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Meaningful Comparison of Robotics Versus Laparoscopy for Nephron-sparing Surgery: No Contest or No Dice?
EUROPEAN UROLOGY 62 (2012) 1037–1039
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial and Reply from Authors Referring to the article published on pp. 1023–1033 of this issue
Meaningful Comparison of Robotics Versus Laparoscopy for Nephron-sparing Surgery: No Contest or No Dice? Anthony T. Corcoran *, Alexander Kutikov, Robert G. Uzzo Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
Aboumarzouk et al. performed a systematic review and meta-analysis of nonrandomized retrospective studies comparing the outcomes of robotic partial nephrectomy (RPN) and conventional laparoscopic partial nephrectomy (LPN) [1]. Although the study is significantly limited by the amount and the quality of available data, the authors offer a preliminary comparative assessment of the two techniques. The take-home message is that RPN is a feasible and safe alternative to LPN, potentially affording patients shorter ischemia times. The authors compared 717 patients who underwent RPN (n = 313) or LPN (n = 404) across seven studies [1]. Several issues must be considered when contextualizing this manuscript. Only three of the selected studies [2–4] included >33 robotic cases. Furthermore, the study with the highest number of RPN patients (n = 108) was a multisurgeon cohort (five surgeons) [2]. Thus, as the authors acknowledge, these data likely captured surgeon experience at the steepest point of the learning curve for RPN. In comparison, the LPN data reflected experiences of single surgeons, with four of seven studies comprising >50 patients. As such, any comparison of the current literature is greatly limited by the reality that RPN and LPN series report experiences at drastically different points on the respective learning curves. Nevertheless, with these limitations, the authors arguably crystallize an important message: RPN, even early in the learning curve, appears to be largely equivalent to LPN performed by seasoned surgeons. As with all meta-analysis and pooled studies, differences in surgical techniques (eg, zero ischemia, early unclamping, full-on clamp renorrhaphy) as well as in data acquisition and reporting can compromise the internal validity of results. Not all of the reviewed studies reported complica-
tion rates, and only half of those reported utilized standardized means of reporting complications (Clavien classification). Despite similar tumor size and location between RPN and LPN pooled cohorts when reported, an objective comparison of tumor anatomic complexity utilizing established metrics (RENAL nephrometry, PADUA score, or C-index) was not reported in this meta-analysis. Such an approach may have identified selection bias with more complex tumors attempted robotically versus laparoscopically or vice versa. Despite no specific cost comparisons of RPN and LPN in the manuscripts included for the meta-analysis [1], the authors note that RPN has an estimated additional cost of $1600 per case [5]. The authors present data that may justify that cost by reducing warm ischemia time early in the learning curve of surgeons performing RPN. Whether this translates to improved renal functional outcomes or more widespread utilization of minimally invasive nephron-sparing surgery (NSS) remains to be seen. As resource utilization within health care systems becomes an increasing priority for policymakers, we, as urologic care providers, must bring data to the table that justify higher costs for one procedure versus another. Although robotics for NSS may shorten the learning curve and improve reproducibility among surgeons who are less experienced with minimally invasive surgery, the meta-analysis by Aboumarzouk et al. [1] underscores the need for more robust data to justify the additional costs of RPN. Such data are starting to emerge as renal masses with high anatomic complexity, which used to be resected using the open approach, are now being treated with RPN [6]. Conflicts of interest: The authors have nothing to disclose.
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2012.06.038 * Corresponding author. Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA 19111, USA. Tel. +1 215 728 6900; Fax: +1 215 214 3939. E-mail address: [email protected] (A.T. Corcoran). 0302-2838/$ – see back matter # 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.
1038
EUROPEAN UROLOGY 62 (2012) 1037–1039
References
[4] Pierorazio PM, Patel HD, Feng T, Yohannan J, Hyams ES, Allaf ME. Robotic-assisted versus traditional laparoscopic partial nephrec-
[1] Aboumarzouk OM, Stein RJ, Eyraud R, et al. Robotic versus laparoscopic partial nephrectomy: a systematic review and meta-analysis. Eur Urol 2012;62:1023–33. [2] Ellison JS, Montgomery JS, Wolf Jr JS, Hafez KS, Miller DC, Weizer AZ. A matched comparison of perioperative outcomes of a single laparoscopic surgeon versus a multisurgeon robot-assisted cohort for partial nephrectomy. J Urol 2012;188:45–50. [3] Haber GP, White WM, Crouzet S, et al. Robotic versus laparoscopic
tomy: comparison of outcomes and evaluation of learning curve. Urology 2011;78:813–9. [5] Yu HY, Hevelone ND, Lipsitz SR, Kowalczyk KJ, Hu JC. Use, costs and comparative effectiveness of robotic assisted, laparoscopic and open urological surgery. J Urol 2012;187:1392–8. [6] Simhan J, Smaldone MC, Tsai KJ, et al. Perioperative outcomes of robotic and open partial nephrectomy for moderately and highly complex renal lesions. J Urol 2012;187:2000–4.
partial nephrectomy: single-surgeon matched cohort study of 150 patients. Urology 2010;76:754–8.
http://dx.doi.org/10.1016/j.eururo.2012.07.038
Platinum Priority Reply from Authors re: Alexandre Mottrie, Marco Borghesi, Vincenzo Ficarra. Is Traditional Laparoscopy the Real Competitor of Robot-assisted Partial Nephrectomy? Eur Urol 2012;62:1034–6 and Reply from Authors re: Anthony T. Corcoran, Alexander Kutikov, Robert G. Uzzo. Meaningful Comparison of Robotics Versus Laparoscopy for Nephron-sparing Surgery: No Contest or No Dice? Eur Urol 2012;62:1037–8 Minimally Invasive Partial Nephrectomy: Is It Early for a Comparison to be Made? Omar M. Aboumarzouk a,b,*, Jihad H. Kaouk c, Remi Eyraud c, Georges-Pascal Haber c, Piotr L. Chlosta d,e, Bhaskar K. Somani f, Robert J. Stein c a
Wales Deanery, Urology Department, Cardiff, Wales, UK; b Islamic University of Gaza, College of Medicine, Gaza, Palestine; c Cleveland Clinic, Glickman Urologic and Kidney Institute, Cleveland, OH, USA; d Department of Urology, Institute of Oncology, Jan Kochanowski University, Kielce, Poland; e Department of Urology, The Medical Centre of Postgraduate Education, Warsaw, Poland; f University Hospitals Southampton NHS Trust, Southampton, Hampshire, UK
We would like to thank Corcoran et al. [1] and Mottrie et al. [2] for their insightful comments regarding our manuscript [3]. Our study was conducted using Cochrane guidelines for systematic reviews as stated in the Cochrane Handbook [4,5]. Furthermore, our review was checked against the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, with all points taken into consideration [6]. We conducted the review in an unbiased and impartial manner with a view to examine what the current literature contains regarding the comparison of the two procedures. We agree with Corcoran et al. [1] about the lack of use of renal nephrometry, PADUA score, or C-index to assess tumour anatomic complexity. Unfortunately, this is an omission of the included studies rather than of the systematic review, and we agree that use of nephrometry would likely
DOIs of original articles: http://dx.doi.org/10.1016/j.eururo.2012.06.038, http://dx.doi.org/10.1016/j.eururo.2012.07.038, http://dx.doi.org/10.1016/j.eururo.2012.07.039 * Corresponding author. Wales Deanery, Urology Department, Cardiff, Wales, UK. Tel. +44 7886 885677. E-mail address: [email protected] (O.M. Aboumarzouk).
allow a more standardised and meaningful comparison. Furthermore, the authors reference their own work on complex renal lesions [7]. We agree that these complex tumours are now being safely and efficiently treated robotically and there likely is an advantage to the robotic approach, nevertheless more data are certainly needed [3,7]. We also agree with the comment of Mottrie et al. [2] that the data were from small observational studies, as was listed among our limitations. This was a systematically performed meta-analysis that is limited by the available literature. Indeed, the small number of patients in these studies and learning curve data can skew the results, due to the initial learning curve experience [1]. This only serves to highlight the need for larger comparisons performed in a rigorous manner and preferably using level 1 evidence. Superiority of any procedure over another should ideally be based on strong evidence and not merely just be assumed. Regarding the authors’ comment that the data in the forest plots do not represent the most recent literature [2], we note that although it is true that more recent studies report better outcomes, these studies did not compare results to a laparoscopic group of patients. Our objectives were clear in the methodology: We aimed to include only those studies comparing the two procedures and hence recommended that further larger studies are needed to compare the two groups after the initial learning curve has been surpassed [3]. Regarding the exclusion of studies from the metaanalysis, several attempts were made to obtain the data needed to conduct a pooled analysis. We received replies from some of the corresponding authors and included their data in a pooled meta-analysis [3]. However, the study data of authors who did not respond could not be included in a pooled meta-analysis, which is in line with Cochrane guidelines [4,5]. Nonetheless, their data were included in the systematic review and discussed for comparison [3]. Missing standard deviations from studies can potentially be imputed from a similar study; however, imputation techniques involve making assumptions, and it is best to avoid using them [4,5]. We agree with the authors that Mullins et al. [8] should have been included; however, the latest date of search, as stated in the Methods section, was February 6, 2012, and the paper by Mullins et al. was accepted a month later, so it did
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial and Reply from Authors Referring to the article published on pp. 1023–1033 of this issue
Meaningful Comparison of Robotics Versus Laparoscopy for Nephron-sparing Surgery: No Contest or No Dice? Anthony T. Corcoran *, Alexander Kutikov, Robert G. Uzzo Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
Aboumarzouk et al. performed a systematic review and meta-analysis of nonrandomized retrospective studies comparing the outcomes of robotic partial nephrectomy (RPN) and conventional laparoscopic partial nephrectomy (LPN) [1]. Although the study is significantly limited by the amount and the quality of available data, the authors offer a preliminary comparative assessment of the two techniques. The take-home message is that RPN is a feasible and safe alternative to LPN, potentially affording patients shorter ischemia times. The authors compared 717 patients who underwent RPN (n = 313) or LPN (n = 404) across seven studies [1]. Several issues must be considered when contextualizing this manuscript. Only three of the selected studies [2–4] included >33 robotic cases. Furthermore, the study with the highest number of RPN patients (n = 108) was a multisurgeon cohort (five surgeons) [2]. Thus, as the authors acknowledge, these data likely captured surgeon experience at the steepest point of the learning curve for RPN. In comparison, the LPN data reflected experiences of single surgeons, with four of seven studies comprising >50 patients. As such, any comparison of the current literature is greatly limited by the reality that RPN and LPN series report experiences at drastically different points on the respective learning curves. Nevertheless, with these limitations, the authors arguably crystallize an important message: RPN, even early in the learning curve, appears to be largely equivalent to LPN performed by seasoned surgeons. As with all meta-analysis and pooled studies, differences in surgical techniques (eg, zero ischemia, early unclamping, full-on clamp renorrhaphy) as well as in data acquisition and reporting can compromise the internal validity of results. Not all of the reviewed studies reported complica-
tion rates, and only half of those reported utilized standardized means of reporting complications (Clavien classification). Despite similar tumor size and location between RPN and LPN pooled cohorts when reported, an objective comparison of tumor anatomic complexity utilizing established metrics (RENAL nephrometry, PADUA score, or C-index) was not reported in this meta-analysis. Such an approach may have identified selection bias with more complex tumors attempted robotically versus laparoscopically or vice versa. Despite no specific cost comparisons of RPN and LPN in the manuscripts included for the meta-analysis [1], the authors note that RPN has an estimated additional cost of $1600 per case [5]. The authors present data that may justify that cost by reducing warm ischemia time early in the learning curve of surgeons performing RPN. Whether this translates to improved renal functional outcomes or more widespread utilization of minimally invasive nephron-sparing surgery (NSS) remains to be seen. As resource utilization within health care systems becomes an increasing priority for policymakers, we, as urologic care providers, must bring data to the table that justify higher costs for one procedure versus another. Although robotics for NSS may shorten the learning curve and improve reproducibility among surgeons who are less experienced with minimally invasive surgery, the meta-analysis by Aboumarzouk et al. [1] underscores the need for more robust data to justify the additional costs of RPN. Such data are starting to emerge as renal masses with high anatomic complexity, which used to be resected using the open approach, are now being treated with RPN [6]. Conflicts of interest: The authors have nothing to disclose.
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2012.06.038 * Corresponding author. Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA 19111, USA. Tel. +1 215 728 6900; Fax: +1 215 214 3939. E-mail address: [email protected] (A.T. Corcoran). 0302-2838/$ – see back matter # 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.
1038
EUROPEAN UROLOGY 62 (2012) 1037–1039
References
[4] Pierorazio PM, Patel HD, Feng T, Yohannan J, Hyams ES, Allaf ME. Robotic-assisted versus traditional laparoscopic partial nephrec-
[1] Aboumarzouk OM, Stein RJ, Eyraud R, et al. Robotic versus laparoscopic partial nephrectomy: a systematic review and meta-analysis. Eur Urol 2012;62:1023–33. [2] Ellison JS, Montgomery JS, Wolf Jr JS, Hafez KS, Miller DC, Weizer AZ. A matched comparison of perioperative outcomes of a single laparoscopic surgeon versus a multisurgeon robot-assisted cohort for partial nephrectomy. J Urol 2012;188:45–50. [3] Haber GP, White WM, Crouzet S, et al. Robotic versus laparoscopic
tomy: comparison of outcomes and evaluation of learning curve. Urology 2011;78:813–9. [5] Yu HY, Hevelone ND, Lipsitz SR, Kowalczyk KJ, Hu JC. Use, costs and comparative effectiveness of robotic assisted, laparoscopic and open urological surgery. J Urol 2012;187:1392–8. [6] Simhan J, Smaldone MC, Tsai KJ, et al. Perioperative outcomes of robotic and open partial nephrectomy for moderately and highly complex renal lesions. J Urol 2012;187:2000–4.
partial nephrectomy: single-surgeon matched cohort study of 150 patients. Urology 2010;76:754–8.
http://dx.doi.org/10.1016/j.eururo.2012.07.038
Platinum Priority Reply from Authors re: Alexandre Mottrie, Marco Borghesi, Vincenzo Ficarra. Is Traditional Laparoscopy the Real Competitor of Robot-assisted Partial Nephrectomy? Eur Urol 2012;62:1034–6 and Reply from Authors re: Anthony T. Corcoran, Alexander Kutikov, Robert G. Uzzo. Meaningful Comparison of Robotics Versus Laparoscopy for Nephron-sparing Surgery: No Contest or No Dice? Eur Urol 2012;62:1037–8 Minimally Invasive Partial Nephrectomy: Is It Early for a Comparison to be Made? Omar M. Aboumarzouk a,b,*, Jihad H. Kaouk c, Remi Eyraud c, Georges-Pascal Haber c, Piotr L. Chlosta d,e, Bhaskar K. Somani f, Robert J. Stein c a
Wales Deanery, Urology Department, Cardiff, Wales, UK; b Islamic University of Gaza, College of Medicine, Gaza, Palestine; c Cleveland Clinic, Glickman Urologic and Kidney Institute, Cleveland, OH, USA; d Department of Urology, Institute of Oncology, Jan Kochanowski University, Kielce, Poland; e Department of Urology, The Medical Centre of Postgraduate Education, Warsaw, Poland; f University Hospitals Southampton NHS Trust, Southampton, Hampshire, UK
We would like to thank Corcoran et al. [1] and Mottrie et al. [2] for their insightful comments regarding our manuscript [3]. Our study was conducted using Cochrane guidelines for systematic reviews as stated in the Cochrane Handbook [4,5]. Furthermore, our review was checked against the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, with all points taken into consideration [6]. We conducted the review in an unbiased and impartial manner with a view to examine what the current literature contains regarding the comparison of the two procedures. We agree with Corcoran et al. [1] about the lack of use of renal nephrometry, PADUA score, or C-index to assess tumour anatomic complexity. Unfortunately, this is an omission of the included studies rather than of the systematic review, and we agree that use of nephrometry would likely
DOIs of original articles: http://dx.doi.org/10.1016/j.eururo.2012.06.038, http://dx.doi.org/10.1016/j.eururo.2012.07.038, http://dx.doi.org/10.1016/j.eururo.2012.07.039 * Corresponding author. Wales Deanery, Urology Department, Cardiff, Wales, UK. Tel. +44 7886 885677. E-mail address: [email protected] (O.M. Aboumarzouk).
allow a more standardised and meaningful comparison. Furthermore, the authors reference their own work on complex renal lesions [7]. We agree that these complex tumours are now being safely and efficiently treated robotically and there likely is an advantage to the robotic approach, nevertheless more data are certainly needed [3,7]. We also agree with the comment of Mottrie et al. [2] that the data were from small observational studies, as was listed among our limitations. This was a systematically performed meta-analysis that is limited by the available literature. Indeed, the small number of patients in these studies and learning curve data can skew the results, due to the initial learning curve experience [1]. This only serves to highlight the need for larger comparisons performed in a rigorous manner and preferably using level 1 evidence. Superiority of any procedure over another should ideally be based on strong evidence and not merely just be assumed. Regarding the authors’ comment that the data in the forest plots do not represent the most recent literature [2], we note that although it is true that more recent studies report better outcomes, these studies did not compare results to a laparoscopic group of patients. Our objectives were clear in the methodology: We aimed to include only those studies comparing the two procedures and hence recommended that further larger studies are needed to compare the two groups after the initial learning curve has been surpassed [3]. Regarding the exclusion of studies from the metaanalysis, several attempts were made to obtain the data needed to conduct a pooled analysis. We received replies from some of the corresponding authors and included their data in a pooled meta-analysis [3]. However, the study data of authors who did not respond could not be included in a pooled meta-analysis, which is in line with Cochrane guidelines [4,5]. Nonetheless, their data were included in the systematic review and discussed for comparison [3]. Missing standard deviations from studies can potentially be imputed from a similar study; however, imputation techniques involve making assumptions, and it is best to avoid using them [4,5]. We agree with the authors that Mullins et al. [8] should have been included; however, the latest date of search, as stated in the Methods section, was February 6, 2012, and the paper by Mullins et al. was accepted a month later, so it did