Robot-assisted radical prostatectomy (RARP) was associated with fewer surgical complications compared with open or laparoscopic prostatectomies, a population-based cohort study in Taiwan found.

Among more than 1,400 patients who underwent radical prostatectomy in 2015, those treated with RARP were less likely to need blood transfusions compared with those who received laparoscopic radical prostatectomy (LRP; adjusted odds ratio [aOR] 0.58, 95% CI 0.37-0.91) or open radical prostatectomy (ORP; aOR 0.25, 95% CI 0.17-0.36), reported Chung-Chien Huang, PhD, of Taipei Medical University in Taiwan, and colleagues.

“To our knowledge, this study is the first in Asia to show that RARP has the lowest risk of blood transfusion,” the authors wrote in JAMA Network Open. “Our study is valuable because surgical outcomes are different between Western and Eastern countries owing to different pelvic anatomies, which has resulted in different challenges in radical prostatectomy between Asian and White patients with prostate cancer.”

In the study, RARP patients also had lower odds of experiencing moderate to severe pain on postoperative day 1 and week 1 versus ORP. And compared with LRP, receiving RARP resulted in lower odds of moderate pain at weeks 1 and 12, and lower odds of severe pain on postoperative day 1 and week 1.

Patients who received RARP had shorter hospital stays versus both ORP (-1.64 fewer days on average, P<0.001) and LRP recipients (-0.57 fewer days, P=0.01).

Three years after surgery, RARP recipients had lower odds of hernia, erectile dysfunction, and urinary incontinence versus ORP and LRP, respectively:

• Hernia: aORs of 0.51 (95% CI 0.31-0.84) and 0.82 (95% CI 0.46-0.92)
• Erectile dysfunction: aORs of 0.74 (95% CI 0.45-0.92) and 0.60 (95% CI 0.36-0.98)
• Urinary incontinence: aORs of 0.93 (95% CI 0.65-0.99) and 0.60 (95% CI 0.42-0.86)

The findings should inform clinical practice and prospective trials, said Huang and colleagues.

“Like those that have preceded it, the present study 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,” wrote Jeffrey Howard, MD, PhD, of the University of Texas Southwestern Medical Center in Dallas, in a commentary accompanying the study. “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.”

Howard said that the findings on postoperative pain were of particular relevance given the increasing risk of harm caused by narcotic use after surgery.

RARP has been criticized for a variety of reasons, he noted, such as the upfront costs of equipment, and he pointed out that studies on cost-effectiveness versus open surgery have been mixed. “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,” he wrote.

However, Howard also pointed out that RARP has essentially become standard of care in much of the high-income world, with RARP accounting for as much as 90% of radical prostatectomies in the U.S., and he suggested 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.”

Study Details

For their study, Huang and colleagues included patients enrolled in the Taiwan Cancer Registry who were diagnosed with resectable prostate cancer and underwent a radical prostatectomy in 2015. These patients were followed until Dec. 31, 2018.

Of the 1,407 patients in the study, 58% underwent RARP, 22% ORP, and 19.6% LRP. Average follow-up was 36.7 months. There were no statistically significant differences in patient age, clinical T stage, pathological T stage, Gleason score, Gleason grade group, preoperative PSA concentration, D’Amico risk classification, or hospital level between the groups.

No significant differences were seen in terms of the amount of blood during transfusions between the three procedures, with patients undergoing ORP, LRP, and RARP having mean (SD) volumes of 914.5 (927.0) mL, 750.0 (893.3) mL, and 766.9 (978.1) mL, respectively.