AN EVIDENCED BASED ASSESSMENT OF OPEN VS. ROBOTIC RADICAL PROSTATECTOMY

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1 AN EVIDENCED BASED ASSESSMENT OF OPEN VS. ROBOTIC RADICAL PROSTATECTOMY Herbert Lepor, M.D. Professor and Martin Spatz Chairman Department of Urology NYU School of Medicine 1

2 INTRODUCTION The three approaches for the management of localized prostate cancer includes: radical prostatectomy, radiation therapy and active surveillance. There is general agreement that radical prostatectomy is the most definitive approach for curing localized prostate cancer. The curative advantage of radical prostatectomy is likely to translate into a survival advantage for younger men and for those individuals with more aggressive cancers. When radical prostatectomy is performed by experienced surgeons, the complications rates are comparable to those of radiation therapy. Radical prostatectomy is most commonly performed through an open incision or laparoscopically with robotic assistance. It is imperative that you select treatment for your localized prostate cancer based on credible medical evidence and not information that you gather from unfiltered websites which are often developed by the manufacturer of the robot. I am confident when you base your decision on factual information, you will conclude that the robotic approach offers no significant advantages over an open approach. The best way to ensure that you achieve the best surgical result possible is to seek out an experienced surgeon, make certain the expert surgeon is doing your surgery, demand that the surgeon provides you with credible statistics regarding their outcomes, and finally, make sure the surgeon is committed not only to the removal of your prostate, but also outlines a postoperative pathway for maximizing recovery of continence and potency. I am often invited to lecture on issues related to localized prostate cancer at medical meetings and academic institutions throughout the world. I am frequently invited to debate the pros and cons of open vs. robotic approaches to radical prostatectomy. I have included my powerpoint presentation titled Radical Prostatectomy for Localized Prostate Cancer: Technique, Outcomes, Future and a recent article I wrote for Reviews in Urology titled Open vs. Laparoscopic Radical Prostatectomy. Also, included in this information package is a recent editorial comment by the Editor-in-Chief of the Canadian Urological Association Journal. QUESTIONS AND ANSWERS ABOUT OPEN VS. ROBOTIC RADICAL PROSTATECTOMY: AN EVIDENCED BASED ASSESSMENT DOES ROBOTIC PROSTATECTOMY COMPROMISE CANCER CONTROL? The most important outcome following radical prostatectomy is to cure the disease. The biggest disadvantage of robotic prostatectomy is the inability to feel the prostate and surrounding tissues during the dissection of the malignant gland. There is great concern amongst open surgeons that this lack of proprioception may compromise local cancer control. The positive surgical margin rates were recently summarized from major centers performing robotic radical prostatectomy. Positive surgical margins were stratified according to whether the cancer was pathologically localized to the gland (pt 2 ) or whether there was pathological evidence of extracapsular extension (pt 3 ). 2

3 SUMMARY OF POSITIVE SURGICAL MARGINS FOLLOWING ROBOTIC RADICAL PROSTATECTOMY Author Year # Case s Pathologic stage Overall PSM rate (%) PSM rate (%) pt2 pt3a pt3b pt2 pt3a pt3b Menon a [52] % 5% 9% 15% 10.5% 40% 40% Wolfram [54] % 31.5% 22% 12.7% 42% Bentas [46] % 22% 15% 30% 8% 67% Ahlering b [43] % 36% 36% 27% 50% Ahlering b [43] % 27% 16.7% 4.7% 44% Chatelineau [50] % 29% 22% 11.7% 43% Patel [48] % 14% 8% 10.5% 5.7% 26.2% 33% Joseph [45] % 14% 5% 13% 9.9% 37.1% 27.3% I have recently reported my positive surgical margins rates following open radical prostatectomy in an article published in the Journal of Urology titled The New York University Nerve Sparing Algorithm Decreases the Rate of Positive Surgical Margins Following Radical Retropubic Prostatectomy J. Urol, 169: , Table 2 and Figure 2 from this article summarizes my positive surgical margins rates for pt 2 and pt 3 disease p Value No. pts. Preop. PSA: Mean (ng./mi.) No ng./ml. (%) 243 (89) 233 (89) 0.78 No. greater than ng/ml. (%) 29 (11) 30 (11) No. clinical stage (%): 0.07 Tla 3 (11 0 Tlc ) 219 (83) T2a 25 (9) 30 (11) T2b 24 (9) 10 (4) T2c 4 ( 1) 3 (1) T3a ) No. preop. Gleason score (%): l1 1(0.4) (72) 186 (71) 7 66)24) 65 (25) (2) 11 (4) No. pathological stage (%): 0.76 Organ confined 218(80) 208 (79) 3

4 Extraprostatic extension 54 (20) 55 (21) No. tumor percentage of surgical specimen (%): Less than 10% 108 (45) 133 (51) % 96 (40) 97 (37) % 26 (11) 30 (11) 50% or Greater 8 (3) 3 (1) No. surgical margins (%): Neg. 234(86) 242 (92) Pos. 38 (14) 21 (8) Neurovascular bundle spared: No. bi/at. (%) 208 (76) 226 (86) No. unilat. (%) 49 (18) 31 (12) No. none (%) 15 (16) 6 (2) % Spared My overall positive surgical margin rate using the NYU algorithm to guide decisions regarding nerve sparing in 2001 was only 8%. Of 460 sides of the prostate with no extracapsular extension (pt 2 disease), the positive surgical margin rate was 2.2%. Of the 66 sides with extracapsular extension (pt 3 disease), my positive surgical margin rates was 24%. Overall, my positive surgical margin rate following open radical prostatectomy is considerably lower than the robotic series reported in the literature. The composite published literature suggests a higher positive surgical margin rate following robotic radical prostatectomy. We will not know definitely whether this apparent higher positive margin rates associated with robotic radical prostatectomy compromises cancer control until longer follow up is available. 4

5 DOES ROBOTIC PROSTATECTOMY ENHANCE POTENCY RATES? Prior to 1992, no one knew the anatomic location of the nerves controlling erections. Working under the direction of Patrick C. Walsh, I discovered the precise pathway of these microscopic nerves. These nerves are so small that it is ludicrous to state that magnification provided by the robot enhances the ability to see and preserve these nerves. One of the disadvantages of the robotic approach is that the dissection of the nerves off the prostate is performed with electrocautery. The heat associated with the cautery may destroy these fragile nerves. Dr. John Mulhull, one of the worlds leading experts in erectile dysfunction, presented a paper at the national meeting of the American Urological Association in May 2007 titled Sexual Health Misinformation on Robotic Prostatectomy Websites The following is the abstract from this presentation. Sexual Function/Dysfunction/Andrology: Evaluation (Ii) Podium Monday, May 21, :00 Pm - 3:00 Pm, 1034 Sexual Health Misinformation On Robotic Prostatectomy Websites Cesar Rojas-Cruz* and John P Mulhall. New York, NY. Introduction and Objective: Robot assisted radical prostatectomy (RARP) has become a wellestablished approach to the management of localized prostate cancer. Much of the marketing surrounding RARP is associated with advantages of this technique as it pertains to erectile function (EF) recovery. To date, there does not exist a comparative analysis of outcomes with RARP versus open radical prostatectomy (ORP). This analysis was conducted to define what the consumers are reading on the premier source of RARP information, the websites of the robotic prostatectomists. Methods: From October 19-26, 2006 we surveyed the website links posted on the Intuitive Surgical web page ( to hospitals and doctors that offer robot assisted radical prostatectomy (RARP). We reviewed the information related to EF outcomes posted on the center's web pages for accuracy and data support, specifically did the center mention that RARP was advantageous over ORP and was any scientific data presented to support these claims. Results: 116 hospital web pages were reviewed. 75 of them had information regarding the DaVinci surgical system, surgery technique and outcomes. 40 (54%) were university hospitals, the remainder community based urologic practices. 42% contained text that that was explicitly copied from the DaVinci prostatectomy website. 40% (30) had a link to the Intuitive Surgical site. 61% had information related to erectile function (EF) being associated with RARP, however 39% had no sexual health information 5

6 whatsoever. 78% of those that mentioned EF, stated that RARP is associated with a better EF outcome compared with ORP. 52% of the sites stated that RARP is better at preserving EF than OS, 26% stated that EF recovery with the RARP may be better than OS. 15% pages stated that the erectile dysfunction risk associated with RARP may be similar to OS. Only 7 sites (15%) had any specific EF data and only 2 had data pertaining to their own center, the others citing published series. No differences were noted in EF information between university and community centers. Conclusions: More than one third of the robotic prostatectomy websites had zero information regarding erectile function recovery. The majority stated that RARP had better EF outcomes compared to open prostatectomy, despite the absence of scientific data in support of these claims. This misinformation is giving patients who are considering radical prostatectomy unrealistic expectations. Source of Funding: None The take home message from this abstract is don t obtain your information from Intuitive Surgical since their goal is to sell robots and not to provide credible information. So, what is the credible medical evidence comparing open vs. robotic approaches. A multicenter study from several major centers in the United States compared potency data for those men undergoing open, laparoscopic, and robotic assisted laparoscopic radical prostatectomy using the identical outcomes instruments. The data analysis from this large study was presented at the national meeting of the American Urological Association in May Interestingly, this study demonstrated that the open approach was associated with the highest recovery of sexual quality of life scores. Prostate Cancer: Localized (II) Moderated Poster Sunday, May 20, :30 PM - 5:30 PM 552 Patient-Reported Outcomes After Retropubic, Laparoscopic, Or Robot- Assisted Prostatectomy: Results From A Prospective, Multi-Center Study. Andrew A Wagner*, John T Wei, Rodney L Dunn, Brent K Hollenbeck, Gerald L Andriole, Jr, David P Wood, Douglas M Dahl, Jim C Hu, Larry Hembroff, Mark S. Litwin, Christopher S Saigal, Eric A Klein, Adam S Kibel, Louis L Pisters, James E. Montie, Martin G Sanda. Boston, MA, Ann Arbor, MI, St Louis, MO, East Lansing, MI, Los Angeles, CA, Cleveland, OH, Houston, TX. Introduction and Objective: The comparative performance of retropubic (RP), laparoscopic (LAP), and robot-assisted prostatectomy (RAP) in quality of life (QOL) outcome has not yet been established in prospective, multi-center studies. 6

7 Methods: 602 prostate cancer patients were enrolled pre-prostatectomy (375 RP, 110 LAP, 117 RAP) at 8 academic centers. QOL was measured by the EPIC at baseline and 2,6,12, and 24 months after treatment. Although RP was associated with better sexual recovery than LAP and marginally better than RAP, there was also a significant difference in overall surgeon expertise with each procedure at start of study, hence learning curves may have influenced the findings. Continued evaluation of LAP and RAP outcomes is indicated. Source of Funding: NIH RO1-CA95662 Another paper presented at the national meeting of the American Urological Association in May 2007 compared outcomes from a single institution for open, laparoscopic and robotic prostatectomy at 18 months following surgery. Once again, this large study demonstrated that potency was better following open compared to robotic radical prostatectomy. General & Epidemiological Trends & Socioeconomics: Outcomes Analysis Moderated Poster Saturday, May 19, :00 PM - 3:00 PM 19 Prospective Longitudinal Comparison Of Health Related Quality Of Life In Patients Undergoing Treatment For Localized Prostate Cancer: An Evaluation Of Three Surgical Treatment Modalities From A Single Institution. C William Schwab, II*, Michael D Fabrizio, Robert W Given, Donald F Lynch, Raymond Lance, Bethany Barrone, Paul F Schellhammer. Norfolk, VA. Introduction and Objective: With multiple treatment options currently available for the treatment of clinically localized prostate cancer, quality of life (QOL) issues play an important role in the selection process of patients and the evaluation of 7

8 outcomes. We maintain a prospective, longitudinal study using validated instruments to evaluate QOL changes in patients treated with one of three surgical treatment options at a single institution: open radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP), or da Vinci Robotic prostatectomy (dvp). We now report outcomes with a minimum 18 months follow up Methods: An IRB approved questionnaire comprised of validated QOL instruments (UCLA-PCI and AUA symptom index) was sent to preoperatively to patients scheduled to undergo one of the three treatment modalities and again at 1, 3, 6, 9, 12, 18, 24, and 36 months following therapy. Comparisons of the change from baseline were made for disease specific domains. Patients with baseline scores of less than 30 were removed from analysis for that domain. Comparisons were made between the groups to evaluate differences in QOL Results: 575 patients undergoing surgical treatment for localized prostate cancer completed baseline questionnaires with 498 (86.6%) completing one or more post operative surveys. There was no statistical difference between the demographics or baseline values of the three groups. Patients undergoing extirpative treatments experienced adverse effects on all disease-specific QOL domains and trended back towards normal over the subsequent 18 months. Patients undergoing bilateral nerve sparing procedures had similar percent return to baseline of sexual function irrespective of surgical modality. A subgroup comparison by age decade suggested that sexual function was recovered better by younger patients though the groups were too small for statistical comparison. At 18 months the mean percent return to baseline urinary function was 79% for ORP, 76% for LRP, and 73% for dvp. The mean percent return to baseline sexual function was 45% for ORP, 36% for LRP, 38% for dvp. There was no statistically significant difference. Conclusions: All surgical treatment modalities for prostate cancer significantly impact disease specific QOL domains. Our early reuslts with LRP and dvp, has revealed no significant difference in HRQOL outcomes for patients compared to ORP. Source of Funding: None IS ROBOTIC RADIAL PROSTATECTOMY A MORE PRECISE TECHNIQUE FOR PERFORMING RADICAL PROSTATECTOMY? It is important to recognize that the robotic surgeon does not program the robot to perform the surgery. Rather, the robotic surgeon manually controls the robotic arm. Would you ever think your penmanship would be improved by putting your pen into a robotic arm and then manually moving the pen by physically moving the robotic arm? 8

9 The clinical relevance of precision should be based on outcomes such as complications, continence, and potency. No robotic series has ever matched the low complications rates that I have published following open radical prostatectomy. IS THE ROBOT MORE MINIMALLY INVASIVE? The factors that should define minimally invasiveness include: length of incision, operative time, length of hospital stay, severity of pain, and return to activities. Length of Incision I perform open radical prostatectomy through a four inch lower midline incision that is made in between the muscles. Robotic prostatectomy is performed by making four one inch incisions to allow placement of the robotic instruments and another incision under the umbilicus (bellybutton) for removal of the prostate. In cases with large prostates, the cumulative length of the incision for robotic prostatectomy is considerably longer than for the open procedure. Operative Time The mean time for me to perform the radical prostatectomy is approximately 60 minutes. Operative times are increased when I perform simultaneous pelvic lymphadenectomy, hernia repairs, or other secondary procedures. My total mean anesthesia time is less than 2 hours. The anesthesia time for robotic prostatectomy performed by the foremost experts is significantly greater. Length of Hospital of Stay The length of stay is determined by how fast the patient recovers and the criteria for hospital discharge. The overwhelming majority of my patients travel a great distance to NYU Medical Center for their surgery. While many of these patients could safely be discharged the following day after surgery, many individuals feel more secure staying in the hospital a second day. I am happy to accommodate one s preference to stay a second day. Therefore, my published mean length of hospital stay is two days. The surgeons at Vanderbilt are skilled at performing both open and robotic radical prostatectomy. They have recently published that the length of stay following open and robotic prostatectomy are identical. The following is the abstract from the Vanderbilt s recent publication. Comparison of Length of Hospital Stay Between Radical Retropubic Prostatectomy and Robotic Assisted Laparoscopic Prostatectomy Bradford Nelson, Melissa Kaufman, Gregory Broughton, Michael S. Cookson, Sam S. Chang, S. Duke Herrell, Roxelyn G. Baumgartner, Joseph A. Smith Jr. Received 2 May

10 Purpose: Minimally invasive surgery has been shown to decrease postoperative morbidity and length of stay for a number of surgical procedures. Furthermore, length of stay after open radical prostatectomy has decreased dramatically during the last decade. We examined differences in length of stay between a prospectively evaluated cohort of patients who underwent radical retropubic prostatectomy and robot assisted laparoscopic prostatectomy. Materials and Methods: Between January 2003 and March 2006, 1,003 radical prostatectomies were performed at our hospital. Data were collected in prospective fashion and a comparison was made between 374 patients who underwent radical retropubic prostatectomy and 629 who underwent robot assisted laparoscopic prostatectomy. Length of stay, factors influencing length of stay, readmission rates and unscheduled clinic or emergency room visits were evaluated. Patients in the 2 groups were treated using the same clinical care pathway. Results: Overall 94.3% of patients in the radical retropubic prostatectomy group and 97.5% in the robot assisted laparoscopic prostatectomy group were discharged home on or before postoperative day 1. Mean length of stay in the radical retropubic and robot assisted laparoscopic prostatectomy groups was 1.25 (median 1.09) and 1.17 days (median 1.03), which was similar and not statistically different (p = 0.27). Readmission rates were similar in robot assisted laparoscopic and radical retropubic prostatectomy patients (7% and 5%, respectively, p = 0.12). Unscheduled clinic or emergency room visits were the same in the robot assisted laparoscopic and radical retropubic prostatectomy groups (10%, p = 0.95). Conclusions: Patients who underwent radical retropubic prostatectomy or robot assisted laparoscopic prostatectomy can be treated on the same clinical pathway. A targeted hospital discharge date of postoperative day 1 can be achieved in the majority of patients who underwent radical prostatectomy. Readmission rates or unscheduled hospital visits are necessary in a small percent of patients treated with an early discharge program, of which the majority is caused by ileus. 10

11 Prostatectomy Robotic Open p Value LOS (days): Mean Median /629 (10) 37/374 (10) 0.95 No. unscheduled clinic + ER visits/total No. (%) No. hospital readmissions/ total No. (%) 45/629 (7) 18/374 (5) 0.12 Pain control Radical prostatectomy is performed through a four inch incision between the muscles. Robotic prostatectomy is performed via five incisions that are typically larger than 4 cm. Robotic prostatectomy distends the abdominal cavity with air which in some cases has a negative effect on return of bowl activity. The technique for removing the prostate is virtually identical between the approaches. Therefore, common sense would dictate that there should be little or no difference in the degree of pain. Once again, the Vanderbilt group compared pain following open and robotic radical prostatectomy using the same assessment instrument. As one would predict, the degree of pain was identical. Robotic Assisted Laparoscopic Radical Prostatectomy Versus Retropubic Radical Prostatectomy: A Prospective Assessment Of Postoperative Pain Todd M. Webster, S. Duke Herrell*, Sam S. Chang, Michael S. Cookson, Roxelyn G. Baumgartner, Laura W. Anderson, Joseph A. Smith Jr Purpose: Laparoscopic prostatectomy, whether or not coupled with robotic assistance, is often considered less invasive than open radical retropubic prostatectomy (RRP). Minimal postoperative pain has been reported following robot assisted laparoscopic prostatectomy (RALP) but there have been few comparative studies with RRP. We compared perioperative narcotic use and patient reported pain in a prospective patient series. Materials and Methods: Between June 2003 and May 2004, 314 patients underwent radical prostatectomy at our institution, including RALP in 159, RRP in 154 and conversion in 1. All patients were treated on a postoperative clinical pathway that included 30 mg ketorolac intravenously immediately postoperatively, followed by 15 mg intravenously every 6 hours. No regional anesthesia (epidural/spinal) narcotics or patient controlled analgesic pumps were used. All narcotic use was converted to morphine 11

12 sulfate equivalents for purpose of analysis. A Likert scale of 0 to 10 was used to assess pain on the day of surgery, and on postoperative days 1 and 14. Results: The total mean morphine sulfate equivalent ± SD in patients in the RALP and RRP groups was low and, when corrected for length of stay, it was not statistically different (22.41 ± 1.13 vs ± 1.16 mg, p = 0.72). Mean Likert pain perception scores were low at all time points in the RALP and RRP groups but statistically lower on the day of surgery in the RALP cohort (2.05 ± 1.99 vs 2.60 ± 2.25, p = 0.027). Patient reported mean pain scores were almost identical for RALP vs RRP on postoperative days 1 (1.76 ± 1.87 vs 1.73 ± 1.77, p = 0.880) and 14 (2.51 ± 1.91 vs 2.42 ± 1.84, p = 0.722). Conclusions: Perioperative narcotic use and patient reported pain are low regardless of the surgical approach used for radical prostatectomy. RALP did not provide a clinically meaningful decrease in pain compared with RRP, primarily because of the low pain scores reported in each group. Outcomes other than pain will ultimately determine the role of laparoscopic radical prostatectomy and RALP. Return to Activities I have collected over 500 pictures from patients engaged in various activities within 3 weeks of their open radical prostatectomy. These photographs show men flying to California to attend a baseball game, playing golf and tennis, and boating within a week of their surgery. I recently published an article in the peer-reviewed literature where we evaluated the actual time to return to work and activities. Over 50% of the men had returned to work within 14 days following open radical prostatectomy. There is no comparable study in the literature regarding robotic prostatectomy. There is absolutely no reason to assume that robotics would exceed our published outcomes. Time to Return to Work and Physical Activity Following Open Radical Retropubic Prostatectomy Raymond Sultan, Denisa Slova, Bob Thiel, Herbert Lepor Received 28 October 2005 Purpose: We identified factors that predict return to part-time and full-time work and resumption of unlimited physical activity following open radical retropubic prostatectomy. 12

13 Materials and Methods: Between July 1, 2002 and February 28, 2005, 537 men with clinically localized prostate cancer underwent open radical retropubic prostatectomy, as performed by a single surgeon. Intraoperative, perioperative and postoperative parameters were recorded in real time and entered into a database. An assessment was made 1 and 3 months postoperatively regarding time to return to work and unrestricted physical activity. Results: Of the men 50% returned to part-time and full-time work, and unrestricted activity within 14, 21 and 30 days after discharge home, respectively. Patient age and hematocrit at hospital discharge significantly predicted return to part-time and full-time work, and unlimited physical activity. The number of days that the urinary catheter was indwelling was also associated with return to part-time work. Occupation (blue vs white collar) and marital status were also associated with return to full-time work. In the multivariate model a unit increase in hematocrit decreased the time to return to part-time and full-time work, and unrestricted physical activity by 0.50, 0.60 and 0.59 days, respectively. Men with discharge hematocrit greater than 32% were 1.57 (p = 0.059), 1.65 (p = 0.041) and 2.03 (p = 0.002) times more likely to return to part-time and full-time work, and unlimited activity before 14, 21 and 30 days, respectively. Overall models were developed that accounted for 9.4%, 14.0% and 4.0% of the time to return to part-time work, full-time work and unrestricted physical activity, respectively. Conclusions: Efforts to increase discharge hematocrit by minimizing intraoperative blood loss or using preoperative blood management strategies and earlier removal of the urinary catheter have a favorable impact on the return to work and physical activity. Work (days) Activity Statistic Part Time Full Time (days) Mean SD Minimum th Percentile Median th Percentile Max

14 IS THERE LESS BLOOD LOSS FOLLOWING ROBOTIC PROSTATECTOMY? I must concede that the average amount of blood loss following robotic prostatectomy is about 300cc less than the open approach. However, this modest advantage does not translate into a lower transfusion rate. I do believe that less blood loss is associated with an earlier return to activities. Over 90% of my patients follow my recommendation to use preoperative erythropoietin to increase red blood cell mass preoperatively. I have demonstrated that the increase in the red cell volume following erythropoietin increases the red blood cell mass equivalent to 400cc of blood volume. In essence, the use of erythropoietin preoperatively totally neutralizes the advantage of robotic prostatectomy. The blood count of my patients at the time of hospital discharge following open radical prostatectomy is identical to that of men undergoing robotic prostatectomy by expert surgeons. I have also published that the use of erythropoietin is extraordinary safe. WHAT HAPPENS WHEN THE ROBOT BREAKS DOWN? A group of expert robotic surgeons from Virginia Mason Medical Center in Seattle recently reported that the robot dysfunctioned in 3% of cases. Mechanical Failure Rate Of Da Vinci Robotic System. Borden LS Jr, Kozlowski PM, Porter CR, Corman JM. Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, Washington, USA. Introduction: Robotic-assisted laparoscopic radical prostatectomy (RLRP) is playing an increasing role in the surgical management of prostate cancer. The benefits of minimally invasive surgery, enhanced surgeon familiarity with the instrumentation, and increased patient demand has led to the popularity of this surgical technique. There are, however, shortcomings specifically associated with this technology. Notably, instrumentation failure associated with robotic procedures represents a new and unique problem in urological surgery. We examine the rate of mechanical failure of the da Vinci robotic system and its impact on our prostate cancer program. Materials and methods: We reviewed our prospective, institutional review board-approved database of the first 350 RLRP procedures that were scheduled for surgery at our institution. We identified all cases in which mechanical failure of the da Vinci robotic system resulted in surgery being cancelled, postponed, or converted to a conventional laparoscopic or an open radical prostatectomy. 14

15 Results: Nine of the 350 (2.6%) scheduled RLRPs were unable to be completed robotically secondary to device malfunction. Six of the malfunctions were detected prior to anesthesia induction and surgery was rescheduled. Three other malfunctions occurred intraoperatively and were converted either to a conventional laparoscopic (1 case) or an open surgical approach (2 cases). The etiology of the malfunctions included the following: set-up joint malfunction (2), arm malfunction (2), power error (1), monocular monitor loss (1), camera malfunction (1), metal fatigue/ break of surgeon's console hand piece (1) and software incompatibility (1). Conclusions: Although uncommon, malfunction of the da Vinci robotic system does occur and may lead to psychological, financial, and logistical burdens for patients, physicians, and hospitals. Patients should be carefully counseled preoperatively regarding the possibility of robotic mechanical failure. I have never broken down during any of the 3,400 cases performed. What happens when the robot dysfunctions and the robotic surgeon is not experienced performing an open radical prostatectomy? I obviously would never want to be the patient who finds themselves in this predicament. WHO SHOULD PERFORM YOUR RADICAL PROSTATECTOMY? A critical evidenced based assessment of the literature demonstrates that there are no major differences between open and robotic prostatectomy when it comes to: length of hospital stay, severity of pain, catheter time, transfusion rate, return to work, continence rates, and potency rates. The only advantage of robotic prostatectomy is lower blood loss which can be totally counterbalanced by the use of preoperative erythropoietin. The primary disadvantages of the robotic prostatectomy are a steep learning curve, increase cost, uncertainty of cancer control and dysfunction of the robot. Therefore, the decision who should perform your radical prostatectomy should not be determined by whether your surgeon is an open or robotic surgeon, rather it should be based on 1) experience 2) is the experienced surgeon performing my surgery? 3) does the surgeon provide credible information to validate their outcomes? 4) is there a commitment to provide a pathway for recovery of continence and potency? I have performed over 3,400 radical prostatectomies which ranks amongst the highest in the world. I will do your prostatectomy! All of the outcomes presented to you are based on a prospective study and these outcomes are published in the peer-reviewed scientific literature. The easiest one hour for the patient and myself is the one hour during the open radical prostatectomy. The greatest challenge is helping you achieve continence and potency, and guiding you through other issues during your recovery. You have my commitment I will be there all along the way. 15