Urology Care

Status of Radical Prostatectomy in 2009:  Is There Medical Evidence to Justify the Robotic Approach?

Herbert Lepor, MD
New York University School of Medicine, New York, NY

This article presents the evolution of open radical retropubic prostatectomy (ORRP) into a minimally invasive procedure and reviews the literature to provide a legitimate comparison between ORRP and robotic-assisted laparoscopic radical retropubic prostatectomy (RALRP). The article is limited to manuscripts cited in the peer-reviewed literature, and an effort was made to identify those articles that fulfilled the highest level of medical evidence. In centers of excellence, ORRP is performed with no mortality, extraordinarily low technical and medical complications (1%), the rare need for blood transfusions, 1 to 2 day hospital stays, urinary catheters that are routinely removed in a week, the majority of men returning to work in 2 weeks, and up to 97% of men regaining urinary continence.  Return of potency remains a challenge, especially for older men with marginal erections. RALRP is now the most common approach for the surgical removal of the malignant prostate. A critical review of the literature fails to support the marketing claims that RALRP is associated with shorter hospitalization, less pain, better cosmetics, shorter catheter time, lower transfusion rates, or improved continence and potency rates.  The highest level of medical evidence suggests that RALRP may significantly compromise oncologic outcomes and that men undergoing this approach have higher regret rates than men undergoing ORRP.
[Rev Ural. 2009;11 (2}:61-70]

Prostate Cancer

Dr. William J. Catalona

Chicago, Illinois

Patients contemplating radical prostatectomy for prostate cancer want the answers to many important questions.  Will I be cured of my cancer? Will I be continent? Will I be able to have spontaneous erections?  What is my risk for other complications? How long will it take to return to my regular activities?  Open nerve sparing radical retropubic prostatectomy is the gold standard for the surgical treatment of prostate cancer, and the answers to these questions are well documented for open prostatectomy. The results have shown that high volume surgeons usually achieve excellent outcomes. Recently largely due to hype and aggressive marketing, there has been increasingly widespread use of robot assisted laparoscopic radical prostatectomy in the United States.¹   Reports directly comparing open and laparoscopic procedures are just beginning to be published because of the relatively recent use of laparoscopic operations to treat prostate cancer. However, during the last year several highly credible studies on comparative data have indicated important disadvantages of these minimally invasive approaches in terms of achieving cancer control, urinary continence and patient’s satisfaction.^2-4  Furthermore, recent studies have called into question whether robotic surgery offers any material advantage in terms of side effects or recovery time.^5,6   These comparative studies are more informative than reports merely claiming that laparoscopic or robotic surgery has significant advantages compared to open surgery.

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Prostate Cancer