Radical Prostatectomy: Open versus Laparoscopic Surgery

What are we measuring and why?

This indicator measures the percentage of radical prostatectomies (RP) by type of surgical approach by province in 2013-2014. RP can be performed using an open or a laparoscopic approach.

• Radical prostatectomy is performed using either an open approach (the surgeon makes a cut in the abdominal or perineal area to reach the prostate gland) or a laparoscopic approach (the gland is removed via several smaller incisions using specialized surgical instruments and guided by a specialized camera).
• The laparoscopic approach is a more technically complex procedure to perform but less invasive for the patient. Some procedures are robotically-assisted (using a Da Vinci robot). This procedure is known as robotic-assisted laparoscopic prostatectomy (RALP). Such robotic assistance gives the surgeon a high-definition, three-dimensional view of the surgical area, providing better magnification and improved control.^{1, 2} However, RALP remains controversial due to the lack of strong evidence that it provides better cancer control compared to the less costly open radical prostatectomy approach.

What are the results?

• There was much variation across provinces in the type of surgical approach used (Figure 4.9). In Saskatchewan and Alberta, most RPs were done using a laparoscopic approach, while in British Columbia, Manitoba, Ontario, Quebec and New Brunswick, most RPs were performed using an open approach. In Prince Edward Island, Nova Scotia and Newfoundland and Labrador, all RPs were done using an open approach.
• There were also marked differences in the type of laparoscopic technique used (Figure 4.9). Among those provinces that did laparoscopic RPs, the reported use of robotic technology varied. Almost all laparoscopic RPs done in Alberta were robotic-assisted, while use of this technique varied in the other provinces.
• The number of RPs performed by provinces during the period under study ranged from a low of 17 surgeries in Prince Edward Island to 2,418 surgeries in Ontario.

What do the results mean?

• It is clear that the technique used for RP depends on the province in which the surgery is done. The variation shown here may be explained by differences in system resources, as well as by surgeon and patient preferences.
• In Canada, it appears that there is still uncertainty regarding the need for laparoscopic rather than open RP procedure. While there are no published studies on Canadian surgeon preferences related to RP, a survey of 56 Canadian urology residents attending a training course in 2010 revealed that most did not regard laparoscopic RP as the gold standard approach; almost half of these residents were unsure about the future of robotic-assisted laparoscopy.³ One explanation could be the evidence that the rate of complications from open RP—when performed by an experienced surgeon—is relatively low.⁴
• RALP is associated with high capital and operating costs. On a per patient basis, a systematic review and meta-analysis found that RALP cost an average of $3,860 more per patient than open surgery, and $4,625 more per patient than non-RALP laparoscopic surgery.⁵ Among the provinces that offer laparoscopic RP, patients from provinces in which robotic-assisted technology is covered by their provincial health insurance may be more likely to undergo RALP. In fact, from 2013-2014, the province with the highest use of RALP was Alberta, where RP was covered regardless of surgical approach. On the other hand, in British Columbia, robotic-assisted RP was not covered; use of this approach was found to be low, despite the availability of the technology.
• The decision by a hospital or a province to use surgical robotic technology has system cost implications, which likely influenced the provincial results shown here. Purchasing the robot has a high initial capital cost and annual maintenance costs. The cost-effectiveness of the Da Vinci robot depends on having a high volume of surgeries; results reported here show that many provinces had fewer than 200 surgeries per year. And those numbers may stabilize or decrease as the recommendation for active surveillance among men with low-risk prostate cancer becomes more widespread.

References

1. Patel VR, Sivaraman A. Current status of robot-assisted radical prostatectomy: progress is inevitable. Oncology. 2012 Jul;26(7):616-19, 22.
2. Tholomier C, Bienz M, Hueber PA, Trinh QD, Hakim AE, Alhathal N, et al. Oncological and functional outcomes of 722 robot-assisted radical prostatectomy (RARP) cases: The largest Canadian 5-year experience. Can Urol Assoc J. 2014 May;8(5-6):195-201.
3. Preston MA, Blew BD, Breau RH, Beiko D, Oake SJ, Watterson JD. Survey of senior resident training in urologic laparoscopy, robotics and endourology surgery in Canada. Can Urol Assoc J. 2010 Feb;4(1):42-6.
4. Ficarra V, Novara G, Artibani W, Cestari A, Galfano A, Graefen M, et al. Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies. Eur Urol. 2009 May;55(5):1037-63.
5. Ho C, Tsakonas E, Tran K, Cimon K, Severn M, Mierzwinski-Urban MC, et al. Robot-Assisted Surgery Compared with Open Surgery and Laparoscopic Surgery: Clinical Effectiveness and Economic Analyses. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2012. 298 p.