The Posterior Surgical Approach to Robot-Assisted Radical Prostatectomy Facilitates Dissection of Large Glands

Abstract

Despite the abundant data on outcomes after robot-assisted radical prostatectomy (RARP), no study has compared outcomes between an anterior vs a posterior approach. We postulated that a posterior approach may facilitate dissection and lead to improved outcomes in patients with larger prostate glands. After Institutional Review Board approval, 404 patients underwent RARP between 2007 and 2011 by two surgeons at our institution. Of these, 187 patients underwent RARP using a posterior surgical approach while 217 patients were approached anteriorly. Retrospective review of preoperative, intraoperative, and perioperative characteristics and outcomes were compared between the two cohorts using two sample t tests and two proportion z tests to calculate statistical significance. There were no significant differences in age, body mass index, prostate volume, or prostate-specific antigen of the two cohorts. Pathology was similar, although there was a significantly increased proportion of Gleason 9 disease in the anterior approach group. Intraoperative and perioperative outcomes including console time, transfusion rate, positive margins, and complication rates were compared. There was no difference observed in outcomes or console time between the two approaches. When console time was stratified for prostate volume, however, a shorter operative time was seen in the two highest quartiles for prostate volume with the posterior approach (163.8 vs 145.9 min and 183.8 vs 166.2 min, P=0.02, P=0.04). Despite the widespread application of RARP, there is no literature that addresses which surgical approach is most advantageous. Our data suggest that the posterior approach offers shorter operative times in patients with large prostate glands while overall outcomes remain the same between the two approaches.