Minimally invasive prostate surgery carries risk, study suggests
Men who need prostate cancer surgery are increasingly choosing minimally invasive techniques because such procedures typically lead to shorter hospital stays and a reduced risk of complications. But a study suggests that the risk of the most serious complications may be higher with the new technology.
Minimally invasive forms of radical prostatectomy (in which the prostate gland is removed), often including the use of a robot, are heavily advertised. Procedures relying on robotic surgery have increased from 1% to 40% of all radical prostatectomies from 2001 to 2006 and may be as high as 75% of all prostate cancer surgeries.
The robotic techniques are advertised as safer or better than a traditional open prostatectomy. But a study published Tuesday in the Journal of the American Medical Assn. found that two of the most serious complications -- incontinence and erectile dysfunction -- appeared more often in men who underwent minimally invasive surgery compared with open surgery.
“There has been rapid adoption of minimally invasive radical prostatectomy; however, outcomes have not been superior,” said Dr. Jim C. Hu of Brigham and Women’s Hospital in Boston, the lead author of the paper. He said hospital marketing departments might have oversold the technology.
“I think that is certainly the story I would tell based on our findings,” Hu said. “In our healthcare system, perhaps a lot of community hospitals felt the need to be competitive . . . and they acquired these robots and marketed them before there has been diffusion of experience among surgeons.”
Hu and his colleagues compared the outcomes for 1,938 men who had minimally invasive radical prostatectomy to the outcomes for 6,899 men who had an open radical prostatectomy. The men who had minimally invasive surgery had shorter hospital stays (two days compared to three), were less likely to receive transfusions (2.7% compared to 20.8%) and were at lower risk of respiratory complications (4.3% compared to 6.6%). However, more of them experienced urinary and genital complications: 4.7% compared to 2.1%.
The study found that rates of minimally invasive prostate surgery varied by geography (with notably higher rates in Los Angeles and Detroit) and by education and income, with higher rates among men in the higher socioeconomic groups.
The death rates did not differ between the two groups, although the study only followed men for 18 months after surgery.
In recent years, minimally invasive surgery for prostate cancer has been advertised as comparable to or better than open surgery, said Dr. Herbert Lepor, chairman of the department of urology at NYU Langone Medical Center, who was not involved in the study.
“All these claims that are driving robotics are not based on any credible evidence,” he said. “We have to ask, how is this technology impacting our healthcare delivery? It has increased costs, and what have we gained? It looks like we are going backward in the most important clinical outcomes.”
Lepor is a leading researcher and advocate of open radical prostatectomy. This year, he presented data at the annual meeting of the American Urological Assn. on factors that affected patients’ satisfaction with prostate cancer surgery.
“We found that six months after surgery, the only thing that drives satisfaction is not that you went home in two or three days or needed a transfusion,” he said. “It’s continence, erections and disease recurrence. That is what is relevant.”
Although minimally invasive robotic surgery may eventually offer advantages over traditional surgery for all men, there is a learning curve among surgeons using the technology, Hu said. Studies should be performed to determine the rate of complications as more surgeons develop expertise with the technology, he said.
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