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Hayes et al. Mini-invasive Surg 2021;5:56 https://dx.doi.org/10.20517/2574-1225.2021.126 Page 3 of 4

[6]
acceptance of RALP in Germany, both patients and families tend to self-select the robot. Stolzenburg et al.
randomised at a ratio of 3:1, in favour of RALP, to combat this. Superior continence rates, defined as “no
use of pads or use of a single safety pad”, at 3-month follow-up were demonstrated with RALP (54% vs. 46%,
P = 0.027). This difference was amplified when adjustments were made for bilateral nerve-sparing
approaches (66% vs. 50%, P = 0.005). Secondary outcomes included continence rates as assessed via the
validated International Consultation on Incontinence-Short Form Questionnaire (ICIQ-SF). Again, a
significant difference was demonstrated at 3-month review with RALP (ICIQ sum scores P = 0.003). Despite
being primarily powered for assessment of continence recovery, recovery of potency (erections sufficient for
intercourse) at early 3-month follow up did demonstrate a significant improvement with the robotic
technique (18% vs. 6.7%, P = 0.007). No significant differences in early oncological outcomes were
[6]
documented .

[7]
Prior to LAP01, Asimakopoulos et al. (RALP n = 64, LRP n = 64) illustrated a significantly improved 12-
month evaluation of capability for intercourse (77% vs. 32%, P < 0.0001) with RALP compared to LRP in
their single surgeon series. The improved potency was not associated with impaired oncological
[7]
[8]
outcomes . Porpiglia et al. (RALP n = 60 and LRP n = 60) demonstrated improved 1-year urinary
continence rates (95% vs. 83.3%, P = 0.042) and more favourable rates of erection recovery at 1-year, among
pre-operative potent patients treated with nerve-sparing approaches (80% vs. 54.2%, P = 0.020).

In a recent meta-analysis, Wang et al. (2018) assessed 8 retrospective case series to date comparing the two
[9]
techniques. Reduced rates of postoperative complications (including anastomotic leakage, anastomotic
stenosis, rectal injury, urinary incontinence, and erectile dysfunction) and improved urinary continence
rates, at 1-year follow-up, were reported with RALP (P < 0.00001) .
[9]

On reflection, RALP will remain the standard-of-care approach. Postoperative complications are reduced,
functional outcomes are improved (both continence and potency), and negative surgical margin rates are at
[10]
least comparable . We await long term data post-prostatectomy, including biochemical recurrence-free
rates between the techniques, and anticipate the late oncological outcomes from the LAP01 study. The
robotic operative techniques will be honed, instruments enhanced, and further innovative software released,
with an ever-increasing weaving of technology into the fabric of the operating theatre.

Albeit associated with significant up-front expenditure, when one considers the cumulative long-term
health care costs, including the management of postoperative complications and functional outcomes, the
argument is more nuanced, particularly in high-volume RALP centres. The higher index hospitalisation
[11]
costs appear to be offset by the post-RALP health gains . There exists however, a considerable inequality
gap between those centres across the globe that can afford robotic technologies and those that cannot. One
hopes that over the forthcoming years challenger companies will emerge, competitive pricing ensues, and
the robotic platform with its associated operating theatre costs will continue to dissipate.

Ultimately, let us not become too reliant on the impressive robotic technology at our disposal to achieve
optimal postoperative outcomes. The attainment of the Pentafecta post-radical prostatectomy is reliant on a
myriad of factors that include the comorbid status of our patients, the disease characteristics and most
vitally, the guile, skill and experience of the urologist. The robot has not quite determined the fall of the
surgeon.