JCO Review article: RALP: Are there advantages

Dr. Smith at Vanderbilt offers a concise review of the current literature on robotic assisted prostatectomy. Click for abstract.
Laparoscopic (with a focus on Robotic-assisted) vs. open RRP was reviewed.


The key findings in the review of the literature were
1) Similar postoperative pain in open vs. robotic prostatectomy in one prospective series.
Most urologists including myself feel that our robotic patients have significantly less pain.
I discharge most of my patients within 24 hours and do not give narcotic pain pills at discharge.
2) Operative times are similar after the learning curve has been passed.
I agree with this. In my experience we achieved similar operating times for non-complicated robotic prostatectomies by 30 operations. After 40 operations the times have been quicker than open.
3) Less bleeding with the robotic approach.
This is almost universally accepted.
We have not transfused a patient to date and have stopped having our patients donate blood after the first 4 operations.
4) Hospital stay – slightly better for robotic, although open series also have short hospital stays.
I think the robotic patients more easily leave the hospital after 24 hours, and some patients are being discharged the same day.
5) Urinary continence- No good studies showing a benefit.
The author pointed out that the method to evaluate continence is highly variable in series.
Our experience is that patients are having return of continence quicker. Some are continent within a week or two, but most are continent within 3 months. The improved visualization has allowed for a more precise dissection to leave the urinary sphincter intact with out compromising our apical margin rate.
6) Erectile dysfunction- Similar to incontinence, there are no good studies for this.
The author points out that the principles and anatomic dissection for nerve sparing is the same regardless of the approach. I disagree with this. My technique for the robotic approach involves finding the prostate at the base, away from where the nerves attach. I believe this allows me to spare the nerve bundle more completely and with less trauma.
4 of my first 20 patients with a bilateral nerve sparing procedure with good erectile function preoperatively have had intercourse within 3 weeks or surgery. This is much rarer with open surgery. I am collecting accurate data by patient questionnaire to follow this more thoroughly.
7) Oncological outcomes- Similar in large series with experienced surgeons.
I agree with this, but I personally feel much more comfortable with a magnified, robotic approach in getting very close to the prostate and sparing the nerves for erection and muscles for urinary continence.
My last 20 dvPs have a 5% positive margin including all 17 with T2 prostate cancer being negative and 2 of 3 with T3 disease being negative.
This has allowed me to spare more nerves than I would feel comfortable with in open surgery.

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