Historic progression of prostatectomy techniques and associated outcomes

Surgical technique for radical prostatectomy has and continues to evolve with each generation of urologists. The first radical perineal prostatectomy was described in 1905 by Hugh Hampton Young introducing surgery as a management strategy for men with localized prostate cancer. The technique, however, was limited by complications (e.g., rectal injury, ureteral injury, anastomotic leaks, impotence) mostly due to limited exposure and a steep learning curve (1). T Millin described the first open retropubic prostatectomy in 1945; and, the technique underwent modifications in 1979 and 1983 by Reiner and Walsh as they refined our understanding of peri-prostatic anatomy. Specifically, early ligation of the dorsal venous complex, preservation of the neurovascular bundles, and the ability to perform a concomitant lymph node dissection greatly improved intraoperative, post-operative, and oncologic outcomes (1-3). Minimally invasive approaches pioneered in the 1990s, specifically laparoscopic prostatectomy, demonstrated reduced blood loss due to pneumoperitoneum, enhanced anatomic preservation due to magnification, and allowed for faster recovery times without sacrificing oncologic outcomes (4). Lastly and most recently, robotic-assisted technology (da Vinci robotic systems) has been utilized for prostatectomy since 2000 and built upon the laparoscopic technique adding better range of motion, visualization, and fine-dissection capabilities. By 2013, nearly 85% of all prostatectomies in the United States were performed robotically compared to open techniques (5). In more recent years, innovations in robotic prostatectomy have included altering surgical approaches (e.g., transvesical, retzius-sparing, extraperitoneal) as well as incorporating the single port robotic system (6).

Initial adoption of robotic prostatectomy was met with skepticism and controversy given limited data to support oncologic control and functional outcomes with a new, expensive technology. Early studies found little difference in oncologic and functional outcomes between open radical retropubic prostatectomy (RRP) and robotic-assisted laparoscopic radical prostatectomy (RALP) as open technique was the vetted standard compared to the early learning curve of robotics (7,8). Later retrospective studies and the Swedish LAPPRO study (non-randomized RRP vs. RALP), in general demonstrated trends of increased operative time, lower blood loss, shorter length of stay, and improved potency rates with robotic compared to open prostatectomy without sacrificing oncologic control (9-11).

Regardless of the technique utilized, the goals of a radical prostatectomy for the management of prostate cancer remain the same: oncologic control, early return to continence, and erectile preservation. While practice patterns have changed from the 1980s, there is limited randomized trial data available to demonstrate superiority of any one technique despite this clear shift in preference. Nahas et al. reinforced our current available literature adding to it a single-center, multi-surgeon, randomized clinical trial comparing 327 men who underwent RRP (n=156) and RALP (n=171) (12). The majority of patients had pathologic grade-group 1 or 2 and clinical stage T1 or T2 prostate cancer. Similar to prior studies, patients undergoing RALP had longer operative time (median 212 vs. 120 minutes; P<0.001), reduced blood loss (median 220 vs. 719 mL; P<0.001), and shorter length of stay (1 day: 69% vs. 50%, P<0.001) compared to RRP with similar complication risk. Functionally, men undergoing RALP had quicker return to continence (3 months; 80.5% vs. 64.7%; P=0.002), higher continence rate at 18 months (95.4% vs. 78.8%; P<0.001), and higher potency rates (6 months; 30.6% vs. 6.9%; P<0.001). At 36 months, authors noted similar oncologic outcomes with 20.5% (RRP) vs. 29.2% (RALP) (P=0.069) requiring additional treatment (e.g., radiation, androgen deprivation therapy, or multimodal options) (12).

Ultimately, technique utilized should be based on surgeon preference and patient characteristics. Surgeon preference has clearly evolved over the last four decades with >85% of radical prostatectomies being performed robotically in recent years (5). As practice patterns have changed, so too have training patterns of resident and fellowship urologists. Fewer and fewer surgical oncologic trainees have meaningful, repetitive exposure to open prostatectomy to ensure similar oncologic and functional outcomes to robotic prostatectomy in the future. Therefore, while this data presented by Nahas et al. reflects current oncologic and functional outcomes between experienced open and robotic surgeons, this data may not be relevant for future generations and should be reassessed over time.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Translational Andrology and Urology. The article has undergone external peer review.

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-3/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-3/coif). N.D.S. reports consulting fees from Accord, Alessa, Amgen, Antev, Arquer, Asieris, Astellas, Astra Zeneca, Aura Biosciences, Bayer, Bioprotect, Bristol Myers Squibb, Clarity, Cg Oncology, Dendreon, Exact Imaging, Ferring, Fize Medical, Glytherix, Invitae, Janssen, Lantheus, Lilly, Mdxhealth, Merck, Minomic, Myriad, Novartis, Photocure, Platformq, Pfizer, Preview Medical, Promaxo, Protara, Sanofi Genzyme, Siemans, Sumitomo, Telix, Tolmar, Tutelix, and Urogen. The other author has no conflicts of interest to declare.

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References

1. Lepor H. A review of surgical techniques for radical prostatectomy. Rev Urol 2005;7:S11-7. [PubMed]
2. Millin T. Retropubic Urinary Surgery. London: Livingston; 1947.
3. Reiner WG, Walsh PC. An anatomical approach to the surgical management of the dorsal vein and Santorini's plexus during radical retropubic surgery. J Urol 1979;121:198-200. [Crossref] [PubMed]
4. Lipke M, Sundaram CP. Laparoscopic radical prostatectomy. J Minim Access Surg 2005;1:196-201. [Crossref] [PubMed]
5. Oberlin DT, Flum AS, Lai JD, et al. The effect of minimally invasive prostatectomy on practice patterns of American urologists. Urol Oncol 2016;34:255.e1-5. [Crossref] [PubMed]
6. Mian AH, Tollefson MK, Shah P, et al. Navigating Now and Next: Recent Advances and Future Horizons in Robotic Radical Prostatectomy. J Clin Med 2024;13:359. [Crossref] [PubMed]
7. Coughlin GD, Yaxley JW, Chambers SK, et al. Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: 24-month outcomes from a randomised controlled study. Lancet Oncol 2018;19:1051-60. [Crossref] [PubMed]
8. Haglind E, Carlsson S, Stranne J, et al. Urinary Incontinence and Erectile Dysfunction After Robotic Versus Open Radical Prostatectomy: A Prospective, Controlled, Nonrandomised Trial. Eur Urol 2015;68:216-25. [Crossref] [PubMed]
9. Lantz A, Bock D, Akre O, et al. Functional and Oncological Outcomes After Open Versus Robot-assisted Laparoscopic Radical Prostatectomy for Localised Prostate Cancer: 8-Year Follow-up. Eur Urol 2021;80:650-60. [Crossref] [PubMed]
10. Alemozaffar M, Sanda M, Yecies D, et al. Benchmarks for operative outcomes of robotic and open radical prostatectomy: results from the Health Professionals Follow-up Study. Eur Urol 2015;67:432-8. [Crossref] [PubMed]
11. Kowalczyk KJ, Yu HY, Ulmer W, et al. Outcomes assessment in men undergoing open retropubic radical prostatectomy, laparoscopic radical prostatectomy, and robotic-assisted radical prostatectomy. World J Urol 2012;30:85-9. [Crossref] [PubMed]
12. Nahas WC, Rodrigues GJ, Rodrigues Gonçalves FA, et al. Perioperative, Oncological, and Functional Outcomes Between Robot-Assisted Laparoscopic Prostatectomy and Open Radical Retropubic Prostatectomy: A Randomized Clinical Trial. J Urol 2024;212:32-40. [Crossref] [PubMed]