Effects of robotic surgery experience on open radical prostatectomy results: single centre & single surgeon experience
Prostate cancer (PCa) is the second most common cancer in men worldwide . Localised PCa accounts for 77% of all cases , and the gold standard treatment for localised PCa is radical prostatectomy (RP) . While only open RP (ORP) was performed in the past, laparoscopic and robot-assisted laparoscopic RP (RALRP) have been available since the early 2000s , . Open, laparoscopic and robot-assisted techniques are comparable in terms of both oncological and functional results . However, there is no doubt that RALRP provides much better visualisation of the surgical field than ORP. The vision system in RALRP provides a clear view of the surgical area at 10 times the magnification of the human eye, providing a tremendous advantage over ORP. Moreover, this vision system can improve our knowledge and experience regarding surgical field anatomy and anatomical variations during RALRP practice. Although many studies have compared RALRP and ORP, we do not yet know how surgeons’ experience with the enhanced visualization associated with RALRP affects ORP outcomes. In this study, we aimed to evaluate peri- and postoperative ORP outcomes before and after surgeons gain robotic surgery experience. 

Study population Patients who underwent RP between 2017 and 2023 were evaluated retrospectively. In our clinic, RALRP was performed between 2019 and 2021 (robotic surgery system was not available after 2021), and patients who underwent RALRP were excluded from the study. All surgeries were performed by a single experienced surgeon (H.I.C.) who had previously performed at least 300 ORP procedures. To minimise the impact of surgical experience during this period, the final 50 patients who underwent ORP before RALRP experience (Group 1) and the first 50 patients after RALRP experience (Group 2) were included in the study. For all patients, the minimum follow-up was 12 months. Age, body mass index (BMI), prostate volume, prostate-specific antigen (PSA), digital rectal examination (DRE), median lobe presence, abdominal surgery history, operation time, nerve-sparing status, estimated blood loss, peri- and postoperative transfusion status, hospitalisation, time to drain removal and time to urethral catheter removal were recorded. Preoperative (Gleason score, positive core number, clinical stage) and postoperative pathological data (Gleason score, tumour localisation, extraprostatic extension, seminal vesicle invasion, lymphovascular invasion, perineural invasion, capsular invasion, positive surgical margin and pathological stage) were analysed. The International Prostate Symptom Score (IPSS) form was used to evaluate patients’ lower urinary tract symptoms. The Charlson Comorbidity Index (CCI) was calculated to analyse preoperative comorbidity status. Peri- and postoperative complications were evaluated according to the Clavien–Dindo classification . Postoperative continence status at 1, 3, 6 and 12 months was evaluated by daily pad count and patients were classified as continent (0 – safety pad), mildly incontinent (1–2 pad) or severely incontinent (> 2 pads). The International Index of Erectile Function (IIEF) short form was used to evaluate patients’ erectile function before surgery and at 1, 3, 6 and 12 months postoperatively. This study was carried out with the approval of the Sakarya University Health Sciences Ethics Committee (approval number: E-71522473-050.01.04-318488-380). Due to the retrospective nature of our study, informed consent from patients was waived by our institutional review board (Sakarya University Health Sciences Ethics Committee). Statistical analysis Statistical analyses were performed using IBM SPSS Statistics for Windows (Version 21.0; IBM Corp., Armonk, NY, USA). The Kolmogorov–Smirnov test was used to evaluate whether the data were normally distributed. Continuous variables were shown by the median and interquartile range (IQR), and the categorical variables were shown as the number of cases (n) and percentage (%). An independent sample t -test or Mann–Whitney U test was used to compare continuous data, and categorical data were analysed with the chi-square test or Fisher’s exact test. Finally, p-values < 0.05 were considered significant. 

Patients who underwent RP between 2017 and 2023 were evaluated retrospectively. In our clinic, RALRP was performed between 2019 and 2021 (robotic surgery system was not available after 2021), and patients who underwent RALRP were excluded from the study. All surgeries were performed by a single experienced surgeon (H.I.C.) who had previously performed at least 300 ORP procedures. To minimise the impact of surgical experience during this period, the final 50 patients who underwent ORP before RALRP experience (Group 1) and the first 50 patients after RALRP experience (Group 2) were included in the study. For all patients, the minimum follow-up was 12 months. Age, body mass index (BMI), prostate volume, prostate-specific antigen (PSA), digital rectal examination (DRE), median lobe presence, abdominal surgery history, operation time, nerve-sparing status, estimated blood loss, peri- and postoperative transfusion status, hospitalisation, time to drain removal and time to urethral catheter removal were recorded. Preoperative (Gleason score, positive core number, clinical stage) and postoperative pathological data (Gleason score, tumour localisation, extraprostatic extension, seminal vesicle invasion, lymphovascular invasion, perineural invasion, capsular invasion, positive surgical margin and pathological stage) were analysed. The International Prostate Symptom Score (IPSS) form was used to evaluate patients’ lower urinary tract symptoms. The Charlson Comorbidity Index (CCI) was calculated to analyse preoperative comorbidity status. Peri- and postoperative complications were evaluated according to the Clavien–Dindo classification . Postoperative continence status at 1, 3, 6 and 12 months was evaluated by daily pad count and patients were classified as continent (0 – safety pad), mildly incontinent (1–2 pad) or severely incontinent (> 2 pads). The International Index of Erectile Function (IIEF) short form was used to evaluate patients’ erectile function before surgery and at 1, 3, 6 and 12 months postoperatively. This study was carried out with the approval of the Sakarya University Health Sciences Ethics Committee (approval number: E-71522473-050.01.04-318488-380). Due to the retrospective nature of our study, informed consent from patients was waived by our institutional review board (Sakarya University Health Sciences Ethics Committee). 

Statistical analyses were performed using IBM SPSS Statistics for Windows (Version 21.0; IBM Corp., Armonk, NY, USA). The Kolmogorov–Smirnov test was used to evaluate whether the data were normally distributed. Continuous variables were shown by the median and interquartile range (IQR), and the categorical variables were shown as the number of cases (n) and percentage (%). An independent sample t -test or Mann–Whitney U test was used to compare continuous data, and categorical data were analysed with the chi-square test or Fisher’s exact test. Finally, p-values < 0.05 were considered significant. 

Age, BMI, CCI, DRE, PSA, prostate volume, and IPSS were similar in both groups ( p > 0.05). Preoperative biopsy Gleason score, positive core number and clinical stage were significantly higher in Group 2 ( p = 0.001; Table 1). Operation time (median = 200 min vs. 115 min, p < 0.001), estimated blood loss (400 mL vs. 200 mL) and perioperative transfusion rates (23% vs. 4%) were lower in Group 2 ( p < 0.001; Table 2). Drain time, hospitalisation time, and urethral catheter removal time were also shorter in Group 2 ( p < 0.001). Nerve-sparing rates were similar, and there was no significant difference between groups regarding postoperative complications and transfusion rates ( p > 0.05). The postoperative oncological data are summarised in Table 3. Postoperative Gleason scores were higher in Group 2. While seminal vesicle invasion and lymphovascular invasion were higher in Group 2 ( p = 0.023 and 0.036, respectively), there was no significant difference between the groups in terms of extraprostatic extension, perineural invasion and capsular invasion ( p > 0.05). In addition, positive surgical margin rates and pathological stage were similar in both groups ( p > 0.05). The incontinence rate was better in Group 2 at postoperative first month ( p = 0.027), but no significant difference was found between the groups 3, 6 or 12 months after surgery ( p = 0.1, 0.3 and 0.6, respectively; Table 4). IIEF scores were similar at the baseline ( p = 0.9), and there was no significant difference at 1, 3, 6 or 12 months post-procedure ( p = 0.1, 0.1, 0.1, and 0.2, respectively; Fig. ). 

ORP is a well-established technique for treating PCa, although surgeons’ preference for laparoscopic and robot-assisted laparoscopic techniques has increased over the past two decades. RALRP provides a superior ability to visualise the surgical field that surpasses the limited vision associated with ORP. We sought to determine whether what surgeons could learn via the RALRP optical system and what impact the learning could have on ORP practices and outcomes. This study compared ORP outcomes before and after surgeons gain experience performing RALRP surgery and to the best of our knowledge, it is the first such study in the literature. Our results showed that operation times and estimated blood loss were reduced, and early continence rates were increased in ORPs after the robotic surgery experience. The apical dissection is the most challenging step in visualising the surgical field during ORP. It becomes even more difficult in patients with obesity and those with narrow and deep pelvises. After the definition and implementation of RALRP, a more precise image could be obtained in this area with up to 10 times magnification. Accordingly, the ligation of some vessels that cannot be seen with the naked eye is possible, which may help improve bleeding control during the transection of the puboprostatic ligament and the ligation of the dorsal venous complex. In a systematic review and meta-analysis comparing RALRP with ORP, the estimated blood loss and transfusion rates were found to be lower with RALRP . Authors have suggested that these advantages are due to its superior visualisation of the surgical field. It has been emphasized that with a widened visual field and three-dimensional imaging, surgeons can perform more precise dissection and haemostasis. Our study found that patients operated after robotic surgery experience had lower estimated blood loss and transfusion rates. The surgeon’s experience with performing RALRPs contributed to this outcome. During robotic surgery, anatomical details that could not be seen with the naked eye in open surgery were clearly observed and defined. Thus, we achieved better blood loss results in ORP after RALRP practice. Our results also showed that operation, drain removal, and hospitalisation times were shorter in patients who underwent ORP after robotic surgery experience. This result is likely due to fewer bleeding and transfusion requirements. In their study investigating the clinical effects of blood loss during ORP, Djavan et al. found that a lower decrease in haematocrit was associated with a shorter hospital stay . Our study indicated that the urethral catheter removal time was shorter in patients who underwent ORP after the robotic surgery experience. Although different suturation techniques are used for RALRP and ORP, such as continuous sutures in RALRP and interrupted sutures in ORP, the urethral catheter removal time was found to be shorter in RALRP compared to ORP in previous studies , . Good visualisation is another critical factor for urethrovesical anastomosis. Providing reasonable bleeding control during apical dissection is essential for the dissection of the urethra. Less bleeding and a cleaner surgical area may contribute to the remaining urethral length. Thus, urethral anastomosis sutures can be placed more confidently, and a more robust urethrovesical anastomosis can be performed. We believe that all these factors encouraged us to remove the catheter after ORP earlier after RALRP experience, therefore the catheter removal time was shorter. The oncological outcomes of RALRP and ORP are considered to be similar , . In our study, the postoperative Gleason score was higher in Group 2, which was consistent with the preoperative prostate biopsy results. This result was attributed to the groups not having homogeneous preoperative prostate biopsy results because they consisted of consecutive patients. Seminal vesicle invasion and lymphovascular invasion rates were also higher in Group 2 because of these patients’ higher Gleason scores. Kristiansen et al. showed that seminal vesicle invasion was associated with a higher Gleason score . Karwacki et al. stated that meta-analyses confirmed the correlation of lymphovascular invasion with a higher biopsy Gleason score . Functional outcomes, specifically continence status and potency, are crucial after RP. Wallerstedt et al. stated that postoperative incontinence and erectile dysfunction are associated with a poor quality of life . In studies comparing RALRP and ORP, no difference was found in postoperative erectile function rates , . Similarly, our results showed that erectile function was similar between the groups; thus, robotic surgery experience did not contribute to it. Furthermore, preserving continence after RP is also important for patients. Unlike ORP, RALRP features improved three-dimensional visualisation and provide more flexible surgical instruments, both of which can contribute positively to improved continence . However, studies with long-term follow-up comparing RALRP and ORP have shown no difference in urinary incontinence after RP , . Other studies, though, have determined that the recovery time for urinary continence after RP is significantly shorter for RALRP than for ORP – . Abdel Raheem et al. established that the time to continence was shorter after RALRP than after ORP. They also found that the early continence rate was higher for RALRP but that there was no difference in the 12th month . Our study found higher continence rates in the first month in patients who underwent ORP after robotic surgery experience. Towards the first year, the groups’ differences gradually decreased and reached similar rates. The better visualisation that robotic surgery offers has also benefited ORP, especially for DVC control and apical dissection. Thus, more meticulous prostatic apex dissection, a relatively bloodless surgical field, and adequate preservation of membranous urethral length may be achieved with an ORP after robotic surgery experience. Better preservation of the bladder neck during bladder neck dissection is another contribution of RALRP experience for ORP. More rapid urinary continence recovery and a higher early continence rate may be attributed to these factors. This study’s main limitations are the small number of patients and its retrospective design. To achieve more objective results, we included the last 50 patients before and the first 50 patients after robotic surgery experience. The study’s main strength is that all patients were operated on by a single surgeon. Moreover, this study is the first to evaluate the effects of robotic surgery experience on ORP. 

The current study shows that after robotic surgery experience, ORP results in shorter operation times, less blood loss, shorter hospital stays, and shorter drain and urethral catheter removal times. Moreover, the early continence rate was higher in the first month. In addition to the ergonomics robotic surgery provides, it contributes significantly to visualising the surgical field. Therefore, it facilitates surgical procedures and can contribute to the anatomy of the surgical field for open surgery. This study revealed that robotic surgery experience can be instructive for open surgery and can contribute to open surgery outcomes. It is time to change the old saying that “those who do not know open surgery should not start robotic surgery.” Nevertheless, more studies are necessary to confirm these results. 

