History of the Prostatectomy
Although fading rapidly in popularity, RRP can still at times be presented to patients as an equivalent or even superior alternative to robotic prostatectomy. When patients are faced with this confusion, Dr. Engel will usually offer an explanation of the history of prostatectomy in general. There are different ways of performing prostatectomy. They represent a progression of technology over time, not equal alternatives as can sometimes be told to patients.
When Dr. Engel first began performing robotic prostatectomy in 2004, 5% of prostatectomies were done this way. Now, well over 90% are done this way.
Originally, and before the development of ultrasound, Urologists only approached the prostate through the skin below the scrotum, called the perineum. Biopsies and surgeries were done this way. Thus, the original approach to prostatectomy was called a perineal prostatectomy. This approach is very rarely performed today, and has little utility as the exposure is limited, and most argue not at all ideal for sparing erectile nerves.
Radical Retropubic prostatectomy (RPP)
A big leap forward came from the description of the erectile nerves, located between the rectum and prostate. Surgeries were then performed in the more invasive approach, RRP, with the idea that the tradeoff between invasiveness through an open lower abdominal incision and the potential of sparing these nerves was justified. This became the predominant approach for nearly 20 years despite very significant drawbacks. With the RRP, the surgeon is deep in the pelvis, using very long instruments, not able to fit his/her hands into the pelvis. It is a very bloody operation, and sometimes not gratifying to the surgeon as visualization can be very limited, and often much of the operation is done bluntly, with traction using a blind finger to dissect.
The technological leap that brought laparoscopy back to the forefront was the invention of robotic instruments for laparoscopy via a system called da Vinci. Here, the laparoscopic instruments now rotated like human wrists, offering all of the functions of a human hand in a very small instrument.
This left an opening for Urologists to be receptive to an approach that would be less bloody, more reproducible and less invasive. The first step forward was laparoscopic prostatectomy, popularized in Europe and a few centers in the United States. Whereas this did provide good visualization, was less bloody and was less invasive, the limitations of using standard laparoscopic instruments in many ways outweighed the benefits, and no real overall advantage was seen. Dr. Engel performed several of these successfully, but abandoned them and went back to the RRP.
The technological leap that brought laparoscopy back to the forefront was the invention of robotic instruments for laparoscopy via a system called da Vinci. Here, the laparoscopic instruments now rotated like human wrists, offering all of the functions of a human hand in a very small instrument. Now, a surgeon could utilize all of the advantages of laparoscopy (tiny incisions, less blood loss, great visualization, shorter recovery) and not only not be disadvantaged by the instruments, but rather perform the operation much better than one could do with their actual hands which are too large to fully utilize in this operation.