# Enduring the Value of Open Radical Prostatectomy in the Era of Robotics: A Single-Center Experience

## TL;DR

This study shows that open radical prostatectomy provides good cancer control and quality of life outcomes, similar to robotic surgery, especially in areas where robotics are not available.

## Contribution

The study provides evidence that open radical prostatectomy remains effective in resource-limited settings with outcomes comparable to robotic approaches.

## Key findings

- 96% of patients remained disease-free at last follow-up.
- Urinary continence improved significantly over time, with 96% continent at one year.
- Potency was regained in all nerve-sparing patients within one year.

## Abstract

Introduction: Prostate cancer is a significant global health challenge, being the second most common cancer diagnosed in men worldwide. Radical prostatectomy is the standard treatment for localized prostate cancer, be it open, laparoscopic, or robot-assisted.

Aim: While robotic surgery is dominating the era, understanding the outcomes of open retropubic radical prostatectomy for organ-confined prostate cancers in resource-limited countries and centers with no robot facility is crucial.

Methods: A retrospective study was conducted at Sher-i-Kashmir Institute of Medical Sciences between 2013 and 2023, focusing on patients who underwent retropubic radical prostatectomy. The study included a comprehensive patient workup, such as age, comorbidities, serum prostate-specific antigen levels, digital rectal examination, multi-parametric magnetic resonance imaging of the prostate, prostatic biopsy (Gleason's score), bone scan, and optional prostate-specific membrane antigen (PSMA) positron emission tomography (PET) scan. Intraoperative and pathological variables, including T stage, nodal status, extra-prostatic extension, apical margin involvement, bladder neck status, seminal vesical invasion, lymph nodal status, and postoperative outcomes such as biochemical recurrence and the need for hormonal and salvage radiotherapy, were recorded. Follow-up assessments emphasized trifecta outcomes, focusing on cancer control, urinary continence, erectile function, and overall satisfaction.

Results: Out of 84 patients, continence was achieved by 28 (33%) patients at one month, 73 (87%) at three months, 75 (89%) at six months, and 81 (96%) at 12 months, with only three (3.5%) patients remaining incontinent at one year. Among the 32 (27%) patients who underwent nerve-sparing retropubic radical prostatectomy, 20 (62.5%) were potent with phosphodiesterase type 5 (PDE-5) inhibitor assistance at six months, and all regained potency at one year. Biochemical recurrence occurred in three (3.5%) patients, all of whom received hormonal and salvage radiotherapy. Eighty-one (96%) patients remained disease-free at the last follow-up.

Conclusion: Radical prostatectomy remains a widely accepted treatment for organ-confined prostatic carcinoma. As long as the trifecta is satisfactory, it seems meaningless whether performed by minimally invasive or open surgery, particularly when the affordability and nonavailability of robotic surgery are limiting factors. Such a subset of patients, when operated on by open retropubic radical prostatectomy, enjoys good personal satisfaction with similar oncological outcomes as achieved by robotics.