Radical prostatectomy: a comparison of open, laparoscopic and robot-assisted laparoscopic techniques

Surgical approaches to prostate cancer continue to evolve and patient demand for prostatectomy continues to increase. Technical modifications have expanded beyond open surgical approaches to include laparoscopy and more recently robotics. It is important that the enthusiasm that accompanies the introduction of new technology to surgery be accompanied by tangible benefits in terms of comparable oncological or functional outcomes and treatment morbidity.

A literature review was performed comparing individual experiences in large clinical centers and where available comparisons within the same institute between open retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALP).

Mortality was extremely low for each approach, with low post-operative pain-scores and analgesic requirements. Oncological outcomes as assessed by positive surgical margin rate were comparable between RRP (13%-21%), LRP (16%-26%) and RALP (6%-23%). Differences in the manner of data accrual and definition for continence and erectile dysfunction make comparison difficult between patient series, however in single institution series comparable continence rates and time to recovery of continence have been shown.

Early data from LRP and RALP series are comparable to RRP in terms of margin-positivity and functional outcomes. Blood loss and transfusion rates appear to be lower for LRP and RALP compared to RRP, while financial costs remain higher than RRP. Long-term oncological results are keenly awaited. Ideally direct comparison between equally experienced surgeons in similar population groups will be required to demonstrate any inherent advantages or disadvantages of individual surgical approaches.