Improvements in robot-assisted prostatectomy: the effect of surgeon experience and technical changes on oncologic and functional outcomes.

PURPOSE To assess the effect of surgeon experience and technical modifications on functional and oncologic outcomes after robot-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS Data were available for 1181 of 1420 consecutive patients undergoing RALP by a single surgeon (DBS). Three techniques were evaluated. The "initial" technique included incision of the lateral endopelvic fascia, suture ligation of the dorsal venous complex (DVC), and anterior tennis-racquet bladder neck reconstruction (n = 590 procedures). The "intermediate" technique included a modified "curtain" nerve-sparing technique and incision of the DVC without previous ligation (n = 170). The "current" technique uses a posterior tennis-racquet bladder neck reconstruction (n = 421). Outcomes included continence and potency recovery and the presence of pT(2) surgical margins assessed in continuous fashion. Validated questionnaires were used to assess baseline and postoperative functional outcomes. RESULTS Continence rates improved between techniques at all evaluated time points, with 1-year continence rates of 88%, 93%, and 96% in the initial, intermediate, and current technique groups, respectively (Ptrend <0.001). One-year potency rates, however, remained similar among the groups, with rates of 77%, 84%, and 79%, respectively (P = 0.58). pT(2) margin rates decreased continuously during the initial technique period, followed by a transient worsening of margin rates during the intermediate time period and a subsequent decrease during the period when the current technique was used. CONCLUSIONS Increased experience with robot-assisted prostatectomy resulted in improvements in oncologic and functional outcomes. Modifications to robot-assisted prostatectomy techniques may aid in this improvement but are also associated with transient worsening of outcomes during the learning curve of the new technique.