Robotics and the Perineal Approach to Radical Prostatectomy (Video)

While the retropubic approach is popular, is the perineal approach equally effective and less invasive?

By Jihad A. Kaouk, MD

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Robotic-assisted laparoscopic radical prostatectomy (RALP) via the retropubic approach is the most commonly used procedure to treat localized prostate cancer in the United States. But could there be a less invasive alternative?

Our team at Cleveland Clinic Glickman Urological & Kidney Institute is exploring that question. We have developed a robotic technique using a perineal approach (radical perineal prostatectomy, or RPP) that offers a more minimally invasive surgical route.

After thoroughly exploring RPP in a cadaveric model, we have gone on to assess the clinical feasibility of the technique in patients with localized prostate cancer. The transabdominal approach was contraindicated in our initial cohort of four patients due to previous abdominal surgeries, adhesions or morbid obesity. All had undetectable prostate-specific antigen postoperatively.

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Since then, we have used robotic-assisted RPP in 12 patients with excellent outcomes. We noticed that urine control is almost immediate after Foley removal and postoperative pain was minimal. There was no need to keep a wound drain after surgery and blood loss was minimal in all cases.

Robotic-assisted RPP avoids the intra-abdominal cavity and has been shown to be oncologically safe, with excellent urine control and a short hospital stay.