Robotic-assisted laparoscopic prostatectomy: the ideal application for antegrade nerve-sparing prostatectomy.

Increasing interest in quality of life, we evaluated the func¬tional results in terms of recovery of continence and potency, showing, after a minimum follow-up of 12 months, a 94% rate of complete continence and 70% potency rate after bilateral nerve-sparing RP [8]. In recent years, the antegrade approach was revisited by surgeons involved in minimally invasive surgery owing to the advent of laparoscopic RP (LRP). The laparoscopic approach perfectly complemented the antegrade approach for the technical needs of laparoscopy in general to work in an antegrade direction. Several reports demonstrated that LRP was associated with advantages such as reducing intraoperative blood loss and transfusion requirements, and also involves safe and easy catheter removal with a faster return to normal life. Complication rates and functional results were similar to those reported after open RP [10,11]. Nevertheless, the acceptance and diffusion of traditional LRP was limited worldwide primarily owing to the technical difficulties inherent in the procedure and to the consequent steep learning curve The advent of the da Vinci operating system (Intuitive Surgical, Inc., CA, USA) has changed current urological practice for prostate cancer in many countries owing to 3D imaging dur¬ing the procedure. 3D imaging creates the possibility of having complete control of the three operating arms plus the camera by one surgeon from the console, and the possibility to filter and translate the surgeon’s hand movements into more precise micromovements of the instruments with seven degrees of free¬dom. Indeed, robot-assisted LRP (RALP) had a rapid and wide diffusion across the world, and as for LRP, the antegrade tech¬nique has also become the standard for RALP. Currently, in the USA, more than 75% of RPs are performed using the da Vinci platform [12]. At present in Italy (data reviewed in January 2011), there are 52 Da Vinci Surgical Systems, and of those, six, nine and 15 were installed in 2008, 2009 and from January 2010 to January 2011, respectively. Approximately 5000 robotic proce¬dures have been performed in Italy in 2010, with most consisting of RALPs, with a documented 30–40% yearly increase in the number of robotic procedures in the last few years [Minervini A; Unpublished Data]. The initial speed of this change was attributed to ‘marketing interests of the robot company’ and this cannot be neglected; however, this cannot be sufficient to justify the success of RALP in displacing open retrograde RP and LRP as the standard surgical approaches for clinically localized prostate cancer, both for surgeons who have the facilities of the robotic unit in their centers, and for most patients. However, every proposed minimally invasive therapy should be compared and confirmed to be at least equal in their onco¬logical and functional efficacy and safety to that of open retrograde RP, and only after this step can it be considered a viable alternative and eventually become the standard method. Unfortunately, there is a lack of standardized assessment and outcome reporting in RALP, and this also applies and was probably more evident when analysing older open retrograde RP studies that did not use validated questionnaires for conti¬nence and erectile dysfunction. Therefore, in reports of prostate cancer, when evaluating surgical, functional and oncological results of open retrograde RP and RALP, there is the real risk of not comparing ‘apples with apples’. There is a clear need for randomized controlled trials to be organized that confirm the superiority of one approach over another; however, at present, it seems extremely difficult to perform such a study owing to the difficulties of most skilled robotic surgeons to randomized patients with clinically localized prostate cancer in the open prostatectomy arm of the treatment, as well as the reluctance of most patients that decided to go for a robotic procedure to be operated by an open approach. Available studies demonstrated that in experienced hands, patients undergoing RALP fare very well, with a shorter hospital stay, less blood loss, and faster recovery of potency and continence [13,14]. The oncological outcomes of RALP are still presented using surrogate end points such as the positive surgical margin (PSM) rate. Using these oncological end points, RALP has been shown to be equivalent to open retropubic prostatectomy with a trend toward lower PSM rates in the RALP group [15,16]. Smith et al. evaluated the incidence and location of PSM between 200 open retrograde RPs and 200 RALPs, and concluded that the use of the robot reduces PSM rates as compared with open RP, especially in low- and intermediate-risk patients, and in those treated with the nerve-sparing technique [17]. Significant data supporting the oncological effectiveness of RALP have also been obtained by two recent studies with a long follow-up that considered the more reliable biochemi¬cal disease-free survival (bDFS) rate as the oncological end point [18,19]. Indeed, Menon et al. evaluated a series of 1384 con¬secutive patients who had RALP, and with a median follow-up of 5 years. The authors reported 189 biochemical recurrences, with a reported actuarial bDFS rate at 3, 5 and 7 years of 90.6, 86.6 and 81.0%, respectively. In a multivariate analysis, the strongest predictors of bDFS were pathological Gleason grade 8–10 (hazard ratio: 5.37; p < 0.0001) and pathological stage T3b/T4 (hazard ratio: 2.71; p < 0.0001) [18]. Similar results were also reported by Mottrie et al. in a recent review, where they provided data from a subgroup of 184 patients with a minimum follow-up of 60 months [19]. Specifically, the 3-, 5- and 7-year bDFS rates were 91, 84 and 81%, respectively. Such long-term oncological data can be considered as confirmation of the oncological safety predicted by previous reports that evaluated the PSM rate. In conclusion, the present impressive increase in robotic surgical volume in many countries, initially attributed to ‘marketing inter¬ests of the robot company’ is truly and mainly owing to the use of an effective approach, the antegrade prostatectomy, coupled with the technical advantages of robotic surgery, and to the consequent documented optimal surgical, oncological and functional results obtained. The era of robotic surgery for the treatment of prostate cancer has come and is here to stay, and a decrease in the price of robotic surgery, making this device more affordable and more accessible, would surely contribute to widen the indications for RALP and to convincing those sceptical of RALP, improve the worldwide diffusion of robotic surgery.