Localized prostate cancer treatment. Open radical prostatectomy. Cabrita Carneiro CHLC Hospital S José Hospital CUF Infante Santo

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1 Localized prostate cancer treatment Cabrita Carneiro CHLC Hospital S José Hospital CUF Infante Santo

2 background - RRP RRP was introduced more than three decades ago RRP has matured over time RRP has been teach and practice by a great number of urologists, without the scrutiny that is seen in the selection of surgeons to perform RALP RRP has slow learning curve RRP remains the gold-standart treatment for localized prostate cancer

3 background JAMA Surg. 2014;149(8): doi: /jamasurg

4 backgroud - RALP Idea of robotics for PCa was well developed, featured and smartly presented RALP is a very appealing procedure from both patients and doctors point of view High trend towards technology, minimally invasive procedures and assumption of better results with these novel technics Strong commercial efforts were deployed to favour technology Most data come from select high-volume, single institution series that cannot be generalized to the populations as a whole This increase has taken place despite the paucity of high-quality data supporting the benefits of RALP over RRP Besides missing solid evidence, robotics was embraced RALP has disseminated rapidly

5 nowadays - RRP vs RALP We are limited to retrospective comparative evaluations Level II evidence comparing ORP and RALP are impossible with if patients are in different cohorts with clinical and pathological characteristics Data from modern RP series cannot be compared to historical RRP controls given the favorable stage migration in the era of PSA screening and disease progression

6 nowadays - RRP vs RALP Patients are extensively counselled and conduct extensive independent research, so they are biased RRP is being abandoned or relegated to those patients with most unfavourable clinical features This hinders the development of comparative studies With the increasing interest in minimally invasive technics the opportunity to conduct comparative studies is dwindling RCT woud be dificult Level I evidence is probably impossible to achieve

7 RCT phase 3 study

8 results 12 weeks follow-up Urinary function scores did not differ significantly Sexual function scores did not differ significantly PSM worse with RALP but not significantly different No differences on pathological indices RALP with a more lymph nodes removed

9 results 12 weeks follow-up Duration of operation was longer for RRP RRP had three times greater estimated blood loss RRP had a longer hospital stay Post operative complications did not differ significantly Less pain for RALP until 1 week, but not later Higher physical qol for RALP at 6 weeks but not after RRP with more distressed patients No significant difference in length of time away from work

10 implications If the short-term findings are maintained with longer follow up results, this could have implications for patient choice and for health care provider decision making Encourage patients to choose an experienced surgeon they trust and with whom they have a rapport, rather than choose a specific surgical approach Yaxley JW et al, Lancet, Set 16

11 comments Short follow up, brfs, CSS or OS not addressed Bad performances for the RRP surgeon (more OT, EBL, low number lymph nodes) A young urologist with 200 RALP can obtain same early functional and oncological results as an experienced RRP surgeon Confirms a shorter learning curve for RALP Technology that allows for fast teaching with good functional and oncological results in a short period of time should be considered not only for patients but also for health care systems

12 evidence based medicine There is no high evidence to inform the comparative effectiveness of LRP or RALP compared to RRP All available outcome data is short term Urinary and sexual qol related outcomes appear similar Overall and serious postoperative complications appear similar The difference in postoperative pain may be minimal LRP or RALP may have a shorter hospital stay and receive fewer blood transfusions Present data is unable to account for surgeon volume or experience Ilic D et al, Cochrane Database Syst Rev, Set 17

13 conclusions Wide spread of heterogeneous, not controlled experience regarding RRP, doesn t favour RRP RALP implies a more controlled teaching and restricted plan (some instead of all) resulting in better trained surgeons Morbidity highly variable based on the experience and skill of the RRP surgeon Even if outcomes are equivalent, at worse to RRP, the greater accessibility of the procedure would seem to justify it The surgeon is the key element affecting the outcomes of RP