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Rebuttal to Drs. Shteynshlyuger and Kibel

  • Kent E. Wallner
    Correspondence
    Corresponding author. Department of Radiation Oncology, Department of Veterans Affairs Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108. Tel.: +1-206-768-5356; fax: +1-206-768-5331.
    Affiliations
    Department of Radiation Oncology, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108
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      Drs. Shteynshlyuger and Kibel cover several valid points regarding cancer control rates, morbidities, and adjuvant radiation for prostatectomy. I agree that in good hands, both prostatectomy and brachytherapy afford very high, durable cancer control rates (
      • Taira A.
      • Merrick G.
      • Galbreath R.
      • et al.
      Natural history of clinically staged low- and intermediate-risk prostate cancer treated with monotherapeutic permanent interstitial brachytherapy.
      ,
      • Paul A.
      • Ploussard G.
      • Nicolaiew N.
      • et al.
      Oncologic outcome after extraperioneal laparoscopic radical prostatectomy: Midterm follow-up of 1115 procedures.
      ). I have little argument with most of their statements. However, their points in no way diminish my concerns over the wildly variable results reported for prostatectomy, even from big-name institutions. Highly variable surgical quality includes perioperative complications, cure rates, and long-term incontinence (
      • Hu J.
      • Pashos C.
      • Lipsitz S.
      • et al.
      Utilization and outcomes of minimally invasive radical prostatectomy.
      ,
      • Reynolds W.
      • Shikanov S.
      • Katz M.
      • et al.
      Analysis of continence rates following robot-assisted radical prostatectomy: Strict leak-free and pad-free incontinence.
      ,
      • Alibhai S.
      • Leach M.
      • Tomlinson G.
      Impact of hospital and surgeon volume on mortality and complications after prostatectomy.
      ). Inconsistent quality appears to be far less with brachytherapy and can be minimized with attention to postimplant dose analysis (with touch up of inadequate implants). In contrast, the path to minimization of surgical quality variance is hazy, other than the volume of cases accrued by each surgeon (
      • Alibhai S.
      • Leach M.
      • Tomlinson G.
      Impact of hospital and surgeon volume on mortality and complications after prostatectomy.
      ). I would not want to be the 28th patient of a recently minted robotic laparoscopic surgeon.
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      References

        • Taira A.
        • Merrick G.
        • Galbreath R.
        • et al.
        Natural history of clinically staged low- and intermediate-risk prostate cancer treated with monotherapeutic permanent interstitial brachytherapy.
        Int J Rad Oncol Biol Phys. 2010; 76: 349-354
        • Paul A.
        • Ploussard G.
        • Nicolaiew N.
        • et al.
        Oncologic outcome after extraperioneal laparoscopic radical prostatectomy: Midterm follow-up of 1115 procedures.
        Eur Urol. 2010; 57: 267-273
        • Hu J.
        • Pashos C.
        • Lipsitz S.
        • et al.
        Utilization and outcomes of minimally invasive radical prostatectomy.
        J Clin Oncol. 2008; 26: 2278-2284
        • Reynolds W.
        • Shikanov S.
        • Katz M.
        • et al.
        Analysis of continence rates following robot-assisted radical prostatectomy: Strict leak-free and pad-free incontinence.
        Urology. 2010; 75: 431-438
        • Alibhai S.
        • Leach M.
        • Tomlinson G.
        Impact of hospital and surgeon volume on mortality and complications after prostatectomy.
        J Urol. 2008; 180: 155-163