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Invited Commentary
Urology
August 25, 2021

Robotic, Laparoscopic, and Open Radical Prostatectomy—Is the Jury Still Out?

Author Affiliations
  • 1Department of Urology, University of Texas Southwestern Medical Center, Dallas
JAMA Netw Open. 2021;4(8):e2120693. doi:10.1001/jamanetworkopen.2021.20693

Elsewhere in JAMA Network Open, Wu and colleagues1 present a novel analysis of a Taiwanese national database comparing the perioperative and long-term functional outcomes of men undergoing radical prostatectomy (RP) via an open (ORP), laparoscopic (LRP), or robotic-assisted (RARP) surgical approach. Compared with ORP and LRP, RARP was associated with improvements in both immediate postoperative outcomes (ie, length of stay, blood loss, and pain) and long-term functional outcomes (ie, erectile dysfunction, urinary incontinence, and hernia). Notably, this is one of only a few studies to compare the 3 major approaches side by side, and to my knowledge, the first to do so in a majority East Asian population.

Historically, the adoption of RARP was attended with considerable controversy. In its early years, the robot was lambasted by some as a solution looking for a problem, an expensive technology adopted for its own sake despite a lack of evidence to support its use, with its adoption driven by emotional, non–evidence-based marketing to patients and clinicians alike.2 It is true that previous high-level evidence has suggested only minimal if any long-term benefit to RARP compared with open radical prostatectomy (ORP) when both are performed in expert hands. In a randomized clinical trial conducted in Australia, there was no difference in functional outcomes between patients undergoing RARP and ORP, with a small difference in biochemical recurrence rates in favor of RARP.3 LAPPRO, a Swedish nonrandomized trial of RARP vs ORP, showed a small benefit of RARP over ORP with regard to erectile dysfunction but not with regard to urinary continence or oncologic outcomes.4 Both studies demonstrated reduced blood loss, reduced hospital length of stay, and increased operative time for RARP compared with ORP. Similar conclusions have emerged from high-quality retrospective series.

Aside from controversy surrounding outcomes, RARP has been criticized because of the high up-front costs of equipment and consumables. A variety of studies have yielded mixed results as to whether RARP is cost-effective compared with ORP after accounting for outcomes and readmission rates. Evidence suggests that as for any expensive technology that needs to justify its own cost of acquisition, the mere availability of the robot resulted in it being presented to patients as a superior option, thus further reinforcing its use regardless of any clinical benefit.5 Finally, the troubling implications of the monopoly power now held by a single corporation over a wide swath of urologic surgery should not be ignored.

These criticisms notwithstanding, the adoption of RARP as the standard of care for RP is now a fait accompli in much of the high-income world, with RARP likely representing more than 90% of RPs in the United States. While the externalities mentioned previously have certainly played a role, this new consensus likely reflects the cumulative experience of numerous urologists who feel the robotic approach makes the operation easier, less bloody, and less morbid. It should also be noted that, in the years since its origin, robotic surgical technique has continued to evolve. A variety of novel robotic techniques have been described, including the Retzius-sparing and single-port approaches, which would be unfeasible with an open approach and may offer further incremental improvements beyond the basic technique.

Compared with the vigorous early controversy surrounding RARP and ORP, there is less evidence regarding the potential advantages or disadvantages of LRP, a technique that gained widespread acceptance in Europe and Asia but not in the United States. Theoretically, LRP offers the benefits of minimally invasive surgery without the need for specialized equipment and high costs associated with the surgical robot; however, it is considered by many to be a difficult technique with a steep learning curve. LAP-01, a randomized, patient-blinded trial of LRP vs RARP, demonstrated superior urinary continence and erectile function at 3 months postoperatively for the robotic procedure, although longer-term outcomes are yet to be reported.6 Conversely, a large retrospective series comparing ORP, LRP, and RARP performed by expert surgeons at high-volume centers showed no difference in functional outcomes.7

In this context, it is interesting to note that the present study shows a significant association of RARP with both improved immediate postoperative outcomes, where the benefits of robotic assistance are generally recognized and accepted, and in long-term functional outcomes, where prior evidence has been less clear. One notable finding is a modest improvement in severe postoperative pain for RARP compared with both ORP and LRP, a finding especially relevant given the increasing recognition of the harms caused by narcotic medication after surgery. Regarding long-term outcomes, patients undergoing RARP had uniformly superior rates of both urinary incontinence and erectile dysfunction compared with both ORP and LRP, with a more striking benefit than reported in most prior studies.

While the present study’s findings1 certainly might be argued to support the use of RARP over alternate techniques, caution should be exercised in drawing conclusions from them. The greater long-term benefits of RARP observed here could be due to further incremental improvements in surgical technique resulting in the genuine superiority of contemporary RARP over LRP and ORP in this recent series or reflective of real-world practice, in which robotic assistance makes a difficult procedure accessible to a broader range of clinicians and therefore shows benefits not apparent in a carefully organized clinical trial at high-volume centers. However, as with any retrospective study, the observed associations could be due to unaccounted confounders rather than genuine differences between the surgical modalities. Notably, due to limitations in the source database, the authors were unable to account for differences in surgeon experience, surgeon or hospital volume, and the use of nerve-sparing techniques. All of these factors have been demonstrated to affect outcomes and potentially have a stronger effect than the choice of RARP vs LRP or ORP. It should also be noted that both urinary incontinence and erectile dysfunction were reported as binary outcomes, despite the fact that both phenomena vary widely in degree and impact on quality of life. Neither preoperative urinary nor sexual function were accounted for in the analysis.

Like those that have preceded it, the present study1 will likely be cited by advocates of RARP as further evidence of its superiority and simultaneously dismissed or ignored by a dwindling number of skeptics. In countries like the United States, where RARP already dominates, such arguments are increasingly moot. However, the question remains germane in countries and health care systems where robotic-assisted surgery is not yet the norm, particularly those with limited financial resources. Policy makers and clinicians in such settings will continue to view this and similar studies with great interest.

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Article Information

Published: August 25, 2021. doi:10.1001/jamanetworkopen.2021.20693

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Howard JM. JAMA Network Open.

Corresponding Author: Jeffrey M. Howard, MD, PhD, Department of Urology, University of Texas Southwestern Medical Center, 2001 Inwood Rd, WCB3 Floor 4, Dallas, TX 75390 (jeffrey.howard@utsouthwestern.edu).

Conflict of Interest Disclosures: None reported.

Additional Contributions: The author thanks Vitaly Margulis, MD (University of Texas Southwestern), for his mentorship and for critical review of the manuscript.

References
1.
Wu  SY, Chang  CL, Chen  CI, Huang  CC.  Comparison of acute and chronic surgical complications following robot-assisted, laparoscopic, and traditional open radical prostatectomy among men in Taiwan.   JAMA Netw Open. 2021;4(8):e2120156. doi:10.1001/jamanetworkopen.2021.20156Google Scholar
2.
Touijer  K.  Marketing versus science: a fight between necessary evil and stern good over the adoption of new technology in medicine.   Eur Urol. 2010;58(4):522-524. doi:10.1016/j.eururo.2010.06.004PubMedGoogle ScholarCrossref
3.
Coughlin  GD, Yaxley  JW, Chambers  SK,  et al.  Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: 24-month outcomes from a randomised controlled study.   Lancet Oncol. 2018;19(8):1051-1060. doi:10.1016/S1470-2045(18)30357-7PubMedGoogle ScholarCrossref
4.
Nyberg  M, Hugosson  J, Wiklund  P,  et al; LAPPRO group.  Functional and oncologic outcomes between open and robotic radical prostatectomy at 24-month follow-up in the Swedish LAPPRO Trial.   Eur Urol Oncol. 2018;1(5):353-360. doi:10.1016/j.euo.2018.04.012PubMedGoogle ScholarCrossref
5.
Scherr  KA, Fagerlin  A, Wei  JT, Williamson  LD, Ubel  PA.  Treatment availability influences physicians’ portrayal of robotic surgery during clinical appointments.   Health Commun. 2017;32(1):119-125. doi:10.1080/10410236.2015.1099502PubMedGoogle ScholarCrossref
6.
Stolzenburg  JU, Holze  S, Neuhaus  P,  et al.  Robotic-assisted versus laparoscopic surgery: outcomes from the first multicentre, randomised, patient-blinded controlled trial in radical prostatectomy (LAP-01).   Eur Urol. 2021;79(6):750-759. doi:10.1016/j.eururo.2021.01.030PubMedGoogle ScholarCrossref
7.
Gershman  B, Psutka  SP, McGovern  FJ,  et al.  Patient-reported functional outcomes following open, laparoscopic, and robotic assisted radical prostatectomy performed by high-volume surgeons at high-volume hospitals.   Eur Urol Focus. 2016;2(2):172-179. doi:10.1016/j.euf.2015.06.011PubMedGoogle ScholarCrossref
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