Robotic vs Laparoscopic vs Open Prostatectomy Compared

Robotic, laparoscopic and open radical prostatectomy remove the same tissue but differ in blood loss, transfusion, hospital stay and recovery. Dr. Amit Goel reads the evidence as favouring the robot over both laparoscopic and open surgery, his preferred technique is the Retzius-sparing approach, and he puts the total cost of robotic surgery at his centre at approximately US$8,700.

Radical prostatectomy, removal of the entire prostate gland with the seminal vesicles, is the most commonly performed operation for prostate cancer. For intermediate-risk and high-risk disease it is the first-choice treatment of Dr. Amit Goel, Senior Director & Unit Head - Urology, Kidney Transplant, Uro-oncology, Robotic Surgery, Max Hospital, Gurugram, India. It can be done through an open incision, laparoscopically or with a surgical robot. Dr. Goel performs both laparoscopic and robotic prostatectomy and trains residents on the robot, and his assessment of the three approaches is grounded in the published comparisons and in the operating theatre. Where surgery sits among the alternatives is set out in prostate cancer treatment options by risk group, and the disease as a whole in the complete guide to prostate cancer symptoms and risk factors, both part of this urology series.

Why bleeding from the dorsal venous complex matters

Bleeding from the dorsal venous complex (DVC), a network of veins in front of the prostate, is the step every prostatectomy technique has to solve, and in Dr. Goel's view laparoscopic and robotic surgery solve it far more easily than open surgery. Surgeons have long dreaded radical prostatectomy for this reason. In the conventional open operation, performed through a large abdominal incision, controlling the DVC is the hazardous step.

Laparoscopic and robotic surgery have changed this. Both are performed under pneumoperitoneum, with the abdomen inflated by gas under pressure, and that pressure itself compresses the veins. Dr. Goel's view is that the DVC can be controlled very easily with either minimally invasive technique, and the operative footage he presents shows the complex being divided with little bleeding.

Prostatectomy outcomes: the trifecta and pentafecta

The trifecta measures urinary continence, erectile function and freedom from biochemical recurrence; the pentafecta adds negative surgical margins and freedom from major complications.

Dr. Goel judges a prostatectomy against defined outcome sets rather than general impressions.

The trifecta covers the three results that matter most to the patient:

• Urinary continence: is the patient dry?
• Erectile function: has potency been preserved?
• Freedom from biochemical recurrence: has the PSA stayed down? A rising PSA after surgery, termed biochemical recurrence, is the earliest marker that cancer remains.

The pentafecta adds two surgical quality measures:

• Negative surgical margins: has the cancer been removed without tumour at the cut edge?
• No major complication: no significant bleeding, no injury to the major vessels such as the iliac vessels, and no injury to the bowel or rectum.

Dr. Goel is candid that some temporary urinary leakage and some risk of erectile dysfunction accompany radical prostatectomy, and that biochemical recurrence can follow any treatment. The value of these frameworks is that they allow the techniques to be compared on the same terms.

Robotic vs laparoscopic vs open prostatectomy: what the studies show

Both minimally invasive techniques outperform open surgery on blood loss, and a 2018 meta-analysis that Dr. Goel cited found robotic surgery superior to laparoscopic surgery on seven measures, from operative time to recovery of erectile function.

Robotic versus open surgery

A study published in The Lancet compared robotic and open radical prostatectomy on urinary function, sexual function and oncological outcome. Urinary function and sexual function scores were the same with the two techniques, and the trial did not show a clear advantage for either approach in early cancer control.

Robotic and laparoscopic versus open surgery

A further study compared all three approaches. Both minimally invasive techniques outperformed open surgery on blood loss. Dr. Goel attributes this to the better DVC control that pneumoperitoneum makes possible. The consequences follow directly: fewer transfusions, and, because the incisions are small, a shorter stay in hospital.

Robotic versus laparoscopic surgery

A 2018 systematic review and meta-analysis that Dr. Goel cited found robot-assisted radical prostatectomy superior to the laparoscopic technique across a broad set of measures:

• Operative time
• Blood loss
• Transfusion rate
• Positive surgical margin rate
• Nerve sparing
• Recovery of full urinary continence
• Recovery of erectile function

In Dr. Goel's reading, the study concluded that the robotic approach is superior to laparoscopic surgery on every one of these parameters, and superior to open surgery on all of them as well. Across the wider literature, the most consistent advantages of robotic over open surgery are lower blood loss, fewer transfusions and a shorter hospital stay; differences in cancer control and long-term continence and potency are less consistent.

His own experience matches the data on the most practical point. Laparoscopic prostatectomy is much more tedious and tiring: it is a long operation with a great deal of intracorporeal suturing. The robot takes much less time and offers what he calls unparalleled vision and precision. His conclusion is that the robot is the most popular and the best surgical platform for radical prostatectomy.

What is Retzius-sparing prostatectomy?

Retzius-sparing prostatectomy removes the prostate from behind the bladder, without entering the space of Retzius in front of it, and in Dr. Goel's assessment it gives earlier return of continence and potency.

The conventional prostatectomy reaches the gland from the front, through the retropubic space of Retzius. Dr. Goel noted that this retropubic approach was associated with problems with erectile function and continence.

The Retzius-sparing approach, introduced by Bocciardi, avoids that space entirely. The surgeon enters behind the bladder, through the retrovesical space, and performs the whole operation from there, from the back of the bladder, without ever entering the space of Retzius.

The advantages, in Dr. Goel's assessment, are substantial. Nerve preservation is excellent, so the rate of erectile dysfunction is very low, and the urinary continence rate is also very good. The technique promises earlier return of both continence and potency, and it is now his preferred approach for radical prostatectomy.

Nerve-sparing prostatectomy: no heat near the nerves

Dr. Goel's central rule for preserving erectile function is to avoid heat near the neurovascular bundles, the nerves and vessels that run alongside the prostate and are responsible for erections. Electrocautery and energy devices should not be used near the nerves.

Instead, he controls the vascular pedicles with clips and divides them with cold cutting, using scissors without current. The cost of this choice is visible: some bleeding is seen where cold cutting is used. Dr. Goel points out that under the robot's roughly ten-fold magnified view even modest bleeding looks prominent, and that it is managed by raising the insufflation pressure rather than by applying energy to the nerves.

Extended pelvic lymph node dissection: how far to go

Dr. Goel's position is that extended pelvic lymph node dissection is the minimum that should be done. The only exception is very low-risk disease, where so extensive a dissection is not warranted.

He distinguishes two templates for pelvic lymphadenectomy:

• Standard dissection: the obturator and external iliac nodes.
• Extended dissection (recommended): the obturator, external iliac and internal iliac nodes, together with the nodes in the triangle of Marcille. The presacral and common iliac nodes may or may not be included.

Laparoscopic radical prostatectomy step by step

Dr. Goel's laparoscopic radical prostatectomy runs in 14 steps, from positioning and posterior dissection to lymph node dissection and closure:

1. Positioning and ports. The patient is placed in the Trendelenburg (head-down) position. The camera port is central, two further ports sit at the same level, and there are two small assistant ports.
2. Posterior dissection first. An incision is made in the retrovesical pouch, and the vas deferens is identified on each side. The seminal vesicles are dissected posteriorly together with the vasa.
3. Dropping the bladder. The obliterated umbilical artery is divided so the bladder can be brought down.
4. Levator fascia and DVC. The levator fascia is incised on both sides. The DVC is then cut without a prior suture; it does not bleed because the pneumoperitoneum pressure has been raised to about 18 mmHg. The DVC is then sutured.
5. Bladder neck. The prostatovesical junction is divided anteriorly using cautery and a shearing force until the catheter comes into view. The catheter is lifted to give upward traction and counter-traction, and the dissection continues posteriorly at the prostatovesical junction until the vasa and seminal vesicles can be pulled up into view.
6. Nerve-sparing pedicle control. The posterior prostatic pedicles are clipped and cut cold on each side, with no current, to preserve the erectile nerves.
7. Urethra and apex. The urethra is divided at the prostatourethral junction, and the apex is freed on all sides.
8. Checking the rectum. The final attachment of the prostate lies just above the rectum, where the risk of rectal injury is high. Once it is divided, an assistant introduces a finger into the rectum to confirm its integrity before the specimen is separated.
9. Haemostasis. Haemostasis is confirmed with gauze and irrigation.
10. Rocco stitch. Before the anastomosis, a Rocco stitch (posterior reconstruction) with a 3-0 barbed suture approximates the periurethral and perivesical tissue, bringing bladder and urethra close so there is no tension on the vesicourethral anastomosis.
11. Vesicourethral anastomosis. A 3-0 double-needle barbed suture is run along the right and then the left posterior plate to complete the anastomosis. If the bladder neck is open, the remainder is closed with a tennis-racket closure.
12. Leak test. The bladder is filled to check for any leak.
13. Lymph node dissection. The pelvic nodes are removed on each side with an ultrasonic energy device. At the end of the right-sided dissection, the bare external iliac artery can be seen pulsating, with the obturator nerve lying below it like a guitar string.
14. Closure. The specimen is removed and a drain is placed.

Dr. Goel stresses how much the laparoscopic operation depends on the team. The surgeon relies entirely on the camera operator for vision, and on an assistant for grasping, counter-traction and suction.

How the robotic operation differs

The robotic operation follows the same principles as the laparoscopic one, with differences that reflect the platform. In a case Dr. Goel has documented while guiding one of his residents through the operation, the bladder neck was divided before the DVC and the posterior Rocco stitch was not needed. The sequence is as follows:

• Posterior dissection with division of both vasa and separation of the seminal vesicles.
• Anterior exposure. The fat is cleared from the front of the prostate, revealing the puboprostatic ligaments and the levator ani, from which the prostate is separated.
• Bladder neck before the DVC. In this case the prostatovesical junction was divided before the DVC was addressed. The posterior pedicles were then clipped and divided with cold cutting and minimal current to protect the neurovascular bundles.
• Bleeding control by pressure. Wherever bleeding appears, the insufflation pressure is raised to 18 to 20 mmHg.
• DVC divided before suturing. The DVC is cut without an initial suture, and the bleeding is controlled by the raised intra-abdominal pressure. Dr. Goel's rationale is that cutting first preserves a good length of urethra for the anastomosis. The DVC is sutured afterwards.
• Anastomosis without a Rocco stitch. Suturing on the robot is easy enough that the posterior Rocco stitch used in the laparoscopic operation is not needed. A double-needle barbed suture creates a mucosa-to-mucosa vesicourethral anastomosis. Before it is completed, the catheter is introduced and its balloon inflated, and the bladder is filled for a leak test.
• Pelvic lymph node dissection as in the laparoscopic operation, followed by removal of the specimen.

Dr. Goel trained on an earlier-generation surgical robot at a cancer centre and now operates on the latest-generation system, which he described as the latest robot available in India.

Robotic prostatectomy cost

Answering a participant's question in the masterclass Live Discussion, Dr. Goel put the average cost of robotic surgery at his centre, as typically offered to patients, at approximately US$8,700. He was explicit that this is the total cost of the robotic operation, not the difference in cost between robotic and conventional surgery. Further cost information is on the robotic radical prostatectomy cost page.

For a patient weighing the platforms, that figure sits against the advantages set out above: lower blood loss, fewer transfusions, shorter hospitalisation, and, in the meta-analytic evidence Dr. Goel cites, better recovery of continence and erectile function than laparoscopic surgery.