The 2004 meeting of the American Urological Association occurred in San Francisco in May. This meeting affirmed that prostate cancer mortality in the western world has decreased by a factor of 20-25% since the early 1990s. The paper of Holmberg was much discussed. This publication was the first randomized control study that demonstrated a significant survival advantage for men managed by radical retropubic prostatectomy as opposed to watchful waiting for early prostate cancer. These were positive messages for patients and surgeons alike. The worldwide acceptance of radical prostatectomy for localised prostate cancer has occurred due to excellent results as judged by cancer cure, preservation of continence and preservation of potency. In well trained surgical hands, it is a low morbidity procedure with a negligible mortality rate.

In contemporary practice most men undergoing radical retropubic prostatectomy are discharged by day 4 or day 5 post operatively. Significant complications are rare and most men have good urinary control by four weeks post operatively. A significant number of pre-operatively younger potent men have return of sexual function over a period ranging from 6-36 months. During this time potency is aided by the use of penile injection therapy and/or oral agents. Excellent sexual rehabilitation by the use of inflatable penile prosthetics can be achieved by men who were preoperatively impotent or who do not regain potency post operatively.

Significant complications such as rectal perforation, bladder neck stricture and anastomotic leak are rare when radical prostatectomy is performed by an experienced surgeon.

Contemporary anatomical retropubic prostatectomy, as popularised by Professor Patrick Walsh, is the gold standard treatment for the management of localised prostate cancer against which all other treatment methods must be compared. It is an operation in which excellent outcomes can be achieved for patients with standard operating equipment available at a district hospital level. Quality outcomes are achieved not by high technology, but rather by excellent surgical training and attention to detail. The AUA meeting in San Francisco saw a very significant commercial push for the introduction of so called “robot assisted” laparoscopic radical prostatectomy. This is a technique developed and popularised by two French urologists who perform the procedure repetitively and on a daily basis. These very experienced French surgeons have achieved low morbidity, quality outcomes with their robot assisted technique.

However, their results are not better than the open operation performed in the standard fashion. There is no improvement in continence, potency or margin positivity. At this stage it appears to me that robot assisted laparoscopic radical prostatectomy is an expensive high technology means of achieving the same outcome. What is the advantage? There is no advantage with respect to the key parameters of margin positivity, continence and potency. Hospital stay may be shortened by one or two days. This is of dubious significance to the individual patient when reviewed in the context of the remaining 10-20 years of his life.

The dark side of robot assisted laparoscopic radical prostatectomy is that it is a potentially lethal operation in the hands of an inexperienced surgeon. The excellent results reported by the French school cannot be readily translated to surgeons who are not performing the robotic technique continually and in large numbers. Major and worrisome complications of robotic assisted surgery were reported at the conference including urinary peritonitis, a complication not seen in the standard open technique.

The question remains; is robot assisted laparoscopic radical prostatectomy merely a high tech expensive way of achieving the same outcome or worse, or is it truly a surgical advance? Until this question is answered, the introduction of this technology should proceed with extreme caution. It is well said that there is no such thing as a brave surgeon. It is the patient that takes the risk.