Currently about 40% of men with newly diagnosed prostate cancer elect for curative-intent treatment with radical prostatectomy (RP), more than 90% of which are performed with robotic assistance (RARP). Improvements in RP outcomes have gone hand in hand with improvements in the anatomic understanding of male erectile and continence mechanisms. The evolution of the modern prostatectomy (Figure 1) is fully rooted in anatomy and augmented by tools which help visualize and preserve that anatomy, such as robotics.

Figure 1. Timeline of the evolution of modern-day robotic prostatectomy. AI indicates artificial intelligence; DVC, dorsal venous complex; FDA, Food and Drug Administration; RP, radical prostatectomy; US, United States.

The Early Years: 1866-1982

In 1866 Kuchler described the first radical perineal prostatectomy, which was subsequently modified and disseminated by Hugh Hampton Young in 1905. Although the perineal route provided good access and exposure to the prostate, most urologists had little or no experience with this approach, leading to a high incidence of urinary fistula and rectal injury and limited utilization. Forty years later Millin described the radical retropubic prostatectomy. Both techniques were exclusively performed in a few US centers, often palliatively, for relief of obstructive symptoms. Unsurprisingly, most men elected for radiation rather than curative-intent RP due to the debilitating side effects.

Introduction of Nerve-Sparing Technique (1982-1995)

In 1982, Patrick Walsh developed an anatomic approach to RP, incorporating early dorsal venous complex control and neurovascular bundle preservation which was quickly adopted by urologists leading to increased utilization of RP. Volumes peaked in the early 1990s, likely corresponding to introduction of widespread PSA screening.¹ During that time, in-hospital complication rates decreased from 38% to 30%, and mean length of stay decreased from 8.1 to 5.1 days.¹ The 3-year incontinence rate decreased from 20% in 1991 to 4% in 1995, although the rates of erectile dysfunction remained stable around 30%.¹

The Minimally Invasive Era: Technology Dissemination (1995-2009)

The feasibility of laparoscopic prostatectomy was demonstrated by Clayman in 1991; however, prolonged operative times, a steep learning curve, and a failure to demonstrate major advantages over open surgery limited its widespread adoption in the US (although it continued to be performed in Europe).²

The game changer for the adoption of minimally invasive prostatectomy came with the introduction of RARP in the early 2000s with the Food and Drug Administration approval of the da Vinci robotic system. Shortly after, in 2001, the feasibility of RARP using the Montsouris technique was demonstrated.³ The authors conclude that the “3-dimensional view of the operating field provides a real benefit for the surgeon, and the urethro-anastomosis is easier to perform. The benefit for the patient is presently not very clear… our initial results show that the robotically assisted procedure is at least as safe and effective as the conventional laparoscopic procedure.”³

The technique spread rapidly, and by 2007, at least 40% of all prostatectomies in the US were performed robotically.⁴ Yet, despite rapid uptake, studies generally failed to show that robot prostatectomy is overwhelmingly superior in terms of cancer control and cancer outcomes as surgeon heterogeneity and skill are crucial components.⁵ However, other perioperative measures favored the robotic approach. A patient undergoing robotic prostate surgery during this time could expect a 2-day hospital stay and a 2.2% to 3.5% risk of perioperative blood transfusion (compared to 4.3 days and 16.6%-18.3% risk of transfusion for open).⁴

The Minimally Invasive Era: Technique Dissemination (2010-Present)

Once the robotic approach was firmly entrenched as the primary method of performing RP, focus began to shift to the development and refinement of new, anatomically based robotic techniques to improve patient outcomes.

Although the anterior approach, akin to the open retropubic prostatectomy, remains the most common technique, numerous alternatives have been described. In 2010, the Boccardi or Retzius-sparing robotic-assisted laparoscopic prostatectomy, resembling the open perineal prostatectomy, was introduced.⁶ By extracting the prostate posteriorly through the pouch of Douglas, this technique preserves the support structures vulnerable in the standard anterior approach.⁶ Level 1 evidence indicates an enhanced early return of continence, although the effects on continence beyond 12 months remain somewhat uncertain.⁷ In addition, Kowalczyk demonstrated less penile shortening, lower risk of development of Peyronie’s disease, and lower inguinal hernia risk with this approach.⁸ However, there is concern about a higher risk of positive margins, particularly early in the learning curve.

Tewari introduced an alternative method to Retzius-sparing robotic-assisted laparoscopic prostatectomy known as the “hood-sparing” approach. This technique, inspired by the research of Robert Myers, aims to conserve the periurethral support structures located in the space of Retzius while employing the more conventional anterior approach.⁹ These fascial-sparing techniques are being studied in an ongoing clinical trial (NCT05155501) which aims to enroll and randomize 600 men to standard vs fascial-sparing RP.

Additional techniques include utilization of the da Vinci Single-Port robot, which has allowed for single-site (incision) surgery, extraperitoneal, and transvesical approaches.¹⁰ Proponents note improved cosmesis, decreased opiate use, shorter length of stay, and faster recovery.¹⁰

Spurred by the COVID-19 pandemic, many surgeons have moved toward outpatient and same-day discharge for radical prostatectomy. A recent comparative analysis found that same-day discharge reduced costs by 20% without compromising patient safety or satisfaction in appropriately selected patients.¹¹ Others have moved from selective to universal same-day discharge. Abaza et al reported 99% success rate with same day discharge in 352 consecutive radical prostatectomy cases with a 2.5% readmission rate.¹²

Today, a man may undergo an outpatient prostatectomy with no narcotics and a reasonable expectation of immediate or early continence return (by 6 weeks) depending on the surgeon and technique used.

The Future: Remote Prostatectomy, Artificial Intelligence

Recently the team at Global Robotics Institute reported via social media successful completion of a remote radical prostatectomy, with the surgeon operating on a console 1500 km away from the patient. In addition, with the expiration of multiple da Vinci patents in 2019 several new robotic platforms are in various stages of development. Remote surgery and novel platforms may increase the availability of robotic surgery to more resource-constrained regions.

Others are incorporating robotic technology and utilizing infrared intraoperative imaging along with fluorescent dye (indocyanine green) to explore improvements in lymph node dissection and nerve sparing. The advent of artificial intelligence and machine learning has allowed teams to develop models to identify surgical gestures associated with improved erectile function recovery. Ma et al identified 34,323 individual gestures performed in 80 nerve-sparing robot-assisted radical prostatectomies, which were then classified into 9 distinct dissection gestures (eg, hot cut) and 4 supporting gestures (eg, retraction).¹³ The authors found that less use of hot cut and more use of peel/push are statistically associated with better chance of 1-year erectile function recovery (Figure 2).

Figure 2. Important clinical features (A) and gesture sequences (B) for 1-year erectile function (EF) prediction. Reprinted with permission under CC BY 4.0. Ma R et al, Surgical gestures as a method to quantify surgical performance and predict patient outcomes. NPJ Digit Med. 2022 Dec 22;5(1):187. http://creativecommons.org/licenses/by/4.0/

Looking to the future, technology holds continued promise for delivering improved outcomes to our patients. Robotics are a tool that can’t negate surgical skill, but perhaps they will allow us to better understand surgeon and surgical heterogeneity and improve individual technique.