As Miller described, it is how we look at things, including change, that determines our destination. Change is not the real issue, but rather how we evaluate and respond to it.
I write this 2 months after our San Diego AUA meeting. Wearing first my program director and then the “laparoscopy and robotics take home messenger” hats, I spent the full week at the AUA this year. And it was only the second time, out of a score of meetings, I felt palpable excitement that something truly unexpected had happened.
The first time, Guillonneau and Vallancien shocked us with their Montsouris technique. They had one-upped the Americans by making laparoscopic radical prostatectomy routine and reproducible. Now, 15 years later, we realize it wasn’t quite so easy, even after we made LRP robotic.
Importantly, how we look at all this technology has changed. A dozen years ago, Dr. Louis Kavoussi stated “For LRP to be an acceptable and reasonable alternative, the oncologic results must be equivalent to the results of RRP, and significant advantages in morbidity (hospital stay, pain, incontinence, impotence) must be attained; otherwise, the steep learning curve and the additional expense of the procedure make it difficult to justify as an alternative therapeutic modality. Besides a reduction in the transfusion rate, no other significant advantages of LRP over radical prostatectomy have been demonstrated definitively to date. As a result, the role of LRP in the management of prostate cancer remains investigational, and patients should be informed appropriately. The oncologic results and low morbidity of nerve- sparing RRP set a high standard for a laparoscopic technique to equal.”1 More recently, other robotic experts have told me they disagree. The outcomes need only be better in any way or potentially even equivalent to justify continuation.
Have we seen the significant advantages Dr. Kavoussi deemed necessary to justify? We agree to disagree. Has our failing to define at the outset what comprises “significant advantages” contributed to the laparoscopic and then robotic prostatectomy adoption? Would things have played out differently if we had?
On July 10th, the U.S. Department of Health & Human Services Agency for Healthcare Research and Quality released its research review draft of “Comparative Effectiveness of Therapies for Clinically Localized Prostate Cancer: An Update of a 2008 Comparative Effectiveness Review.”2 This report reminds me what I knew but now understand more fully after working the past year on an AUA Leadership program group project; it is near impossible to compare treatment effectiveness or develop a value-based pay-for-performance system without level one evidence. However, it is not just treatment efficacy that is being increasingly scrutinized, cost and now trainee competence documentation (Next Accreditation System, RRC required robotic console logs) have joined center stage.
Yes, Vincent Laudone surprised me with his Monday plenary session late-breaking cystectomy data. Sloan- Kettering had accomplished the somehow too difficult, randomizing 120 patients to open versus robotic cystectomy (with extracorporeal ileal conduit diversion). Laudone hammered home their interim results at high noon: “No difference”! I exhaled wondering “Will we seriously consider this data?… or has Drs. Gill and Desai’s Intracorporeal Orthotopic Neobladder live session Saturday surgery already set the cystectomy train whistle a-blowin’?”
I hustled to talks on robotic haptic sensation, LESS and near infrared fluorescence imaging after attending my first Laparoscopic, Robotic and New Surgical Technology committee meeting. Then it came to me. Shouldn’t our experts gather not only to determine best practice policies but also to accurately define agreed-upon criteria that new technology and treatments must surpass in order to supplant current standards of care? Until we do, we will be unable to respond effectively to the Laudones of the world… and shape our optimal destiny.
James A. Brown, MD
Department of Urology, University of Iowa
Iowa City, IA USA
1. Cadeddu JA, Kavoussi LR. Laparoscopic radical prostatectomy: is it feasible and reasonable? Urol Clin North Am 2001;28(3):655-661.
2. Agency for Health Care Research and Quality. Comparative effectiveness of therapies for clinically localized prostate cancer: an update
ageaction=displayProduct&productID=1586&ECem=130710. Accessed July 17, 2013.
© The Canadian Journal of Urology™; 20(4); August 2013