Platinum Priority – Review – Prostate CancerEditorial by Quoc-Dien Trinh, Khurshid R. Ghani and Mani Menon on pp. 16–18 of this issuePositive Surgical Margin and Perioperative Complication Rates of Primary Surgical Treatments for Prostate Cancer: A Systematic Review and Meta-Analysis Comparing Retropubic, Laparoscopic, and Robotic Prostatectomy☆
Introduction
Prostate cancer is the most common nondermatologic cancer in Western men [1]. More than 90% of cases are diagnosed when the disease is organ confined and potentially curable by radical prostatectomy (RP) [2]. This was traditionally performed by open retropubic RP (ORP), although minimally invasive surgery (MIS; conventional laparoscopic and robot-assisted laparoscopic RP, LRP and RALP, respectively) has become popular recently. There is substantial evidence of lower bleeding rates for MIS [3], [4], [5], [6] but no good evidence of an overall benefit for one modality over another, and it is uncertain whether MIS, especially robotics, justifies its increased costs and training requirements [7].
The most important outcomes to assess when comparing ORP, LRP, and RALP are cancer control, complications, urinary continence, and sexual potency. Unfortunately, biochemical recurrences, metastases, and survival statistics, as well as continence and potency, require long-term follow-up to assess and can be subject to significant reporting and interpretational biases. Positive surgical margin (PSM) and perioperative complication rates thus remain early outcome measures of importance in comparing surgical modalities. Accrual to randomized controlled studies (RCTs) has been notoriously poor [3] with only one such trial reported comparing ORP and LRP [8]. In addition, of the thousands of papers published on the surgical treatment of prostate cancer with radical prostatectomy, there have been relatively few comparative studies. A recent review found 37 comparative studies: 23 ORP and LRP, 10 ORP and RALP, and 4 LRP and RALP [9]. Meta-analyses based solely on comparative articles [9], [10], [11], although informative, do not represent most of the literature available in this area, which are single cohort studies. Also, these reports do not adequately adjust for differences between surgical cohorts. Therefore we performed a meta-analysis of all of the available peer-reviewed observational studies, controlling for differences between ORP, LRP, and RALP cohorts with propensity score adjustments [12], [13], a technique used by other authors [14], [15], [16], [17].
Section snippets
Evidence acquisition
The methods used in reporting this meta-analysis follow those outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [18] (see Appendix 1, available online). The study design, search strategy, data abstraction, and excluded studies (with justification) are detailed in Table 1, Figure 1 [19], [20], [21], [22], Appendix 2 (citations for excluded studies, available online), and Figure 2 (early experience analysis). PubMed and Scopus (2002–2010,
Evidence synthesis
There were differences in the rate of publications across the three cohorts over time (p < 0.0001). Specifically, a statistically significantly greater proportion of ORP and LRP cohorts came from early publications (2002–2004) compared with RALP (12.5% and 18.1% vs 1.2%; ORP vs LRP, p = 0.18; ORP vs RALP, p < 0.0001; LRP vs RALP, p < 0.0001) (Table 2a, Table 2b). There were differences in preoperative PSA between surgical cohorts, with the RALP cohort having a significantly lower average preoperative
Conclusions
This study represents the largest compilation of radical prostatectomy patients to date, and it serves as a systematic review and meta-analysis of this vast body of literature. However, due to the lack of RCTs, differences in patient characteristics between surgical cohorts might explain differences in outcomes between treatment groups. These differences cannot be fully corrected with statistical methods. Additionally, unknown differences in certain attributes of the patients and physicians
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