The diffusion of minimally invasive radical prostatectomy in the United States: a case study of the introduction of new surgical devices

• Published in: Prostate cancer and prostatic diseases Vol. 18; no. 1; pp. 75 - 80
• Main Authors: Anderson, C B, Elkin, E B, Atoria, C L, Eastham, J A, Scardino, P T, Touijer, K
• Format: Journal Article
• Language: English
• Published: London Nature Publishing Group UK 01.03.2015; Nature Publishing Group
• Subjects: 692/308/409; Aged; Aged, 80 and over; Analysis; Biomedical and Life Sciences; Biomedicine; Bladder; Cancer; Cancer Research; Cancer surgery; Care and treatment; Case studies; Comparative analysis; Confidence intervals; Demographics; Diffusion; Endpoint Determination; Epidemiology; Erectile dysfunction; Erectile Dysfunction - epidemiology; Erectile Dysfunction - pathology; Government programs; Health hazards; Humans; Laparoscopy; Male; Methods; Minimally invasive surgery; original-article; Patient outcomes; Patients; Postoperative Complications; Prostate cancer; Prostatectomy; Prostatectomy - adverse effects; Prostatic Neoplasms - epidemiology; Prostatic Neoplasms - pathology; Prostatic Neoplasms - surgery; Regression analysis; Robotic surgery; Statistical analysis; Surgeons; Surgery; Treatment Outcome; United States; Urological surgery; United States; United States > US
• ISSN: 1365-7852; 1476-5608
• DOI: 10.1038/pcan.2014.49

Background: The diffusion of minimally invasive radical prostatectomy (MIRP) in the United States may have led to adverse patient outcomes due to rapid surgeon adoption and collective inexperience. We hypothesized that throughout the early period of minimally invasive surgery, MIRP patients had inferior outcomes as compared with those who had open radical prostatectomy (ORP). Methods: We used the Surveillance, Epidemiology and End Results-Medicare dataset and identified men who had ORP and MIRP for prostate cancer from 2003–2009. Study endpoints were receipt of subsequent cancer treatment, and evidence of postoperative voiding dysfunction, erectile dysfunction (ED) and bladder outlet obstruction. We used proportional hazards regression to estimate the impact of surgical approach on each endpoint, and included an interaction term to test for modification of the effect of surgical approach by year of surgery. Results: ORP ( n =5362) and MIRP ( n =1852) patients differed in their clinical and demographic characteristics. Controlling for patient characteristics and surgeon volume, there was no difference in subsequent cancer treatments (hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.76–1.05), although MIRP was associated with a higher risk of voiding dysfunction (HR 1.31, 95% CI 1.20–1.43) and ED (HR 1.43, 95% CI 1.31–1.56), but a lower risk of bladder outlet obstruction (HR 0.86, 95% CI 0.75–0.97). There was no interaction between approach and year for any outcome. When stratifying the analysis by year, MIRP consistently had higher rates of ED and voiding dysfunction with no substantial improvement over time. Conclusions: MIRP patients had adverse urinary and sexual outcomes throughout the diffusion of minimally invasive surgery. This may have been a result of the rapid adoption of robotic surgery with inadequate surgeon preparedness.