David Horovitz MD is a Southern California urologist who diagnoses and treats conditions involving the prostate, bladder, kidneys, urethra, and male reproductive system. With advanced training in minimally invasive surgery and endourology, David Horovitz MD employs techniques such as robotic surgery and laparoscopy to enhance surgical precision and support improved patient outcomes. He is co-president and co-founder of the Bakersfield Institute of Advanced Urology and has been affiliated with the San Joaquin Valley Surgical Center.
Board certified and fellowship trained, Dr. Horovitz earned his medical degree from the University of Western Ontario and completed additional fellowship training at the University of Rochester Medical Center. His experience with robotic-assisted procedures provides relevant context for understanding modern surgical approaches to localized prostate cancer.
Robot Assisted Radical Prostatectomy for Prostate Cancer
Prostate cancer primarily affects men above 60 years old and is the second leading cause of cancer mortality in the United States. If cancer is deemed to be clinically localized (has not spread beyond the prostate), treatment options typically include radical prostatectomy or radiotherapy although many forms of prostate cancer do not require immediate treatment and patients may safely be placed on an active surveillance or watchful waiting protocol. Alternative treatments such as High Intensity Focused Ultrasound and focal therapy are still considered experimental and lack robust evidence regarding their efficacy.
Radical prostatectomy consists of surgical removal of the prostate and the tissues surrounding it, including the seminal vesicles, a gland that contributes to semen production. The surgeon may also choose to remove the pelvic lymph nodes at the same time as prostate removal, with this decision based on several clinical and disease-specific factors such as the Gleason score, pre-operative PSA level, clinical stage and percentage of positive biopsy cores. The first robot-assisted radical prostatectomy (RARP) was performed in 2000, and now, roughly 90% of radical prostatectomies performed in the United States utilize this approach.
Most urologists perform this RARP through a transperitoneal approach (through the abdominal cavity) which has minimal perioperative morbidity and excellent long-term oncological and functional outcomes. There are, however, some risks associated with violations of the peritoneal cavity and as a result, many medical centers, particularly in Europe, chose to utilize an extraperitoneal (eRARP) approach.
In 2017, the paper “Extraperitoneal vs. transperitoneal robot-assisted radical prostatectomy in patients with a history of prior inguinal hernia repair with mesh (IHRm)” compared these two surgical approaches. This retrospective review included patients with prior IHRm who underwent RARP between mid-2003 and the end of 2014 and had at least three months of follow-up. 2927 patients had RARP as a primary prostate cancer treatment, of which 286 had a clear history of IHRm. Among this cohort, 170 patients underwent tRARP (transperitoneal) and 116 patients underwent eRARP (exraperitoneal).
Patients in the tRARP group had elevated D’Amico risk classification scores and thus, underwent less nerve-sparing procedures and more concomitant pelvic lymph node dissections. This group also had a higher incidence of having had prior laparoscopic and bilateral IHRm. Using regression analysis with model selection, a trend was noted towards lower operating room time in the tRARP group but no other differences were noted. The researchers concluded that prior IHRm does not preclude the use of eRARP, as quality indicators are similar for tRARP and eRARP procedures.
Many other technical modifications have been described to improve functional and oncological outcomes of RARP. These include efforts to avoid interrupting the fascial planes surrounding the prostate, the suspensory ligaments, the urethral sphincter, and the neurovascular bundles. Further, efforts are often made to maintain maximal urethral length and to spare the bladder neck fibers. A posterior reconstruction is commonly performed to take tension off the vesicourethral anastomosis, control oozing and potentially facilitate the return of continence. Some surgeons suspend the urethra to the pubic symphysis to mimic historic continence operations which where commonly performed to treat female stress urinary incontinence before the widespread introduction of mid urethral and retropubic slings. Finally, single-port systems have been designed to make this procedure even less invasive than standard systems which typically utilize four separate robotic ports.
In summary, RARP is a safe and highly effective method to treat localized prostate cancer. Many specialized techniques have been developed over several decades with the goal of optimizing oncological and functional outcomes. When considering radical prostatectomy of any kind, it is very important to choose a surgeon who possesses the experience, knowledge and skillset required to perform this intricate and precision-focused operation.
About David Horovitz MD
David Horovitz MD is a Bakersfield, California-based urologist specializing in conditions of the urinary system and male reproductive organs. He holds a medical degree from the University of Western Ontario and completed fellowship training in minimally invasive surgery and endourology at the University of Rochester Medical Center. A Fellow of the Royal College of Surgeons of Canada, he has authored scholarly publications and presented research at scientific meetings while maintaining active hospital privileges in Southern California.
