STATE OF THE ART: SURGICAL TREATMENT OF LOCALISED DISEASE
Bob Djavan, Professor of Urology,
Chairman Department of Urology, Rudolfiner Foundation Hospital Vienna,
Executive Board ESOU Chairman Regional office of the EAU
HISTORY REVISITED !
Actuarial PSA Progression-free and Cancer Specific Survival after RP
Number of Patients at risk For Ca Specific Survival 1716 1225 915 359
63 for PSA Recurrence 1716 1115 724 214
38
PSA Progression
Ca Specific Survival
77% 75%
96% 93%
Swindle et al. J Urol;174(3):903-7, 2005
CONTINENCE at 1 year
Author N % Author N %
Ravery 567 79 Geary 458 80Rassweiler 500 84 Rassweiler 219 90Salomon 100 90 Steiner 593 94Bollens 275 94+ Leandri 620 95+
Total USA 79 -94ESRPE 82-96
+ 1 safety padDjavan et al, BJU, 2007
Time Kinetics of Continence
Time Range (%)
3 Months 51 - 63 6 Months 70 - 81 12 Months 91 - 9624 Months 92 - 97
Potency rates at 1 yr (bilateral NS)
Author N % Author N %
Salomon 17 59 Huland 366 56Rassweiler 41 67 Catalona 798 68Roumeguere 26 63 Roumeguere 33 55Eden 58 64 Walsh 64 86+
Total USA 59-67ESRPE 56-86
Open and Laparoscopic RPE
• Oncological results (R0 Margins) • Continence • Preservation of sexual function • Pain & QoL
Suture of dorsal vein complexOpen RPE
Suture of dorsal vein complex Laparoscopic RPE
Suture of dorsal vein complex Robotic RPE
Djavan 2009/211/B277
Incision Length
•Lap. RPE 7.9 cm
•Open RPE 8.6 cm
Postoperative Pain
• Comparison of 314 open and 154 robotic RP • Patient-reported pain scores were similar • Perioperative narcotic use was similar
• Authors concluded that outcomes other than pain and early convalescence will ultimately determine the role of lap/robotic RP
Webster et al. J Urol 174: 912, 2005
Bhayani, et al. Urology 61: 612-616, 2003.
Lap vs open RP : QOL studies
I Hara, J Urol, 169. 2045. 2003
LAP vs Open
• Oncologial results: No Difference • Continence: No Diference • Potency: No Difference • Pain & QoL: No Difference • Surgical Technique maters and not the
Approach • SUO, AUA, 2008
Eastham et al, J Urol , 2006
Overall potency results
Eastham et al, J Urol A, 2006
Touijer StudyJ Urol, May 179:1811, 2008
• No difference in oncological oucome • Less blood loss with laparoscopic approach • BUT higher number of post OP visits • Higher readmission rates • Continence better with open approach • Potency quicker with laparoscopy
Oncological outcome
The Early Studies
Open/Lap/Robotic RPE
2000-2010
One surgeon with 2 approaches Outcome measures
Open surgery (N=160)
Robotic laparoscopy (N=160)
Body mass index 27 26Operating time (hours) 3.6 3.9Positive margins (%) 12% 10%Blood loss (mL) 418 103*
Transfusion rate: % 1% 0%Hospital stay (days) 2.2 1.1*
Catheterisation time (days) 9 7Complications 10% 6.7%Continence at 3 months 75% 76%N = 120; * P < 0.05
Ahlering et al. Urol;63:819-22, 2005
Schroek Study BJU int Jul, 102:28, 2008
• Robot vs open RPE • N = 797 patients • No difference in oncological outcome • No difference in PSA recurence free survival • No difference in clinical and pathological
features, SM
Frotta & Gill Study Int Br J Urol, Jun;34(3):259 2008
• Robot vs open RPE vs LAP • Literature analysis 1982-2007 • G square ANALYSIS • No difference in oncological outcome • No difference in functional outcome • Equivalent in intermediate follow up
Parsons Metanalysis Urology, Aug, 72:412, 2008
• No difference in pos surgical margins (SM) • No difference in erection status (slightly
better with open and robot than lap) • No difference in continence status • Less blood loss with lap and robotic
ESOU Hamburg 2012
37 comparative studies - 16 prospective studies - one single PRT
Meta-analysis Eur Urol 2009
ED
Incont
GU compl
Strictures
Misc surg compl
Resp compl
BT
LOS
0,0 % 7,5 % 15,0 % 22,5 % 30,0 %
2,0 %
2,7 %
4,3 %
4,3 %
5,8 %
4,7 %
15,9 %
26,8 %
3,0 %
20,8 %
6,6 %
5,6 %
14,0 %
2,1 %
12,2 %
19,2 %
RRPMIRP
The Newer Studies
open/Lap/Robotic RPE
2010-2017
Medicare Study Barry et al., JCO, 30(5), 513, 2012
• Medicare patients 2008 • 685 patients • No difference in erection status • No difference in continence status • Patients should not expect fewer adverse
events following robotic prostatectomy
ONCOLOGIC OUTCOME
79 selected papersNovara et al. Eur Urol 62 (2012) 382-404
■ BIOCHEMICAL RECURRENCE FREE SURVIVAL • Very few papers with a follow-up duration >5 yr demonstrated 7-yr BCR-free survival
estimates of approximately 80%
■ COMPARISON BETWEEN RARP AND OTHER APPROACHES • SIMILAR PSMs rates (overall and pT2) and BCR-free survival estimates
Open vs Robotic assisted RPEin HIGH RISK
▪ UCSF Study ▪ 177 vs 233 patients ▪ Is RALP suitable in high risk? ▪ RALP less Blood loss and more Bilat Nerv
sparing cases ▪ Higher Postive Margins with RALP early on ▪ Equal recurrence rates at 2 and 4 yrs FU!
Punnen and Carroll, BJU Int, march, 2013
PASADENA CONSENSUS PANEL
PASADENA CONSENSUS PANEL
■ RARP is EQUIVALENT to RRP in terms of biochemical disease-free survival:
95.1% at 1 yr; 90.6% at 3 yr; 86.6% at 5 yr; 81.0% at 7 yr
■ RARP may be used in patients with high-risk cancers
■ PSMs rates after RARP are EQUIVALENT to those reported after RRP and LRP
Average rate of PSMs: in pT2= 8–10%; in pT3= 37%
■ When appropriately performed, RARP DOES NOT expose patients to an increased risk of adjuvant therapies
Open vs Lap vs Robotic assisted RPE
▪ UK NHS study ▪ Higher Costs with the Robot ▪ Growing evidence for lower surgical margins
and better potency results ▪ But: need > 150 cases to achieve better results
with the Robot. ▪ If < 150 cases: Open better!
Close et al, Eur Urol, march, 2013
Open vs Lap vs Robotic assisted METANALYSIS
▪ MED and EMBASE ▪ Random effect metanalysis ▪ Robotics better than Laparoscopy! ▪ In pT2: PSM and Potency better with Robotics
than with Open at 12 months !!
Moran PS et al, Int J Urol, march, 2013
Conclusions:
Lower overall likelihood of PSMs and adjuvant therapy with RARP versus ORP.
URINARY CONTINENCE
51 selected papers
■ PREVALENCE AND RISK FACTORS FOR URINARY INCONTINENCE POST-RARP = no pad! 12-mo urinary incontinence rates: mean value 16% (4%-31%) • Increasing age • BMI >30 • Prostate volume (cut-off value: 70-80 cm3) • Comorbidities • LUTS severity • Surgeon experience
Ficarra et al. Eur Urol 62 (2012) 405-417
URINARY CONTINENCE■ SURGICAL TECHNIQUES ABLE TO IMPROVE URINARY CONTINENCE RECOVERY Posterior musculofascial reconstruction (with or without anterior reconstruction):
slight advantage in terms of 1-mo urinary continence recovery
Significant ADVANTAGES for RARP in comparison with RRP/LRP in terms of 12-mo urinary continence rates
POTENCY RATES
31 selected papers
■ PREVALENCE AND POTENTIAL RISK FACTORS OF ERECTILE DYSFUNCTION POST-nerve sparing RARP
12-mo erectile dysfunction: 10%-46% 24-mo: 6%-37%
• Age at surgery • Baseline erectile function • Nerve-sparing extension and techniques
Ficarra et al. Eur Urol 62 (2012) 418-430
POTENCY RATES■ SURGICAL TECHNIQUES ABLE TO IMPROVE POTENCY RECOVERY Interfascial VS intrafascial dissection: inconclusive results Athermal dissection: significant advantages in terms of early potency recovery
Significant ADVANTAGES for RARP in comparison with RRP in terms of 12-mo potency rates
Non statistically significant trend in favor of RARP in comparison with LRP
Complications of Robotic RPE
• Migration of cases to low volume centers • Significantly higher CR in low volume
centers 14.7% vs 5.7% • Reduction in quality of patient care • Increase in Costs (vs highvolume centers)
Sammon et Menon, BJU Int, march, 2015
Cost comparison of robotic, laparoscopic and open radical prostatectomy
RALP LRP openRPE
OR Time (median) 235 225 198 0.001 Length of stay (median) 1 2 2 <0.001 Direct Cost (median, $) 6623 5636 3631 <0.001 OR Service Cost (median, $) 3175 2111 1260 <0.001 Surgical Supply Cost (median, $) 1314 1488 246 <0.001 Anesthesia Cost (median, $) 419 365 234 <0.001 Medication Cost (median, $) 296 271 270 0.001 Room and Bed Cost (median, $) 514 699 708 <0.001 Lab Cost (median, $) 295 386 657 <0.001
Gupta, Caddedu et al, Eur Urol, A 973, 2009
+150/+280%
Yaxley et al. – Lancet 2016• RCT, open (163) versus robot (163) prostatectomy • Localized prostate cancer, Brisbane, 2 surgeons
Urinary function
Sexual function
6 weeks
P=0.09 P=0.45
12 weeks
P=0.48 P=0.18
Open
Robot
Positive margins 10% 15% P=0.21Complications 9% 4% P=0.052
Beginners learn much faster the robot than laparsocopy or…
Virtual Surgery
Flight Simulator LUFTHANSAFlugsimulatoren wurden 1939 von Edward Link eingeführt um
Piloten auf schwierige Situationen vorzubereiten
Laguna, M. P., Hatzinger, M., and Rassweiler, J.: Simulators and endourological training. Curr Opin Urol, 12: 209, 2002
Oncological outcome
Urinary continence
Potency
CLINICAL PRACTICE
TotalRARP
ORP
DO OPEN SURGEONS BENEFIT FROM ROBOTIC EXPERIENCE?
• Open Survey of senior open surgeons having had robotic training and performed > 50 RALP cases
• n= 24 senior urologists with >500 cases each
• 6 countries • 15/24 believe they have changed significantly the open procedure
• 6/24 believe they have changed moderately • 3/24 have not changed
Conclusions• Robotic RPE better if high volume center only!
•Benefits: slight earlier recovery of continence and potency and May be oncological benefit
•“Robot assisted Open Surgery”
• Robotic exposure seems to improve the open technique
• Basis: 1) better perception of the anatomy 2) changing the technical approach
ESOU Hamburg 2012
„A Fool with a Tool is still….a
Fool…“
Me and Konfuzius
The Rudolfinerhaus Foundation Hospital
First oRPE by Theodor Billroth In 1867
My Message
Even if you don’t have a Robot, go and get robotic training/exposure, It will improve your open technique