Letter to the Editor NOT referring to a recent journal article

Why I Perform Robotic-Assisted Laparoscopic Radical Prostatectomy, Despite More Incontinence and Erectile Dysfunction Diagnoses Compared to Open Surgery: It's Not About the Robot

By: Jim C. Hulowast

European Urology, Volume 57 Issue 3, March 2010, Pages 544-545

Published online: 01 March 2010

Abstract Full Text Full Text PDF (60 KB)

For 70 yr following Hugh Hampton Young's perineal radical prostatectomy series, few surgical innovations transpired until improved comprehension of pelvic anatomy and surgical maneuvers to decrease venous bleeding and attenuate erectile dysfunction (ED) led to the widespread adoption of retropubic radical prostatectomy (RRP) [1]. The advent of prostate-specific antigen furthered additional technical modifications to preclude incomplete prostate resection, as demonstrated by the reduction of postoperative thresholds for organ-confined disease from <0.4 to <0.1. Minimally invasive radical prostatectomy (MIRP) was initially rejected, and then gained traction. MIRP with robotic assistance and the Internet have been disruptive technologies, upsetting traditional word-of-mouth referral patterns by drawing patients to early adopters and Web sites that contain inaccuracies and that heighten expectations regarding potency [2]. This trend may contribute to treatment regret and dissatisfaction with MIRP [3].

Against this backdrop, we used Surveillance, Epidemiology, and End Results (SEER)–Medicare data to compare outcomes of MIRP with and without robotic assistance versus RRP from 2003 to 2007 [4]. Although men undergoing MIRP versus RRP experienced shorter lengths of stay, fewer transfusions and strictures, and similar early cancer control, MIRP was associated with more incontinence and ED diagnosed >18 mo postoperatively. Two possibilities explain these findings: either MIRP technology inherently compromised functional outcomes or surgeons had yet to fully master MIRP instrumentation during early, rapid adoption. According to Intuitive Surgical, 600 press clippings accentuated MIRP negatives rather than positives, and many patients and urologists may have been misled by headlines and sound bytes without appreciating the findings within the framework of the study design.

Although SEER-Medicare data lack the granularity to determine nerve-sparing technique and validated instrument evaluation of incontinence and ED, it allows a population-based comparison of MIRP versus RRP outcomes for surgeons whose findings might otherwise go unpublished. This is relevant, as >70% of radical prostatectomies are performed by low-volume surgeons [5]. Although we adjusted for surgeon volume during our study period in subanalyses, the administrative code for MIRP was initiated in 2003, and we were unable to adjust for surgeon experience prior to 2003. Moreover, adjusting for surgeon volume does not capture formal training in RRP versus MIRP experience learned on the fly, and there is tremendous heterogeneity in individual techniques and outcomes. Our study is akin to comparing mean scores of professionally instructed golfers and/or those with >20 years of experience using vintage clubs (RRP) versus mostly self-taught beginners using high-tech clubs (MIRP).

MIRP attributes (ie, smaller incisions, carbon dioxide insufflation, and ×10 magnification) contributed to shortened hospitalizations and reduced transfusions and strictures. My learning curve (after fellowship training of 397 robotics cases), however, was hundreds of cases to minimize tissue trauma, incontinence [6], and ED and required meticulous tracking and correlation of technical modifications with improved functional outcomes. My initial goals, like many neophyte MIRP surgeons, were to avoid open conversions and to maximize efficiency. Only after achieving improved short-term outcomes was I able to improve functional outcomes. It therefore comes as no surprise that incontinence and ED were more frequently diagnosed with nascent MIRP technique during our 5-yr study period, given individual MIRP surgeon milestones that must be overcome and the aforementioned lengthy timeline for surgical innovation and radical prostatectomy evolution.

Conflicts of interest

The author has nothing to disclose.


  • [1] P.C. Walsh. Anatomic radical prostatectomy: evolution of the surgical technique. J Urol. 1998;160:2418-2424
  • [2] Mulhall JP, Rojaz-Cruz C, Muller A. An analysis of sexual health information on radical prostatectomy websites. BJU Int. In press.
  • [3] F.R. Schroeck, T.L. Krupski, L. Sun, et al. Satisfaction and regret after open retropubic or robot-assisted laparoscopic radical prostatectomy. Eur Urol. 2008;54:785-793 Crossref
  • [4] J.C. Hu, X. Gu, S.R. Lipsitz, et al. Comparative effectiveness of minimally invasive vs open radical prostatectomy. JAMA. 2009;302:1557-1564 Crossref
  • [5] T.J. Wilt, T.A. Shamliyan, B.C. Taylor, R. MacDonald, R.L. Kane. Association between hospital and surgeon radical prostatectomy volume and patient outcomes: a systematic review. J Urol. 2008;180:820-828 discussion 828–9
  • [6] M.P. Freire, A.C. Weinberg, Y. Lei, et al. Anatomic bladder neck preservation during robotic-assisted laparoscopic radical prostatectomy: description of technique and outcomes. Eur Urol. 2009;56:972-980 Crossref


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