Minimally invasive prostatectomy decreased hospital stay, increased ED, other complications

A rapid rise in minimally invasive procedures since 2001 prompted the comparative effectiveness study.

Men with prostate cancer who underwent minimally invasive radical prostatectomy had shorter length of hospital stay and fewer surgical complications, but a greater risk for genitourinary complications, incontinence and erectile dysfunction than men who underwent open retropubic radical prostatectomy.

Jim C. Hu, MD, MPH, of Brigham and Women’s Hospital in Boston, and colleagues conducted a population-based observational cohort study that included 1,938 men who underwent minimally invasive radical prostatectomy and 6,899 men who underwent open retropubic radical prostatectomy. The men were identified using SEER-Medicare-linked data from 2003 to 2007.

The use of minimally invasive radical prostatectomy increased drastically from 9.2% in 2003 to 43.2% in 2006 to 2007.

“There has been rapid adoption of the minimally invasive approach; however, outcomes were not uniformly superior to the open approach, which has a lead time of more than 20 years,” Hu said during a press briefing yesterday. “Complications [of the procedure] such as incontinence and erectile dysfunction certainly contribute to the indirect cost of treating prostate cancer.”

Men who underwent minimally invasive radical prostatectomy stayed in the hospital a median of two days compared with three days for men who underwent open retropubic radical prostatectomy (P<.001). Blood transfusion rates were also lower for men who underwent minimally invasive radical prostatectomy — 2.7% vs. 20.8% (P<.001) — as were postoperative respiratory complications (P=.004), miscellaneous surgical complications (P<.03) and anastomotic stricture (P<.001).

However, 4.7% of men who underwent the minimally invasive procedure experienced genitourinary complications compared with 2.1% who underwent the open procedure (P=.001). Men who underwent the minimally invasive procedure also had higher rates of incontinence (15.9 vs. 12.2 diagnoses per 100 person-years; P=.02) and erectile dysfunction (26.8 vs. 19.2 cases per 100 person-years; P=.35).

Rates of additional cancer therapies were similar between the two groups of patients, the researchers reported.

Demographics and study limitations

The minimally invasive procedure was more common among Asian men, those living in areas with at least a 90% high school graduation rate and those with median incomes of $60,000 or more; the procedure was less commonly reported for black and Hispanic men (P<.001 for all).

Hu noted that because of the study design using Medicare claims data, he and his colleagues were not able to determine whether robotic assistance during minimally invasive radical prostatectomy or nerve sparing were used. He also noted that Medicare claims may not have captured data on incontinence and erectile dysfunction cases that do not cause bother or draw medical attention.

In addition, “while we adjusted for year of surgery and surgeon volume in a subanalyses, dissemination of surgical technique takes years to unfold,” Hu said. “Our study of comparative effectiveness needs to be revisited in the future when dissemination of sound minimally invasive radical prostatectomy techniques have had an opportunity to diffuse.” – by Tina DiMarcantonio

Hu JC. JAMA. 2009;302(14):1557-1564.

The paper by Hu et al which recently appeared in JAMA provides information on an important topic — the effects and efficacy of two techniques for prostatectomy. Since there are no randomized comparisons of open vs. minimally invasive prostatectomy — and very limited data derived from randomized trials of other approaches to treatment of localized prostate cancer, this study is highly relevant and topical. These data suggest very similar cancer control outcomes for minimally invasive and open techniques and raise the possibility of equivalent or even less satisfactory potency and continence outcomes for minimally invasive techniques.

This study was a retrospective, national, Medicare claims database analysis which appropriately suggests the need for caution in evaluating new treatments and procedures. There is enormous enthusiasm for minimally invasive techniques in prostate surgery, and this study should give us pause for reflection and caution.

On the other hand, there are limitations in this study: 1) Patients in the minimally invasive cohort underwent either laparoscopic OR robotic prostatectomy. So one must be careful — this is not an analysis of robotic or open prostatectomy. 2) This analysis incorporated patients operated on between 2003 and 2007. These were 'early days' in minimally invasive procedures, especially robotic approaches and hence include patients treated early in the minimally invasive experience of many surgeons. Experience is clearly an important outcome variable in minimally invasive prostatic surgery. 3) As a Medicare database analysis, this paper does not examine outcomes in younger patients — this limits the generalizability of conclusions. Hence, this analysis is an important beginning, but considerably more information and follow-up are required to determine the relative efficacy and effectiveness of laparoscopic and robotic prostatectomy. Considerable effort must be expended to assure the comparability of groups examined. Our patients and our health care system deserve solid, reliable data on which to judge the choice — open vs. minimally invasive prostate surgery. Patient outcomes and health care costs demand these data.

– Donald L. Trump, MD, FACP

HemOnc Today Editorial Board member