning that residents aren’t [better] trained in open surgery because some patients will have to be converted,” said panelist and urologist E. David Crawford, MD, from the University of Denver Health Sciences Center. And, he added, all urologists aren’t in large urban groups. Many urology practices are located in small towns that do not have access to a robot.
Still, patients are seeking out the robot for their prostatectomies via the Internet, and there is the promise, if not the expectation, among some physicians that the technology has altered the surgical treatment of prostate cancer in a permanent way.
“This is a fantastic tool that is only going to get better…with a lot of improvements and innovation… [but it is] still a tool and just a tool,” Austenfeld said, and ultimately dependent on the skill of the surgeon just as with open retropubic prostatectomy or any other type of surgery.