European Urology

Prostate Cancer

In this paper, Bolenz and coworkers present a detailed cost analysis of the various surgical approaches for radical prostatectomy (RP) [1]. The message of this study is clear: Robotic-assisted RP (RALP) is by far the most expensive surgical approach “on the market.” The authors calculated additional costs of US$2315 for each case done with the robot, but this calculation still does not reflect “real life urology,” as the purchase costs (US$1.5–1.75 million) and the maintenance fees (US$112 000–150 000 per year) were not included in this calculation. Bolenz et al stated that including these costs would add another US$2698 per case. Even though cost analyses differ from hospital to hospital and between health systems, the fact that RALP is extraordinarily more expensive than open RP will not change, regardless of how the calculations are done.

Are these extra costs justified? Maybe yes, if an advantage for RALP over other approaches were documented, but this is not currently the case. In a collaborative review article by Ficarra et al comparing results of the various approaches, it was surgical volume that mattered, and RALP was not superior to conventional laparoscopy or open RP [2]. In a population-based study (which reflects daily routine much better than the results of extra-high-volume surgeons), Hu et al [3] showed that the likelihood of a salvage therapy due to cancer recurrence increased when minimally invasive approaches were used. In other words, in this large-scale study, cancer-control rates were compromised when the robot was used.

What about functional outcome? Mulhall and coworkers showed that many Web sites advertise RALP with the promise of better potency and urinary continence rates (usually without having data) [4]. A recently published JAMA paper, however, reported that patients who underwent RALP had worse functional outcome compared to open RP [5]. Furthermore, Schroeck and coworkers showed that the likelihood of regretting a treatment decision was higher when patients underwent RALP compared to open RP [6].

Robotic surgery is a fascinating approach, and we use a robot in our hospital with results that are comparable to open surgery; however, a growing body of evidence shows that the results of RALP are not superior to other surgical approaches. It is certainly up to urologists to give the patient a realistic view of what he can expect when prostate surgery is performed. Furthermore—and this is what the paper from Bolenz et al emphasizes—we must be aware of our responsibility to society and to our patients to deliver the best possible care at justifiable cost.