Robotic assisted radical prostatectomy (RARP) has become the commonest minimally invasive surgical procedure for the treatment of localized prostate cancer. Despite limited data supporting the excellence of RARP over laparoscopic radical prostatectomy (LRP) or open radical prostatectomy (ORP), it has gained wide acceptance among the patients and surgeons.

1. Robotic assisted radical prostatectomy

2. Review Article
Robotic assisted radical prostatectomy
Anshuman Agarwal a
, Praveen Pushkar b,
*
a
Senior Consultant, Department of Urology, Indraprastha Apollo Hospital, New Delhi 110076, India
b
Registrar, Department of Urology, Indraprastha Apollo Hospital, New Delhi 110076, India
1. Introduction
Robot system in surgical field was introduced to reduce the
difficulty in performing complex laparoscopic surgeries. The
first system, with a surgeon's console and remotely controlled
telemanipulators, was developed in 1991 and was named the
Stanford Research Institute (SRI) Green Telepresence Surgery
System after Phil Green, PhD, a researcher at SRI.1,2
In 1995,
Fredrick Moll licensed the commercial rights to the SRI Green
Telepresence Surgery System and used this acquisition to find
Intuitive Surgical Systems. A renovated master–slave clinical
system was later released in April 1997 in prototype form as
the da Vinci surgical system, which received US Food and Drug
Administration (FDA) approval in July 2000. The da Vinci robot
includes a true three-dimensional imaging system that
provides magnification up to Â12. This system also incorpo-
rates the patented Endowrist technology, which duplicates the
dexterity of the surgeon's forearm and wrist at the operative
site, thus providing 7 degrees of freedom.
The first robotic assisted radical prostatectomy (RARP) was
performed in May 2000 by Binder and Kramer. Since then there
a p o l l o m e d i c i n e 1 2 ( 2 0 1 5 ) 8 2 – 8 6
a r t i c l e i n f o
Article history:
Received 25 April 2015
Accepted 1 May 2015
Available online 4 June 2015
Keywords:
Radical prostatectomy
Prostate cancer
Robotics
Laparoscopy
da Vinci
a b s t r a c t
Background: Robotic assisted radical prostatectomy (RARP) has become the commonest
minimally invasive surgical procedure for the treatment of localized prostate cancer. Despite
limited data supporting the excellence of RARP over laparoscopic radical prostatectomy
(LRP) or open radical prostatectomy (ORP), it has gained wide acceptance among the patients
and surgeons.
Objectives: The aim of this review is to present the most recent data and analyze the current
status of RARP.
Methods: Medline was searched from 2005 to March 2015, restricted to English language. The
Medline search used a strategy including medical subject headings (MeSH) and free-text
protocols.
Results: RARP is equivalent to ORP in cancer control and may be advantageous in the
preservation of continence and potency.
Conclusions: Available data suggest that RARP is a valuable therapeutic option for localized
prostate cancer.
# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights
reserved.
* Corresponding author. Tel.: +91 8826144969.
E-mail address: praveenpushkar@yahoo.co.in (P. Pushkar).
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
http://dx.doi.org/10.1016/j.apme.2015.05.001
0976-0016/# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights reserved.

3. is no looking backwards. It has revolutionized the minimally
invasive approach to prostate cancer. Already many institu-
tions have adopted it as a standard of care for localized
prostate cancer.3
Steep learning curve of laparoscopic radical
prostatectomy (LRP) has contributed substantially in the
evolvement of RARP. The first RARP in the United States
was performed in November 2000 at the Vattikuti Institute of
Urology (Detroit, MI) by Vallencien.4
Vattikuti Institute prostat-
ectomy (VIP) team described an original technique and
performed >1000 robot-assisted radical prostatectomies until
2004.5,6
2. Methods
Medline was searched from 2005 to March 2015, restricted to
English language. The Medline search used a strategy
including medical subject headings (MeSH) and free-text
protocols.
A literature review was made using the keywords robotic
prostatectomy, Robot assisted radical prostatectomy, RARP,
robot assisted laparoscopic radical prostatectomy, RALP,
cancer prostate, indications and contraindications, technique,
efficacy, complications, Clavien, and the MeSH terms prosta-
tectomy, oncological outcome, continence, potency, tech-
nique, intraoperative complications, or postoperative
complications.
Case reports, editorials, reviews, and letters to the editor
were not included.
3. Indications and contraindications
The indications of RARP are no different from that of open
radical prostatectomy (ORP). Clinical stage T2 or less with no
evidence of metastasis are indications of curative surgery in
prostate cancer. Severe cardiopulmonary disease and uncor-
rectable bleeding diatheses are absolute contraindications.
4. Technique
Initial approaches described by European surgeons were
antegrade Montsouris technique,7
retrograde Heilbronn tech-
nique,8
and the Frankfurt technique, which is a combined
antegrade and retrograde technique. In the antegrade ap-
proach, dissection of prostate is done from bladder neck to
apex, and in retrograde approach, it is done from apex to
bladder neck. The former is most popular and recommended
for minimizing the bleeding and traction, and optimizing the
nerve-sparing dissection. Menon et al. described an original
approach of robotic radical prostatectomy which is popular-
ized as VIP technique.9
All these are transperitoneal techni-
ques. Later on extraperitoneal technique of RARP was
developed. Though transperitoneal approach has advantages
in those patients requiring pelvic lymph node dissection
(PLND), yet no comparative studies between transperitoneal
and extraperitoneal RARP have been published. Subsequently,
attention was diverted to nerve-sparing techniques. Kaul et al.
described a nerve-sparing VIP technique in 2005 by preserving
prostatic fascia. Kaul et al. called this dissected prostatic fascia
the ‘‘veil of Aphrodite’’.10
RARP is performed using the three- or four-arm da Vinci
Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). Port
placement and number of trocars for the assistant can vary
according to surgeon preference, but it must provide sufficient
distance between the camera and working ports to prevent
internal or external collision of instruments.11
In the com-
monly used transperitoneal anterior/antegrade approach, first
an inverted U-shaped incision is made starting lateral to
medial umbilical ligament of one side extending anterome-
dially dividing the urachus in the midline and then continuing
to the other side. Dissection is carried out, and the bladder is
dropped. Prostatovesical junction is identified by bimanual
bladder neck pinch. Bladder neck is then dissected. The
seminal vesicles and vas deferens are identified and dissected
one by one. Posterior dissection is done in the plane between
seminal vesicles and the surrounding fascia. Lateral to seminal
vesicals are the neurovascular bundles (NVBs). These have to
be preserved while doing nerve sparing approach. Prostatic
pedicles are clipped and divided here. To avoid injury to
cavernous nerves, the minimal use of cautery and traction in
the area of the seminal vesicles is recommended.12
Earlier
interfascial dissection and intrafascial dissection were the
terms used to describe the nerve sparing approach. Now these
terms have become obsolete with change in understanding in
prostatic anatomy. Now newer concepts of incremental nerve-
sparing procedures (full, partial, and minimal) are being used.
Circum-apical dissection of urethra is then done carefully,
as prostatic apex is the most frequent site of positive surgical
margin (PSM). The puboprostatic ligaments are then exposed,
and divided sharply to gain access to the dorsal vascular
complex (DVC). DVC is ligated with either one or two
interrupted sutures, and then divided using scissors, mono-
polar electrocautery, or stapler devices. After the exposure of
the prostatic apex, urethra is transected completely distal to
the apex of prostate. The urethra is divided carefully to avoid
injury to the neurovascular bundles and the sphincter. Finally,
lymph node dissection is done, and the specimen is bagged.
Wide bladder neck is reconfigured using a ‘‘tennis racquet’’
stitch. Posterior reconstruction is done taking a few bites into
the posterior aspect of Denonvilliers' fascia and the retro-
trigonal layer (Rocco stitch). This step is an optional step, but
has been proposed to improve the recovery of urinary
continence. Although no prospective randomized trials have
proven this hypothesis, better results were reported when a
periurethral suspension stitch13
or an anterior reconstruc-
tion14
was added to the Rocco stitch. Vesico-urethral anasto-
mosis is done in running suture using 3/0 V-lock suture (Van
Velthoven suture). Proper mucosal approximation, tension-
free approximation with avoidance of NVBs, and a secure
water-tight anastomosis have to be created. Finally, Foley
catheter and drain are placed. The anastomosis is to be tested
intraoperatively by filling the bladder via catheter with normal
saline and checking for leaks.
Postoperatively, oral diet is started from day 1. Patients are
usually discharged with catheter, which is removed after 7–10
days post-surgery. A cystogram may be done before catheter
removal in patients with high risk of leakage, e.g., post-TURP,
salvage RARP.
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4. 5. Results
There are only two, single-institute, randomized studies that
have been published in the literature comparing RARP with
LRP. It is difficult to analyze the oncological outcomes of RARP
since the data are scarce on long-term biochemical recurrence
and disease free survival. As of now, PSM is regarded as a valid
parameter to compare oncological outcome.
There are a few comparative studies available based on
PSM rates. Two prospective randomized studies comparing
RARP with LRP have shown no difference in PSM out-
comes.15,16
Both the studies had small number of subjects,
so any conclusions could not be made. Till now there is no
long-term large scale randomized controlled trials on oncol-
ogical outcomes. However, most of the studies have reported
either similar or lower PSM rates in RARP, compared to LRP or
ORP. Most PSMs are reported to occur at the apex (6%),
posterolaterally adjacent to the NVB (5%), anteriorly (1–2%), or
at the bladder neck (2%).17
Studies have shown that the
average rate of PSMs in pT2 disease is 8–10%, and in pT3
disease it is about 37%.18
Randomized controlled trials (RCTs) comparing the preva-
lence of PSMs following ORP, LRP, and RARP are lacking.
However, the available evidence from non-randomized stud-
ies suggests that PSMs rates are likely to be similar regardless
of the different possible surgical approaches.18
PSM rates
ranging from 11% to 38% were reported following ORP, from
12% to 31% following LRP, and from 9% to 29% following
RARP.19
Biochemical recurrence-free survival for RARP has been
reported for up to 5 years. Schroeck et al. did not find any
significant difference in PSA recurrence in 1 year of follow-up
when he compared RARP to ORP.20
Similar observations
were also made by Barocas et al., Krambeck et al., and
Drouin et al.21–23
The most detailed RARP series that is available reports
biochemical recurrence-free survival estimates of 95.1%,
90.6%, 86.6%, and 81.0% at follow-up durations of 1, 3, 5, and
7 years, respectively (median follow-up: 5 year).24,25
Parker et al. report that at the 5-year postoperative mark,
only 38% of men returned to their preoperative continence
level.26
Another study found that up to 47% of men had worse
continence at 1 year than they expected preoperatively.27
Ficarra et al. found better urinary continence results after 12
months for RARP patients (97%) compared with ORP patients
(88%).28
The mean time to continence recovery for RARP
patients was 25 days compared with 75 days for ORP patients
( p < 0.001). Tewari et al. also showed a more rapid return of
urinary continence for RARP patients, with a median time to
return of continence for the RARP group of 44 days compared
with 160 days for the ORP group.29
Krambeck et al. found no
statistically significant difference in urinary continence out-
comes between surgical approaches.30
In a recent study of 2625 men who underwent radical
prostatectomy either by robotic approach or by open approach,
21.3% were incontinent after 1 year of RARP compared to 20.2%
after ORP.31
Erectile dysfunction was observed in 70.4% of men
12 months after RARP and 74.7% after ORP.
Regarding the sexual dysfunction following RARP, again the
data comparing the outcomes are limited. Krambeck et al.
reported no significant difference in 1-year potency rates
between ORP and RARP (63% vs 70%; p = 0.08), with potency
defined as erections satisfactory for intercourse with or
without phosphodiesterase type 5 inhibitors.30
Tewari et al.
reported a shorter median time to potency recovery with RARP
than with ORP (180 vs 440 days; p < 0.05).29
A significant advantage for RARP in terms of preserving
erectile function was found by Ficarra et al. in a study that
measured erectile function with the International Index of
Erectile Function-5. With the analysis limited to patients
receiving bilateral nerve-sparing RP with at least 1 year of
follow-up, 49% of ORP vs 81% of RARP patients were potent
( p < 0.001).32
6. Discussion
Post-prostatectomy outcomes may be best represented by the
trifecta concept, which is primarily cancer control and
secondarily recovery of urinary continence and erectile
function.33
Current evidence shows that RARP is equivalent to ORP in
terms of biochemical disease-free survival. A clear association
between PSM and cancer-specific mortality was shown,
indicating that patients with PSM had a 1.7-fold higher risk
of death compared with those without.34
Other studies have
also demonstrated that PSM is a risk factor for disease
progression after surgery.19
Evidence suggests that PSM in
pT2 disease is, for the most part, iatrogenic and hence
potentially avoidable.19
In pathologic pT3 cancers, PSM is
much more frequently associated with the extent of disease.
Positive surgical margin rates after RARP are equivalent to
those reported after ORP and LRP. Biochemical disease-free
survival after RARP seems to be equivalent to other
approaches, although existing data are limited.
Urinary incontinence (UI) has been shown to be one of the
most important factors affecting patient quality of life (QoL)
following radical prostatectomy. There is a lack of standardi-
zation to define UI (no pad or one pad) in the literature, which
hampers accurate assessment of its prevalence. There are a lot
of risk factors for UI following radical prostatectomy (Table 1).
It is recommended that surgeon should counsel patient
preoperatively about the potential for UI and the options
available for correcting and/or minimizing this potential
outcome, such as pelvic floor exercises, medications, or
lifestyle modifications.36
Table 1 – Risk factors for UI following RP.35
Increased age
Obesity
Short membranous urethral length
Post RP anastomotic strictures
Low institutional/surgeon case load
NVB not preserved
BN injury
Large prostate
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5. During RARP, the cavernous nerves can be damaged by
direct mechanical trauma, traction, or thermal energy. Robotic
technology may improve the precision of movements in small
and deep spaces, potentially reducing mechanical, thermal, or
traction injury to nerve tissue. Cautery-free dissection is
recommended to avoid thermal injury of cavernous nerves.
However, the judicious use of thermal energy including
pinpoint coagulation at low cautery levels (i.e., <30 W) applied
briefly (i.e., <1 s) is a valid alternative that has been reported in
the literature. More significant use of thermal energy and/or
higher cautery levels is not advised during nerve-sparing
procedures.
Systematic reviews have shown that RARP is advantageous
in potency recovery in comparison with ORP.37
Postoperative
recovery of erectile function may be influenced by the patient's
preoperative condition and postoperative rehabilitation.
Patients need to be counseled regarding the potential sexual
complications of surgery and available options for post-
surgical management.
7. Complications
The risk of complications is related to various risk factors
including age, body mass index, comorbidity, experience of the
surgeon, previous lower abdominal surgery, previous TURP,
and previous radiation and/or hormone therapy, as well as
intraoperative risk factors (prostate volume, median lobe).
The perioperative complication rate for RARP ranges from
2.5% to 26%.38
Complications include hemorrhage, rectal
injury, ureter injury, anastomotic strictures, urethrovesical
anastomosis urinary leakage, infection, rectourethral fistula,
urinary retention, urinary incontinence, erectile dysfunction,
thrombosis, and lymphocele.
8. Conclusion
A systematic review of the available evidence suggests that in
patients with clinically localized prostate cancer, RARP is
equivalent to ORP in cancer control. Systematic review
indicates that RARP may be advantageous in the preservation
of continence and potency, though well-controlled long-term
prospective studies of functional outcomes of RARP, compared
with ORP, are lacking. RARP definitely offers advantages in
reduced blood loss, lower transfusion rates, and shorter length
of hospital stay than ORP.
Conflicts of interest
The authors have none to declare.
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