Which is better: open, laparoscopic, or robotic?

Another question: Does it matter?

Abstract & Commentary

By Frank W. Ling, MD, Clinical Professor, Departments of Obstetrics and Gynecology, Vanderbilt University School of Medicine, and Meharry Medical College, Nashville, TN, is Associate Editor for OB/GYN Clinical Alert, also published by Same-Day Surgery's publisher AHC Media.

Synopsis: This commentary challenges the urologic medical community to get past its "collective obsession with technology" and try to figure out why some surgeons have better outcomes, irrespective of the surgical approach taken.

Source: Vickers AJ. Great meaningless questions in urology: Which is better, open, laparoscopic, or robotic radical prostatectomy? Urology 2011;77:1025-1026.

The author informs us that the winner of the 2010 Tour de France was Alberto Contador, riding a Specialized SL3 racing bike. The U.S. rider Chris Horner finished 12 minutes behind riding a Trek, Madone. The best rookie finisher, Daniel Loyd, rode a Cervelo S3, and finished more than four hours behind the leaders. The author opines that "no self-respecting urologist" would use this information to claim that the Trek is a faster bike than the Cervelo or that Loyd would have won the race had he ridden a Specialized.

The reader also is told that surgical complication rates among high-volume surgeons who perform radical prostatectomies range from < 5% to > 50%. He also cites in one study that functional outcomes differ by up to 40% with regard to erectile and urinary function. The author points out that the difference between surgeons and their performance dwarfs the inherent differences of the surgical approach. As in the Tour de France, where the focus should not be the bicycle, in urology, the focus should not be on the surgical approach when performing radical prostatectomies.

Comparative publications analyzing complications and success rates are unable to control for pathologists' skills, patient population characteristics, and/or definitions of "success" or "complication." He compares this to asking the three cyclists to go on a 100-mile ride, with the best bike being the one ridden by the first person to get to the finish line, irrespective of the route taken, weather, etc.

The analogy is carried further: The cycle judged to be the best cannot be the one that finishes first because of variables such as the experience of the rider. As with cycling, a skilled, experienced surgeon is different from a novice surgeon, and both are different from the "average" surgeon. In fact, the term "average" raises the statistical issue of results. Vickers points out that depending on how the results are collected and reported, surgical outcomes numerically might look similar, but, as far as patient outcome is concerned, might be very different.

The author concludes that Lance Armstrong said, "It's not about the bike." He asserts that some doctors seem to be saying, "No, but it is all about the robot." Studying how to get the best results should be the goal, but this will require "far greater investment of time, resources, and scientific ingenuity than retrospective analyses of surgical databases."

Commentary

Admittedly, you probably don't get this journal. Even if you did, you probably wouldn't think of this article (it's an opinion piece, not a research study) as something worth reading or reviewing since it's about radical prostatectomy. When's the last time any of us even discussed the prostate with our patients? So why are you being asked to read about it? It's because if you squint your eyes a little, and allow the words to morph a bit, suddenly you're seeing someone discussing open, laparoscopic, or robotic hysterectomy, oophorectomy, lysis of adhesions, incontinence surgery, prolapse surgery, cancer surgery, etc.

We're being challenged by the author, and he doesn't even know he's doing it! He suggests that urologists as a group get past its "obsession with technology" and try to identify factors that lead to some surgeons getting better results than others, irrespective of the surgical approach used.

Let's relate what the urologists are facing and compare the issues with other fields.

First, I like that the author is a PhD in the Department of Epidemiology and Biostatistics at Memorial Sloan-Kettering Cancer Center. He isn't someone who does any of these procedures. In essence, there is less chance that he has a bias regarding one procedure or another. He also is unlikely to have a conflict of interest relating to an instrument company or another product being used during the surgery. We should be watchful for who is writing the articles that we read, particularly when it's involving surgical approaches and technique. Does someone have an ax to grind?

Second, I love the analogy. It makes sense and gives us a fresh perspective on how we look at surgical literature. Their issues of radical prostatectomy are similar to ours related to benign, malignant, and urogynecologic procedures. Unless you actually believe that one of the "cycles" is better than others, you can see how we gynecologic surgeons need to focus on our patients and how to get them the best results.

Third, what defines "success?" In the case of radical prostatectomy, the urologists are trying to avoid recurrence and maintain intact sexual and urinary function. As our gynecologic oncologists look at endometrial and ovarian cancers, they similarly are looking at recurrence, but also at areas in which benign surgeons focus a lot of attention. When we perform benign surgery, is our goal a shortened convalescence? Shorter anesthesia time? Greater patient satisfaction? Improved cosmesis? Fewer complications? Greater physician satisfaction? Can our urogynecologists define success for sacral colpopexy as any case that doesn't require a laparotomy? What about a five-year success rate? What would the world class cyclists define as "successful?"

Fourth, aren't there factors in the equation beyond just the surgeon's decision-making and skills? What about the patient who has done her "research" and knows the surgical approach that she feels is appropriate for her case? What about the role of the hospital and its administration who might be publicly extolling the virtues of a newly acquired (and very expensive) piece of equipment? How long a learning curve for new technology is acceptable? Is it the same for everyone? For a surgeon to gain needed experience, how long is it reasonable for patients who might not need the new technology to be treated with it?

Finally, you might notice that the cyclist wears a jersey boldly displaying the sponsor's name. I don't think any of us has seen any surgeons with similar commercialized garb entering the operating room (I know I haven't ... have you?). Whether the influence of industry on us is subtle or overt, each of us is responsible for being as candid as possible with our patients regarding all surgical approach options … including no surgery at all. Informed consent requires that of us. We should expect that of ourselves. We should expect that of each other. Until definitive information is available (and, honestly, we might never get it), overzealous rushing to a new technology is probably no worse than an unswerving aversion to it.

I'm taking us far beyond our usual comfort zone by literally stealing the thrust of this thoughtful piece of writing in the urology literature and asking us to do the same: Let's get past our fascination with the latest technology and try to determine how to best serve our patients by getting the best outcomes. Sometimes newer is, indeed, better. Sometimes, it isn't.