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Open vs laparoscopic vs robotic radical prostatectomy

Open vs laparoscopic vs robotic radical prostatectomy. Oliver Hakenberg Department of Urology, Rostock University Rostock, Germany. NEWSWEEK, December 5, 2005. Alaska. 2001. 2002. 2003. 2004. 2005. daVinci systems in the USA 2005. Über 16000 Roboter-assistierte RPEs in den USA 2005.

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Open vs laparoscopic vs robotic radical prostatectomy

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  1. Open vs laparoscopic vs roboticradical prostatectomy Oliver Hakenberg Department of Urology, Rostock University Rostock, Germany

  2. NEWSWEEK, December 5, 2005

  3. Alaska 2001 2002 2003 2004 2005 daVinci systems in the USA 2005 Über 16000 Roboter-assistierte RPEs in den USA 2005

  4. 5 cm 1 cm

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

  6. Oncological results after RPEsurvivaln=787, 1954-1994, 25year survival data Porter et al, Urology 2006

  7. Positive margins Offen (RRP), laparoskopisch (LRP) und Roboter-assistierte (RAP) RPE

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

  9. Perioperative Faktoren offene (RRP), laparoskopische (LRP) und Roboter-assistierte (RAP) RPE

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

  11. Continenceinfluence of nerve-sparingn=536 RRPs 94.2% fully continent, 27 (5%) grade I, 4 (0.8%) grade II stress incontinent Burckhard et al, J Urol 2006

  12. reported continence rates after RPE open LRP robotic

  13. continence after RPE patient based results

  14. Continence laparoscopic vs open (n=1430) Full recovery of continence [%] p<0.001 100 80 open 27 % 60 laparoskopic 40 20 months 0 Touijer et al, J Urol 2008

  15. recovery of potency after ns RPE (n=70, 89% bilateral) potency (%) 100 80 60 40 20 0 18 3 6 12 months after RPE Walsh et al, Urology 2000

  16. influence of age on potency recovery after RPE (n=188) Noh et al, AUA 2002

  17. potency open (RRP), laparoscopic (LRP) and robotic (RAP) RPE

  18. Montorsi et al, Eur Urol 2008

  19. 5-year results for continence and potencyn=1288, population-based cohort Penson et al, J Urol 2005

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

  21. open vs laparoscopicin-hospital and recovery Bhayani et al, Urology 2003

  22. Prospective assessment of postoperative pain in open RRP (n=154) versus robotic RPE (n=159)all patients received i.v. ketorolac (clinical pathway) Webster et al, J Urol 2005

  23. return to workopen RRP, n=537 factors of significance were age hematocrit at discharge catheter time Sultan et al, J Urol 2006

  24. complications open (RRP), laparoscopic (LRP) and robotic RPE

  25. Long term complicationsRPE in Austria: n=16.5241992-2003 Mohamad et al, Eur Urol 2007, 51, 684-689

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

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

  28. influence of hospital case load on oncological outcomeRRP, n=12,635, SEER data, cT1cadjusted for age, comorbidity, grade and stage Ellison et al, J Urol 2005

  29. Transperitoneal (TLRP) vs extraperitoneal (ELRP) laparoscopic RPE Eden et al, J Urol 2004

  30. 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

  31. model calculation of relative costsof open, laparoscopic and robotic RPELiteraturrecherche assumptions robotic investment 1.2 million US$ yearly maintenance costs 120.000 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

  32. costs depend on case numbers and local structuresmodel 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

  33. Ficarra et al, Eur Urol, 2009

  34. continence rates after 12 months in prospective studieslaparoscopic vs open Ficarra et al, Eur Urol, 2009

  35. Ficarra et al, Eur Urol, 2009

  36. 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.

  37. Outcome of minimally invasive RPE vs open RPE 2003-2005n= 2702, 5% sample of MediCare patients Hu et al, J Clin Oncol 2008

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

  39. „…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

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