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Open vs laparoscopic vs robotic radical prostatectomy. Oliver Hakenberg Department of Urology, Rostock University Rostock, Germany. NEWSWEEK, December 5, 2005. Alaska. 2001. 2002. 2003. 2004. 2005. daVinci systems in the USA 2005. Über 16000 Roboter-assistierte RPEs in den USA 2005.

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open vs laparoscopic vs robotic radical prostatectomy
Open vs laparoscopic vs roboticradical prostatectomy

Oliver Hakenberg

Department of Urology, Rostock University

Rostock, Germany

slide3

Alaska

2001

2002

2003

2004

2005

daVinci systems in the USA 2005

Über 16000 Roboter-assistierte RPEs in den USA 2005

slide4

5 cm

1 cm

what are the criteria
What are the criteria?
  • oncological outcome
  • functional results
  • complications
  • increasing case numbers
  • costs and revenues from surgery
oncological results after rpe survival n 787 1954 1994 25year survival data
Oncological results after RPEsurvivaln=787, 1954-1994, 25year survival data

Porter et al, Urology 2006

slide7

Positive margins

Offen (RRP),

laparoskopisch (LRP) und Roboter-assistierte (RAP) RPE

slide8

recurrence-free survival

RPE

LRPE

„…the available scientific evidence

has not been able to confirm any major advantage.“

Touijer & Guilloneau et al, Eur Urol 2009

slide9

Perioperative Faktoren

offene (RRP), laparoskopische (LRP) und Roboter-assistierte (RAP) RPE

functional results
functional results
  • continence
  • potency
  • cosmesis
  • duration of hospital stay
  • time out of work
  • complications
continence influence of nerve sparing n 536 rrps
Continenceinfluence of nerve-sparingn=536 RRPs

94.2% fully continent, 27 (5%) grade I, 4 (0.8%) grade II stress incontinent

Burckhard et al, J Urol 2006

slide13

continence after RPE

patient based results

slide14

Continence

laparoscopic vs open (n=1430)

Full recovery of continence [%]

p<0.001

100

80

open

27 %

60

laparoskopic

40

20

months

0

Touijer et al, J Urol 2008

slide15

recovery of potency after ns RPE

(n=70, 89% bilateral)

potency (%)

100

80

60

40

20

0

18

3

6

12

months after RPE

Walsh et al, Urology 2000

slide17

potency

open (RRP), laparoscopic (LRP) and robotic (RAP) RPE

5 year results for continence and potency n 1288 population based cohort
5-year results for continence and potencyn=1288, population-based cohort

Penson et al, J Urol 2005

slide20

cosmesis

Open prostatectomy: mini laparotomy

8 cm

day 12

at 6 months

slide22

Prospective assessment of postoperative pain in open RRP (n=154) versus robotic RPE (n=159)all patients received i.v. ketorolac (clinical pathway)

Webster et al, J Urol 2005

return to work open rrp n 537
return to workopen RRP, n=537

factors of significance were

age

hematocrit at discharge

catheter time

Sultan et al, J Urol 2006

slide24

complications

open (RRP), laparoscopic (LRP) and robotic RPE

long term complications rpe in austria n 16 524 1992 2003
Long term complicationsRPE in Austria: n=16.5241992-2003

Mohamad et al, Eur Urol 2007, 51, 684-689

increasing case numbers
increasing case numbers
  • OR time and capacity
  • surgical volume
  • complications
  • costs & revenues
slide27

Increase in RPE caseload

Dept. of Urology, Dresden University 2006

slide28
influence of hospital case load on oncological outcomeRRP, n=12,635, SEER data, cT1cadjusted for age, comorbidity, grade and stage

Ellison et al, J Urol 2005

transperitoneal tlrp vs extraperitoneal elrp laparoscopic rpe
Transperitoneal (TLRP) vs extraperitoneal (ELRP) laparoscopic RPE

Eden et al, J Urol 2004

costs depend on surgery time lrp vs rrp cost analysis
costs depend on surgery time LRP vs RRP, cost analysis
  • LRP increases costs by 17.5%
  • factors for cost increase (in this order)
    • surgery time
    • in-hospital stay
    • use of disposables
  • cost equivalence
    • if surgery time for LRP < 160 minutes
    • or if LRP is outpatient surgery!!

Link et al, J Urol 2004

model calculation of relative costs of open laparoscopic and robotic rpe literaturrecherche
model calculation of relative costsof open, laparoscopic and robotic RPELiteraturrecherche

assumptions robotic investment 1.2 million US$

yearly maintenance costs 120.000 US$

robot use of 300 caeses / year (interdisciplinary)

surgery time RAP 140 min vs RRP 160 min

hospital stay RAP 1.2 days vs RRP 2.5 days

Lotan et al, J Urol 2004

costs depend on case numbers and local structures model calculation
costs depend on case numbers and local structuresmodel calculation
  • extra costs of RAP vs RRP of 783 $/case
  • cost effective with 10 cases/week
  • with 14 cases/week or more RAP becomes cheaper if in-patient stay is < 1.5 days

Scales et al, J Urol 2005

continence rates after 12 months in prospective studies laparoscopic vs open
continence rates after 12 months in prospective studieslaparoscopic vs open

Ficarra et al, Eur Urol, 2009

slide36

Comparing robotic, laparoscopic and open retropubic

prostatectomy…

the available data were not sufficient to prove

the superiority of any surgical approach

in terms of functional and oncologic outcome.

outcome of minimally invasive rpe vs open rpe 2003 2005 n 2702 5 sample of medicare patients
Outcome of minimally invasive RPE vs open RPE 2003-2005n= 2702, 5% sample of MediCare patients

Hu et al, J Clin Oncol 2008

slide38

„Minimally invasive“

„modern“

„high tech“

„no blood loss“

„fully continent“

„fully potent“

slide39

„…wide acceptance of new techniques

based on hypothetical benefits or extrapolated

proven advantages from other surgical operations

such as cholecystectomy…“

„This study is more of a comparison of surgeons

and their techniques

than a pure comparison of surgical technique.“

Touijer et al, J Urol 2008

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