Improvements in Robot-Assisted Prostatectomy: The Effect of Surgeon Experience and Technical Changes on Oncologic and Functional Outcomes

Abstract

PURPOSE: To assess the effect of surgeon experience and technical modifications on functional and oncologic outcomes after robot-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS: Data were available for 1181 of 1420 consecutive patients undergoing RALP by a single surgeon (DBS). Three techniques were evaluated. The "initial" technique included incision of the lateral endopelvic fascia, suture ligation of the dorsal venous complex (DVC), and anterior tennis-racquet bladder neck reconstruction (n = 590 procedures). The "intermediate" technique included a modified "curtain" nerve-sparing technique and incision of the DVC without previous ligation (n = 170). The "current" technique uses a posterior tennis-racquet bladder neck reconstruction (n = 421). Outcomes included continence and potency recovery and the presence of pT(2) surgical margins assessed in continuous fashion. Validated questionnaires were used to assess baseline and postoperative functional outcomes. RESULTS: Continence rates improved between techniques at all evaluated time points, with 1-year continence rates of 88%, 93%, and 96% in the initial, intermediate, and current technique groups, respectively (Ptrend <0.001). One-year potency rates, however, remained similar among the groups, with rates of 77%, 84%, and 79%, respectively (P = 0.58). pT(2) margin rates decreased continuously during the initial technique period, followed by a transient worsening of margin rates during the intermediate time period and a subsequent decrease during the period when the current technique was used. CONCLUSIONS: Increased experience with robot-assisted prostatectomy resulted in improvements in oncologic and functional outcomes. Modifications to robot-assisted prostatectomy techniques may aid in this improvement but are also associated with transient worsening of outcomes during the learning curve of the new technique.