The use of laparoscopic robotic assisted prostatectomy has become the new standard of care in the definitive surgical treatment of operable prostate cancer. In a review published in July, 2016 in The Journal of Urology (the link is to the abstract; Dr. Stark can provide the entire paper upon request) the authors examined claims data from Medicare to look at outcomes in men undergoing this procedure versus standard open prostatectomy. They identified nearly 100,000 men who underwent surgery in 2010-2011, three quarters of whom had the robotic procedure. They found that the thirty-day surgical mortality, incidence of positive surgical margins and the subsequent need for post-operative radiation were diminished with the robotic procedure. Since the risk of dying of prostate cancer for those men studies (all had favorable or somewhat favorable tumors) was so small the authors were not able to say that overall mortality was also reduced. This paper would seem, therefore to prove conclusively that all urologist performing radical prostatectomy use this approach. So…what is wrong with this paper?
The authors admit that they had no way to control for the skill of, or the volume of cases of, the surgeons doing the procedures. Everyone involved in the care of these patients acknowledges the steep learning curve associated with laparoscopic robotic assisted surgery. Large volume centers such as Johns Hopkins and Memorial Sloan Kettering Cancer Center, each with world famous urologic oncologists, were early adapters of this new technology and presumably have gotten very good at it. The authors acknowledge this bias; nonetheless, they conclude that the new robotic procedure is better. Dr. Stark would submit that this conclusion is premature, and that men who feel good about their urologist and/or who live a long distance away from a high-volume center should not feel intimidated out of being treated locally. Whether this operation should still be done is a subject for another discussion.