Comparative Studies
Relatively few studies have directly compared robotic or laparoscopic radical prostatectomy with open radical retropubic prostatectomy. Even fewer studies have compared pure laparoscopic prostatectomy with robotic prostatectomy. Because of the inherent difficulty with performing a prospective randomized trial for minimally invasive prostatectomy, most studies are designed as case-matched control studies.

Tooher et al (2006) published a systematic review of comparative studies involving laparoscopic prostatectomy.32 Twenty-one studies compared laparoscopic prostatectomy with open prostatectomy, with a total of 2301 and 1757 patients, respectively. The authors concluded that the literature shows laparoscopic prostatectomy is associated with a longer operative time but results in shorter hospital stays and duration of catheterization. Based on the available studies, the authors concluded that the two procedures yielded similar positive-margin rates and recurrence-free survival. The authors criticized the overall poor reporting in terms of functional outcomes such as continence and potency but suggested that the two techniques appeared to yield similar results.

Rozet et al (2007) compared 133 laparoscopic prostatectomies to a case-matched 133 robotic-assisted laparoscopic prostatectomies.33 They found few differences in terms of operative parameters. They concluded that the two procedures were equivalent with respect to operative time, blood loss, hospital stay, length of catheterization, and positive-margin rate.

Smith et al (2006) from Vanderbilt University attempted a prospective study to compare blood loss between robotic-assisted radical prostatectomy and radical retropubic prostatectomy.34 The choice of the procedure choice was left up to the patient; 176 elected robotic prostatectomy and 103 elected open radical prostatectomy. The authors found that the robotic procedure yielded less intraoperative blood loss and a higher hematocrit at the time of hospital discharge. The transfusion rate (very low in both groups) did not differ.

Conclusions
Most of the major leaps in the evolution of minimally invasive surgical treatments for prostate cancer have been driven by the efforts of only a few pioneering groups. These groups are to be commended for their hard work and commitment to improving these complex procedures. Although laparoscopic radical prostatectomy still requires considerable technical skill, robotic technology has bridged the gap for open surgeons to perform these complex procedures.

The literature supports improved operative and perioperative parameters with minimally invasive techniques, including decreased blood loss, shorter hospital stay, and decreased time of catheterization. In the available studies, both laparoscopic and robotic prostatectomy seem to improve functional parameters, namely potency and continence, compared with open prostatectomy. Unfortunately, these studies are usually reported by high-volume single-center experiences and are criticized for their reproducibility across multiple centers and levels of surgeon experience. Reported oncologic outcomes for laparoscopic and robotic prostatectomy are comparable with those of open series, although long-term oncologic data are currently limited.

As the penetration of robotics increases, urologists are challenged to adapt to the rapid changes in this procedural technology. This raises challenges both for established urologists and for urology training programs. Little has been done to establish firm parameters in terms of case volume and operative learning curve, and most large centers are in a constant state of procedural evolution intended to improve clinical outcomes. Finally, the definitive prospective, randomized clinical trial comparing laparoscopic or robotic prostatectomy to open radical prostatectomy would be very difficult to perform given the reported benefits from the minimally invasive procedures. The highest level of achievable data will likely be a well-performed meta-analysis of the literature intended to confirm the consistency of data between clinical centers and individual surgeons.

Multimedia

Media file 1: Laparoscopic and robotic radical prostatectomy. Incision of the medial umbilical ligament. Courtesy of Vattikuti Urology Institute - Henry Ford Health Systems.

Media file 2: Laparoscopic and robotic radical prostatectomy. Division of the urachus and entry into the space of Retzius. Courtesy of Vattikuti Urology Institute - Henry Ford Health Systems.

Media file 3: Laparoscopic and robotic radical prostatectomy. Incision of the endopelvic fascia. Courtesy of Vattikuti Urology Institute - Henry Ford Health Systems.

Media file 4: Laparoscopic and robotic radical prostatectomy. Incision of the bladder neck. Courtesy of Vattikuti Urology Institute - Henry Ford Health Systems.

Media file 5: Laparoscopic and robotic radical prostatectomy. Dissection of the seminal vesicles. Courtesy of Vattikuti Urology Institute - Henry Ford Health Systems.

Media file 6: Laparoscopic and robotic radical prostatectomy. Clipping of the prostatic pedicle. Courtesy of Vattikuti Urology Institute - Henry Ford Health Systems.

Media file 7: Laparoscopic and robotic radical prostatectomy. Division of the urethra. Courtesy of Vattikuti Urology Institute - Henry Ford Health Systems.

Media file 8: Laparoscopic and robotic radical prostatectomy. Anastomosis. Courtesy of Vattikuti Urology Institute - Henry Ford Health Systems.

Media file 9: Laparoscopic and robotic radical prostatectomy. Anastomosis. Courtesy of Vattikuti Urology

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