EURURO Vol. 72 No. 5

856 860

been demonstrated to occur, the ureters can function as
reservoirs of disease and cancer cell dissemination could
occur from spillage. In our institution, we have observed
unusual cases of peritoneal carcinomatosis occurring
within 3 mo after cystectomy in one such patient with
multifocal CIS of the bladder and ureters. In order to avoid
this, we routinely clip ureters in cases with CIS despite the
risk of short-term creatinine and potassium elevation
postoperatively.
Although the findings of these studies still warrant
further investigation, it is somewhat reassuring that recent
reports have found that early recurrence rates have
improved over time, indicating that not only technical
factors, but surgical experience is also contributing to the
phenomenon observed [5].
Conflicts of interest: The authors have nothing to disclose.
References
[1]
.
[2]
.
[3]
.
[4]
.
[5]
.
Niranjan Jude Sathianathen*, Badrinath R. Konety
Department of Urology, University of Minnesota, Minneapolis, MN, USA
*Corresponding author. Department of Urology, University of Minnesota,
420 Delaware St SE, B563, Minneapolis, MN 55455, USA.
Tel. +1 6603340774.
E-mail addresses:
(N.J. Sathianathen ).
© 2017 European Association of Urology.
Published by Elsevier B.V. All rights reserved.
Re: Robot-assisted Laparoscopic Prostatectomy Versus
Open Radical Retropubic Prostatectomy: Early
Outcomes from a Randomised Controlled Phase 3 Study
Yaxley JW, Coughlin GD, Chambers SK, et al
Lancet 2016;388:1057–66
Expert's summary:
Yaxley and colleagues [1] reported 3-mo results from the first
prospective, controlled, randomised phase 3 study comparing
robot-assisted laparoscopic prostatectomy (RARP) to open ret-
ropubic prostatectomy (ORP). They enrolled 326 patients in 4 yr.
However only 151 and 157 patients assigned to ORP and RARP,
respectively, proceeded to surgery. The study was conducted in
Australia and the most experienced open and robotic surgeons
were selected to perform the procedures. The RARP surgeon had
completed 200 robotic prostatectomies at the beginning of the
trial, while the ORP surgeon had performed 1500 operations. At
the end of the study, the RARP and ORP surgeons had performed
1000 and 2000, procedures respectively.
Baseline and postoperative questionnaires were used in
both groups to evaluate pain, urinary function, sexual
function, positive surgical margin rates, intraoperative
adverse events, and postoperative complications. The results
showed that the two techniques were equivalent in terms of
functional outcomes. The authors concluded that longer
follow-up is needed to find significant differences and they
encouraged patients to choose an experienced surgeon.
Expert's comments:
This study allows comparison of not only two different techni-
ques for radical prostatectomy but also two surgeons with
different characteristics and experience: a young post-residency
robotic surgeon and an experienced open surgeon [1]. The
difference between the two is considerable. However, the qual-
ity of the open surgery reported warrants comment.
Lymph node dissection with a mean of 3.26 lymph nodes
retrieved, operating time (OT) of 280.37 min, and mean
blood loss of 1338.14 cm3 are not within the standard range
for an experienced surgeon [2]. Therefore, an average rather
than a skilled ORP surgeon has been compared to a young
RARP surgeon. The main message is that a young urologist
who has performed 200 RARPs can obtain the same early
functional and oncological results as an experienced ORP
surgeonwho has performed sevenfoldmore ORP procedures.
The learning curves for RALP and ORP have been
reviewed by Abboudi et al. [3]. The variables included in
their calculations were OT, mean estimated blood loss (EBL),
positive surgical margin (PSM), complication rate, length of
hospital stay (LOS), transfusion rate, early continence, and
potency. Their systematic review of 44 studies revealed that
the number of open procedures needed to significantly
reduce OT, EBL, PSM, and complication rates ranged from
250 to 1000 cases for OLP, compared to 100 cases for RALP
[3]. The results reported by Yaxley et al seem to confirm that
the learning curve is shorter for RALP than for ORP.
Costs are always mentioned as a negative factor for
robotic compared to open surgery, and this can influence
the decision-making processes of health care systems at
both hospital and country levels. However, the question we
should pose is how much money can be spared if a young
urologist can perform a good standard operation in less time
with a shorter teaching programwhen compared to an open
surgeonwho needs a greater number of procedures to reach
the same skill level. This calculation has never been
performed, and the article by Yaxley et al induces us to
consider this issue.
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