Evaluation of Oncological Outcomes from a single Surgeon in relation to Open Radical Prostatectomy and Robotic Assisted Radical Prostatectomy

Abstract

Background

Introduction- Prostate cancer represents a major global and national health burden, accounting for over 397,000 deaths worldwide in 2022 and is the most common cancer diagnosed in men in Ireland, with approximately 4,000 new cases annually. Radical prostatectomy remains a cornerstone of curative treatment. While open radical prostatectomy (ORP) was the standard approach, robotic-assisted radical prostatectomy (RARP) has been widely adopted, with comparable oncological outcomes. Outcomes are surgeon-dependent, and learning-curve effects complicate interpretation of multi-surgeon datasets. Irish data directly comparing ORP and RARP at a single-surgeon level remain limited. This study compares oncological outcomes between ORP and RARP in a single-surgeon cohort.

Objectives- To compare oncological outcomes of ORP and RARP performed by a single surgeon while evaluating temporal trends and adjusting for relevant baseline variables in positive surgical margin and post-operative PSA detectability.

Methods and Materials

Study Design and Setting- This was a retrospective single-surgeon cohort study conducted at Cork University Hospital.

Participants- Between 2017 and 2024, 428 consecutive men underwent radical prostatectomy performed by a surgeon trained in both ORP and RARP. No patients were excluded from the cohort. Of these, 63 patients (14.7%) underwent ORP and 365 patients (85.3%) underwent RARP.

Interventions- Radical prostatectomy was performed using either an ORP or RARP surgical approach.

Outcome Measures- The primary oncological outcomes were surgical margin status (positive vs negative) and post-operative prostate-specific antigen (PSA) detectability, defined as <0.1 ng/mL versus >=0.1 ng/mL at first post-operative follow-up. Secondary analyses assessed pathological stage, temporal trends across the study period, and multivariable adjustment for relevant confounding factors.

Results

Age (ORP: 58.5 +/- 6.0 years vs RARP: 59.4 +/- 6.3 years, p = 0.321) and pathological stage distribution (pT2 vs pT3, p = 0.867) did not differ between groups, while year of surgery differed significantly (p < 0.001). Positive surgical margins declined from 15/62 (24.2%) in the ORP cohort with available margin data to 28/225 (12.4%) in late RARP (p = 0.016), with the greatest improvement observed in pT2 tumours 8/33 (24.2%) vs 13/122 (10.7%), p = 0.046. Margin rates in pT3 tumours were similar across eras 7/29 (24.1%) vs 15/103 (14.6%), p = 0.163. Detectable post-operative PSA (>=0.1 ng/mL) increased from 2/63 (3.2%) in ORP to 34/233 (14.6%) in late RARP (p < 0.001). On multivariable analysis, no variable independently predicted margin positivity, while tumour stage (aOR 3.55, 95% CI 1.72-7.33, p < 0.001) and year of surgery (aOR 1.25, 95% CI 1.03-1.53, p = 0.027) independently predicted PSA detectability. Sensitivity analysis using a PSA threshold of >=0.2 ng/mL attenuated the observed difference in PSA detectability.

Conclusions

RARP achieved oncological outcomes equivalent to ORP, with improving surgical margin rates over time. Post-operative PSA detectability was driven by tumour stage and evolving PSA assay sensitivity rather than surgical approach. Long-term survival and functional outcomes require further evaluation within the Irish context.