Die Macht der Maschinen – Notwendigkeit der roboterassistierten Prostatektomie

Zusammenfassung

Die Etablierung des roboterassistierten Opera­tionsverfahrens bei der radikalen Prostatektomie hat sich, ohne dass bislang eine medizinische Evidenz für die Überlegenheit dieses Opera­tionsverfahrens besteht, in den letzten 10 Jahren explosionsartig entwickelt. Inzwischen lässt sich aufgrund der zahlreich publizierten Ergebnisse zu diesem Operationsverfahren eine Einschätzung des Systems vornehmen. Bei der roboter­assistierten radikalen Prostatektomie handelt es sich um ein sicheres Operationsverfahren. Die Rate an technischen Defekten des Systems ist gering. Die perioperative Komplikationsrate ist vergleichbar mit der anderer Zugangswege. Ähnlich wie bei der klassischen laparoskopischen bzw. extraperitoneoskopischen Operationstechnik ergibt sich der Vorteil eines geringeren Blutverlustes und einer geringeren Transfusionsrate. Diese Verringerung der Transfusionsrate erscheint jedoch klinisch nicht relevant. Aus aktuellen Metaanalysen und Einzelstudien finden sich hinsichtlich des onkologischen Ergebnisses keine klaren Vorteile für die roboterassistierte Prostatektomie. Sowohl die Häufigkeit an positiven Absetzungsrändern als auch Daten zum Langzeitverlauf zeigen keinerlei Verbesserung des onkologischen Ergebnisses. Ebenso sind die funktionellen Ergebnisse einzuordnen. Zwar demonstrieren einige retrospektive Arbeiten durchaus Vorteile für die roboterassistiert operierten Patienten. Allerdings sind diese Daten aufgrund methodischer Schwächen von geringem Evidenzgrad. Eine aktuelle vergleichende Untersuchung an Medicare-Daten zeigt signifikant schlechtere funktionelle Ergebnisse für roboterassistiert operierte Patienten im Vergleich zu offen operierten Patienten. Die Fachgruppe Urologie der Helios Klinikgruppe findet keinen Vorteil für die roboterassistierte Prostatektomie und empfiehlt den Einsatz nicht.

Abstract

During the last decade urologists have faced a dramatic increase in robotic surgery. Despite the exceptional acceptance of this technique there is a complete lack of evidence for the equi-efficacy or superiority of this technique compared to open or laparoscopic prostatectomy. There is now an increasing body of evidence for the evaluation of robotic assisted prostatectomy. Robotic assisted prostatectomy is a safe procedure. The rate of technical failure is small. The rate of surgical complications is comparable with that of open or conventional laparoscopic prostatectomy. Similar to the conventional laparoscopic prostatectomy there is a trend for a minor blood loss and a smaller transfusion rate compared to the retropubic approach. In recent meta-analyses there is no advatage regarding the oncological or functional outcome for robotic prostatectomy. Neither the rate of positive surgical margins nor the rate of biochemical recurrence favours robotic prostatectomy. Regarding functional outcome some publications describe better results for urinary and sexual function for robotic surgery. Careful evaluation of these data reveals a low level of evidence due to a strong bias in favour of robotic surgery. In contrast, recent analysis of “Medicare” data reveal a considerable poorer urinary function after robotic prostatectomy compared to open retropubic prostatectomy. The Urological Board of the Helios Hospital Group does not recommend the use of a robotic device for radical prostatectomy.

Schlüsselwörter

Robotik - Prostatakarzinom - Prostatektomie - Outcome - HTA-Report

Key words

robotics - prostate cancer - prostatectomy - outcomes - HTA report

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