David I. Lee colleagues reported on a 9-year experience with 61 laparo- scopic radical nephrectomy cases. The cohort was compared to an open counterpart of radical nephrectomy. Blood loss was cut from 451 cc to 172 cc. Hospital stay was 3.4 versus 5.2 days. Pain medication requirement and time to normal activities were much improved. Most importantly however, cancer recurrence rates were identical. Oncological soundness has been demon- strated in this and other large studies.7 Laparoscopic radical prostatectomy was later explored by Clayman and Schussler.8 However they concluded from their series of 9 laparoscopic cases that the procedures were too difficult with very long operative times with a mean of 9.4 hours. Of the 9 patients, 1 had a positive margin and 6 were continent. However, there were significant complications consisting of cholecystitis, thrombophlebitis, and a small bowel port site hernia. Thus, they concluded that the potential benefits of a minimally invasive procedure are lost since the morbidity of the open surgical wound is well tolerated. However, further improvement in laparoscopic skills and refinement of techniques allowed Guillonneau to report on the Montsouris experience in 2000.9 The results of their technique were very encouraging. The average OR time was 3 hours. Estimated blood loss was 250 cc. The conversion rate was zero. Patients were typically discharged to home on day 3 or 4 without a Foley catheter. Thus, the race began to reproduce the results of this series. However, Kavoussi published an editorial questioning the wisdom of tackling prostatectomy with a laparoscopic approach until the procedure became better established by centers of excellence.10 While reports suggested early continence and improved convalescence for the laparo- scopic approach, data regarding cancer control in regard to margins and prostate-specific antigen (PSA) recurrence was still immature. The advent of robot assisted radical prostatectomy One center attempting to reproduce the results of Guillonneau reported on their frustration and subsequent solution. Menon and colleagues reported on their first difficult steps of laparo- scopic prostatectomy. They added the daVinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) and their outcomes began to improve.11 Their initial report focused on 48 standard laparoscopic prostatectomies and 50 robotic assisted cases in a 12-month period. Preoperative characteristics were identical. Most of the postoperative outcomes were very close, however, even in this early series, robotic cases had a lower mean estima- ted blood loss. Also of note, the operative (OR) case time trend seemed to continue to improve using the robotic technique while time improvement seemed to have plateaued with the standard laparoscopic approach. The benefits the robotic surgical system are well touted. Wristed instrumentation, tremor filtration, three dimensional vision and an ergonomic surgeon console clearly benefit surgeons with minimal laparoscopic experience to quickly feel comfortable with even complex laparoscopic reconstructive tasks. Menon followed this initial report with other maturing data from their series. In a report of their initial 1,100 cases, Menon compared his mature series of open radical prostatectomy to his large experience of the new robotic technique.12 They found that their OR was actually faster with the robot. Blood loss was markedly improved as were complication rates, catheter time, hospital stay, postoperative pain score and times to continence and potency.12 Menon’s group most recently reported their series of over 2,700 patients. Their now very mature series demonstrates excellent functional outcomes with 93% of men wearing 1 pad or less per day and 79.2% of men who underwent bilateral nerve sparing were able to have successful sexual intercourse by defined as a positive response to question 2 of the Sexual Health Inventory for Men (SHIM) questionnaire. Perioperative data remained consistent with a mean estimated blood loss (EBL) of 100 cc, 96% day 1 discharge rate, and mean OR time of 154 minutes. Most importantly, however, the 5 year actuarial biochemical free survival was 84%.13 Spurred by Menon’s initial work, Perer et al.14 reported on a their initial experience with robotic prostatectomy. In another article, Ahlering demonstrated excellent proficiency over his learning curve for a surgeon who was laparoscopically naïve. The time to 4-hour proficiency was 12 cases. Mean blood loss was 145 cc. Early continence was excellent with zero pad continence being gained by 81% of patients at 3 months. The mean positive margin rate was 35.5% however this number has dropped substantially in the University of California (UCI) experience. Using a distinct technique change of using a stapler to divide the dorsal venous complex, the pT2 margin rates dropped to 4.7%.15 Smith has also shown an experienced open radical prostat- ectomist can be successful with a robotic approach. Although in early reports of their work they did not see a difference in length of hospital stay16 or transfusion17 rate, Smith et al. did note a significantly lower positive margin rate with use of the robotic approach than with their very large open radical prostatectomy experience at Vanderbilt. They examined the last 200 cases of open against their last 200 robot prostatectomy cases.18 Altho- ugh there was a trend toward higher percentage of tumor to gland involvement in the open cases, the margin rate was lower (15% to 35%) for robotic prostatectomy. For pT2 margins, the difference was striking; 9.4% with the robot versus 24.1% for the open procedure. The location of the positive margins was not different with the apex being the most common area for both approaches. The penn experience The author’s own experience of robot prostatectomy at the University of Pennsylvania has now reached over 1,300 cases to the date of this writing. My personal experience is now over 178 Yonsei Med J http://www.eymj.org Volume 50 Number 2 April 2009