Is Robotic Prostate Surgery Better Than Open Surgery

For decades, the standard surgical treatment for localized prostate cancer was open radical retropubic prostatectomy (RRP). While open surgery successfully cured thousands of men, it required a large lower abdominal incision (typically 6 to 8 inches), significant muscle retraction, noticeable intraoperative blood loss, and an extended recovery period.

The introduction and refinement of robotic-assisted radical prostatectomy (RARP)—particularly utilizing the multi-arm da Vinci surgical platform—has fundamentally shifted clinical practice. Today, more than 85% to 90% of all radical prostatectomies in the United States are performed robotically.

Renowned robotic urologic oncologist Dr. David Samadi—Director of Men’s Health at St. Francis Hospital and developer of the SMART (Samadi Modified Advanced Robotic Technique) prostatectomy—has performed more than 10,000 successful prostate surgeries. Having trained and practiced extensively in open surgery, standard laparoscopy, and robotic oncology, Dr. Samadi provides a clear clinical perspective: robotic surgery offers clear anatomical and physiological advantages over open surgery, but the technology is only as effective as the hands operating it.

Understanding the technical differences between open and robotic surgery helps men make an informed decision regarding cancer cure and quality of life.

The Technical Differences: Human Eye vs. 3D Robotic Precision

The prostate sits deep within the narrow, bony confines of the male pelvis, surrounded by the dorsal venous complex, the voluntary urinary sphincter, and the microscopic neurovascular bundles responsible for erections. The limitations of open surgery in this deep anatomical space highlight the strengths of the robotic approach:

1. Direct Line-of-Sight vs. 3D High-Definition Magnification

• In Open Surgery: The surgeon peers down into a deep, narrow pelvic cavity through an open incision. Lighting is provided by overhead surgical lamps and headlamps, and natural visualization is limited by the depth of the pelvis and bleeding from overlying veins.
• In Robotic Surgery (SMART Technique): A dual-optical stereoscopic camera sits millimeters from the surgical field, projecting an immersive, true three-dimensional image with 10x to 15x magnification. Dr. Samadi visualizes tissue layers, microvascular capillaries, and delicate nerve fibers that are invisible to the naked human eye during an open operation.

2. Rigid Hand Instruments vs. EndoWrist® Articulation

• In Open Surgery: Surgical tools are rigid, handheld instruments that operate with limited angles of access in the deep pelvis.
• In Robotic Surgery: Robotic instruments feature EndoWrist® micro-joints capable of rotating with 7 degrees of freedom, exceeding the range of motion of the human wrist. Tremor-reduction software filters out microscopic hand tremors, enabling sub-millimeter precision when dissecting the prostate off the rectum and urethral sphincter.

3. Hemostasis and Blood Loss

• In Open Surgery: The dorsal venous complex bleeds readily once incised, obscuring the field and historically leading to blood transfusion rates of 10% to 20% or higher.
• In Robotic Surgery: The carbon dioxide gas used to expand the abdomen (pneumoperitoneum) exerts gentle positive pressure that naturally tamponades small venous bleeding. Typical blood loss during Dr. Samadi’s SMART procedure is minimal (often under 50 to 100 mL), virtually eliminating the need for blood transfusions.

Comparing Outcomes: Open vs. Robotic Prostatectomy

Clinical comparative data highlights the functional and perioperative distinctions between the two platforms:

The “Technique Over Technology” Philosophy

While the robotic platform provides superior visualization and dexterity, Dr. David Samadi frequently cautions patients against assuming that the robot performs the surgery. The da Vinci system cannot make decisions, cut tissue autonomously, or navigate unexpected anatomical variations.

[ROBOTIC ADVANTAGE: THE THREE CRITICAL PILLARS]

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┌───────────────────────┼───────────────────────┐

▼ ▼ ▼

[SURGICAL PLATFORM] [SURGEON VOLUME] [SMART TECHNIQUE]

• 3D HD Magnification • 10,000+ Cases Done • Athermal Dissection
• EndoWrist Dexterity • Pattern Recognition • Max Urethral Length
• Tremor Elimination • Low Complications • Solo Surgeon Care

The difference between a successful robotic procedure and an open procedure often hinges on the surgeon’s custom technique:

• Athermal Cold Dissection: In traditional open and standard robotic surgeries, electrocautery heat is frequently used to stop bleeding. However, thermal energy radiates outward, burning adjacent cavernous nerve fibers. Dr. Samadi avoids thermal cautery near the nerve bundles, relying strictly on cold micro-scissors and clips to preserve nerve sheath viability.
• Maximum Urethral Length Preservation (MULP): Dr. Samadi leaves the dorsal vein complex unstitched until the end of the operation, allowing him to preserve the maximum possible length of the urethra and safeguard the striated urinary sphincter. This technique promotes faster return of urinary continence compared to traditional open reconstructions.
• Single Surgeon Accountability: Dr. Samadi operates on one patient at a time and personally executes the entire procedure from start to finish, ensuring that tissue planes are manipulated with precision.

Frequently Asked Questions (FAQ)

Is cancer cure higher with robotic surgery compared to open surgery?

Both open and robotic radical prostatectomies achieve comparable oncologic cure rates in experienced hands. However, the 3D magnified optical view and wristed articulation of the robot allow for superior visualization of the prostate apex and bladder neck, which can reduce positive surgical margin rates—especially in tight pelvic spaces.

Why is the catheter removed so much sooner after robotic surgery?

In robotic surgery, the 3D high-definition view allows the surgeon to place precise, watertight microsutures when reconnecting the bladder neck to the urethra (anastomosis). Because the connection is sealed cleanly without tension, the bladder heals faster, allowing the catheter to be safely removed in approximately 7 days, compared to 2 to 3 weeks for open surgery.

Can a patient with prior abdominal surgeries still have robotic prostatectomy?

Yes. Previous appendectomies, hernia repairs (even with mesh), or gallbladder surgeries create scar tissue (adhesions), but an experienced robotic surgeon can lyse (cut through) these adhesions safely under magnification to complete the prostatectomy without converting to an open incision.

Conclusion

Robotic prostate surgery has largely replaced open radical prostatectomy because it minimizes tissue trauma, reduces blood loss, shortens catheter duration, and accelerates overall convalescence while achieving oncologic control. However, robotic technology alone does not guarantee a successful result. The optimal surgical outcome—complete cancer clearance, early return of continence, and preservation of sexual potency—relies on pairing robotic instrumentation with an experienced, high-volume urologic oncologist.

Consult with Dr. David Samadi

Whether evaluating newly diagnosed localized prostate cancer, comparing open versus robotic options, or seeking an expert second opinion on high-risk disease, surgical volume and technique are paramount. Dr. David Samadi is a board-certified urologic oncologic surgeon, Director of Men’s Health at St. Francis Hospital, and pioneer of the SMART robotic technique with more than 10,000 successful surgeries performed.

• Office Locations: 485 Madison Avenue, 21st Floor, New York, NY 10022 & Roslyn, NY
• Clinical Specialization: SMART Robotic Radical Prostatectomy, Open vs. Robotic Surgical Revisions, Continence & Potency Preservation
• Direct Consultation Line: (212) 365-5000
• Case Review Portal:roboticoncology.com