Editorial Comment to Stratified analysis of 800 Asian patients after robot-assisted radical prostatectomy with a median 64 months of follow up.

Abstract

As of the 21st century, robot-assisted radical prostatectomy (RARP) has been rapidly replacing open radical prostatectomy in developed countries. Abdel Raheem et al. reported oncological outcomes of 800 RARP cases with a median follow up of 64 months at a single Korean high-volume center.1 This study, derived from the largest RARP series with the longest follow-up period in Asia, is considered as one of the benchmark studies for oncological outcomes of RARP. The authors reported positive surgical margin (PSM) rates of 36.6% for the overall cohort, 17.7% for pT2 disease and 66.1% for pT3/4 disease. These PSM rates appear higher compared with previously reported series of radical prostatectomy including RARP (see Tables 4 and 5 in Abdel Raheem et al.1). The authors attribute higher PSM rates to higher proportions of patients with high Gleason (≥8) and D'Amico high-risk disease. Another reason for the higher PSM rates might be a higher proportion of nerve-sparing procedures (bilateral and unilateral nerve sparing in 63.7% and 18.3%, respectively) in the Korean series. Indeed, the authors reported that the most common PSM site was a lateral site (41.5%) followed by the apex (19.3%), although the apex is the most common PSM site in most radical prostatectomy series.2 As a contemporary systematic review showed, PSM does not necessarily increase the risk for development of metastasis or cancer-specific mortality.3 Nevertheless, PSM absolutely increases the risk of biochemical recurrence, and thus increases the demand of additional therapy including salvage radiotherapy and androgen deprivation, eventually straining the patients in terms of quality of life and medical costs.3 We, urological surgeons, should make persistent efforts to reduce PSM by improving the accuracy of preoperative risk assessment, improving surgical techniques, clarifying the role of frozen section and so on. Although no large-scale randomized controlled trial has shown its superiority to open radical prostatectomy, observational large population-based cohort studies show that RARP is associated with decreased blood loss and shorter hospital stay.4 However, long-term oncological and functional outcomes appear equivalent between the two procedures.5 The biggest issue regarding RARP is the large expenditure associated with disposable instruments predetermined by the manufacturer and annual maintenance of the robot. From the viewpoint of cost-effectiveness, these extra expenditures are interpreted to be paid for improving the short-term postoperative recovery but not the long-term oncological and functional outcomes. Whether these additional costs are socioeconomically reasonable in relation to the benefits provided by using the technology must be seriously assessed. None declared.