There is an increasing trend of minimally invasive treatments for prostate cancer with increased utilization of robotic technology contributing largely to this trend. Our study found that increased utilization of MIRP corresponded with a decreasing trend for complications, blood transfusions, lengths of stay and need for reoperation. Additionally, MIRP was found to have fewer associated complications compared with men undergoing open procedures. OBJECTIVE • To determine differences in surgical outcomes by surgical approach during a period of rapid adoption of minimally invasive surgical approaches in radical prostatectomy. PATIENTS AND METHODS • We identified 19 542 men undergoing minimally invasive (MIRP), perineal (PRP), and retropubic (RRP) radical prostatectomy from 2003 to 2006 from the MarketScan® Medstat database, a national employer-based administrative database. • We assessed for temporal trends in perioperative complications, use of postoperative cystography and anastomotic strictures by surgical approach. RESULTS • Between 2003 and 2006, MIRP use increased 33.6% vs 31.8% and 1.7% decreases in RRP and PRP, respectively. During the 4-year study, median length of stay for MIRP decreased from 2.0 to 1.0 day (P= 0.004) and overall perioperative complications decreased from 13.8 to 10.7%, (P= 0.023). • These findings were driven by reductions in genitourinary complications (3.3 to 2.5%, P= 0.049), miscellaneous surgical complications (3.6 to 2.3%, P= 0.006) and intestinal injury (1.5 to 0.1%, P= 0.009). • Median length of stay for RRP decreased from 3.2 to 2.9 days, (P <0.001), overall perioperative complications decreased from 18.1 to 14.6%, (P= 0.007), because of reductions in both wound/bleeding complications (2.0 to 1.1%, P= 0.002) and heterologous blood transfusions. • Men undergoing MIRP vs RRP were less likely to have perioperative complications (12.5 vs 17.1%, P <0.001), blood transfusions (1.5 vs 8.9%, P <0.001) and anastomotic strictures (6.3 vs 12.8%, P <0.001), and they had shorter mean lengths of stay (1.8 vs 3.1 days, P <0.001) during the study period. CONCLUSION • The increased use of MIRP corresponds with a decreasing trend for complications, blood transfusions, lengths of stay and need for reoperation. Additionally, MIRP was found to have fewer associated complications compared with men undergoing open procedures. Further study is needed to assess the impact of tumour characteristics and surgeon volume on these perioperative outcomes as well as effects on long-term cancer control.