Minimally Invasive Radical Prostatectomy. 
Training, experience and innovation matter.

In a recent issue of the prestigious Journal of the American Medical Association (JAMA) a group of surgeon-scholars from Harvard compare the effectiveness of Minimally Invasive (MIRP) and "open" Radical Prostatectomy (RRP) (1). The authors identified a national sample of several thousand men over 65 years old, who had prostatectomy from 2003-2007, and calculated complication rates and functional outcomes from claims data. As the authors state, claims data are primarily designed to provide billing information and not detailed clinical information. Nevertheless, there is a high correlation between information gathered from claims data and actual clinical outcomes. 

Claims data do not distinguish laparoscopic from robotic prostatectomy, but it is reasonable to assume that most MIRP patients had robotic prostatectomy, given the popularity of the procedure. Compared with open surgery, patients who had MIRP had shorter hospital stays, less bleeding, fewer heart and lung complications and less  internal scarring at the site where the bladder is surgically reconnected to the urethra.

While these are undoubtedly important benefits, what the study also showed was that at 18 months after surgery,  a greater proportion  of MIRP patients  were diagnosed with urinary incontinence  or erectile dysfunction. However, MIRP patients did not require any more surgical procedures for treatment of incontinence or impotence than the open surgery  patients, suggesting that many of these problems were not major.

How do the results of MIRP compare with what those from a center of excellence like VUI?  We perform just robotic prostatectomy, not laparoscopic prostatectomy. Thus, our results relate only to robotic MIRP. In 2006, we did a very similar claims data analysis on the first 1500 robotic MIRP patients operated upon by one surgeon, Dr. Menon.  The data were then verified with detailed reviews of the charts, strengthening the accuracy of our conclusions. The JAMA study showed a 22% complication rate with MIRP; ours was 4%. The national stricture rate was 5%; at VUI, less than 1%. Incontinence, nationally, 18%; at VUI, 2%. Erectile dysfunction, 34%; in our hands, less than 10%.  Most of the complications that we saw were graded as minor complications using the Clavien classification. Thus, the moderate-severe complication rate in these 1500 patients was 0.9% We just don't see the same number of complications reported in the JAMA paper. 
 

Clinical follow-up confirms that these trends have continued for the more than 3,000 robotic MIRP patients we've operated on since that analysis of the first 1500 cases. Why the big difference? The JAMA article looked at Medicare patients alone, we looked at all comers, not just Medicare patients. In general, younger patients tolerate surgery better and have better functional outcomes for continence and potency. However, the differences are so marked that it is unlikely that age alone accounts for all of them. I think that there are three additional reasons to consider: training, experience, and innovation.

The JAMA article looked at a national sample of patients who were operated upon by surgeons with varying levels of training, experience and expertise. The article sagely  pointed out that all that is required to perform robotic prostatectomy in the US is to attend a 2-day course and be proctored for a few cases by a surgeon who has performed at least 20 robotic prostatectomies. While we acknowledge  that  some surgeons are more facile in learning robotics than others, this level of training seems a bit inadequate. At VUI,  every new surgeon is required to observe and assist  an established surgeon for at least 12 months before they can perform an operation independently. Thus, our training requirements far exceed national norms.

Furthermore, surgeons at the VUI have been doing this procedure for nearly a decade. In fact, we were the first robotic MIRP program in the world and have done nearly 5000 robotic prostatectomies. Our experience with robotic prostatectomy is unparalleled. Finally, the surgeons at the VUI are innovative. We developed new techniques of nerve-sparing, which improved potency (2). (The JAMA article did not examine differences in nerve-sparing). We developed new techniques of muscle preservation which resulted in much earlier recovery of urinary control (3). We developed a urethral catheter-free operation which resulted in improved patient comfort and decreased scarring (4). We developed a newer lymph-node dissection technique, which is safer and decreases genitourinary complications (5). All of these have been scrutinized in detail, and the results published 2-5. So, when comparing techniques, this is what the  VUI score-card looks like in 2009. An X suggests results that are better than those reported in the JAMA paper.      

What is the take home message? I believe that our results are better than those published in JAMA. This is partly because of patient selection, but also because of training, experience and innovation. Functional outcomes are important so, choose your surgeon carefully. A well-trained, experienced surgeon who uses newer techniques for nerve sparing and continence preservation is likely to achieve better results than someone who is  less well trained and experienced.
                                     

Mani Menon, M.D., FACS
The Raj and Padma Vattikuti Distinguished Chair
Director, Vattikuti Urology Institute
Henry Ford Health System (Detroit, Michigan)

Clinical Professor of Urology
   Case Western Reserve University School of Medicine (Cleveland, Ohio)
   New York University School of Medicine (New York, New York)
   University of Toledo School of Medicine (Toledo, Ohio)

References

1. Hu, JC, Gu, X, Lipsitz,S.R et al  Comparative effectiveness of minimally invasive vs open radical prostatectomy. JAMA.2009, 302(14):1557-64.
2. Menon, M , Kaul,S, Bhandari,A  et al  Potency following robotic radical prostatectomy: a questionnaire based analysis of outcomes after conventional nerve sparing and prostatic fascia sparing technique. J Urol.2005,174:2291-6 
3. Menon , M, Muhletaler , F, Campos , M, Peabody, J.  Assessment of early continence after reconstruction of the periprostatic tissues in patients undergoing computer assisted (robotic) prostatectomy: Results of a 2 Group Parallel Randomized Controlled Trial. J Urol.2008,180:1018-23
4. Krane , LS, Bhandari , M, Peabody , J , Menon, M   Impact of percutaneous suprapubic tube drainage on patient discomfort after radical prostatectomy EUR UROL 2009,56(2):325-31
5. Menon ,M, Shrivastava, A, Bhandari, M et al  Vattikuti Institute Prostatectomy: Technical Modifications EUR URO  2009,56 (1): 89-96