Originally published 5/31/2015
In 2015, our original blog below summarized 12-mo follow-up from the LAPPRO trial, a prospective, controlled, nonrandomized trial comparing robotic-assisted laparoscopic prostatectomy (RALP) vs. traditional open retropubic prostatectomy (RRP). LAPPRO found no statistically significant difference for urinary incontinence, but a statistically significant advantage for RALP with regard to erectile dysfunction (ED).
In 2018, a team of authors from the same 14 institutions reported 24-month comparisons from the LAPPRO data. Adding another year to follow-up gives weight to the longer-term results. Again, there was no significant difference in incontinence (RALP 19%, RRP 16%); and still a significant difference in ED (RALP 68%, RRP 74%). Rates of recurrence or residual disease were the same, at 13%.[i]
What we find noteworthy is that at 24 months, there was a slight decrease in incontinence rates for both procedures. However, for RRP the erectile dysfunction rate seems to be stable at roughly 74%, while for RALP there has been a small improvement from 70.4% ED at 12 months to 68% at 24 months. In short, there was little change in the post-treatment rates of incontinence and ED a year after the first report. The thought of over two-thirds of post-robotic prostatectomy patients living with sexual dysfunction as long as two years after their surgery is sad, especially since robotic RP in the U.S. is promoted as offering men a strong chance of retaining potency.
There are many studies with more favorable rates of regaining sexual function after RALP. Still, we are inclined to believe that men who decide on robotic surgery for their localized prostate cancer should be informed about LAPPRO results in order to help manage their expectations.
Over the years, I have spoken with many patients about the idea of doctors being 100% open with regard to their treatment results. I came across a large-scaled Swedish study on prostatectomy side effects, and it’s as transparent as it gets.
The fact that the study came out of Sweden might say something about how frank it is. Sweden is a nation that prides itself on openness. One of the government’s official websites says that openness and transparency are vital parts of Swedish democracy, noting that the press and the general public have access to government records. “Scrutiny is seen as valuable for a democracy, and transparency reduces the risk of power being abused.” [ii] These principles are upheld in their constitution. I found myself asking, what if these same principles universally applied to medicine? What if physicians were expected to keep accurate data on their treatment results, and patients had open access to it? (Statistics only—the identities of all patients would continue to be protected as required by HIPAA law.) In any case, the spirit of openness and transparency that is so treasured by the Swedes is exemplified in this new study.
The research article is titled “Urinary Incontinence and Erectile Dysfunction after Robotic versus Open Radical Prostatectomy: A Prospective, Controlled, Nonrandomised Trial.”[iii] The fact that it is prospective and controlled, coupled with the number of patients and medical centers that participated, makes it a very respectable study. (I’m proud to say that the same authoritative journal in which it’s published, European Urology, is carrying our new article on focal laser ablation.)
Fourteen Swedish medical centers were involved, and 2431 patients were evaluated 12 months after radical prostatectomy. The patients had either laparoscopic robotic radical prostatectomy (RALP) or open retropubic radical prostatectomy (RRP), which has long been the gold standard. The method of recording results tracked patients at baseline and again at 12 months after treatment, using clinical record forms and validated patient questionnaires. “The primary end point was urinary incontinence (change of pad less than once in 24h vs one time or more per 24h) at 12 mo. Secondary end points were erectile dysfunction at 12 mo and positive surgical margins.” Here is a summary of their results:
| 12 months post RALP | 12 months post RRP | |
| Incontinence | 366 men (21.3%) | 144 (20.2%) |
| Erectile dysfunction | 1200 men (70.4%) | 531 (74.7%) |
| Positive surgical margins | 21.8% | 20.9% |
The authors concluded that the robotic surgery was only “modestly beneficial in preserving erectile function” compared with open prostatectomy, with no significant differences in rates of incontinence and positive surgical margins.
The reality of > 70% ED rates at a year after surgery is an honestly acknowledged problem by experts. A 2015 paper out of Rush University Medical College, Department of Urology contains this observation: “Robot-assisted laparoscopic prostatectomy (RALP) has emerged as the most common treatment for localized prostate cancer. With improved surgical precision, RALP has produced hope of improved potency rates, especially with the advent of nerve-sparing and other modified techniques. However, erectile dysfunction (ED) remains a significant problem for many men regardless of surgical technique.”[iv] This admission tells me that there’s more transparency about the “modest” benefits of robotic prostatectomy than we might be aware of.
I see a “disconnect” between the difference between transparent data as reported in scientific literature and the often-wishful beliefs of patients that nerve-sparing robotic prostatectomy has high rates of preserving potency. Wiser minds than mine can explain how this disconnect occurs, and I’m not suggesting that there is a deliberate deception going on by the medical profession. I believe as patients eager for honest answers become more familiar with how to use services like the National Institute of Health’s huge database of research abstracts (http://www.ncbi.nlm.nih.gov/pubmed/), they will discover that the transparency is there for the taking.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.
[i] Nyberg M, Hugosson J, Wiklund P, Sjoberg D et al. Functional and Oncologic Outcomes Between Open and Robotic Radical Prostatectomy at 24-month Follow-up in the Swedish LAPPRO Trial. Eur Urol Oncol. 2018 Oct; 1(5): 353–360.
[ii] https://sweden.se/society/openness-shapes-swedish-society/
[iii] Haglind E, Carlsson S, Stranne J et al. Urinary incontinence and erectile dysfunction after robotic versus open radical prostatectomy: A prospective, controlled, nonrandomised trial. Eur Urol. 2015 Mar 11. pii: S0302-2838(15)00194-3.
[iv] Whelan P, Ekbal S, Nehra A. Erectile dysfunction in robotic radical prostatectomy: Outcomes and management. Indian J Urol. 2014 Oct;30(4):434-42
About Dr. Dan Sperling
Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.
