Robot-Assisted Radical Prostatectomy: Is the Dust Settling?
2010; Elsevier BV; Volume: 59; Issue: 1 Linguagem: Inglês
10.1016/j.eururo.2010.10.032
ISSN1873-7560
Autores Tópico(s)Urological Disorders and Treatments
Resumo‘‘Friends, Romans, Countrymen, lend me your ears. I cometo bury Caesar, not to praise him. The evil that men dolives after them, the good is oft interred with their bones.So let it be with Caesar.’’William Shakespeare, Julius Caesar, Act III, Scene 2Like Mark Antony, I am not impartial. I confess that I likedoing robotic surgery. I like being able to see, I like theergonomics, and I do not miss the bleeding. Is this a badthing? But Brutus and his friends were honorable men, andAntony swore not to criticize them. Open surgeons arehonorable, and I will not criticize them. (I remember whathappened to Antony in the end.)On November 29, 2010, it will be 10 yr since theestablishment of the first robotic urology program in theworld at the Vattikuti Urology Institute (VUI), Henry FordHospital in Detroit, Michigan, USA [1]. The purpose of VUIwas to explore the role of minimally invasive surgery forthe treatment of prostate cancer—surely an innocent, evenhonorable goal. I was trained by Patrick Walsh, and I thinkthatIamagoodopensurgeon.Itiptoedintolaparoscopywithtrepidation,andthenrushedintorobotics,primarilybecauseIstank at laparoscopy.We were surprised at what happened then. Robot-assisted radical prostatectomy (RARP) was easy for us,certainly easier than laparoscopy, and, within a shortperiod, was easier than open radical retropubic prostatec-tomy (RRP). Within a matter of months, we were quickerand had less bleeding and a lower complication rate thanafter thousands of RRPs. Was this a fluke? Were we kiddingourselves? Maybe, but the article by Di Pierro andcolleagues in this issue of European Urology suggestsotherwise [2].Let’slookattheDiPierropaperinperspective.Theauthorspresent a nonrandomized series of consecutive patientsundergoing RRP and RARP at their center. The authorsmodestly refer to themselves as a low-volume center that isexperienced with RRP but getting started with RARP. Over a2-yr period, the surgeons performed just 150 radicalprostatectomies, 75 open RRPs, followed by 75 RARPs—respectable numbers but scarcely overwhelming. Thesurgeons, however, had a great deal of experience withRRP. The two open surgeons had >15 yr of individualexperience with open radical prostatectomy (ORP), and onehad worked with Urs Studer at Bern for 15 yr, where >100RRPs per year are performed. The robotic surgeon hadworkedwithStuderfor9yrandthenspent6mowithRichardGaston, the father of modern laparoscopicprostatectomy.Inotherwords,hewaswellpreparedtostartanRARPprogram,far more than if his preparation were a one day course in ananimallaboratoryfollowedbymentoringforafewcases(thetraining currently mandated by the robot manufacturer). DiPierro et al acknowledge that they were still in the learningperiodforrobotics,withoperativetimesaveraging330min—longer than seen with more experienced surgeons [3].Yetcomplication rates were lower and functional rates werebetterwithRARPthanwithRRP.Thedifferencesinoperativesafety, early continence, and positive margin rates wereindisputable. The conclusions are generally similar tothose from a much larger series from Vanderbilt University[4] and from us (unpublished data, 2010).Shouldthissurpriseus?Surgeryisavisualart,andnooneargues that vision is better with minimallyinvasive surgery.Thebloodlossisaround10–15%thatofopensurgery[5],andyou can see the apex and do the dissection under vision, notjustbyfeel.Withexperience,youcandissectinfascialplanesclosertothe prostateandpreservethe neurovascularplexus
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