Publications Management System

ROBOTIC RADICAL PROSTATECTOMY

Received on 23 September 2016

Abstract

Robotic radical prostatectomy when compared to the conventional (open) technique, mostly shows that the robotic has a lower rate of bleeding, lower rate of blood transfusion and shorter hospital stay. The results are, yet, controversial in the analysis of other outcomes. It seems the robotic decreases urinary incontinence and impotency, accelerates the recovery of sexual function and recovery of urinary continence. However, it has a higher cost. Randomized trials that are in progress may clarify these issues.

Introduction

The prostate cancer is treated individually, considering the patients’ age, the tumor staging, the histologic degree, the prostate size, comorbidities, life expectancy, the patient’s expectations and the technical resources available.1

The vigilant observation is an option for the located disease, but it must be used only in patients above 75 years old, with limited life expectancy and low histologic degree tumors.1

The radical prostatectomy is the gold pattern procedure for the treatment of located prostate cancer. It was performed via perineal by Theodor Billroth in 1867, in the Medical School of the University of Viena.2 In 1904, Hugh Hampton Young was the first to extract the whole prostate via perineal and in 1947, Millin described the first open prostatectomy through retropubic via for the treatment of a benign prostatic hyperplasia. However, in earlier stages, several men became impotent. Thus, many preferred radiotherapy to surgery. The modern era of the radical retropubic prostatectomy began with Patrick Walsh’s, according to Laviana, who described the retropubic and periprostatic anatomies in 1979. 2 This allowed Walsh to have a safe control of the dorsal venal complex, achieving less local bleeding, including the first nerve preservation and showing the erection could be maintained without compromising the cancer control.2 In 1992, Schuessler et al performed the first laparoscopic prostatectomy.3 In 1999, the Da Vinci surgical system, initially designed for the use of cardiac surgeons when doing coronarian bypass, started to be used by urologists. In 2000, in France, Abbou CC et al4 reported the first robotic prostatectomy. Following this, in Germany, Binder J and Kramer5, and in the USA, Menon et al6 performed the first cases of robotic prostatectomy. The robotic surgery, according to the producer of the Da Vinci Surgical System, was performed in about 80% of radical prostatectomies in the USA in 2010. The use of robotics increased from 0.7% to 42% between 2003 and 2010 in the USA.7

The use of Robot support during prostatectomy has reduced the adversities related to the laparoscopic prostatectomy. The robotic has the following characteristics: it allows the magnification of the image by 10 times, three-dimensional imaging and a new periprostatic view, since it is fitted with a camera with endoscopic stereo lens, an increase of the wrist movements, with seven different degrees, which facilitates a vesicoureteral anastomosis and allows a better ergonomic position for the surgeon.

From 2003 to 2010, there was an increase of the number of robotic surgery equipment and, thereby, there was a decrease in hospital stay time, with readmission rates in 20 days similar to the open technique, besides allowing higher reimbursement to the hospital.8

Both the open access and the access via laparoscopy conducted by Robot produce alterations in urinary incontinence and erection,9 besides other adverse events. However, some outcomes may suffer modifications with the time. The fact is the comparison between open and robotic prostatectomy for the treatment of prostate cancer is still in debate. And this is the issue to be discussed in this review.

Literature Review

Lowrance WT et al, 201010 critically analyzed robotic and open prostatectomy literature regarding perioperative, oncologic, functional and cost wise results of the case series type.

a- Perioperative results.

-Complications. From six quoted papers, only 1 (one) reports a higher complications frequency on patients submitted to open prostatectomy. Globally there were no significant difference between both access types. It appears that genitourinary and intestinal complications relate more towards the surgeon than to access via.

– Hospital stay time and blood loss. According to eight studies, robotics surgery is associated to less loss than open surgery. There is no study that states otherwise. The blood transfusion rate is higher in the group of open surgery according to seven studies. Hospital stay time is lower in robotics group as well, according to three studies.

b- Oncologic results:

– Surgical margin. From eight studies, four report that surgical margin had higher positivity on open via and four other don’t.

To conclude, surgeons experienced at robotic and open via are capable of obtaining a disease free margin in a high percentage of patients and, therefore, it is possible that surgical margin depends more on the surgeon than on the access via.

– Biochemical recurrence. From three studies that assessed this outcome, none detected difference on biochemical recurrence between both access via. However, the observation time was short.

c- Functional outcome

The goal of radical surgery is to heal the patient and keep continence and erectile function (trifecta).

Only 1 study validated the tools to characterize urinary continence and impotence after the robotic.

– Continence. Ficarra V, 2009, quoted by Lowrance WT et al 2010, in a prospective study, comparative, non-random, observed better urinary continence in robotic surgery than in open. These authors reported a urinary continence rate of 97% in robotic and of 88% in open (p=0.001). The patients were considered continent if they reported no urine loss in about a week or less, or none at all. The average time of continence recovery was of 25 days in robotic and 75 days in open via (p<0.001). Ahlering et al, mentioned by Lowrance WT et al 2010, using a non-validated questionnaire, defined continence as the non-need for dippers, and reported similar continence rate between both access via (75 vs 76%). Tewari et al, according Lowrance WT et al 2010, showed a faster continence return in robotics (44 days vs 160 days). Krambeck et al, according Lowrance WT et al 2010, found no difference in urinary continence between both access via. Using a non-validated questionnaire, the patients were considered continents if they had no urinary loss or if they had no need for a second dipper. Urinary continence in 1 year was of 92% in robotic and 94% in open (p=0.34). - Erectile function. Comparing robotic to open via it can be observed that data are limited by follow-up time and restricted to only a few centers. Krambeck et al, according to Lowrance WT et al 2010, reported having no significant difference of potency between robotic and open in one year (open 63% robotic 70% p=0,08). Potency was defined as satisfactory erection for intercourse with or without 5-phosphodiesterase inhibitor. Tewari et al, according to Lowrance WT et al 2010, using a phone interview, reported a median time shorter in recovery of potency with robotic than with open (180 vs 440 days, p<0.05). In a single study using a validated tool of potency (International Index of Erectile Dysfunction-5, IIEF-5), Ficarra et al, according to Lowrance WT et al 2010, defined potency when IIEF-5 had a score higher than 17. Limiting the analysis of at least 1 year of follow up to these patients that received a bilateral nervous preservation, the authors noted that 49% of patients that had surgery via open and 81% of patients under robotic surgery were potent according to its definition (p<0.001). Finally, when comparing functional outcomes of robotic and open, the literature is scarce and inadequate. While there are few studies with few patients to draw definitive conclusions, robotic does not seem to be inferior to open regarding erectile function and urinary continence. -Costs/economy: Data of costs between robotic and open are scarce. According to Lowrance et al 2010, the costs reported by Lotan et al, Mouraviev et al, Scales et al and Bolenz et al showed that robotic has high cost when compared to open, however, these costs were related to procedure and initial duration of hospital stay. Scales et al, according to Lowrance et al 2010 reported that the cost of patients hospitalized for robotics are dependent on volumes, and the equivalent cost to open is possible in specialized centers with high volume. Bolenz et al found that the direct median cost was higher in robotics then in open (6,752 dollars vs. 4.437, p<0.001). Economic evaluation of robotics via goes by Da Vinci surgical system, which costs about 1.6 million dollars with annual maintenance of 120,000 dollars after the first year. The average cost of devices is approximately 1,500 dollars per case. These authors estimated the purchase of extras and robot maintenance costs by about 2,700 dollars per patient, based on an annual increase of 126 cases. This additional cost of the robot is probably overestimated in this number that will decrease with time, especially in centers of large volume. Conclusions: The quick adoption of robot occurred without evidence level I showing superiority or equivalence to open. However, there are no randomized studies to the present. Available data points to advantages on blood loss and hospital stay time in robotics as of open. The positive surgical margin seems to be shorter with robotic, but follow-up duration of existing studies is short to evaluate the biochemical recurrence and other important oncologic aspects. Besides, it is necessary to have more studies using validated tools to define differences in functional outcomes between robotic and open. It is necessary to define if the cost increase of robotic is justified by the improvement of perioperative, oncologic and functional results and economic outcomes. Laviana AA & Hu JC 20132 reviewed literature from January 2000 to April 2013 and observed a paucity of randomized controlled trials comparing the two access methods. They evaluated the outcomes: blood loss, need for blood transfusion, postoperative pain, length of hospital stay, mortality and complications. Oncologic results included surgical margin status, biochemical recurrence-free survival, and need for recovery therapy or rescue. Functional outcomes included quality of life and return to continence and potency.

Novara et al, according to Laviana AA & Hu JC 2013,2 performed a meta-analysis of 110 studies on robotic assisted prostatectomy and reported an average operative duration of 152 minutes, blood loss of 166ml, average transfusion rate of 2%. Furthermore, the average catheterization time was of 6,3 days with average hospital stay time of 1,9 days. Complications occurred in 9% of patients under robotic and the most common were: lymphocele (3.1%) loss of urine (1.8%), and recovery (1.6%). The authors concluded that robotic can be performed with lesser blood loss and transfusion than the open.

Perioperative mortality is low on both access methods.

The operative time is influenced by the experience of the surgeon, surgeons volume and hospital volume. Krambeck et al, mentioned by Laviana AA & Hu JC 20132 in an initial assessment of 294 robotic, found that the operative time was longer in robotics. In the last hundred cases there was no difference (p=0.14).

Complications. Some studies examining the complications of robotics and conventional surgery report that the robotic produces fewer complications (rectal injury, pulmonary embolism, pneumonia, wound infection (15.7% in robotics – 1235 cases and 22.8% in conventional – 485 cases). Other studies report less readmission, ureteral injury, deep venous thrombosis, hematomas, lymphocele, wound infection, but higher likelihood of intestinal damage in robotics. The probability of reoperation, ileus, nerve damage, bladder, rectal are similar in the two access methods. Other studies show no difference between the two access methods. Some studies show less risk of narrowing of the urethral-bladder anastomosis in robotics, probably because of the magnification of the image that robotics offers.

-Blood loss and transfusion with robotics: Tewari et al, mentioned by Laviana AA & Hu JC 20132 after evaluating nine studies that directly compared the three access methods, found that robotics was associated with less blood loss and blood transfusion.

Post-operative outcomes.

– Hospital stay time is shorter in robotic than in open, according to three studies and in one study there was no difference.

– There were lesser post-operative pain in robotic according to two studies and in one study there were lesser pain in open, however there was no difference in the subsequent days, as well as there were no difference in analgesic use.

Oncologic outcomes.

– Biochemical recurrence-free survival: It is limited by follow-up time, with few studies having a follow-up median of five years.

When comparing open with robotic, one meta-analysis showed positive surgical margin and seven years of recurrence-free survival similar in both groups.

– Positive surgical margin: It is associated with biochemical recurrence. Some studies point to a lower positive surgical margin in the robotic group, others show no difference. This may be because the pathologist observation bias and the development and stage of the disease. For example, in pT2 disease and Gleason score greater than 6, the surgical margins were less positive in robotic. Another study showed lower positive margin in robotic in pT2 disease, but in pT3 disease the margin was similar. In a recent meta-analysis, the margin was positive in 16.2% in robotic and 24.3% in the open, but after adjusting the score, the positive margin was similar (p = 0:19). A recent review, according Laviana AA & Hu JC 2013,2 showed lower positive margin of safety with robotic in than to open.

Functional results.

Many studies that evaluates life quality after prostatectomy have forsaken tools (UCLA-PCI, EPIC, SHIM) in favor to dichotomous variables such as: non-use of dippers, ability to have erection enough for sexual intercourse.

– Continence recovery. It is associated with surgeon’s experience, surgery technique, such as division and control of the dorsal vascular complex, anterior and posterior urethrovesical anastomosis reconstruction, preservation of the bladder neck and nerve preservation technique.

While three studies of case series type showed 95% of urinary continence recovery after open, Di Perro et al., mentioned by Laviana AA & Hu JC 20132 reported faster recovery of continence in three months after robotic as of open, although there was no difference after a year. Additionally, other non-randomized studies favored robotic, regarding to continence recovery.

A meta-analysis performed by Ficarra et al, mentioned by Laviana AA & Hu JC 2013,2 of 12 studies (five robotic), using as parameter of continence the non-use of dippers, showed better continence recovery in robotic as of open (p=0.03). However, Krakembeck AE et al, mentioned by Laviana AA & Hu JC 2013,2 in a comparative study combined with some papers, did not report continence difference between both access methods.

– Erectile recovery.

The evaluation of potency after prostatectomy varies according to obtainment technique. Potency is affected by patient age, degree of erectile dysfunction in pre-operative, comorbidities, nerve preservation technique, phosphodiesterase inhibitor drug use and exact definition of impotency.

Laviana AA & Hu JC 20132 state that Di Pierro et al reported better erectile recovery after robotic than the radical retropubic prostatectomy (55% vs 26%, p==0.009), that Krambeck et al demonstrated a tendency for erectile improvement in robotic as of open (p=0.08), and that Tewari et al in 2003 and Kim et al in 2011 demonstrated erectile improvement of 84% in robotic versus 47% in open.

A recent retrospective study performed by Alemozaffar et al, according to Laviana AA et al 2013, investigated the outcomes of sexual function and learning curve to attenuate neuropraxia. This research demonstrated erectile improvement in 5 months (p=0.007) and tendency for improvement in 1 year (p=0.061) and stabilization after 250-450 cases.

Malcom et al, according to Laviana AA & Hu JC 2013,2 analyzed post-operative sexual function using a questionnaire (UCLA-PCI – University of California, Los Angeles, Prostatic Cancer Index) and verified that in approximately 3 years the sexual function was better after robotic, although did no statistic. Another study with 406 robotic versus 220 open showed no urinary and sexual function difference. Miller et al compared life quality of patients submitted to robotic with life quality of patients submitted to open surgery using a Short Form Health Survey (SF-12) questionnaire. Men submitted to robotic had higher score in the physical component from the first week, which remained up through sixth week. The physical component returned to basal earlier in robotic than in open and mental component did not differ between both access methods.

In another study, according to Laviana AA, the robotic showed fewer ill days (nauseated, tired – 11 versus 49) and in an adjusted analysis, men submitted to robotic had twice as many conditions to return to work than to men submitted to open surgery (HR 2.13, IC 95% 1.62-2.80).

Costs: The initial costs for robotic installation are bigger than U$ 1.5 million and the estimated costs for maintenance are of U$ 150.000 per year. Robot’s tools cost approximately U$1.500 per case. Although shorter hospital stay, the robotic cost was significantly higher than open’s (U$6.752 versus U$4.437). Lotan Y et al, according to Laviana reported an advantage of U$1.726 of open on robotic.

Conclusions: The lack of prospective randomized studies and of standardized outcomes, particularly regarding functional outcomes, limits the generalization of comparative outcomes between robotic and open. Besides, there is the heterogeneity of surgeon’s experience. There is no thorough long term comparison of cancer control in both access methods. Existing studies shows that robotic produces lesser blood loss, lesser need for transfusion and lesser hospital stay time. It seems that there is also lesser anastomotic stricture, lower convalescence and faster recovery of continence and erection with robotics. While costs remain high with robotic, there is need for thorough randomized prospective studies to determine if robotic is cost-effective in centers with high volume of surgery.

Moran PS et al, 2013 compared assisted robotic radical prostatectomy with open prostatectomy or with conventional laparoscopic prostatectomy. The main outcomes were: positive surgical margin for tumors pT2 and pT3, sexual function and urinary continence in 12 months, blood loss, blood transfusion rate, complication rate, operative time in minutes and hospital stay time. Postoperative sexual function was defined as the ability to sustain erection long enough to perform intercourse with or without help of type 5 phosphodiesterase, or with use of a validated sexual function questionnaire. Urinary continence was defined as non-loss of urine, use of one or less dipper per day or through a validated continence questionnaire. The research interval was of January 2000 to March 2011.

It was included in this review the randomized controlled studies, non-randomized controlled studies and studies that compared assisted robotic radical prostatectomy with the open and with the laparoscopic. All studies were individually revised by two independent revisers and any disagreement was solved by discussion. The quality of studies was evaluated using an evaluation tool of a study previously published that was based on design and performance of individual study. The quality of the included studies was evaluated using an evaluation method developed by Hailey and modified by Ho et al in 2011.

Results: It was found 1 randomized study of a surgeon and 50 observational studies. Of the observational, 27 were comparative retrospective or studies that used historic comparing groups and 23 were observational prospective studies.

Characteristics of included studies:

A total of 37 studies compared robotic with open surgery, nine compared robotic with conventional laparoscopic surgery and five compared the three methods.

The 31 included studies involved more than one surgeon in the intervention or did not mention the number of surgeons that participated in the surgery and reported the surgeon experience. The degree of the surgeon’s experience in the assisted robotic surgery was relative to his/her first case series (8 studies). 12 studies reported how the operative time was determined. Continence was defined in 15 studies (12 – non-loss of urine or use of dippers for 0-1 day, 3 – continence questionnaire). Definition of sexual potency was considered as the ability to sustain erection for intercourse with or without type 5 phosphodiesterase inhibitors aid. Complications report varied between studies: some reported only occurring complications and others categorized complications as major and minor or provided a list of registered complications.

Studies quality: Most of the studies were retrospective or prospective observational, with score of ≤ 2 points in study design. Of 51 evaluated studies, 3 were of high quality, 14 of good quality, 25 of medium quality and 9 of poor quality.

Assisted robotic surgery versus radical open prostatectomy.

Data of 15 studies with nearly 3000 patients showed that robotic surgery was associated with lesser safety margin in pT2 tumors. This result had no occurrence in pT3 tumor.

Data from nine studies with nearly two thousand patients submitted to assisted robotic prostatectomy showed that sexual function recovery in 1 year was higher in this than in open. However, these data showed high level of heterogeneity (I2=70%). As for urinary function in 12 months, meta-analysis results from seven studies with around 1800 patients showed a significant increase of urinary function with assisted robotic prostatectomy (p=0.009).

The assisted robotic prostatectomy, in the reports of the studies in this review, was associated to lesser blood loss and transfusion rate when compared to open surgery. There is a high level of heterogeneity associated to the difference on blood loss between both procedures (I2=98%) showing the different ways to estimate blood loss. The results of transfusion rate had higher consistency (RR 0.23, CI 95% 0.18-0.29, p<0.001, I2=17%). The complication risk was smaller in assisted robotic surgery than in open prostatectomy (p=0.047). The operative time of assisted robotic was 40 minutes longer than the open (p<0.001). Conclusions: Despite the increase of published articles on assisted robotic prostatectomy, the methodological quality of available evidence remain low. The long term outcomes as well as recurrence of cancer and mortality are deficient. Most evidence comes from prospective studies or retrospective and case series. This projects doubt on reliability of results, once these studies have high risk of bias. Besides, this review shows the direction of bias tending to overestimate the benefits of assisted robotic surgery. Based on results of the present study, the assisted robotic radical prostatectomy is associated with reduced positive surgical margin for pT2 tumors as well as improves the return of sexual function in 12 months, when compared to open radical prostatectomy. Estimated blood loss and blood transfusion rate are also reduced in robotic, but operative time is longer.

Discussion

The goal of this review was to search in literature (2000-2014) for studies that verify the long term benefits of robotic surgery over open surgery in localized prostatic cancer surgery when performing radical prostatectomy. Three literature review were found, two of which included meta-analysis studies and one was a systematic literature review, and two studies that are yet to be finished.

The intraoperative bleeding is less intense in robotics23-26,45 and decreased with the learning curve of the first 50 cases.27 In fact there is a consensus in the literature that robotics is associated with less blood loss than open according to eight studies. There is no study that says otherwise.10

However, one study reported 1,6% of bleeding in robotic surgery that needed blood transfusion.29

The need for blood transfusion is less frequent in robotic.11,26,28,29According to seven studies, the transfusion rate is smaller in robotic.10

One study showed that there is no difference between the hospital stay time, blood transfusion rate and incidence of perioperative complications in robotic and open surgeries.32 However, most studies states that hospital stay time is shorter in robotic.

The surgical site infection has been studied comparatively between robotic and open. The studies’ results have shown that infection is less frequent in robotic surgery, and when it occurs in robotic it is taken care of quicker, without need to drain and return to surgery room, with lower probability of hospital readmission.33

The pain assessed in one study34 by Likert score was lesser in robotic in the surgery day, but there was no difference in morphine sulphate dose during hospitalization between the two groups.

Patients submitted to minimally invasive surgery, including robotics, have adverse urinary and sexual events in the initial postoperative period. This may result from the surgeon’s inadequate preparation35. Complications decreased after learning curve of 150 cases.36

Some measures have been proposed to prevent urinary incontinence in robotic surgery, such as: 1- preservation: the bladder neck, the puboprostatic ligament, the pubovesical complex, the neurovascular complex and extension of the urethra; 2- reconstruction: before and after and/or reinsertion of tendinous arch the bladder neck; 3-reinforcement – plication of the bladder neck and/or suspension of the neck.37 A multi-centric, prospective, randomized study showed that the anterior retropubic suspension (puboprostatic ligament) with the subsequent reconstruction of rhabdomyo sphincter improves early return of continence without increasing complications.38 One study showed no difference in urinary continence between robotics and open, but there is need for randomized studies to clarify this issue.39

Another study showed that robotic allowed faster recovery of urinary continence, reduced positive surgical margin presence and the period of urinary catheterization.40

The sexual potency evaluated by an index of erectile function (IIEF) and for erection hardness score (EHS), while preserving bilateral nerves did not differ between the robot and opened. One study showed no difference in erectile function between the two access methods, one year after surgery, but the authors report the need for randomized study to clarify this issue.39

A positive surgical margin is an outcome of much study in radical prostatectomy. It was reported increased risk of positive margin in patients who have preserved the nerves bilaterally than when not preserved in patients with category pT2 disease, in multivariate analysis, after adjustment for confounding factors, which did not occur in patients with category pT3 disease.41

The assisted robotic surgery is associated to lower positive surgical margin and to lesser early cancer control because of the reduced use of antiandrogen drugs and radiotherapy in a two-year period, thus having and important effect in quality of life and health care, as well as in costs.42 A systematic literature review study states that access method does not have clear advantages regarding oncologic results.43

A multi-centric study in Europe, USA and Australia reported that the surgical safety margin might be inferior after minimally invasive techniques and might be affected by the volume of surgeries in the surgical center where the robotic is performed.44

Another study states that the rate of positive safety margin does not differ among the access methods and that patients with high PSA levels in preoperative, in univariate analysis, as more likely to have positive safety margin.45 Similar oncologic results may be obtained with both access methods by a surgeon experienced in robotic surgery, even in locally advanced disease.46

Tewari et al, 2012, in systematic literature review with meta-analysis evaluating 400 articles comparing robotic with open, observed that robotic is equivalent to open access via and laparoscopic in terms of safety margin, and suggests that robotic offers advantages specially regarding adverse events. Readmission rate, reoperation, nerve injury, rectal, deep vein thrombosis, pneumonia, hematoma, lymphocele, leaking anastomosis, fistula, surgical site infection showed significant difference among the groups, usually in favor of robotic. However, authors claim that the lack of randomized studies, use of state of margin as oncologic control and inability to compare costs are limitations of the study.11

In a retrospective analysis, evaluating 357 open prostatectomies and 669 robotic, safety margin of the results favored robotic, but the study has methodological limitations in T3 disease.47 Another study shows that, in fact, there was no difference of positive surgical margin between the two access methods, and there was no difference in biochemical recurrence that has as independent predictors the preoperative PSA and the number of positive surgical margins.48 The positive safety margin rate was more frequent in robotics that in open and laparoscopic, but no difference in pT2 disease, although the biochemical recurrence has not suffered difference between the three methods (robotic, laparoscopic and open).49 Another study reports that there is a higher probability of positive surgical margin in robotic that in the open.50 However, another study claims that the safety margin is similar in robotics and open in low-risk and intermediate-risk patients.51 In a study of meta-analysis of observational studies, the authors suggested that robotics has similar risk of positive surgical margin.52

The positive surgical margin was lower in robotic than in open in pT2 stage and did no differ in pT3 stage, being the localization of positive surgical margin in the 3 methods the prostate apex.53 Another literature review of 73 studies report similar surgical margin, however the functional results are difficult to be evaluated due to the studies biases.54

The positive surgical margin may decrease when the urologist changes from open to robotic, probably due to increased viewing and for dissection accuracy,55 and may decrease depending on the surgeon’s experience after 30 patients.56 Biochemical recurrence is an important outcome. It had as an independent predictor in multivariate analysis, extra prostatic extension, seminal vesicle involvement, lymph node involvement, the sum of Gleason scores and positive surgical margin.57 This recurrence defined as PSA ≥0.1 ng/ml or PSA ≥0.05 ng/ml in patients with additional therapy did not differ between the robot and open held by a large number of surgeons.58

The recurrence-free survival has been compared between robotic and open. A study show that survival did not differ between both access methods at two and at four years.59 Dariane C et al.60 showed that recurrence-free survival has not been associated to PSA level below 4ng/ml, but to positive surgical margin and to Gleason score.7

When life quality is evaluated by EPIC among patients submitted to robotic surgery and open surgery for radical prostatectomy, there is no significant difference in 12 months, however patients on both groups had low response levels in twelve months, which  implicates in performing other studies to clarify this issue.61 The life quality (SF-12 version 2 of PMHSAF) evaluated in preoperative and weekly during six weeks showed higher physical score in robotic from first to sixth week, but the physical component score returned to basal earlier in robotic and mental component did not differ between both groups.62

The cost of the two access roads has been often compared. A recent study showed that the total cost of robotics is higher than the open, with longer anesthesia, although with robotic lower complication rate, less blood transfusion and shorter hospital stay.63 Another retrospective study that compared 20,242 patients submitted to robotic with 9,413 patients submitted to open surgery showed that although robotic produce fewer complications and shorter hospital stay, unfortunately still has the highest cost of hospitalization.

Analyzing the results altogether, robotic when compared to open is associated with less blood loss and lower transfusion rate, shows a similar incidence of positive surgical margin and oncologic outcomes and appears to have advantages in terms of continence, potency and quality of life, but there are methodological limitations in existing studies in the literature.64

Other studies report no oncologic differences (positive surgical margin, progression of disease-free survival) and functional results among access methods (continence and potency).65,66

The Pasadena Consensus Panel in 2012, based on a systematic review concludes that robotics compared to open produces less bleeding, lower rate of blood transfusion, similar rates of complications and of positive surgical margin, advantages in the recovery of continence and potency, but there are methodological limitations on studies.67

In a systematic literature review comparing assisted robotic prostatectomy with open, the authors reported that assisted robotic surgery produces significant improvement in positive surgical margin for pT2 tumors and improves sexual function in 12 months, however these results should be interpreted carefully, due to evidence limitations. The studies that compares assisted robotic to open are of retrospective type, prospective case series and non-randomized, there for subject to biases.22

It should be noted that there are two randomized studies in literature still in development. The first is from Gardiner RA.68 This study was initially published in 2012, but without definitive results.69 The second is from Thompson RH and Tollefson MK.70 Therefore, these publications should be waited to evaluate their results, which will contribute to evaluate the real benefit for robotic surgery over open during a longer period.

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Authors

Danilo Nagib Salomão Paulo¹; Ronney Antonio Guimarães2

1 PhD from the Federal University of Minas Gerais – UFMG, Medical Doctor, Professor of Surgery Fundamentals of the Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória-EMESCAM.

2 Master of Medicine (Obstetrics) from the Federal University of São Paulo – UNIFESP, Professor of Universidade Vila Velha – VV and of the Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória-EMESCAM.

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