Robotic-Assisted Radical Prostatectomy after the First Decade: Surgical Evolution or New Paradigm

Early studies indicate that robotic-assisted radical prostatectomy (RARP) has promising short-term outcomes; however, RARP is beyond its infancy, and the long-term report cards are now beginning. The important paradigm shift introduced by RARP is the reevaluation of the entire open radical prostatectomy experience in surgical technique by minimizing blood loss and complications, maximizing cancer free outcomes, and a renewed assault in preserving quality of life outcomes by many novel mechanisms. RARP provides a new technical “canvas” for surgical masters to create upon, and in ten years, has reinvigorated a 100-year-old “gold standard” surgery. 1. Introduction The first successful report of a laparoscopic nephrectomy was in 1991 [1], and just one year later Schuessler et al. [2] reported the first laparoscopic radical prostatectomy (LRP). They later abandoned the surgery due to its difficulty and great length of time. The challenge of continued development of LRP moved across the Atlantic Ocean when in 1999 two groups in Paris reported fairly large promising series. In 1998, the group led by Dr. Guillonneau at the Institut Mutualiste Montsouris in Paris presented their initial experience with LRP [3] and led the way for other well-trained teams, to achieve comparable oncologic outcomes and perhaps improved functional outcomes, notably groups led by Dr. Jacob in France [4] and Dr. Rassweiler in Germany [5]. The technique was accepted in Europe but only embraced by a few centers in the United States. The laparoscopic experts in Europe were more readily able to overcome the learning curve of LRP and perform some of the more technically challenging aspects of LRP, such as the vesicourethral anastomosis, versus the experienced open but laparoscopically na？ve surgeons in the United States. Thus, laparoscopy was quickly adopted and applied in Europe, but the technical and ergonomic challenges dampened the adoption of LRP over the vast open retropubic radical prostatectomy (RP) experience in North America. To overcome these counterintuitive movements and limitations of vision of standard laparoscopy, newly developed robotic-assisted systems introduced magnified three-dimensional imaging, full-range motion surgical arms, articulating instruments with 7 degrees of freedom, and intuitive movements. Although originally designed for performing battlefield operations with the surgeon controlling the tele-manipulators in a console from a remote distance, robotic systems have been adapted in civilian hospitals and are effective in cardiac surgery and other medical