Open surgery vs robotic surgery

A recent publication in the Lancet of a randomised trial of 326 men (men were assigned randomly to either treatment to minimise biases) of open versus robotic surgery found that cancer control, continence and sexual function 3 months after surgery were similar in the two groups. So, what does this mean in practice?

As is often the case in medical research, all is not always as it seems at first sight. Firstly, patients having open surgery lost three times more blood during surgery, had more complications, experienced more pain at 1 week after surgery and reported a worse quality of life at 6 weeks after surgery compared to patients having robotic surgery.

Secondly, and most importantly, the experience of the operating surgeons was not equal. Despite the open surgeon having 15 years of experience at performing radical prostatectomy, the robotic surgeon produced equivalent results with only 2 years’ experience and 200 cases completed at the start of the trial. One wonders what the result would have been if it had been conducted by surgeons of equal experience, as several studies have emphasised that the experience and skill of the surgeon is a huge factor in surgical outcome.

This study has attracted a great deal of media attention across the globe but this is a flawed study, essentially comparing the surgical experience and ability of surgeons, rather than investigating potential variations in outcomes between different surgical approaches to radical prostatectomy. Once again we are reminded of the huge potential confounding influence of surgical experience and ability and we can’t therefore use this study to conclusively say which method is better for the patient.

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