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      The Comparative Harms of Open and Robotic Prostatectomy in Population Based Samples

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          Abstract

          Purpose

          Robotic assisted radical prostatectomy has largely replaced open radical prostatectomy for the surgical management of prostate cancer despite conflicting evidence of superiority with respect to disease control or functional sequelae. Using population cohort data, in this study we examined sexual and urinary function in men undergoing open radical prostatectomy vs those undergoing robotic assisted radical prostatectomy.

          Materials and Methods

          Subjects surgically treated for prostate cancer were selected from 2 large population based prospective cohort studies, the Prostate Cancer Outcomes Study (enrolled 1994 to 1995) and the Comparative Effectiveness Analysis of Surgery and Radiation (enrolled 2011 to 2012). Subjects completed baseline, 6-month and 12-month standardized patient reported outcome measures. Main outcomes were between-group differences in functional outcome scores at 6 and 12 months using linear regression, and adjusting for baseline function, sociodemographic and clinical characteristics. Sensitivity analyses were used to evaluate outcomes between patients undergoing open radical prostatectomy and robotic assisted radical prostatectomy within and across CEASAR and PCOS.

          Results

          The combined cohort consisted of 2,438 men, 1,505 of whom underwent open radical prostatectomy and 933 of whom underwent robotic assisted radical prostatectomy. Men treated with robotic assisted radical prostatectomy reported better urinary function at 6 months (mean difference 3.77 points, 95% CI 1.09–6.44) but not at 12 months (1.19, −1.32–3.71). Subjects treated with robotic assisted radical prostatectomy also reported superior sexual function at 6 months (8.31, 6.02–10.56) and at 12 months (7.64, 5.25–10.03). Sensitivity analyses largely supported the sexual function findings with inconsistent support for urinary function results.

          Conclusions

          This population based study reveals that men undergoing robotic assisted radical prostatectomy likely experience less decline in early urinary continence and sexual function than those undergoing open radical prostatectomy. The clinical meaning of these differences is uncertain and longer followup will be required to establish whether these benefits are durable.

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          Most cited references 27

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          Comparative effectiveness of minimally invasive vs open radical prostatectomy.

          Minimally invasive radical prostatectomy (MIRP) has diffused rapidly despite limited data on outcomes and greater costs compared with open retropubic radical prostatectomy (RRP). To determine the comparative effectiveness of MIRP vs RRP. Population-based observational cohort study using US Surveillance, Epidemiology, and End Results Medicare linked data from 2003 through 2007. We identified men with prostate cancer who underwent MIRP (n = 1938) vs RRP (n = 6899). We compared postoperative 30-day complications, anastomotic stricture 31 to 365 days postoperatively, long-term incontinence and erectile dysfunction more than 18 months postoperatively, and postoperative use of additional cancer therapies, a surrogate for cancer control. Among men undergoing prostatectomy, use of MIRP increased from 9.2% (95% confidence interval [CI], 8.1%-10.5%) in 2003 to 43.2% (95% CI, 39.6%-46.9%) in 2006-2007. Men undergoing MIRP vs RRP were more likely to be recorded as Asian (6.1% vs 3.2%), less likely to be recorded as black (6.2% vs 7.8%) or Hispanic (5.6% vs 7.9%), and more likely to live in areas with at least 90% high school graduation rates (50.2% vs 41.0%) and with median incomes of at least $60,000 (35.8% vs 21.5%) (all P < .001). In propensity score-adjusted analyses, MIRP vs RRP was associated with shorter length of stay (median, 2.0 vs 3.0 days; P<.001) and lower rates of blood transfusions (2.7% vs 20.8%; P < .001), postoperative respiratory complications (4.3% vs 6.6%; P = .004), miscellaneous surgical complications (4.3% vs 5.6%; P = .03), and anastomotic stricture (5.8% vs 14.0%; P < .001). However, MIRP vs RRP was associated with an increased risk of genitourinary complications (4.7% vs 2.1%; P = .001) and diagnoses of incontinence (15.9 vs 12.2 per 100 person-years; P = .02) and erectile dysfunction (26.8 vs 19.2 per 100 person-years; P = .009). Rates of use of additional cancer therapies did not differ by surgical procedure (8.2 vs 6.9 per 100 person-years; P = .35). Men undergoing MIRP vs RRP experienced shorter length of stay, fewer respiratory and miscellaneous surgical complications and strictures, and similar postoperative use of additional cancer therapies but experienced more genitourinary complications, incontinence, and erectile dysfunction.
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            Vattikuti Institute prostatectomy: contemporary technique and analysis of results.

            Contemporary techniques of radical prostatectomy achieve excellent oncologic outcomes; erectile dysfunction is the most common adverse effect. We have modified our technique of robotic radical prostatectomy (Vattikuti Institute prostatectomy [VIP]) in an attempt to minimize decrease of erectile function while maintaining the excellent oncologic outcomes achieved by the radical retropubic prostatectomy. We present our current technique of VIP with preservation of the lateral prostatic fascia ("veil of Aphrodite"). A total of 2652 patients with localized carcinoma prostate underwent VIP. The salient features of our current technique are early transection of the bladder neck, preservation of the prostatic fascia, and control of the dorsal vein complex after dissection of the prostatic apex. Oncologic and functional outcomes were obtained through a questionnaire collected by a third party not involved in patient care. Complete follow-up information was obtained in 1142 patients with a minimum follow-up of 12 mo (range: 12-66 mo; median: 36 mo). The actuarial 5-yr biochemical recurrence rate was 8.4% and the actual biochemical recurrence rate was 2.3%. Median duration of incontinence was 4 wk; 0.8% patients had total incontinence at 12 mo. The intercourse rate was 93% in men with no preoperative erectile dysfunction undergoing veil nerve-sparing surgery, although only 51% returned to baseline function. VIP with veil nerve sparing offers oncologic and continence results that are comparable to the results of conventional nerve-sparing radical prostatectomy. Early potency results are encouraging.
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              Perioperative outcomes of robot-assisted radical prostatectomy compared with open radical prostatectomy: results from the nationwide inpatient sample.

              Prior to the introduction and dissemination of robot-assisted radical prostatectomy (RARP), population-based studies comparing open radical prostatectomy (ORP) and minimally invasive radical prostatectomy (MIRP) found no clinically significant difference in perioperative complication rates. Assess the rate of RARP utilization and reexamine the difference in perioperative complication rates between RARP and ORP in light of RARP's supplanting laparoscopic radical prostatectomy (LRP) as the most common MIRP technique. As of October 2008, a robot-assisted modifier was introduced to denote robot-assisted procedures. Relying on the Nationwide Inpatient Sample between October 2008 and December 2009, patients treated with radical prostatectomy (RP) were identified. The robot-assisted modifier (17.4x) was used to identify RARP (n=11 889). Patients with the minimally invasive modifier code (54.21) without the robot-assisted modifier were classified as having undergone LRP and were removed from further analyses. The remainder were classified as ORP patients (n=7389). All patients underwent RARP or ORP. We compared the rates of blood transfusions, intraoperative and postoperative complications, prolonged length of stay (pLOS), and in-hospital mortality. Multivariable logistic regression analyses of propensity score-matched populations, fitted with general estimation equations for clustering among hospitals, further adjusted for confounding factors. Of 19 462 RPs, 61.1% were RARPs, 38.0% were ORPs, and 0.9% were LRPs. In multivariable analyses of propensity score-matched populations, patients undergoing RARP were less likely to receive a blood transfusion (odds ratio [OR]: 0.34; 95% confidence interval [CI], 0.28-0.40), to experience an intraoperative complication (OR: 0.47; 95% CI, 0.31-0.71) or a postoperative complication (OR: 0.86; 95% CI, 0.77-0.96), and to experience a pLOS (OR: 0.28; 95% CI, 0.26-0.30). Limitations of this study include lack of adjustment for tumor characteristics, surgeon volume, learning curve effect, and longitudinal follow-up. RARP has supplanted ORP as the most common surgical approach for RP. Moreover, we demonstrate superior adjusted perioperative outcomes after RARP in virtually all examined outcomes. Copyright © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.
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                Author and article information

                Journal
                0376374
                5331
                J Urol
                J. Urol.
                The Journal of urology
                0022-5347
                1527-3792
                9 June 2016
                03 September 2015
                February 2016
                01 February 2017
                : 195
                : 2
                : 321-329
                Affiliations
                Department of Urologic Surgery (BO, MJR, DAB, DFP) and Department of Biostatistics (TK, JA), Vanderbilt University, and Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System (MJR, DFP), Nashville, Tennessee, CEASAR Patient Advocacy Network (RMC), Division of Urology, University of Connecticut Health Center, Farmington, Connecticut (PCA), Department of Urology, University of California San Francisco, San Francisco (MRC), Department of Medicine, University of California, Irvine, Irvine (SG, SHK), Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles (ASH), California, Department of Epidemiology, Emory University, Atlanta, Georgia (MG), Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas (KEH), Division of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa (RMH), Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington (JLS), New Jersey State Cancer Registry, Trenton, New Jersey (AMS, LEP), Louisiana State University Health Sciences Center, New Orleans, Louisiana (XCW), and Division of Urology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah (RAS)
                Author notes
                [* ]Correspondence: A-1302 Medical Center North, Nashville, Tennessee 37232 (telephone: 615-322-2101; brock.oneil@ 123456vanderbilt.edu )
                Article
                PMC4916911 PMC4916911 4916911 nihpa793529
                10.1016/j.juro.2015.08.092
                4916911
                26343985
                Categories
                Article

                robotics, prostatectomy, patient outcome assessment

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