Evidence from Robot-Assisted Laparoscopic Radical Prostatectomy: A Systematic Review

Abstract

Objective

To review the literature available on robot-assisted laparoscopic radical prostatectomy (RALP).

Methods

A literature search was performed using EMBASE, MEDLINE, and Web Science databases through a “free text” protocol, including the following terms: robotic radical prostatectomy, da Vinci, and radical prostatectomy. Three of the authors separately reviewed the records to select the papers relevant for the topic of the review, with any discrepancies solved by open discussion. The selected articles were recorded in an electronic database and analysed by version 13.0 SPSS software.

Results

We identified 71 manuscripts. Eleven papers focused on surgical technique, and 35 manuscripts reported clinical, pathologic, and/or follow-up data. Seven studies included clinical data concerning surgical series with fewer than 10 patients, whereas the remaining 26 series reported larger surgical series of RALP. RALP turned out to be a feasible procedure, with limited blood loss, favourable complication rates, and short hospital stays. Positive surgical margin rates decreased with the surgeon’s experience and technique improving, reaching percentages similar to those of retropubic and laparoscopic series. The available oncologic data are only preliminary. Especially interesting are the data on postoperative continence rates, whereas results on potency, although promising, are based only on a limited number of patients and have to be considered as incomplete and premature.

Conclusion

Literature showed that RALP had a short learning curve and interesting postoperative results, especially with regard to continence recovery. The available data on recovery of erectile function and oncologic follow-up are still incomplete.

Introduction

Although first performed in 1992 [1], laparoscopic radical prostatectomy (LRP) received little attention until the first reports from France. In Europe, the first LRP was performed by Richard Gaston in September 1997. In the following years, Guillonneau and Vallancien standardised the Montsouris technique and facilitated the spread of LRP to several European centres [2], [3], [4], [5], [6], [7].

The shift from open to laparoscopic surgery represents a completely new experience for the surgeon, who must learn a new surgical anatomy and new operative procedures and must deal with new surgical tools. More specifically, the reduction of the range of motion (only 4 df), two-dimensional vision (two-dimensional camera and display), the impaired eye–hand coordination (misorientation between real and visible movements), and the reduced haptic sense (only minimal tactile feedback) are the main restrictions associated with a steep learning curve [7]. For surgeons with no experience with laparoscopy, the learning period could amount to as many as 80–100 consecutive cases, extending over several years [8].

Robotic systems have recently been introduced in an attempt to reduce the difficulty in performing complex laparoscopic urologic procedures, particularly for nonlaparoscopic surgeons [9]. The first system, with a surgeon’s console and remotely controlled telemanipulators, was developed with funding from the US Department of Defense in 1991 and came to be called the Stanford Research Institute (SRI) Green Telepresence Surgery System after Phil Green, PhD, a researcher at SRI [10], [11]. That early system had only 4 df, similar to standard laparoscopic instruments. In 1995, Fredrick Moll licensed the commercial rights to the SRI Green Telepresence Surgery System and used this acquisition to found Intuitive Surgical Systems. After further development, a renovated master–slave clinical system was released in April 1997 in prototype form as the da Vinci surgical system, which received US Food and Drug Administration (FDA) approval in July 2000. The da Vinci robot includes a true three-dimensional imaging system that provides magnification up to ×12. This system also incorporates the patented Endowrist technology, which duplicates the dexterity of the surgeon’s forearm and wrist at the operative site, thus providing 7 df.

The first robotic-assisted radical prostatectomy was performed in May 2000 by Binder et al., a skilled open surgeon without laparoscopic experience who worked in Frankfurt [12]. In the same year, other European surgeons skilled in LRP began performing this new technique [13], [14], [15]. The first robot-assisted prostatectomy in the United States was performed in November 2000 at the Vattikuti Institute of Urology (Detroit, MI) by Vallencien during a mentorship program [16]. Subsequently, the Vattikuti Institute prostatectomy (VIP) team described an original technique and performed >1000 robot-assisted radical prostatectomies until 2004 [17], [18].

Robotic-assisted laparoscopic prostatectomy (RALP) is now in widespread and rapidly expanding use. A great deal of data are now available that allow us to draw some initial conclusions about the reproducibility, safety, and efficacy of RALP in terms of functional and oncologic results. For this reason, we decided to perform a systematic review of this very interesting oncologic field.