Robot-Assisted Radical Prostatectomy Leads to Greater Treatment-Free Survival Than Open Radical Prostatectomy

Robot-assisted radical prostatectomy (RARP) has comparable health outcomes and fewer associated adverse events than open radical prostatectomy (ORP), according to results published in the Journal of Urology.

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Prostate cancer is the most common solid organ tumor in the United States and in the United Kingdom. Radical prostatectomy remains the most common treatment for clinically localized prostate cancer. In 2000, RARP was introduced as a way of treating patients with fewer complications. However, while RARP is associated with lower intraoperative blood loss, fewer transfusions, complications, anastomotic strictures, perioperative mortality, and shorter length of hospital stay compared with ORP, it is also significantly more expensive.

In a study led by Jim H Hu, MD, MPH, NewYork-Presbyterian and Weill Cornell Medicine (New York, NY), researchers compared RARP with ORP on primary outcomes of additional cancer therapy after surgery as well as all-cause and prostate-specific mortality in a nationally representative cohort.

Researchers used the SEER-Medicare linked database to identify patients with prostate cancer treated with RARP or ORP between 2003 and 2012. All patients with prior cancers, those who underwent radiation or had androgen deprivation therapy before prostatectomy, those not linked to SEER, and those without hospitalization records or clinical or pathological stage were excluded from analysis. 

A total of 15,591 patients were identified as eligible and included in the study; 9161 patients were treated with ORP, and 6430 were treated with RARP. Overall, the use of RARP rose significantly during the study period, increasing from 13.6% in 2003-2004 to 72.6% in 2011-2012. Patients in lower income areas with lower high school graduation rates were more likely to receive ORP, while individuals in metropolitan areas were more likely to receive RARP.

Propensity score matching and time-to-event analysis were used to compare patients on the primary outcome measures. After a median follow-up of 7.1 years, only freedom from additional treatment was significantly better among patients treated with RARP, in which the risk of undergoing additional treatment was 22% lower compared with those who received ORP. Prostate-specific and all-cause mortality were similar in both groups.

“This study is the first to our knowledge that demonstrates improved treatment-free survival associated with RARP vs ORP in the intermediate to long-term setting,” authors of the study wrote. “The reduction in additional cancer therapies associated with RARP is likely to offset the criticism of higher costs for robotic vs open surgery and stretch the benefits of RARP beyond perioperative advantages of lower blood loss, fewer transfusions and anastomotic strictures, shorter hospitalizations and lower 30-day mortality.”

They concluded that the associated improvement in treatment-free survival without any significant change in all-cause or disease-specific mortality makes RARP a non-inferior option to ORP. These findings may have significant quality and cost implications, helping clinicians and patients to make better health care decisions in the absence of robust comparative data.—Sean McGuire

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Hu JH, O’Malley P, Chughtai B, et al. Comparative effectiveness of cancer control and survival after robot-assisted versus open radical prostatecomy [published online October 5, 2016]. J Urol. doi:10.1016/j.jur.2016.09.115.