Improving Outcomes for Robotic Prostate Surgery

Experience counts! There is more and more scientific evidence that patient outcomes for prostate cancer surgery are directly related to the experience and skill of the surgeon. A recent survey of 72 prostate cancer surgeons demonstrated that the risk for cancer recurrence was reduced by 40% if the surgeon had performed more than 250 open radical prostatectomies. It has also been shown that complications are less in the hands of experienced surgeons. Robotic surgery is equally challenging to master and it has been demonstrated that the “learning curve” for robotic prostatectomy is a minimum of 250 cases. It has also been shown that experience is not the only determinant of surgical outcome since not all “high volume” surgeons achieve equally good results. Thus, when choosing a robotic surgeon it is not only important to ask about experience, but one should also ask about results.

Dr. Ornstein tracks his results carefully in order to help him continually improve his techniques so that he can provide his patients the best opportunity for successful outcomes.


In last 65 robotic prostate cancer surgeries performed by Dr. Ornstein in Naples, the average blood loss was less than 100 cc and no patient required a blood transfusion. A surgical drain was not used in any of these cases and 99% stayed in the hospital less than 24 hours (1 patient stayed 2 days). There was only 1 complication; a wound separation requiring a 2nd surgery to repair. There were no urine leaks the foley catheter was removed within 1 week of surgery for all patients.

The primary goal of robotic prostatectomy is cancer control which is accomplished best by removing the entire prostate and all of the cancer. The true measure of success is long-term cancer free survival, but one of the most important short-term indicators of a successful robotic prostatectomy, as it pertains to prostate cancer control, is the surgical margin status. The surgical margin is determined by the pathologist examination of the prostate once it has been removed from the patient's body. A positive surgical margin means that the pathologist sees cancer cells at the border of the cut edge of surgical specimen (the prostate and surrounding tissue that has been removed from the patient). If it is not an artifact, a positive surgical may be an indicator that prostate cancer has been left behind in the patient and that the patient may need additional prostate cancer treatments such as radition therapy.  Fortunately, when Dr. Ornstein performs robotic prostatectomy the cancer is successfully removed with negative surgical margins 92.3% of the time (i.e. Dr. Ornstein's overall positive surgical margin rate is 7.7%. For patients with prostate cancer that had not invaded beyond the prostatic capsule (stage pT2) the positive surgical margin rate is 5.2%. Dr. Ornstein continuously reviews his results and modifies his technique when he feels that his outcomes can be improved. For example in his first 216 cases the overall positive surgical margin rate was 14.8%. After reviewing multiple videos of prior cases and modifying his technique he was able to lower his positive margin rate to 7.7%.
Another example of where a modification in surgical technique has directly resulted in improved outcomes relates to urinary control. For many robotic surgeons, including Dr. Ornstein, their early experience with robotic prostatectomy was associated with good outcomes in regards to continence, but for many patients it took as long as 1 year for urinary control to recover. Dr. Ornstein recognized that this delay in regaining urinary control negatively impacted his patient’s quality of life so he sought out to modify his surgical technique to hasten recovery of urinary control. To this effect he developed a technical modification that aims to reconstruct the normal anatomy of the sphincter that is responsible for urinary continence. He has termed this novel anti-incontinence procedure the PRASS  technique. This technique is simple to perform, requires only 1 additional suture and takes less than 5 minutes to perform. By incorporating the PRASS technique during robotic prostate surgery (robotic prostatectomy), Dr. Ornstein has improved his 3 month continence rate (1 or fewer pads) from 43 to 91%