Dr. Nelson pointed out that there are no randomized prospectively clinical trials, but definitions should be standardized. He addressed all outcomes in a question directed format.

Dr.William Catalona, Northwestern University, presented the argument for open radical prostatectomy. He focused on the outcomes of this surgical approach as time tested, consistent and excellent. Dr. Catalona cited his data on potency, continence, positive surgical margin rates and survival. He felt that the surgical margin rates and nerve sparing are compromised in laparoscopic surgery primarily due to the use of electrocautery. He thought that tactile ability in open surgery is very important and its absence in robotic surgery is significant. In his perspective, the prostate capsule is more often violated with the laparoscopic approach.

Dr. Mani Menon, Henry Ford Health System presented the case for robotic radical prostatectomy. Dr. Nelson cited Dr. Menon's recent quote in the NEJM stating that robotic RP has better continence and potency outcomes compared to open RP. Dr. Menon used 3 different cutoff rates for biochemical failure and by using >0.2, >0.3 or >0.4ng/ml their outcomes still demonstrated 93% 5-year biochemical free outcomes. He showed data that a PSA recurrence in the literature does not predict for death from CaP. Dr. Menon's data on sexual function in 154 men operated on in 2003 was shown (as defined as successful intercourse) and was 96%. He did not find any effect of age, except slightly decreased outcomes in men >70 years of age. The nerves within the Veil of Aphrodite, according to Dr. Menon may be responsible, although he could not verify that these could actually be implicated in erectile function. Release of the anterior lateral fascia (the Veil of Aphrodite) is what Dr. Menon proposes gives the high potency rates.

Dr. Bertrand Guillonneau, Memorial Sloan Kettering Cancer Center pointed out that comparison is not possible and surgery is "a scientific activity not a religion." Endpoints are often not standardized, which makes comparisons between series inaccurate. He did cite nonrandomized retrospective data comparing his laparoscopic series (485 cases) with an open series (almost 700 cases) of Dr. Peter Scardino. Most outcomes were comparable, although early return of urinary continence was better in the open group. He discussed functional outcomes by a patient survey performed at home and sent directly to a data manager. At one year, continence at 12 months was 59% and 79% in the lap and open groups, respectively. At 14 months the numbers were 79% and 97%, respectively. Dr. Guillonneau felt that 1000 lap RPs would make a surgeon maximally competent.

Written by Christopher P. Evans, MD, a Contributing Editor with UroToday.

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