Trends in immediate perioperative morbidity and delay in discharge after open and minimally invasive radical prostatectomy (RP): a 20‐year institutional experience

Abstract

The present very interesting article reflects on two decades of radical prostatectomy (RP) in perhaps historically the most influential centre in the world for this surgery 1. From the setting of a single high-volume prostatectomy centre (>18 000 cases under review), it offers a contemporary and relevant ‘gold standard’ with regard to the current hospitalisation pathways for men undergoing this surgery. Furthermore, the article enjoyably traces the pathway of change over two decades, culminating in an alluring comparison of open with minimally invasive RP in the modern era. While Pierorazio et al. admit that length of stay in hospital (LOS) as a pure outcome measure may not be able to be fairly compared between institutions (certainly when international, cultural and financial factors are included), the authors make valid observations about change over time and comparison of subsets within their analysis. All urologists around the world are probably aware that patients who have undergone RP now spend a considerably shorter time in hospital than at the start of this series. The experience reported in this article shows clearly that the achievable short-term morbidity borders on negligible for the vast majority of men undergoing surgery in the high-volume setting. Importantly, it must be remembered that long-term outcomes cannot be touched upon in an analysis such as this, and indeed there is no strong reason to believe that LOS has any correlation with long term oncological or functional outcomes. Perhaps what I found most interesting in this article was the comparison between open and minimally invasive prostatectomy. In the absence of good evidence regarding oncological or long-term functional differences, there has been much lauding of the benefits of robot-assisted prostatectomy in terms of an enhanced early recovery, both in terms of comparison with the open and laparoscopic alternatives 2, 3. Pierorazio et al. beg to differ, as they report an array of early complications, including bleeding, none of which show in favour of robot-assisted surgery. In fact, three defined complications (transfusion rate, P = 0.01; operative urine leak, P = 0.009; and postoperative ileus, P < 0.001) achieved statistical significance in favour of open surgery. Of course it is not a fair comparison as learning curves are not factored in, and it is of course possible (and perhaps even likely) that future justification of the robot will be provided from other centres with less wealth of expertise in the open technique; however, I suspect the business managers for many hospitals who have already invested in robotic technology will not relish the lack of demonstrable difference in LOS in this sizeable and relevant series. Furthermore, the statistically significant findings in favour of open surgery will no doubt be music to the ears of those who have continued to pursue open surgery and thereby resist the considerable temptations posed by the overt attraction of the robotic surgical technique. In unpublished correspondence about this article, the authors state that in the last 30 years >50 surgeons have performed a prostatectomy at this centre and they claim there is no detectable difference based on a specific surgeon. As always, this powerful American institution continues to offer observations on prostatectomy surgery that demand considerable attention. None declared