Advantages and Disadvantages of Robotics Versus Laparoscopy
The robotic techniques have several advantages over laparoscopic techniques for performing radical prostatectomy.

• Because the display system of the da Vinci projects the image in the direction of the surgeon's hands, the optically correct hand-eye coordination is restored. This is more difficult with laparoscopy, in which the camera is sometimes offset to the plane of dissection.
• The 11-mm telescope in the da Vinci system is a combination of two 5-mm optical channels (one for the right and one for the left eye), which have 2 separate 3-chip–charged coupling devices in the camera head. The 2 images are displayed to provide 3-dimensional stereoscopic vision to the surgeon, providing depth perception lacking in laparoscopy. The conventional laparoscopic technique does not provide a 3-dimensional depth of view.
• The movements of the robotic system are intuitive (ie, a movement of the master control to the right causes the instrument to move to the right), as opposed to the counterintuitive movements in laparoscopy with fulcrum movement effects (ie, movement of the laparoscopic instrument to the right by the surgeon causes the tip of the instrument to move to the left inside the patient's body).
• The robotic systems provide increased precision by filtering hand tremors, providing magnification (10X or 15X), and providing scaling for the surgeon's movements (a 1:3 scaling means that a 3-in movement of the master is translated into a 1-in movement of the instrument tip).
• The robotic instruments have articulated tips, which permit 7° of freedom in movements (ie, they mimic human wrist movements, including rotation), which is unlike laparoscopy, with which only 4° of freedom are permitted.

Robotic techniques also have disadvantages.
• The current-generation robot is still bulky and tends to limit the working space of the assistant(s).
• The availability of instrumentation for the robotic systems is presently limited, although development of new instruments is ongoing.
• Economically, the robotic system is viable only for centers with a high volume of cases or multidisciplinary robotic use. The system cost exceeds $1.2 million, and the annual maintenance costs range from $100,000-$150,000.

Table 1. Outcomes of Operative Parameters Using Laparoscopic Radical Prostatectomy

As can be appreciated, the mean operating-room time for laparoscopic radical prostatectomy is approximately 4.5 hours. However, note that European centers report longer hospitalization times than US hospitals. The laparoscopic approach compares very favorably with open radical prostatectomy in terms of blood loss, hospital stay, and catheterization times. Operative times for laparoscopic prostatectomy are significantly longer than for open surgery, even after the learning curve has been mastered.

Functional outcomes

Relatively few studies have discussed functional outcomes following laparoscopic radical prostatectomy. Most series are from the same European laparoscopic centers of excellence.

Table 2. Outcomes of Functional Parameters Using Laparoscopic Radical Prostatectomy

Continence rates vary from 85-90%, and potency rates range from 40-59.9% according to unilateral or bilateral bundle preservation. Patient self-reported survey results are probably more reflective of morbidity results because the ratings of physicians and patients may be divergent. Especially in embarrassing clinical aspects, such as sexual and urinary symptoms, physician and patient assessments may have significant differences, as reported by Penson and Litwin in 2003.22 The much greater postoperative sexual and urinary dysfunction rates reported in recent surveys of patients after radical prostatectomy support that concept.

Preservation of neurovascular bundles, younger patient age, and an experienced surgeon are the main factors associated with the best results regarding erectile function; however, these factors are similar for both open and laparoscopic approaches.7,23,24 Earlier concerns of higher positive margin rates following laparoscopic radical prostatectomy have been shown to be incorrect in published series.16,25,17,26

Robotic Radical Prostatectomy
Operative outcomes
Robotic radical prostatectomy has gained substantial momentum largely because of factors discussed above, including a shorter learning curve and increased accessibility. Multiple large published series have reported operative outcome data. Of these, the HenryFordHospital (Detroit, Michigan) has the largest patient experience with robotic prostatectomy.

Table 3. Outcomes of Operative Parameters Using Robotic Radical Prostatectomy

Robotic radical prostatectomy offers significantly lower operative times and blood loss than laparoscopic or open surgery. Catheterization times and hospital stay are also superior to those associated with open and laparoscopic approaches. 29,10,12 The learning curve is less with robotic assistance compared with laparoscopy. The one significant question that remains unanswered pertains to the cost-effectiveness of robotic prostatectomy compared with open and laparoscopic radical prostatectomy.

Functional outcomes
Long-term follow-up after robotic prostatectomy is not available because the technique is relatively new; however, early functional results are available and are summarized below.

Table 4. Outcomes of Functional Parameters Using Robotic Radical Prostatectomy

Preliminary results from the above series show that oncologic and functional results following robotic prostatectomy compare very favorably with those of either open or laparoscopic radical prostatectomy. 7,8,9,10,12 The margin rates and rates of PSA recurrence are similar, but potency and continence rates are better than those of open and laparoscopic approaches. 7,8,10 The excellent results reported from several large-volume centers suggests that the data are reproducible with appropriate surgical volume. Long-term functional and oncologic results are needed to establish the role of robotic radical prostatectomy in the treatment of localized prostate cancer.

Oncologic Outcomes

Table 5. Oncologic Outcomes with Laparoscopic and Robotic-assisted Laparoscopic Radical Prostatectomy

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