A comparison of robot-assisted radical prostatectomy (RARP) and open radical prostatectomy (ORP) in more than 5000 Medicare patients has found that the 2 procedures are equally safe. This finding comes from a study  published online April 14 in the Journal of Clinical Oncology.

The study results also show a similar rate of complications with the 2 procedures, although when  early results from the study were presented at the 2012 annual congress of the European Association of Urology, the results favored RARP superiority.

However, the researchers caution that the latest results showing no difference between the 2 procedures could be subject to selection bias. There has been concern recently that complications after robotic surgery  are under-reported.

No Differences in Complication Rates                    

In their comparative-effectiveness trial, Quoc Dien Trinh, MD, from the Dana-Farber Cancer Institute in Boston, and colleagues analyzed SEER–Medicare data on 5915 patients who underwent RARP (58.8%) or ORP (41.2%) from October 2008 to December 2009.

Complication rates for RARP and ORP were similar at 30 days (odds ratio [OR], 1.19; 95% confidence interval [CI], 0.97 - 1.46; P = .1) and at 90 days (OR, 1.13; 95% CI, 0.94 - 1.37; P = .2). Adjustments were made for treatment year, socioeconomic factors, tumor grade and stage, and whether pelvic lymphadenectomy was performed.

RARP was associated with significantly higher rates of genitourinary and miscellaneous complications at 30- and 90-day follow-ups (P ≤ .02), significantly decreased requirements for blood transfusion (OR, 0.25; 95% CI, 0.15 - 0.43; P < .001), and significantly longer hospital stays (OR, 0.30; 95% CI, 0.24 - 0.37; P < .001). Neither approach was linked to an increased risk for adjuvant treatment or additional therapy at any time after surgery (P > .2 for both).

"RARP and open radical prostatectomy have comparable rates of complications and additional cancer therapies, even in the postdissemination era," the researchers write. "Although RARP was associated with lower risk of blood transfusions and a slightly shorter length of stay, these benefits do not translate to a decrease in expenditures."

The average age of the study patients was 69 years, which is 7 or 8 years older than the average man undergoing prostatectomy in the United States or worldwide, report Debasish Sundi, MD, and Misop Han, MD, from Johns Hopkins Medical Institution in Baltimore, Maryland, in an  accompanying editorial. In addition, the model did not account for the use of salvage therapies after the first year, or consider body mass index, a known correlate of surgical difficulty/complications and cancer recurrence.

"Do the results of this study prove superiority or safety of one technique over another? The simple answer is no," write Drs. Sundi and Han, suggesting that experience might trump method. "Our recommendation for patients...is not to choose a technique, but to choose a surgeon who is an expert at a given technique, to minimize surgical complication risk."

Given the rapid rise in RARP, the advice might be moot. Study data showed that overall use of RARP increased from 47.8% in October 2008 to 59.7% in December 2009, and from 46.6% to 57.8% of Medicare-eligible men.

"The train has left the station. In my experience, the robot has taken over and open prostatectomy is becoming a thing of the past," said Nicholas J. Vogelzang, MD, from the Comprehensive Cancer Centers of Nevada in Las Vegas.

But that might not be such a bad thing, he told Medscape Medical News.

"RARP is easier on the patient and easier on the surgeon. This work shows that in patients over the age of 65, the robot is at least as good as open," Dr. Vogelzang. "I suspect that it will expand the patient age range over which surgeons will be willing to operate, and that with time we will see improved surgical and cancer outcomes. It may also make operating on more advanced cases more feasible."

Dr. Trinh, Dr. Sundi, Dr. Han, and Dr. Vogelzang have disclosed no relevant financial relationships.                    

J Clin Oncol. Posted online April 14, 2014.  Abstract,  Editorial