Comparison of Open, Laparoscopic and Robotic Approaches on Oncological and Functional Results Prof. Dr. Murat Binbay: https://muratbinbay.com/prof-dr-murat-binbay

1. COMPARISON OF OPEN, LAPAROSCOPIC AND
ROBOTIC APPROACHES ON ONCOLOGICALAND
FUNCTIONAL RESULTS
Associated Professor in Urology
HasekiTraining & Research Hospital,
Istanbul –Turkey
muratbinbay@yahoo.com

2. PROSTATE CANCER
v Most common urologic malignancy
v In USA 2.1 milion men are living with disease
> 50 , 1/6 of men receive diagnosis, 86% localized
•
*** In second place of cancer
related death

3. TREATMENT MODALITIES
v DEFFERED THERAPY
v RADICAL PROSTATECTOMY
v RETROPUBIC
v PERINEAL
v LAPAROSCOPIC
v ROBOT ASSISTED LAPAROSCOPIC
vDEFINITIVE RADIATION THERAPY
v BRACHYTHERAPY

4. 1900
2013
1979 1992 2001 2010
Retropubic radical
prostatectomy (Nerve
Sparing)Walsh et al.
Laparoscopic radical
prostatectomy,
Schuessler et al.
Robotic radical
prostatectomy
LESS radical
prostatectomy,
Kaouk et al.
1947
1904
Perineal radical
prostatectomy,
Young et al.
Retropubic radical
prostatectomy,
Millen et al.

5. OBJECTIVES OF MINIMAL INVASIVE TECHNIQUES
§ Better oncological and functional outcomes
§ Less blood loss
§ Less complication rates
§ Less pain
§ Less insicion
§ Less hospital stay
OBJECTIVES OF RADICAL PROSTATECTOMY
“TRIFECTA”
1) Oncological results (negative surgical margins)
2) Recovery of continence (as early as possible)
3) Recovery of erectyle functions

6. What should we expect more?
§ Reproducibility
ú Learning Curve
ú Volume needed for quality control
§ Cost
ú SurgicalTime
ú Length of Hospital Stay
ú Cost of Equipment Required
ú Time to Normal Life Reincorporation

7. TECHNICAL CONSIDERATIONS
FUNCTION OPEN LAPAROSCOPY ROBOTIC
Magnification Loupe 2D (mostly) – 3D 3D
Tactile Sensation Intact Decreased Muted
Degrees of freedom 4 7 and improving
Running anastomosis No Yes Yes

8. OPEN
ROBOTIC

9. Results Unproven, Robotic SurgeryWins Converts
Robotic surgery grows, but so do questions
Is robotic surgery growth only marketing driven?

10. DOES MINIMAL INVASIVE SURGERY OFFER
SUPERIOR OUTCOMES WHEN COMPARED TO RRP
?
• SMALLER INCISION
• LESS SCARRING
• FASTER RECOVERY

12. NEED PROSPECTIVE RANDOMIZED TRIALS
§ No PRTs
§ Possible advertisies;
ú Lack of standard definitions for
Positive surgical margin
Urinary continence
Sexual functions
ú Centers where RARP is performed are usually focused
on this approach, limiting their practice with open or
laparoscopic procedures
ú Studies comparing 3 approaches in the same
institution are scarce and include small patient
series,which usually represent the surgeons’ learning
curve

13. COMPLICATIONS

14. COMPLICATIONS
In multivariable analyses of propensity score-matched populations,
Patients undergoing RARP are less likely
to receive a blood transfusion
to experience an intraoperative/ postoperative complication
to experience prolonged length of hospital stay

15. Open& Robot
Lap & Robot
This meta-analysis suggest that robotic assisted radical prostatectomy
can be performed with reasonably risk of complications

16. Blood loss and transfusion rates were significantly lower with RARP than with RRP;
Transfusion rates were lower with RARP than with LRP

17. ONCOLOGICAL OUTCOMES
*** Primary goal of prostate cancer surgery is to provide
satisfactory oncological outcomes.
*** Biochemical progression and margin positivity are
common indicators
POSITIVE SURGICAL MARGIN:
4 x increased with biochemical recurrence
( Eastham J, Int J Urol 2009)

18. POSITIVE SURGICAL MARGIN
PRE OPERATIVE DATAS
OR
OPERATIVE TECHNIQUE

19. POSITIVE SURGICAL MARGIN
KARIM TOUJIER
MSKCC
*** LRP AND ORP PROVIDED COMPARABLE ONCOLOGICAL RESULS,
PRE OPERATIVE PARAMETERS WERE MOST IMPORTANT FACTORS
TO PSM.

20. POSITIVE SURGICAL MARGIN
KARIM TOUJIER, J UROL
GREY LINES FOR LRP
*** AFTER 100 CASES IN LRP GROUP; SURGEON EXPRIENCE
AFFECTED ON PSM RATE AND DECREASED PSM

21. *** Oncological results are same
in both open and laparoscopic
group.

22. ONCOLOGICAL OUTCOMES
Recurrence rate for pT2 and pT3were similar

24. Positive surgical margin rates are similar following RARP, RRP and LRP
** Major evidence suggests that RARP as performed by experienced surgeons
can jeopardize patient outcome

27. RADICAL PROSTATECTOMY – ERECTILE DYSFUNCTION
v DIFFERENT DEFINATION AND MEASUREMENT
v CHARACTERISTICS OF THE SURGERY
vNerve sparing
vDegree of traction
vUsage of thermal energy
v PATIENT SELECTION
v POST SURGICAL REHABILITATION

31. *** FOR THE FIRST TIME; CUMULATIVE ANALYSIS OF
COMPERATIVE STUDIES DEMONSTRATES SIGNIFICANT
ADVANTAGES IN FAVOR OF RARP IN COMPARISION WITH ORP.
CONSIDERING THE LIMITATIONS DUE TO THE LIMITED NUMBER
OF PATIENTS INCLUDED IN STUDIES COMPARING RRPAND LRP

32. § It has been proposed that;
ú RARP may prevent damage to neurovascular bundle
because
3D magnified vision allows more precise dissection
Prevents inadvertent incision, traction or incorporation
of the neurovascular bundle into the suture or clip
Dissection in a bloodless field

33. INCONTINENCE
***Faster recovery and
significantly better continence rates
with robot assisted radical
prostatectomy!!!!

35. v AGE
v BODY MASS INDEX
v COMORBIDITY INDEX
v LUTS
v PROSTATE VOLUME
MOST RELEVANT PREOPERATIVE FACTORS OF URINARY INCONTINENCE

36. v SURGEON EXPRIENCE
v SURGICAL TECHNIQUE
v METHODS USED TO COLLECT AND REPORT DATA
EFFECT ON RESULTS
**** POSTERIOR MUSCULOFASCIAL RECONSTRUCTION SEEMS TO OFFER
SLIGHT ADVANTAGE IN TERM OF 1 MO URINARY CONTINENCE
RECOVERY

37. COELHO RF
OPEN SURGERY

38. COST OF PROCEDURES

39. COST OF PROCEDURES
RARP IS THE
MOST
EXPENSIVE BUT
WITH
EXPRIENCE
COST OF RARP
WILL
DECREASED!!!!!

40. AN EXPERT SURGEON IN EITHERTECHNIQUE HAVE OUTSTANDING OUTCOMES,
AFTER MORETHAN 2000 CASES
DOES AN AVARAGE SURGEON HAVE BETTER OUTCOMES WITH A ROBOT
THAN HE WOULD WITH AN OPEN APPROACH?

41. NOW WE DISCUSS WHICH TECNIQUE IS THE BEST FOR
FUNCTIONALAND ONCOLOGICAL OUTCOMES???
‘’… it should be obvious that ‘ what is better open,
robotic or pure laparoscopic?' is meaningless outside the
context of the learning curve…..

42. “…..but it helps surgeons to further improve
their outcomes and ultimately shorten the
learning curve for surgeons in training…..”

43. CONCLUSION
§ RARP is currently the most common approach to radical
prostatectomy in US; it will probably will become the most
common approach also in the rest of the world in the near future
§ RARP offers better functional outcomes when compared to pure
LRP
§ A systematic review of available evidence shows that RARP
offers better functional and perioperative outcomes and
equivent cancer control when compared to RRP
§ There are lack of RCTs comparing RARP and LRP in the literature

44. § “It is not the strongest of the species that
survives, nor the most intelligent that
survives. It is the one that is the most
adaptable to change…”

45. THANK YOU !!!!