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A Comparison of Perioperative Outcomes Between Robot-Assisted Laparoscopic Prostatectomy And Retropubic Radical Prostatectomy for Prostate Cancer

(2017) Brummelstroete, G. te (Gerhard)

Introduction
Prostate cancer is (when skin cancer is excluded) the leading cause of cancer in men and causes approximately 2500 deaths in the Netherlands each year. Several options are available in the treatment for organ-confined prostate cancer. From an oncological point of view, radical prostatectomy (RP) is often the preferred option. Open retropubic RP has been the gold standard for several years. The robot-assisted laparoscopic prostatectomy (RALP) was introduced over a decade ago and is still an increasingly popular approach. Recently, the Martini Hospital in Groningen purchased the newest version of the Da Vinci-robot. Although more evidence that RALP offers advantages over the open approach is becoming available, there is, in absence of randomized controlled trials, still discussion about the subject.
Goal
The goal of this study is to evaluate whether the robot-assisted prostatectomy offers perioperative advantages compared to the open prostatectomy in the early post-introduction phase.
Method
Following approval of the Martini Hospital MEC, a database was created containing 197 patients who underwent radical prostatectomy. Preoperative patient characteristics such as age, weight, BMI, Charlson-score, ASA-score, iPSA, clinical stage, prostate volume and Gleason-score were collected. The two surgical approaches were then compared for blood loss, hospital stay, complications, postoperative pain, positive surgical margins and operation time. Statistical analysis was performed using independent t-tests, Mann-Whitney U-tests and chi-square-tests. To minimize the effect of confounding, instrumental variable analysis and multivariate logistic regression was performed.
Results
No significant differences were observed in patient characteristics between the two groups. A significant difference was found for blood loss (RALP: 200 mL (IQR: 100-250) vs. RRP: 1100 mL (IQR: 775-1645)), hospital stay (RALP: 3 (IQR: 3-3,3) days vs RRP: 7 (IQR: 6-8) days), blood transfusions (RALP: n=0 vs. RRP: n=21) and operation time (RALP: 2:53 hours:min vs. RRP: 3:19 hours:min). There were significantly less observed positive surgical margins in robotic procedures for pT2-tumours (RALP: 9/76 vs. RRP: 26/68), but not for pT3-tumours (RALP: 12/20 vs. RRP: 13/28). A total of 118 complications occurred in 87 patients. Clavien grade I and II complications were more common in RRP-patients (n=72) than in RALP-patients (n=34).
Conclusion
Robot assisted prostatectomy offers significant advantages in terms of blood loss and length of hospital stay. More importantly, there were significantly less positive margins for pT2-tumours and less blood transfusions. No significant differences were found for number of patients with PSA >0,2 on 3 months and grade III/IV complications. The most apparent weakness of this study is the lack of information on functional outcomes.





ID 3553
Moeder ID 3463
Volgorde Brummelstroete, G. te
Naam BrummelstroeteGte
Publiceren yes
OAI-naam Student_thesis
Path root/geneeskunde/2017/BrummelstroeteGte/
Gemaakt op: 2017-08-22 08:52:20
Gemodificeerd op: 2017-08-22 08:53:26
Digitaal ID 599bf0c5b8ff2
Afstudeerrichting opleiding/afstudeerrichting 1
Studierichting Studierichting 1
Titel A Comparison of Perioperative Outcomes Between Robot-Assisted Laparoscopic Prostatectomy And Retropubic Radical Prostatectomy for Prostate Cancer
Ruilverkeer mogelijk no
Printen in opdracht no
Aantal pagina's 30
Publicatiejaar 2017
Taal en
Engelse samenvatting Introduction
Prostate cancer is (when skin cancer is excluded) the leading cause of cancer in men and causes approximately 2500 deaths in the Netherlands each year. Several options are available in the treatment for organ-confined prostate cancer. From an oncological point of view, radical prostatectomy (RP) is often the preferred option. Open retropubic RP has been the gold standard for several years. The robot-assisted laparoscopic prostatectomy (RALP) was introduced over a decade ago and is still an increasingly popular approach. Recently, the Martini Hospital in Groningen purchased the newest version of the Da Vinci-robot. Although more evidence that RALP offers advantages over the open approach is becoming available, there is, in absence of randomized controlled trials, still discussion about the subject.
Goal
The goal of this study is to evaluate whether the robot-assisted prostatectomy offers perioperative advantages compared to the open prostatectomy in the early post-introduction phase.
Method
Following approval of the Martini Hospital MEC, a database was created containing 197 patients who underwent radical prostatectomy. Preoperative patient characteristics such as age, weight, BMI, Charlson-score, ASA-score, iPSA, clinical stage, prostate volume and Gleason-score were collected. The two surgical approaches were then compared for blood loss, hospital stay, complications, postoperative pain, positive surgical margins and operation time. Statistical analysis was performed using independent t-tests, Mann-Whitney U-tests and chi-square-tests. To minimize the effect of confounding, instrumental variable analysis and multivariate logistic regression was performed.
Results
No significant differences were observed in patient characteristics between the two groups. A significant difference was found for blood loss (RALP: 200 mL (IQR: 100-250) vs. RRP: 1100 mL (IQR: 775-1645)), hospital stay (RALP: 3 (IQR: 3-3,3) days vs RRP: 7 (IQR: 6-8) days), blood transfusions (RALP: n=0 vs. RRP: n=21) and operation time (RALP: 2:53 hours:min vs. RRP: 3:19 hours:min). There were significantly less observed positive surgical margins in robotic procedures for pT2-tumours (RALP: 9/76 vs. RRP: 26/68), but not for pT3-tumours (RALP: 12/20 vs. RRP: 13/28). A total of 118 complications occurred in 87 patients. Clavien grade I and II complications were more common in RRP-patients (n=72) than in RALP-patients (n=34).
Conclusion
Robot assisted prostatectomy offers significant advantages in terms of blood loss and length of hospital stay. More importantly, there were significantly less positive margins for pT2-tumours and less blood transfusions. No significant differences were found for number of patients with PSA >0,2 on 3 months and grade III/IV complications. The most apparent weakness of this study is the lack of information on functional outcomes.
Nederlandse samenvatting Introductie
Voor klinisch gelokaliseerde prostaatkanker zijn er, afhankelijk van conditie en leeftijd van de patiënt, verschillende behandelmodaliteiten. Oncologisch gezien heeft chirurgische behandeling in veel situaties de voorkeur. De gouden standaard voor het verwijderen van de prostaat was jarenlang de radicale retropubische prostatectomie (RRP). Sinds enkele jaren investeren steeds meer ziekenhuizen in een operatierobot, die de uroloog de gelegenheid geeft om nauwkeuriger en onder beter zicht te werken. Sinds begin 2016 worden prostatectomieën in het Martini Ziekenhuis in Groningen verricht met behulp van de Da Vinci operatierobot. Er bestaat echter nog enige discussie over de aangetoonde meerwaarde van de operatierobot.
Doel
Het doel van dit onderzoek was om in het kader van de stage wetenschap te onderzoeken of het nieuwe zorgpad van de operatierobot ook in de initiële fase direct al perioperatieve voordelen biedt ten opzichte van de eerder uitgevoerde open prostatectomieën.
Methode
In een retrospectief observationeel onderzoek is een database aangelegd met daarin verzamelde gegevens van patiënten met klinisch gelokaliseerde prostaatkanker die in het Martini Ziekenhuis werden geopereerd middels een open of een robot-geassisteerde laparoscopische prostatectomie (RALP). In deze database zijn gegevens van de eerste 100 patiënten verzameld die een RALP in het Martini Ziekenhuis ondergingen. Daarnaast werden gegevens uit een historisch cohort van 97 open geopereerde patiënten verzameld. Van beide werden preoperatieve gegevens verzameld zoals leeftijd, gewicht, body-mass-index (BMI), Charlson-score, ASA-score, initieel prostaat specifiek antigeen (iPSA), klinisch stadium, prostaatvolume en Gleason-score. Tussen beide groepen werd een vergelijking gemaakt wat betreft bloedverlies, opnameduur (LOS: length of stay), complicaties, positieve snijvlakken (PSV’en), operatieduur, verblijfsduur op verkoever, PSA 3 maanden postoperatief en postoperatieve pijn (Visual analogue scale (VAS)). Statistische analyses vonden plaats door middel van onafhankelijke t-toetsen, Mann-Whitney-U-toetsen, chi-kwadraat-toetsen en multivariate analyses door middel van logistische en multiple regressie.
Resultaten
Er waren geen significante verschillen in patiëntkarakteristieken. Het mediane bloedverlies was 1100 mL (IQR: 775-1645) en 200 mL (IQR: 100-250) in respectievelijk de RRP- en de RALP-groep. Mediane LOS was 7 (IQR: 6-8) dagen en 3 (IQR: 3-3,3) dagen in respectievelijk de RRP- en de RALP-groep. Beide uitkomsten waren significant in het voordeel van de RALP. De operatieduur was korter (3:19 vs. 2:53 uur), het aantal PSV’en bij pT2-tumoren was lager (38,2% vs. 11,8%) en er waren minder peroperatieve bloedtransfusies (21 vs 0) in de RALP-groep. Er waren minder graad I en II complicaties in de RALP-groep. Er werd geen significant verschil gevonden voor graad III en IV complicaties en aantal patiënten met PSA hoger dan 0,2 ng/mL 3 maanden (p>0,05).
Conclusie
Er zijn significante verschillen gevonden in het voordeel van de RALP voor bloedverlies, aantal bloedtransfusies, LOS en PSV’en bij pT2-tumoren. De robot-geassisteerde prostatectomie biedt ook in de beginfase voor de patiënt direct al perioperatieve voordelen. Belangrijkste beperking van deze studie is het ontbreken van informatie over functionele uitkomsten.
Onderwijsinstelling Medical Sciences
Type embargo abstract openbaar, scriptie op aanvraag
Auteur(s) Brummelstroete, G. te (Gerhard)
UMCG begeleider(s) Begeleider:; Wymenga, L.F.A.; Locatie: Martini Ziekenhuis; Afdeling: Urologie
Auteur(s) Brummelstroete, G. te (Gerhard)
UMCG begeleider(s) Begeleider:; Wymenga, L.F.A.; Locatie: Martini Ziekenhuis; Afdeling: Urologie


 
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