By: Dan Sperling, MD
In the United States today, more prostatectomies are now performed with less invasive robotic assistance than by means of open surgery. In fact, robotic prostatectomy represents the single largest application of clinical robotics. However, there is a lack of data showing superiority of robotic vs. open prostatectomy.[i] With rising healthcare costs, it is important to explore whether newer treatments offer equal or greater benefits but at lower expense to the system.
A research team within the University of British Columbia (The Vancouver Prostate Centre and Department of Urologic Sciences) did a comparison study between open and robotic radical prostatectomy along several parameters, including financial factors.[ii] Four hundred consecutive cases were analyzed: 200 patients underwent open prostatectomy (OP) by a single experienced surgeon, and 200 had robotic-assisted prostatectomy (RAP) by another experienced surgeon; however, the RAP surgeon had a relatively short robotic learning curve of 70 cases prior to the beginning of data collection. The two patient groups were very similar in average age and body mass index. However, a key difference between the groups was the greater percentage of higher risk disease among the OP group (32.5% vs 8.5%). The following table summarizes their findings:
|Open Prostatectomy||Robotic Prostatectomy|
|Mean operating time||114.2 minutes||234.1 minutes|
|Mean length of stay*||1.78 days||1.76 days|
|Gleason >8 in specimen||23.5%||3.5%|
|Positive surgical margin rates||31%||24.6%|
|Postop. stress urinary incontinence||4.8%||4.6%|
|ED rates at 12 months||72.8%||61.5%|
|12 month biochemical disease free||91.8%||96%|
|Avg. additional cost of RAP per case||$5629**|
*For the last 100 patients in each group
**This amounts doubles the cost of OP in this institution
The authors point out, “While hospital length of stay, transfusion rates, positive surgical margin rates and postoperative urinary incontinence were similar, OP had a shorter operative time and a lower cost compared to the very early experience of RAP.” Taking into account that the robotic surgeon had done only 70 cases before comparison records were assembled and analyzed, the authors admit that more parallel comparison is needed when the robotic surgeon as acquired extensive experience. They also acknowledge that a limitation of the research is its basis in retrospective data.
Given the significantly higher cost of RAP in this Canadian study, a country in which operating time and resources are “precious and limited commodities,” the article raises an important question about the value of RAP over OP. It is possible that as a surgeon’s learning curve flattens, RAP may lower healthcare costs over the long term if complication rates and length of stay are significantly reduced. In this study, however, OP appears to be the better value, justifying the authors’ concern that the surge in robotic prostatectomies is due in part to “widespread marketing by institutions and manufacturers of RAP and public perception that new technology is inherently better.”
[i]Heidenreich A, Bellmunt J, Bolla M, Joniau S et al. EAU guidelines on prostate cancer. Part I: screening, diagnosis and treatment of clinically localized disease. Eur Urol. 2011;59:61-71.
[ii]Gagnon L-O, Goldenberg SL, Lynch K, Hurtado A, Gleave M. Comparison of open and robotic-assisted prostatectomy: The University of British Columbia experience. Can Urol Assoc J. 2014 Mar-Apr; 8(3-4): 92–97.