Which approach to radical prostatectomy?

September 1, 2011

A high-volume surgeon will have good results regardless of approach, but that the surgeon with less experience might do a better job with the robotic approach.

A randomized trial performed at University of São Paolo Medical School compared the outcomes of robotic and open surgical radical prostatectomy, with each procedure being performed by a very experienced surgeon (see article, "Robotic radical prostatectomy shows less morbidity than open technique"). The major differences were less blood loss, less variability of hospital stay, fewer postoperative complications, and better sexual function at 3 months in the robotic group, which came at the price of a longer operative time (and, of course, greater operating room cost as well). The balance of these data would seem to suggest a superiority of robotic over open surgical prostatectomy, assuming the health care system can bear the greater resource utilization. Randomized trials are considered the pinnacle of clinical research-level 1 evidence-but problems with generalizability can reduce their utilization.

Potentially more generalizable is the meta-analysis, performed at Weill Cornell Medical College, of literature reporting on more than 100,000 robotic, laparoscopic, and open surgical radical prostatectomies (see article, "In less experienced hands, robotic radical prostatectomy has the edge"). Similar to the randomized trial, the robotic approach was associated with less blood loss and fewer complications compared to open surgery (with the laparoscopic group being intermediate). Analysis by surgeon experience revealed that the differences between the techniques were minimal for high-volume surgeons and that the greatest benefit of the robotic approach appeared to be for surgeons with less experience.

In summary, these data suggest that a high-volume surgeon will have good results regardless of approach, but that the surgeon with less experience might do a better job with the robotic approach. The choice to use the robot, however, must be tempered by economic considerations.

J. Stuart Wolf, Jr, MD a member of the Urology Times Editorial Council, is professor of urology at the University of Michigan, Ann Arbor.