Laparoscopic and robotic surgery: Into the 21st Century

Are there any disadvantages to robotic prostatectomy?

Drs. Engel and Frazier, as pioneers in the field, have faced nearly all of the criticisms of robotic surgery over the last five years. We have answered nearly every criticism of the technology by thoroughly and prospectively collecting data since our program's inception in order to critically analyze our performance, complications and outcomes. We have used these data to honestly critique ourselves and make changes that result in improvement.

In short, in experienced hands, there are absolutely no disadvantages of the robotic approach - only advantages. Early criticisms included the thought that robotic prostatectomy takes longer, that the recovery time is no different, and that complications were higher than with open radical prostatectomy. To date, our average operative time is less than 120 minutes, which is far less than would be seen with open surgery. The recovery time in nearly every category is cut in half, including hospital stay (<24 hours vs. <48 hours), catheterization time (6 days versus 10-14 days), and return to work (10-14 days versus approximately 1 month). We recently reviewed our complications, and have found that our total complication rate is among the lowest in the country, with major complications such as bleeding, anastomotic leak, infection, blood clot or rectal/bowel injury being exceedingly low. We have also published our rate of bladder neck contracture as being significantly less than would be seen in an open series, and a transfusion rate that also provides similar superiority over the open procedure.

One criticism we took to heart was the accusation that cancer cure is lower with robotic surgery. In a recent review of his first 500 cases, looking at positive margin rates, it was shown that positive margin rates very much correlate with experience, with a plateau in performance coming at approximately 300 cases. After that point, robotic surgery actually has the ability to produce margin rates that are superior to many open series. Interestingly, the same correlation between experience and cancer cure exists strongly with open radical prostatectomy as well.

It is true that to date there have been no studies that prove that robotic prostatectomy produces superior continence, but the general impression is that robotic prostatectomy likely produces earlier continence than open surgery. And with regards to impotence, the best head to head comparison of this topic will actually be Dr. Engel's own research on post-prostatectomy penile rehabilitation. His current study will reveal data that compares his series with a large open series from a prominent center in Manhattan, using the exact same study design. Initial data suggests that although impotence rates are similar, measurement of stretched penile length after prostatectomy, a known problem with open prostatectomy, is not affected after robotic prostatectomy. Many believe that stretched penile length is a better marker for overall penile blood flow after prostatectomy, since so many other factors affect sexual activity such as partner interest, patient co-morbidities, depression, and patient interest. These factors, as well as the difficulty in finding groups that are well matched in these categories, make it very difficult to study this phenomena. Coupled with the fact that potency is usually very loosely defined in studies, the study of post-prostatectomy potency will unfortunately likely never elucidate a clear advantage of robotic over open prostatectomy in this regard.

One final criticism warrants mention here. Open surgeons often stress the inability to use your hands to feel around the prostate to judge the extent of cancer. Experienced robotic surgeons don't find this to be of a disadvantage at all. Experienced robotic surgeons substitute a far better sense for blind palpation, and that is direct vision of the nerves as they are being dissected. With experience, the robotic surgeon has a far better ability to tailor the amount of nerve resection required to achieve a positive margin than is possible with blind palpation, and as a result almost always resects less nerve in a case of extensive cancer than one would be forced to do in the open procedure. The advantage of this improved vision is clear in the operative videos found on this site.

Feel free to review several of our manuscripts in the research section of this site to examine our results in further detail.

Telephone (202) 223 1024 / FAX (202) 223 2152


Address Urologic Surgeons of Washington 2021 K St. NW, Suite 408, Washington D.C. 20006

Copyright (c) 2006 Urologic Surgeons Of Washington

Website development: Salem Mountain design group