Is newer prostate surgery really better than the old?
NEW YORK (Reuters Health) - Robot-assisted laparoscopic, or "keyhole," surgery appears to be no better at reducing side effects than traditional "open" surgery to remove a cancerous prostate gland, according to new study from Memorial Sloan-Kettering Cancer Center in New York. Critics, however, claim the study relied on old data that doesn't reflect current practice.
Typically, in traditional open radical prostatectomy, a 6-inch long incision is made in the abdomen and the walnut-sized prostate gland and nearby lymph nodes are removed.
With the newer laparoscopic radical prostatectomy (LRP), several small incisions are made in the lower abdomen through which long-armed surgical instruments, including a camera, are inserted. While watching on a monitor, the surgeon manipulates the tools to cut away and extract the cancerous prostate and other tissue. Most laparoscopic surgeries performed today are robot-assisted.
While robot-assisted LRP usually leads to less blood loss and time spent in the hospital, the high cost of the equipment, its annual maintenance, and a long learning curve for surgeons has raised questions about its value, especially if patient outcomes are no better than the gold standard open surgery.
To investigate, Dr. William T. Lowrance and colleagues analyzed the outcomes for 5,923 men who had surgery to remove the prostate between 2003 and 2005. Overall, 4,858 men (82 percent) had the open procedure and 1,065 (18 percent) had the less-invasive LRP procedure. The claims data did not distinguish between LRP and robot-assisted LRP.
According to a report in The Journal of Urology, there were no differences between the older open procedure and the newer laparoscopic procedure in terms of deaths or medical or surgical complications 90 days after surgery, nor in use of additional cancer therapies in the year after surgery.
Yet, the researchers report that hospital advertising of LRP services was widespread and often overstated and implied benefits "not currently supported by existing evidence."
"It's perfectly reasonable for a man today to want a robot-assisted laparoscopic prostatectomy but patients need to have realistic expectations," which may be lacking, Lowrance told Reuters Health in an interview.
In a commentary published with the study, Dr. Yair Lotan, a cancer surgeon at the University of Texas Southwestern Medical Center in Dallas, wrote that the level of experience of the surgeon performing the procedure is more important for patient outcome than the type of procedure itself.
Lotan thinks patients "should be educated on likely outcomes of a procedure based on individual surgeon experience."
Dr. Jason Engel, Director of Urologic Robotic Surgery at George Washington University Hospital in Washington, D.C., agrees that surgeon experience is key to patient outcomes. He performs about 200 robot-assisted LRPs every year.
The Lowrance study, Engel told Reuters Health, is based on old data that does not reflect the level of surgeon expertise in robot-assisted LRP that is common today. In addition, the Medicare claims used in the study did not distinguish between patients who got the older LRP procedure and the new robot-assisted method.
"Nobody does the old LRP procedure any more," he said. "It's like comparing apples and oranges."
He acknowledged that some institutions over-sell the benefits of the robot-assisted LRP but he defended honest marketing campaigns.
"If I'm doing a great job, how am I going to get my name out there to let people realize there is this great product, when everyone knows to just go to an established institution, like Johns Hopkins, which specializes in the open RP (radical prostatectomy)," Engel said.
Engel also predicted that looking at data from surgeries performed more recently will likely show a difference in outcomes favoring robot-assisted LRP. The Lowrance study hinted at it, he noted, by finding no difference in outcomes at a time when surgeons were just starting to build experience.
"There's never been a head-to-head comparison between an experienced open surgeon and experienced robotic surgeon," Engel told Reuters Health.
Lotan believes the exponential growth of robot-assisted LRP services has been driven by a particularly American phenomenon - the perception that the newest high-tech procedures are the best even if supporting evidence is lacking.
Hospitals, noted Lotan, rarely recoup the millions of dollars spent on the robot equipment and its upkeep, but must have it to attract doctors and patients to their institutions.
Prostate cancer is the most commonly diagnosed cancer in American men. According to the American Cancer Society, more than 192,000 Americans are diagnosed with the disease annually; more than half are over the age 65.
SOURCE: The Journal of Urology, published online February 22, 2010.
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