Oliver Hakenberg Department of Urology, Rostock University Rostock, Germany Open vs laparoscopic vs robotic radical prostatectomy

NEWSWEEK, December 5, 2005

Alaska daVinci systems in the USA 2005 Über Roboter-assistierte RPEs in den USA 2005

5 cm 1 cm

What are the criteria? oncological outcome functional results complications increasing case numbers costs and revenues from surgery

Oncological results after RPE survival n=787, , 25year survival data survival disease-specific81-99% overall19-93% PSA-recurrence-free54-84% free from local progression88-95% free from systemic progression78-95% Porter et al, Urology 2006

Surrogate parameters for oncological results: positive margins n=2029 7,7 %21,8%32,3%59,4% Dept. of Urology, Dresden University, 2007

Positive margins Offen (RRP), laparoskopisch (LRP) und Roboter-assistierte (RAP) RPE n+SM/pT2+SM/pT3+ SM Scardino, Walsh, Catalona, Blute, Dresden, Guillonneau Rassweiler Stolzenburg Vallancien Menon Ahlering Tewari, Van Appledorn

„…the available scientific evidence has not been able to confirm any major advantage.“ Touijer & Guilloneau et al, Eur Urol 2009 RPE LRPE recurrence-free survival

Perioperative Faktoren offene (RRP), laparoskopische (LRP) und Roboter-assistierte (RAP) RPE n OP time Blood losstransfusionsCatheter time Zinke, %11 Scardino, % Lepor, %7-21 Rassweiler %7 Guillonneau %5.8 Stolzenburg %6.2 Vallancien % Menon %7 Ahlering %7 Van Appledorn %

functional results continence potency cosmesis duration of hospital stay time out of work complications

Continence influence of nerve-sparing n=536 RRPs nerve sparingbilateralunilateralnone incontinence after 12 months 1/75 (1.3%) 11/322 (3.4%) 19/139 (13.7%) 94.2% fully continent, 27 (5%) grade I, 4 (0.8%) grade II stress incontinent Burckhard et al, J Urol 2006

reported continence rates after RPE n FU (months) padscontinent Eastham, % Walsh, % Wie, % Catalona, % Rassweiler % Stolzenburg % Vallancien % Menon % Ahlering % Tewari % Patel, % Joseph % open LRP robotic

continence after RPE patient based results nVorlagenkontinent Fowler, % Murphy, % Litwin, bother score 75% Stanford, % Wei, no micturition problems 48% Begg, no symptoms 81% Karakiewicz, no urine loss 51%

Continence laparoscopic vs open (n=1430) Touijer et al, J Urol Full recovery of continence [%] months open laparoskopic p< %

potency (%) recovery of potency after ns RPE (n=70, 89% bilateral) Walsh et al, Urology 2000 months after RPE

influence of age on potency recovery after RPE age (years)unilateral nerve- sparing bilateral nerve- sparing < 50100% %76% %65% %39% Noh et al, AUA 2002 (n=188)

potency open (RRP), laparoscopic (LRP) and robotic (RAP) RPE nFU inter- course spontaneous erections method Walsh, %questionnaire Catalona, %questionnaire Abbou, %questionnaire Stolzenburg %questionnaire Vallancien % 64% questionnaire Menon %82%questionnaire Ahlering %questionnaire

Montorsi et al, Eur Urol 2008

5-year results for continence and potency n=1288, population-based cohort continenceintercourseuse of sildenafil function after 60 months 86%28%43% Penson et al, J Urol 2005

cosmesis Open prostatectomy: mini laparotomy day 12at 6 months 8 cm

open vs laparoscopic in-hospital and recovery Open RRP (n=24)laparoscopic RPE (n=36) p surgery time2.85.8< blood loss < analgesic requirements (Oxycodon tablets) 17±159±13<0.04 days until complete recovery 47±2130±18<0.002 Bhayani et al, Urology 2003

Prospective assessment of postoperative pain in open RRP (n=154) versus robotic RPE (n=159) all patients received i.v. ketorolac (clinical pathway) Lickert pain score (0-10)total analgesics (morphine equivalents) day of surgery day 1day 14 open RRP 2,601,732,4223,01 robotic RPE 2,051,762,5122,41 p value< 0,03 n.s. n.s Webster et al, J Urol 2005

return to work open RRP, n=537 achieved in 50% of patients part time work full time workunrestricted physical activity after 14 daysafter 21 daysafter 30 days factors of significance were age hematocrit at discharge catheter time Sultan et al, J Urol 2006

complications open (RRP), laparoscopic (LRP) and robotic RPE nMinorMajortotalmortality Zinke, Scardino, Catalona, Lepor, Rassweiler Guillonneau Stolzenburg Vallancien Menon Ahlering

Long term complications RPE in Austria: n= Mohamad et al, Eur Urol 2007, 51,

increasing case numbers OR time and capacity surgical volume complications costs & revenues

Increase in RPE caseload Dept. of Urology, Dresden University 2006

influence of hospital case load on oncological outcome RRP, n=12,635, SEER data, cT1c adjusted for age, comorbidity, grade and stage RPE caseload per hospital/year >108 likelihood of adjuvant treatment within 6 months (HR) 1,251,111 Ellison et al, J Urol 2005

Transperitoneal (TLRP) vs extraperitoneal (ELRP) laparoscopic RPE nsurgery time (h) blood loss (ml) in-patient stay (d) catheter time (d) pad-free after 12 months erections after 12 months TLRP , %61% ELRP , %82% Eden et al, J Urol 2004

costs depend on surgery time LRP vs RRP, cost analysis LRP increases costs by 17.5% factors for cost increase (in this order) –surgery time –in-hospital stay –use of disposables cost equivalence –if surgery time for LRP < 160 minutes –or if LRP is outpatient surgery!! Link et al, J Urol 2004

model calculation of relative costs of open, laparoscopic and robotic RPE Literaturrecherche costs per case open (RRP) laparoscopicrobotic (RAP) including robotic investment $+ 1,726 $ without robotic investment + 1,155 $ assumptionsrobotic investment 1.2 million US$ yearly maintenance costs US$ robot use of 300 caeses / year (interdisciplinary) surgery time RAP 140 min vs RRP 160 min hospital stay RAP 1.2 days vs RRP 2.5 days Lotan et al, J Urol 2004

costs depend on case numbers and local structures model calculation extra costs of RAP vs RRP of 783 $/case cost effective with 10 cases/week with 14 cases/week or more RAP becomes cheaper if in-patient stay is < 1.5 days Scales et al, J Urol 2005

Ficarra et al, Eur Urol, 2009

continence rates after 12 months in prospective studies laparoscopic vs open Ficarra et al, Eur Urol, 2009

openlaparoscopicrobotic OR timeshorterlonger blood lossmoreless transfusion ratemoreless catheter timelongershorter in-hospital timelongershorter costslowesthigher/much higher complicationsno difference positive marginsno difference potencyno difference continenceno difference Ficarra et al, Eur Urol, 2009

Comparing robotic, laparoscopic and open retropubic prostatectomy… the available data were not sufficient to prove the superiority of any surgical approach in terms of functional and oncologic outcome.

Outcome of minimally invasive RPE vs open RPE n= 2702, 5% sample of MediCare patients openminimally invasive p < complications36,4%29,8%0,002 hospital stay4,4 d1,4 d0,001 salvage treatment9,1%27,8%0,001 Hu et al, J Clin Oncol 2008

„Minimally invasive“ „modern“ „high tech“ „no blood loss“ „fully continent“ „fully potent“

„…wide acceptance of new techniques based on hypothetical benefits or extrapolated proven advantages from other surgical operations such as cholecystectomy…“ „This study is more of a comparison of surgeons and their techniques than a pure comparison of surgical technique.“ Touijer et al, J Urol 2008