Open Prostatectomy is Best

Transcription

1 Open Prostatectomy is Best William J. Catalona, M.D. The Trifecta Trifecta Cure Continence Potency Northwestern University Feinberg School of Medicine Eastham, J et al, JUrol 179:2207 Continence (Pad Free at 18 months) T1A/B T1C p value < % NA % 96.6% % 95.6% % 90.2% 0.65 Potency (Sufficient Erections at 18 Mos + PDEI) T1A/B T1C p value < % NA % 89.4% % 80.8% % 73.2% 1.0 1

2 Biochemical Free Survival Overall Survival PSA recurrence- Overall Population T1a T1b T1c Overall-survival T1a T1b T1c 10 year PFS (%) year rates CaP Specific Survival Prostate-cancer specific survival T1a T1b T1c % 10 yr CSS DD 2

3 Hype and Marketing of Robot Have Been Impressive Better Care Path Pain Hospital stay Return to normal activity Shorter catheterization Visualization Bleeding Potency Continence Margins Cosmesis Regret treatment choice 4.45-fold greater with robotic prostatectomy Care Path Essentially equivalent Same clinical pathway for laparoscopic/robotic and open prostatectomy - Vanderbilt University 3

4 Bleeding comparable short-term postdischarge recovery, including time to normal and full activity, driving and postdischarge narcotic use. University of Michigan With proper surgical technique, there is no significant difference in non-autologous transfusion rate 4-0 plain catgut 3-0 plain catgut sutures Prophylactic hemostatic sutures Prophylactic hemostatic sutures 4

5 Visualization Usually adequate with either approach Better global view with open Dorsal Venous Complex Divided and Sutured and Urethra Exposed Right Anterolateral Anastomotic Suture Completed Anastomosis 5

6 Comparison of the Incidence and Location of Positive Surgical Margins Margins Variable results reported with both methods At Vanderbilt, robotic prostatectomy had lower positive margin rate pt2 SM+ 9% robotic vs. 24% open However, patients treated with open RRP had higher-risk risk tumor features and were treated by less experienced surgeons Smith JA Jr et al J Urol 2007;178: Fallicacy of positive margins for pt2 disease Consider a patient with organ-confined disease If the operation is good, the tumor is called pt2 with negative margins If the operation is bad, and the surgeon transects the capsule of the prostate, the tumor is called pt3 with positive margins Therefore, it is important to consider all positive margins together (pt2 and pt3) Positive margins are also affected by thoroughness of pathology examination pt2 M- vs pt3 M+ Surgical Margins after Robotic Prostatectomy University of Michigan first 200 cases treated with robotic prostatectomy have 22% positive margins Walsh reports at Johns Hopkins, 1.8% with pt2 disease have positive margins Positive margin rate is not as meaningful as 10-year PSA-free survival Weizer AZ et al Urology 2007;70: Walsh PC, J Urol 2008;179:

7 Invasiveness and Cosmesis No real advantage for laparoscopic/robotic Is laparoscopic surgery really less invasive? Six 1 inch incisions vs. one inch incision Lap/Robotic is more invasive Lap/Robotic surgical complications more common and more serious Touijer et al: Open vs Lap Return ER visits: : 11% vs. 15.5% Re-operations operations: : 0.4% vs. 1.9% Re-admissions admissions: : 1.2% vs 4.6% Potency Continence 7

8 Open Surgery Better global view Human touch Ability to palpate induration Haptic feedback Better access No need for cautery or thermal energy Visual and tactile assessment during open surgery by an experienced surgeon provides valuable information when and where it is safe to preserve the neurovascular bundle Laparoscopic and robotic [surgery] needs to undergo a similar evaluation to determine whether magnification is sufficient to overcome the lack of haptic feedback and ability to palpate the tissue. Burning the Prostate Out Compromises Nerve Sparing Heat from electrocautery or harmonic scalpel can cause irreversible damage to the neurovascular bundles Patients are less likely to achieve the trifecta If patient is cured, less likely to be potent If patient is potent, less likely to be cured Potency and Continence after Laparoscopic Radical Prostatectomy: Johns Hopkins 424 Consecutive Cases Age Group Potency Catalona Continence Catalona 40s 70% 94% 80% 95% 50s 67% 86% 79% 95% 60s 46% 72% 74% 93% Rogers CG, et al J Urol, 176: ,

9 Open Patients who underwent laparoscopic radical prostatectomy were less likely to become continent. Bertrand Guillonneau - Memorial Sloan-Kettering Cancer Center Laparoscopic The Most Important Question What will the PSA be in 10 years? Lap/Robotic Prostatectomy No long-term cure results available Cancer control may be compromised Early results not promising 9

10 Patterns of care for radical prostatectomy in the US from 2003 to 2005 Salvage therapy for tumor recurrence within 6 months: 27.8% vs 9.1% Anastomotic strictures 15.2% vs. 12.0% (40% higher) Minimally invasive vs open radical prostatectomy MarketScan Commercial Claims and Encounters vs Medicare Supplemental and Coordination of Benefits database Hu JC et al, J Urol 180:1969,2008 Patterns of care for radical prostatectomy in the US from 2003 to 2005 Minimally invasive increased from 5% to 25% Conversion to open decreased from 28% to 4% Complications: 14.2% vs 17.5% Transfusion: 2.2% vs 9.1% Stricture: 6.8% vs 12.9% Patterns of care for radical prostatectomy in the US from 2003 to 2005 No data on cancer control, continence, potency Stricture assessed at 6 months postop (vs 9 months postop in previous paper) GU complications higher with robotic: 4.0% vs 2.6% Tumor characteristics not available in databases Hu JC et al, J Urol 180:1969,2008 WJC 10

11 The Most Important Factor The surgeon My Position I do not believe the robotic prostatectomy is as safe a cancer operation as open radical prostatectomy, and I do not believe that nerve-sparing can be as readily or safely accomplished. For patients, the most important outcomes of radical prostatectomy are: Am I cured of my cancer? Am I continent? Can I have erections sufficient for intercourse? Opinion The answers to these questions have been well documented for open prostatectomy with an experienced surgeon The jury is still out with laparoscopic/robotic prostatectomy. Time will tell but, so far, some of the important evidence begs the question 11