SURGICAL STANDARDS

Robotic surgeon. According to whom?

Why prostate cancer surgery needs honest outcome auditing

By Dr. Sachin Arakere Nataraj
23 September 2026 · Uro-Oncology & Robotic Surgery

“Robotic surgeon” is an easy title to display. The harder question is what happens to the patient after the operation.

Does the cancer remain controlled? Does the patient regain urinary control? What happens to sexual function? Were complications recognised and managed promptly? And do we know these answers for all our patients, or only for those who return with a good result?

As a robotic surgeon, I believe we should welcome these questions. If we promote the sophistication of our technology, we should apply the same seriousness to measuring our results.

A photograph at the console proves very little

Access to a robotic system does not establish independent surgical competence. A course certificate, an impressive operating video or a large cumulative case count tells only part of the story.

Radical prostatectomy requires judgement about who needs surgery, how much tissue to remove, when nerve preservation is appropriate and how to respond when the operation does not go as planned. Learning to operate a platform is one component of that training.

My concern is the gap that can open between the expertise we advertise and the evidence we can offer for it. The appropriate response is structured training, supervised progression, assessment of competence and continued review of outcomes. That responsibility applies to established surgeons as much as to those starting their practice.

What does the literature actually show?

The platform does not guarantee functional recovery

In a randomised study of 326 men, Coughlin and colleagues reported similar urinary and sexual functional outcomes at 24 months after robotic and open radical prostatectomy.¹ This does not establish equivalence across every surgeon, technique or outcome. It does challenge the assumption that the word “robotic” alone guarantees better recovery.

Surgeon-level variation deserves attention

The Michigan Urological Surgery Improvement Collaborative (MUSIC) examined patient-reported sexual outcomes in a cohort of 1,426 men. Significant variation between surgeons persisted after accounting for patient characteristics. In that analysis, case volume was not significantly correlated with sexual function outcomes.²

This is observational evidence, not proof that a particular surgeon is incompetent. Its practical message is that volume should not replace direct measurement of results. It also creates an opportunity for surgeons to learn from one another.

There is more than one learning curve

Bock and colleagues studied 2,672 robotic prostatectomy patients from seven Swedish centres. Erectile function improved with increasing surgeon experience, while continence and oncological outcomes did not show the same pattern.³ Different outcomes therefore require separate assessment. A single case threshold cannot certify excellence across every aspect of the operation.

These studies support a reason to audit. They do not provide a universal pass-or-fail score for individual surgeons.

“95% continent” needs a definition

Consider an illustrative claim: “95% of patients regain continence.” Before interpreting it, I would want to know:

Does continence mean no pads, a precautionary pad or no more than one pad?
Was it measured after catheter removal, at three months or at one year?
Did patients report their own symptoms using a consistent questionnaire?
How many patients were eligible, how many responded and how many were missing?
What was their urinary function before surgery?

The same questions apply to sexual recovery. Baseline erections, age, nerve-sparing eligibility, treatment aids and the definition of recovery all affect interpretation. A percentage without these details can sound reassuring while answering very little.

What a useful prostatectomy audit should contain

I would build routine audit around the following domains, with agreed definitions and follow-up points.

Cancer control: Surgical margins stratified by pathological stage, postoperative PSA, biochemical recurrence using a stated definition, and subsequent treatment. Long-term follow-up should address metastasis and cancer-specific survival where feasible. A margin result alone is not a complete measure of cancer control.
Urinary recovery: Baseline function, pad use and patient-reported urinary symptoms at specified intervals. Record both the severity of leakage and how much it affects daily life.
Sexual recovery: Baseline function, patient-reported recovery and treatment aids, interpreted alongside nerve-sparing status and clinical eligibility.
Safety and recovery: Complications graded consistently, including events within 90 days, readmissions and further procedures. Capture complications treated at another hospital whenever possible.

Validated patient questionnaires, such as EPIC-26, can make the patient's experience part of the record. MUSIC provides a working example of collecting functional information before surgery and at defined postoperative intervals.^2,5

Who is already doing this?

There are established models from which an Indian collaborative programme could learn.

Martini-Klinik, Hamburg: longitudinal outcome collection, including patient surveys, supports review of continence and sexual outcomes by its surgeons.⁴
MUSIC, Michigan: a collaborative infrastructure measures patient-reported recovery before and after radical prostatectomy.⁵
National Prostate Cancer Audit, England and Wales: evaluates patterns of care and treatment outcomes across services.⁶
PCOR-ANZ, Australia and New Zealand: collects clinical and patient-reported outcomes and supplies clinical quality reports for benchmarking.⁷

These programmes differ in their scope and reporting. They are not interchangeable public rankings of individual surgeons. Their shared lesson is that measuring outcomes can become part of organised clinical care.

Fair audit must protect difficult patients

A surgeon treating older patients, more advanced cancers or men with poor baseline function may have different results from someone operating mainly on favourable cases. A crude league table could reward patient selection and discourage appropriate complex surgery.

Audit should include consecutive patients, describe case mix, report missing follow-up and present uncertainty. Comparisons need to account for relevant baseline differences. Small samples require particular caution.

An adverse outcome should trigger thoughtful review. It should not automatically become an accusation. Equally, a lack of published data is not proof of poor surgery. The question is whether there is a credible process for knowing the results and acting on what they reveal.

Should robotic privileges depend on outcome audit?

I believe participation in a credible audit programme should be a condition for granting and renewing robotic surgical privileges, alongside appropriate training and assessment. This is a proposal for professional discussion, not a claim that every jurisdiction currently requires it.

Hospitals also have responsibilities. Reliable follow-up needs staff, patient questionnaires, data quality checks and time for clinical review. Collecting numbers without feedback or a route to improvement achieves little.

For India, a useful next step would be an agreed minimum dataset across participating centres, with confidential comparative feedback and a clear process for addressing concerns. Public reporting should follow only when definitions, completeness and fair interpretation are sufficiently robust.

The question patients can ask

“What outcomes do you measure in your own patients, and what do those results mean for someone like me?”

That is a reasonable question in a consultation. It invites a discussion about cancer control, function, complications and the limits of what any operation can promise.

We should be able to explain our training. We should be willing to examine our results. And we should apply that standard to ourselves before asking it of others.

If we are confident enough to advertise our expertise, we should be willing to measure it.

A clinician's perspective with a focused review of selected literature, rather than a systematic review. This article discusses standards of care and makes no allegation about an individual surgeon or institution.

AI disclosure: AI tools assisted with drafting portions of this article and refining its grammar and language.

References and audit programmes

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