A group from Brisbane Australia has recently published a high profile clinical trial comparing open and robotic prostate cancer surgery. This trial is the first of its kind, and the authors deserve congratulation for carrying it out. The conclusion of the trial is that open and robotic prostate cancer surgery produced equivalent results in terms of cancer cure, erectile function and urinary control.
As exciting as this sounds, it is worth critically appraising some limitations of the design and conclusions of this trial before accepting the outcome at face value.
Firstly, the surgeons who participated in this trial were at very different stages of their careers. Robotic surgery was not compared to an operation by an ‘average’ open surgeon, but with an individual who has over 1500 cases to his name and is one of only a handful of surgeons in Australasia with that level of experience. Essentially by making this comparison, the authors have demonstrated that robotic surgery matches extremely high quality open surgery for cancer control, erectile function and urinary control.
In terms of secondary outcomes however, robotic surgery had less blood loss (about a litre less on average!), less complications, no unplanned admissions to intensive care (unlike 8% of open surgery), and shorter hospital stay.
The trial suggests that erectile function and urinary control outcomes in robotic and open surgery are equivalent, but this has only been assessed at 12 weeks after surgery. We know that urinary control and erectile function do typically take longer than that to recover, and so the longer-term information from this trial will be much more meaningful.
So what can we take away from all this? A patient facing a cancer diagnosis is in a vulnerable position and should not see any surgical technique as more than a tool in the hands of their surgeon. Ultimately the robot is a fantastic tool, which in the hands of an experienced surgeon can assist in producing excellent outcomes. This study (despite it’s flaws) illustrates that there are other tools available to patients, and that it is the surgeon and not the tool that creates a positive outcome.
At Perth Urology clinic we have a complement of Urological surgeons with international fellowship training in all forms of prostate cancer surgery (open, laparoscopic and robotic). We work collaboratively with medical and radiation oncologists and pride ourselves on our ability to give patients all the options.
One conclusion from this trial that we fully agree with is the importance of choosing an experienced surgeon who you trust and with whom you have rapport.
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