Robot-Assisted Radical Prostatectomy: A Prostate Surgeon’s Perspective

  • Hao G. Nguyen
  • Cole Davis
  • Helena Chang
  • Peter R. CarrollEmail author


The availability and promulgation of robotic technology have resulted in a paradigm shift in the use of radical prostatectomy. Historically radical prostatectomy was performed using an open approach, usually the retropubic approach and rarely using a laparoscopic approach. Recently, however, robotic-assisted radical prostatectomy (RARP) [1] has swept across the United States at an extremely rapid rate, accounting for greater than 85% of cases performed in 2011 [2, 3]. While the early adopters and promoters of RARP were laparoendoscopic specialists, the robotic-assisted approach is becoming the procedure of choice for urologic oncologists as well. In addition, residents are being trained in the use of such technology. The actual costs, benefits, and risks of robotic as compared to open radical prostatectomy remain somewhat controversial. Often lost in such debate is the role of radical prostatectomy, by whatever approach, in the management of prostate cancer, given the considerable stage/grade migration that has occurred because of widespread PSA testing and the mounting concerns regarding prostate cancer over detection and treatment.


Robotic prostatectomy Open prostatectomy Surgical outcomes Cancer control Urinary function Sexual function 


  1. 1.
    Castle EP, Lee D. Working group of urologic robotic surgeons scientific c: nomenclature of robotic procedures in urology. J Endourol. 2008;22:1467–70.CrossRefPubMedGoogle Scholar
  2. 2.
    Hu JC, O'Malley P, Chughtai B, et al. Comparative effectiveness of cancer control and survival after robot-assisted versus open radical prostatectomy. J Urol. 2017;197:115–21.CrossRefPubMedGoogle Scholar
  3. 3.
    Lowrance WT, Eastham JA, Savage C, et al. Contemporary open and robotic radical prostatectomy practice patterns among urologists in the United States. J Urol. 2012;187:2087–92.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Society AC. Cancer facts & figures 2017. Atlanta, GA: American Cancer Society; 2017.Google Scholar
  5. 5.
    Albertsen PC, Hanley JA, Fine J. 20-year outcomes following conservative management of clinically localized prostate cancer. JAMA. 2005;293:2095–101.CrossRefPubMedGoogle Scholar
  6. 6.
    Wilt TJ, MacDonald R, Rutks I, et al. Systematic review: comparative effectiveness and harms of treatments for clinically localized prostate cancer. Ann Intern Med. 2008;148:435–48.CrossRefPubMedGoogle Scholar
  7. 7.
    Bill-Axelson A, Holmberg L, Filén F, et al. Radical prostatectomy versus watchful waiting in localized prostate cancer: the Scandinavian prostate cancer group-4 randomized trial. J Natl Cancer Inst. 2008;100:1144–54.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Steineck G, Helgesen F, Adolfsson J, et al. Quality of life after radical prostatectomy or watchful waiting. N Engl J Med. 2002;347:790–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Cookson MS, Aus G, Burnett AL, et al. Variation in the definition of biochemical recurrence in patients treated for localized prostate cancer: the american urological association prostate guidelines for localized prostate cancer update panel report and recommendations for a standard in the reporting of surgical outcomes. J Urol. 2007;177:540–5.CrossRefPubMedGoogle Scholar
  10. 10.
    Donovan JL, Hamdy FC, Lane JA, et al. Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med. 2016;375:1425–37.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Shahinian VB, Kuo YF, Freeman JL. Determinants of androgen deprivation therapy use for prostate cancer: role of the urologist. J Natl Cancer Inst. 2006;98:839.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Cooperberg MR, Broering JM, Kantoff PW, et al. Contemporary trends in low risk prostate cancer: risk assessment and treatment. J Urol. 2007;178:S14–9.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Cooperberg MR, Cowan J, Broering JM, et al. High-risk prostate cancer in the United States, 1990–2007. World J Urol. 2008;26:211–8.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Dall'Era MA, Cooperberg MR, Chan JM, et al. Active surveillance for early-stage prostate cancer. Cancer. 2008;112:1650–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Cooperberg MR, Carroll PR. Trends in management for patients with localized prostate cancer, 1990–2013. JAMA. 2015;314:80–2.CrossRefPubMedGoogle Scholar
  16. 16.
    Abdollah F, Sood A, Sammon JD, et al. Long-term cancer control outcomes in patients with clinically high-risk prostate cancer treated with robot-assisted radical prostatectomy: results from a multi-institutional study of 1100 patients. Eur Urol. 2015;68:497–505.CrossRefPubMedGoogle Scholar
  17. 17.
    Yossepowitch O, Eastham JA. Radical prostatectomy for high-risk prostate cancer. World J Urol. 2008;26:219–24.CrossRefPubMedGoogle Scholar
  18. 18.
    Ward JF, Slezak JM, Blute ML, et al. Radical prostatectomy for clinically advanced (cT3) prostate cancer since the advent of prostate-specific antigen testing: 15-year outcome. BJU Int. 2005;95:751–6.CrossRefPubMedGoogle Scholar
  19. 19.
    Berglund RK, Jones JS, Ulchaker JC, et al. Radical prostatectomy as primary treatment modality for locally advanced prostate cancer: a prospective analysis. Urology. 2006;67:1253–6.CrossRefPubMedGoogle Scholar
  20. 20.
    Thompson IM, Tangen CM, Paradelo J, et al. Adjuvant radiotherapy for pathological T3N0M0 prostate cancer significantly reduces risk of metastases and improves survival: long-term followup of a randomized clinical trial. J Urol. 2009;181:956–62.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Messing EM, Manola J, Yao J, et al. Immediate versus deferred androgen deprivation treatment in patients with node-positive prostate cancer after radical prostatectomy and pelvic lymphadenectomy. Lancet Oncol. 2006;7:472–9.CrossRefPubMedGoogle Scholar
  22. 22.
    Walsh PC. Anatomic radical prostatectomy. J Urol. 1998;160:2418–24.CrossRefPubMedGoogle Scholar
  23. 23.
    Nielsen ME, Schaeffer EM, Marschke P, et al. High anterior release of the levator fascia improves sexual function following open radical retropubic prostatectomy. J Urol. 2008;180:2557–64.CrossRefPubMedGoogle Scholar
  24. 24.
    Schroeck FR, Krupski TL, Sun L, et al. Satisfaction and regret after open retropubic or robot-assisted laparoscopic radical prostatectomy. Eur Urol. 2008;54:785–93.CrossRefPubMedGoogle Scholar
  25. 25.
    Berryhill JR, Jhaveri J, Yadav R, et al. Robotic prostatectomy: a review of outcomes compared with laparoscopic and open approaches. Urology. 2008;72:15–23.CrossRefPubMedGoogle Scholar
  26. 26.
    Catalona WJ, Carvalhal GF, Mager DE, et al. Potency, continence and complication rates in 1,870 consecutive radical retropubic prostatectomies. J Urol. 1999;162:433–8.CrossRefPubMedGoogle Scholar
  27. 27.
    Ficarra V, Cavalleri S, Novara G, et al. Evidence from robot-assisted laparoscopic radical prostatectomy: a systematic review. Eur Urol. 2007;51:45–56.CrossRefPubMedGoogle Scholar
  28. 28.
    Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: the montsouris experience. J Urol. 2000;163:418–22.CrossRefPubMedGoogle Scholar
  29. 29.
    Herrell SD, Smith JRJA. Robotic-assisted laparoscopic prostatectomy: what is the learning curve? Urology. 2005;66:105–7.CrossRefPubMedGoogle Scholar
  30. 30.
    Zorn KC, Orvieto MA, Gong EM, et al. Robotic radical prostatectomy learning curve of a fellowship-trained laparoscopic surgeon. 2007;21:441–7.
  31. 31.
    Ahlering TE, Woo D, Eichel L, et al. Robot-assisted versus open radical prostatectomy: a comparison of one surgeon’s outcomes. Urology. 2004;63:819–22.CrossRefPubMedGoogle Scholar
  32. 32.
    Grossfeld GD, Chang JJ, Broering JM, et al. Impact of positive surgical margins on prostate cancer recurrence and the use of secondary cancer treatment: data from the CAPSURE database. J Urol. 2000;163:1171–7.CrossRefPubMedGoogle Scholar
  33. 33.
    Karakiewicz PI, Eastham JA, Graefen M, et al. Prognostic impact of positive surgical margins in surgically treated prostate cancer: Multi-institutional assessment of 5831 patients. Urology. 2005;66:1245–50.CrossRefPubMedGoogle Scholar
  34. 34.
    Punnen S, Meng MV, Cooperberg MR, et al. How does robot-assisted radical prostatectomy (RARP) compare with open surgery in men with high-risk prostate cancer? BJU Int. 2013;112:E314–20.CrossRefPubMedGoogle Scholar
  35. 35.
    Yaxley JW, Coughlin GD, Chambers SK, et al. Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: early outcomes from a randomised controlled phase 3 study. Lancet. 2016;388:1057–66.CrossRefPubMedGoogle Scholar
  36. 36.
    Tewari A, Srivasatava A, Menon M. A prospective comparison of radical retropubic and robot-assisted prostatectomy: experience in one institution. BJU Int. 2003;92:205–10.CrossRefPubMedGoogle Scholar
  37. 37.
    Roumeguere T, Bollens R, Bossche MV. Radical prostatectomy: a prospective comparison of oncological and functional results between open and laparoscopic approaches. World J Urol. 2003;20(6):360–6.PubMedGoogle Scholar
  38. 38.
    Menon M, Tewari A, Baize B, et al. Prospective comparison of radical retropubic prostatectomy and robot-assisted anatomic prostatectomy: the Vattikuti Urology Institute experience. Urology. 2002;60:864–8.CrossRefPubMedGoogle Scholar
  39. 39.
    Ghavamian R, Knoll A, Boczko J, et al. Comparison of operative and functional outcomes of laparoscopic radical prostatectomy and radical retropubic prostatectomy: single surgeon experience. Urology. 2006;67:1241–6.CrossRefPubMedGoogle Scholar
  40. 40.
    Fromont G, Guillonneau B, Validire P, et al. Laparoscopic radical prostatectomy. Urology. 2002;60:661–5.CrossRefPubMedGoogle Scholar
  41. 41.
    Smith JRJA, Chan RC, Chang SS, et al. A Comparison of the incidence and location of positive surgical margins in robotic assisted laparoscopic radical prostatectomy and open retropubic radical prostatectomy. J Urol. 2007;178:2385–90.CrossRefPubMedGoogle Scholar
  42. 42.
    Trabulsi EJ, Linden RA, Gomella LG. The addition of robotic surgery to an established laparoscopic radical prostatectomy program: effect on positive surgical margins. Can J Urol. 2008;15(2):3994–9.PubMedGoogle Scholar
  43. 43.
    Hu JC, Wang Q, Pashos CL, et al. Utilization and outcomes of minimally invasive radical prostatectomy. J Clin Oncol. 2016;26:2278–84.CrossRefGoogle Scholar
  44. 44.
    Nelson B, Kaufman M, Broughton G, et al. Comparison of length of hospital stay between radical retropubic prostatectomy and robotic assisted laparoscopic prostatectomy. J Urol. 2007;177:929–31.CrossRefPubMedGoogle Scholar
  45. 45.
    Lotan Y, Cadeddu J, Gettman M. The new economics of radical prostatectomy: cost comparison of open, laparoscopic and robot assisted techniques. J Urol. 2004;172:1431–5.CrossRefPubMedGoogle Scholar
  46. 46.
    Lotan Y. Economics of robotics in urology. Curr Opin Urol. 2010;20:92–7.CrossRefPubMedGoogle Scholar
  47. 47.
    Bolenz C, Gupta A, Hotze T, et al. Cost comparison of robotic, laparoscopic, and open radical prostatectomy for prostate cancer. Eur Urol. 2010;57:453–8.CrossRefPubMedGoogle Scholar
  48. 48.
    Nguyen HG, Punnen S, Cowan JE, et al. A randomized study of intraoperative autologous retropubic urethral sling on urinary control after robotic assisted radical prostatectomy. J Urol. 2017;197:369–75.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Hao G. Nguyen
    • 1
  • Cole Davis
    • 2
  • Helena Chang
    • 1
  • Peter R. Carroll
    • 1
    Email author
  1. 1.Department of UrologyUCSFSan FranciscoUSA
  2. 2.TulsaUSA

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