Radical prostatectomy: surgical planning, execution, and outcomes

Open radical prostatectomy has evolved in the past 25 years to become the standard of care for most clinically significant tumors localized to the prostate gland. This operation effectively interrupts the natural progression of prostate cancer, yet it is sensitive to nuances in surgical technique and execution that affect cancer control and perioperative and functional outcomes. In general, surgical technique improves with experience, yet involves a steep learning curve that typically requires a couple hundred cases to overcome. Moreover, there is significant variability in outcomes even among experienced surgeons. Surgeons beginning practice and those adopting new techniques, such as robotics, should measure results carefully, realizing that there may be an oncologic learning curve different from that needed to execute the procedure. This article recognizes the formidable challenges for randomized clinical trials (eg, assuring stratification among surgeons in terms of randomization and demonstrating the absence of significant heterogeneity among providers that may explain differences among arms). Research is needed to identify the most effective technical steps that can be taught through formal educational programs.