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Page 2 of 4 Hayes et al. Mini-invasive Surg 2021;5:56 https://dx.doi.org/10.20517/2574-1225.2021.126

Prior to the current era of minimally invasive surgery, the standard approach was open radical
prostatectomy. The postoperative morbidity associated with the procedure however led surgeons to explore
less invasive approaches. Laparoscopic radical prostatectomy (LRP) subsequently gained traction with the
prospect of smaller incisions, less bleeding, fewer postoperative complications and reduced length of
hospital stay . The new anatomical perspective encountered, manipulation required for suturing and
[1]
cumbersome ergonomics no doubt proved challenging, particularly for laparoscopic naïve surgeons.
Perhaps akin to “painting one’s hallway through the letterbox” and associated with a steep learning curve,
many urologists opted to continue their open prostatectomy practice. A more attractive option was needed.

Since the turn of the millennium, the emergence of robotic technology has led to a new dawn in urological
[2]
practice. The first RALP was undertaken in 2000, by Binder et al. , at the Department of Urology of
Frankfurt University.

Perhaps a misnomer, a better description of the robotic approach would be “enhanced laparoscopic surgery”.
Comprising a surgeon console, patient cart and vision cart, the surgeon is provided with improved
ergonomics, more versatile dexterity, beyond that of the human wrist, and enhanced three-dimensional
high-definition optics. The impressive hardware has been further complemented, in recent iterations, with
innovative software such as tremor filtration and intraoperative fluorescence imaging. The da Vinci system,
manufactured by Californian based company Intuitive, is synonymous with robotic surgery and has
remained the market leader since launching in 1999. Prostatectomy lends itself to the robot. The improved
visualisation, for the dissection of the peri-prostatic fascia, down the deep male pelvis, and the resultant
precision it allows, facilitating the preservation of the neurovascular tissue for nerve-sparing approaches,
and the suturing of the vesico-urethral anastomosis. The anatomy of the prostate is so clearly visualised and
appreciated. Ashutosh Tewari offers a helpful analogy whilst arguing the case for the robotic approach, with
its improved visuals, in the Wall Street Journal (2018): “When Swiss watchmakers start working in the dark,
relying on tactile feedback and not magnifying glasses, then we’ll believe that surgery should be done by touch
and not by direct visualisation of the anatomical structures”.

The training of the future generation of minimally invasive surgeons is complimented with robotics. The
learning curve is significantly less daunting and steep, with reported minimum numbers of 40 compared to
200-750 cases for RALP and LRP respectively. Even for the laparoscopic naïve surgeon, following the
completion of 100 RALPs, the evidence would allude to a significant reduction in operating time, estimated
blood loss and complications . Another aspect of the debate to consider, and perhaps not greatly
[3]
acknowledged, is the impact operating might have on our physical health. A significant number of surgeons
report musculoskeletal discomfort, impairing longevity and potentially catalysing early retirement. The
awkwardness associated with the laparoscopic approach contrasts with the adjustable robotic surgical
console. Surgeons when surveyed are in agreement; robotic surgery is a more comfortable experience that
enables mitigation of these occupational ailments .
[4]
Fundamentally it is the patient who should derive most benefit from any difference between techniques.
The Trifecta of prostate cancer survivorship consists of (1) biochemical recurrence-free (2) urinary
continence and (3) sexual potency. A Pentafecta has more recently been proposed that includes (4) no
postoperative complications and (5) negative surgical margins .
[5]

To date, there is a paucity of high-quality literature assessing these 5 pillars of outcome between RALP and
LRP. The LAP01 (2021) Randomised Controlled Trial attempted to address this. Heralded as the first
patient blinded, multi-centre and multi-surgeon study (RALP n = 586, LRP n = 196). Given the widespread