Judd Moul, MD Commentary:

To a urologist in my generation who trained in the late 1980s, this seems like a shocking topic to debate! However, as I reflect further, it really does deserve our attention because open prostatectomy is rapidly disappearing. If open radical prostatectomy (RP) experience does matter for urology trainees, the field needs to react and make sure there are experienced open prostatectomists at high volume centers to carry on the art. If open RP becomes a historical footnote, then we seem to be well on our way there in 2021.

Historically, the Golden Era of open RP was from the mid to late 1980s until about 2005. Dr Patrick Walsh ushered in this era with the discovery of the neurovascular bundles and the nerve-sparing technique. Other prominent urological surgeons, such as Peter Scardino, Bill Catalona, Tom Stamey and many others, further popularized and modified the technique and created very high volume practices and training programs that rapidly led to improved urinary and sexual outcomes. Despite this, the golden era was only about 20 years long before the robotic technique (RALP) started to dominate. This meant that only about 10–15 urology graduating classes were trained during the time where they could have gone out and started an open practice. This second generation did include the likes of Herb Lepor, Joel Nelson, Eric Klein, Peter Carroll, Jay Smith and others who took up the craft. Some of these superb surgeons switched to the RALP, further diminishing the chances of the open RP to survive. Now, in 2021, the remaining high volume open RP surgeons, of whom I am one, are in the 60s age group and nearing the end of our surgical careers. Despite the common and undisputed knowledge that volume and experience are the main drivers of outcomes, the open RP has largely been abandoned by the public and most urological surgeons since the RALP era began. If there is a value to open RP in the training of urological residents, we need to take action now. Some have proposed open surgery fellowships, but this has not formally materialized to my knowledge. In a few years, there will be no open RP surgeons left, having gone by the wayside just like radical perineal prostatectomy and straight laparoscopic radical prostatectomy.

Having said this, I believe there is value in our trainees continuing to learn open RP skills. First, knowing and understanding the anatomy from directly seeing and feeling it makes a better overall well-rounded surgeon. Open RP skills help to hone trauma surgery skills, the skill for open simple prostatectomy, radical cystectomy and any open bladder surgery. As other open surgery in urology diminishes, the open RP experience for a resident or fellow becomes even more valuable. Interestingly, as I write this, I was just called to the Durham VAMC to staff a bladder rupture. The exposure will be identical to my RP approach, and my Chief Resident just completed a 4-month rotation with me so he is very comfortable with the technique.

Of course, I am biased in my valuing open RP for resident training. But I do not have any true objective evidence to show that open RP experience makes a better urology graduate. I have tremendous respect for Professor Su and I wish I could beat him on this debate, but I am not sure. There are quite a number of urology training programs already that have no open RP surgeons. Those trainees seem to graduate just fine and enthusiastically enter our field. There is certainly no argument that open RP and the pioneers who perfected it have allowed RALP surgery to take hold and to quickly flourish.

In preparing for this debate, we went to Twitter:

“In your urology training program, is there any faculty member still doing open RP at a volume of more than 25 cases/year?”

• Yes: 31% (48)
• No: 69% (106)

“Do you think there is any value in retaining open RP experience in urology training programs?”

• Yes: 63% (60)
• No: 37% (35)

“Among practicing urologists 35 to 50 years old, is there anyone doing more than 25 open RP cases per year?”

• Yes: 13% (10)
• No: 87% (70)

“At your program, what percentage of RP cases are performed by open technique?”

• <10%: 75% (69)
• 10%–30%: 14% (13)
• 31%–60%: 4% (4)
• >60%: 7% (6)

In summary, there is discordance between the perceived value of open RP training and access to it. While a clear majority of respondents (63%) believed open RP training is valuable, only a minority of cases are performed with this technique and even fewer by high volume masters of the craft (13%). In conflating a lack of access to training with its relevance, we risk producing an era of trainees who–despite a desire to learn open RP–will be unable to truly master this approach. Conscious effort on the part of training programs and the advisory bodies overseeing them will be needed to keep access to this technique available for both trainees and patients

Li-Ming Su, MD Commentary:

It is indisputable that the introduction of robotic surgery into the field of urology stands among a handful of events that have truly transformed the field. Just as extracorporeal shock wave lithotripsy, ureteroscopy, anatomical nerve-sparing prostatectomy, medical therapy for benign prostatic hyperplasia and androgen deprivation therapy for prostate cancer are recognized as sentinel events leading to a complete frame shift in urological management of disease, robotic prostatectomy has likewise been rapidly adopted, now overshadowing traditional open retropubic prostatectomy. As a consequence of the current widespread practice of robotic prostatectomy as the dominant surgical approach for prostate cancer, it is only natural that open radical prostatectomy has had a significantly diminished role in resident education and training as compared to decades past. In this debate, I will do my best to remain impartial and unbiased, especially since I was trained as an open prostatectomist well before becoming a pioneer in minimally invasive prostatectomy. I will seek to convince the audience that this shift toward robotic from open prostatectomy surgery is not only practical but represents a new training paradigm.

Training our residents to perform robotic prostatectomy is pragmatic as there is evidence that patients who choose to undergo prostatectomy for the treatment of prostate cancer are more likely to choose the robotic approach over open surgery.¹ Furthermore, recent data confirm a growing trend with robotic prostatectomy as the dominant surgical technique for the treatment of prostate cancer in the United State.² The attributes of enhanced magnification and superior high-definition, 3-dimensional visualization associated with robotic surgery has allowed surgeons to modify the surgical technique based upon the anatomical foundations first established in open surgery, including enhanced quantitative and qualitative cavernous nerve preservation to improve postoperative sexual function and improved mucosa-to-mucosa vesicourethral anastomosis with various reconstructive techniques to improve postoperative urinary continence. These important modifications have resulted in outcomes (both oncologic and functional) equivalent to and in some cases even better than open surgery, with the added patient benefits of reduced blood loss, pain and recovery. Where I will agree with Dr. Moul is that surgeon volume and experience are undoubtedly the most important factors in providing an optimal patient outcome. With this in mind and with the overwhelming shift towards robotic prostatectomy, a greater emphasis needs to be placed on the quality of robotic surgical training during residency and fellowship in order to help our learners achieve optimal outcomes for their patients.

Training learners how to perform robotic prostatectomy is not only practical, but also represents a paradigm shift from the days of open surgical training. This assertion is supported by the simple fact that although the anatomy has not changed, robotic prostatectomy at its essence is a very different operation from open surgery and requires a very different set of skills. The simple fact is that the loss of kinesthetic feedback in robotic surgery requires that a surgeon rely more upon visual cues than tactile feedback to perform a meticulous operation. This is supported by the abundance of research in the occupational and physical therapy arena involving patients with sensory and proprioceptive losses who are trained to rely upon visual cues to navigate their activities of daily living.³ Furthermore, there is growing evidence in our own literature that novice surgeons learn and perform differently than expert surgeons when performing minimally invasive surgery. Objective kinematic motion studies show that expert surgeons are far more efficient in their instrument and camera movements as compared to novice surgeons who show more erratic patterns when completing steps of robotic prostatectomy. Novel eye tracking studies have shown that the visual fixation is higher and cognitive load lower in expert surgeons as compared to novice surgeons when performing simulated and live laparoscopic procedures.⁵ Functional brain imaging studies of surgeons undergoing motor and visual laparoscopic tasks demonstrate that novice surgeons utilize regions of the cerebral cortex involved more with implicit and visuospatial learning, whereas these same regions are relatively deactivated in the expert surgeon.⁴ In sharp contrast, experts who presumably have already acquired learning of how to perform the task relied more upon the motor cortex of the brain involved with effective execution of the laparoscopic task than novice surgeons.⁶ Taken together, these studies suggest a neurological underpinning to how minimally invasive procedures are learned between surgeons of different levels. Furthermore, it suggests that enhancing “brain training” through simulation exercises in various settings (dry lab, animate, augmented/virtual, high fidelity 3-D models) may be critical and perhaps even more important than exposure to open prostatectomy to help learners achieve proficiency in performing robotic prostatectomy.

Lastly, to say that exposure of residents to open prostatectomy is no longer relevant is perhaps an overstatement and an oversimplification. Exposure to open surgery in all areas of urology is a good thing, but the undeniable fact is that resident exposure to open radical prostatectomy is declining rapidly and simply becoming less relevant. Nevertheless, we should remember that our trainees are still afforded the opportunity to learn about the periprostatic anatomy and tissue planes through other open surgical procedures, ie open cystectomy and simple prostatectomy, in lieu of routinely performing open radical prostatectomy. Although the giants of open nerve-sparing prostatectomy who came before us were critical in laying the anatomical foundations of where robotic surgery has taken us today, I would submit to my colleagues that we have entered into a different era of advanced technology that requires a pioneering spirit and intentional effort at finding new and creative ways to train the next generation on these techniques, which likely will require a completely different approach than that used for open surgical training.