Comparison of perioperative and oncological outcomes between two different surgical procedures for the treatment of prostate cancer

Much discussion has occurred regarding the surgical outcomes of robot-assisted laparoscopic radical prostatectomy (RALP) and open retropubic radical prostatectomy (RRP) for localized prostate cancer (PCa) (1-8).

The study titled “Perioperative, Oncological, and Functional Outcomes Between Robot-Assisted Laparoscopic Prostatectomy and Open Radical Retropubic Prostatectomy: A Randomized Clinical Trial” was published in the Journal of Urology. It was a randomized trial conducted at high-volume centers in Latin America. This study compared the therapeutic outcomes of RALP and RRP for PCa performed by multiple experienced surgeons. Patients enrolled in the study were randomized in a 1:1 ratio to receive either RALP or RRP and analyzed using the as-treated approach. The primary endpoint was the incidence of complications within 90 days of surgery. Secondary outcomes included quality of life over 18 months, assessment of urinary and sexual functions, and oncological outcomes over 3 years postoperatively. The Clavien-Dindo classification was used to classify surgical complications (9). The evaluation of urinary and sexual functions was conducted using the Expanded Prostate Cancer Index Composite (EPIC), International Prostate Symptom Score (IPSS), and Sexual Health Inventory for Men (SHIM) questionnaires, whereas quality of life (QOL) was assessed by means of the EuroQol 5 Dimension (EQ-5D). Urinary continence was defined as 0–1 pads/d. A SHIM score >17 was defined as the maintenance of maintaining erectile function. Assuming that the absolute difference in complication rates between RALP and RRP is 10.1%, setting α at 0.05 and power at 80%, a sample size of 342 cases is required. This study enrolled 342 patients with PCa, which is a reasonable sample size.

In total, 171 patients who underwent RALP and 156 patients who underwent RRP were included in this study. No statistically significant differences were observed; however, a relatively higher trend of complications was seen, with 27 cases (17.3%) after RRP compared with 19 cases (11.1%) after RALP (P=0.107). It is noteworthy that one patient who underwent RALP died of acute myocardial infarction 23 days after surgery, although no causal relationship with the surgery was found. The patients who underwent RALP had longer operative times, lower estimated blood loss, and shorter length of hospital stay (LOS) than those who underwent RRP. No significant differences were observed in the number of perioperative blood transfusions or surgery-related adverse events between the RRP and RALP groups. Although positive surgical margins were found in 9% of the RRP cohort and 13.5% of the RALP cohort, a statistically insignificant discrepancy was observed between the two groups (P=0.153). The RALP group had higher IPSS scores at every observation period, especially at 12 months postoperatively, than the RRP group. The median urinary EPIC score demonstrated superiority for RALP at 18 months and showed more favorable continence outcomes than RRP at 3 (80.5% vs. 64.7%; P=0.002), 6 (90.1% vs. 81.6%; P=0.036), and 18 months (95.4% vs. 78.8%; P<0.001) after surgery. The median sexual EPIC and SHIM scores demonstrated higher value for the RALP group compared to the RRP at 12-month evaluation period, with superior erectile recovery at 3 months (23.9% vs. 5.3%; P=0.001) and 6 months (30.6% vs. 6.9%; P<0.001). No significant differences were observed in the oncological outcomes between the two groups at 36 months after surgery.

The authors found that the complication rate at 90 days was not statistically different between RALP and RRP and concluded that the main benefits of RALP were reduced postoperative LOS, less bleeding, and improved postoperative sexual and urinary function.

Several studies have compared the surgical and oncological outcomes of RALP and RRP (1,3,7,8). In a study of 547 patients who underwent RALP vs. 428 who underwent RRP, estimated blood loss (188 vs. 316 mL; P<0.01), transfusion rate (3% vs. 7%; P=0.021), LOS (4 vs. 7 days), and mean duration of urinary catheterization (12 vs. 15 days) were better in the RALP group, although the operative time was significantly shorter in the RRP group (196 vs. 160 min; P<0.01) (1). The survival curves for the two study cohorts in this study were found to be non-equivalent; however, the OS at 84 months was similar in the two study groups (87.3% and 83.2% in the RALP and RRP groups, respectively) (1). In a systematic review that included two randomized controlled trials and nine prospective trials, no significant differences were found between RALP/laparoscopic radical prostatectomy (LRP) and RRP with respect to the incidence of complications, the prevalence of major complications rate, overall positive surgical margin (PSM) rate, the proportion of PSM in cases of ≤ pT2 and ≥ pT3 tumors PSM rate (3). Although RARP/LRP had significantly lower estimated blood loss [95% confidence interval (CI): −1,038.52 to −460.82; P=0.001], lower transfusion rates (odds ratio =0.17; 95% CI: 0.10 to 0.30; P<0.001) and shorter LOS (95% CI: −2.18 to −0.19; P=0.02), RARP/LRP required more operative time (95% CI: 6.50 to 93.55; P=0.02) and higher cost (3). However, RARP/LRP and RRP have similar rates of biochemical recurrence 3, 12, and 24 months after surgery (3). The 327 patients who received RALP had less blood loss (250.0 vs. 719.5 mL; P<0.0001) and had a shorter LOS (P<0.0001) (7). A lack of statistically significant disparities was observed when comparing RRP and RALP with regard to perioperative blood transfusions and the occurrence of adverse events during surgery. In addition, no substantial discrepancy was observed in the 36-month biochemical recurrence-free survival rate, and no requirement for postoperative adjuvant therapy between RALP and RRP (P=0.1) (7). Furthermore, the median values of the EPIC urinary domain were found to be significantly elevated in the RALP group at all time points up to 18 months (7). Among the 522 high-risk PCa patients who underwent neoadjuvant chemohormonal therapy, the median operative time was found to be considerably less in the RRP group in comparison to the RALP group (115 vs. 166 min; P<0.001); however, the median estimated blood loss was significantly higher in the RRP group than in the RALP group (866 vs. 25 mL; P<0.001) (8). Biochemical recurrence without clinical recurrence occurred in 60 (23.9%) patients in the RRP group and 5 (1.8%) patients in the RALP group during the entire follow-up period (8). The 5-year biochemical recurrence-free survival rates were 76.5% and 97.6% in the RRP and RALP groups, respectively (P<0.001) (8).

Several studies have compared RALP and RRP in terms of the postoperative QOL and voiding function. In this phase III randomized controlled trial, participants with newly diagnosed, clinically localized prostate cancer who chose surgery as their treatment of choice were randomized to receive RALP or RRP (4). The primary endpoints were the EPIC and International Index of Erectile Function Questionnaire scores to assess voiding and sexual function at 6, 12, and 24 months postoperatively as well as oncological outcomes (4). A total of 326 men were enrolled, of whom 163 were randomized to the RALP group and 163 to the RRP group (4). Up to 24 months postoperatively, a comparative analysis of urinary and sexual function scores revealed no statistically significant differences with regard to the RALP and RRP groups (4). Although biochemical recurrence occurred in 4 (3%) and 13 (9%) patients in the RALP and RRP groups, respectively, no significant differences were observed between the two groups (P=0.309) (4). In a prospective non-randomized trial conducted at 14 Swedish medical centers, 2,545 patients with PCa were enrolled, of whom 753 underwent RRP and 1,792 RARP (6). In a study of 1,702 patients with preoperative erection, it was observed that recovery of erectile function at three months was more rapid in the RARP group than in patients with low- and intermediate-risk PCa (6). Similarly, in patients with high-risk PCa, the point estimates of recovery of erectile function at 24 months were superior in the RARP group compared with the RRP group (6). The prospective multicenter LAPPRO trial enrolled 4,003 patients with PCa undergoing RALP or RRP at 14 centers in Sweden (5). At 24 months postoperatively, the RALP group performed better than the RRP group for erectile dysfunction (68% vs. 74%; 95% CI: 0.57 to 0.91; P=0.006) (5). No significant differences were observed in urinary incontinence (P=0.053), recurrence, or PSM (P=0.13) (5).

Although previous reports have shown no significant differences between RALP and RRP in terms of postoperative QOL, Nahas et al. (7) reported that RALP is likely to provide better postoperative QOL than RRP, including perioperative outcomes. The significance of the results of this study should be confirmed by accumulating more cases and reevaluating the results of RALP. However, the current availability of various robot models and changes in RARP techniques over time suggest that the outcomes of robotic surgery for the prostate may also change further (10-13).

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Translational Andrology and Urology. The article has undergone external peer review.

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2024-739/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2024-739/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was approved by the institutional review board of Gifu University (approval No. 2019-267).

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