Robotic Radical Prostatectomy; The New Gold Standard?

In 2002, Menon et al. reported on their initial experience with the Robotic Radical prostatectomy with the DaVinci robot (Intuitive Surgical Inc, Sunnydale, CA). Five years later the majority of prostate cancer surgery in the United States is now being done robotically. Physicians in my practice adopted the technology early. Since that time four teams of surgeons at 4 different hospitals have a combined experience with the procedure of nearly 2000 cases. Why?

Prostate cancer surgery has an extirpative as well as a reconstructive component. The cancer must be resected with the intent of achieving “negative margins”. At the same time, it is essential to preserve the quality of life our patients. Laparoscopic robotic surgery allow the surgeon to operate under magnification with excellent dexterity. Clearly, debate exists on whether robotics is any better than a standard open procedure. Certain points, however, remain undebatable.

First, robotic radical prostatectomy has consistently in virtually every series shown a lower risk of blood loss. Blood transfusion rate is lower (less than a 1%) than the standard open approaches to prostate cancer surgery (10-30% depending on series). Additionaly, hospital stay is shorter (usually 1 day compared to 2-5 days), and convalescence is shortened. Cancer control (margin status) has been shown to be equal if not better.

While patients with more extensive disease, larger prostates, previous abdominal surgery, or higher body mass indexes (heavier set patients), may still be offered open surgery, we are now routinely are able to offer this subset of patients the robotic approach while achieving excellent outcomes.

Most urologist would agree that this technology is “here to stay”. Robotic surgery is now part of the routine training that Urology residents are receiving at many institutions. As with any new technology or procedure, (laparoscopic cholecystectomy, laparscopic nephrectomy and partial nephrectomy) there always exists a period of time of learning and transition. In the last five years, we have witnessed a very rapid transition from open prostate cancer surgery to robotic laparoscopic prostate cancer surgery. The debate may continue for a number of years on whether it is the new gold standard. However, the ultimate winner will be our patients, who will routinely be offered this procedure when appropiate .