Platinum Priority – Review – Prostate Cancer Editorial by Peter C. Albertsen on pp. 365–367 of this issue Best Practices in Robot-assisted Radical… [619112]

Platinum Priority – Review – Prostate Cancer
Editorial by Peter C. Albertsen on pp. 365–367 of this issue
Best Practices in Robot-assisted Radical Prostatectomy:
Recommendations of the Pasadena Consensus Panel
Francesco Montorsia,*, Timothy G. Wilsonb, Raymond C. Rosenc, Thomas E. Ahleringd,
Walter Artibanie, Peter R. Carrollf, Anthony Costellog, James A. Easthamh, Vincenzo Ficarrai,
Giorgio Guazzonij, Mani Menonk, Giacomo Novarai, Vipul R. Patell, Jens-Uwe Stolzenburgm,
Henk Van der Poeln, Hein Van Poppelo, Alexandre Mottriep
aVita-Salute San Raffaele University, Milan, Italy;bCity of Hope Cancer Center, Duarte, CA, USA;cNew England Research Institutes, Inc., Watertown, MA,
USA;dUniversity of California, Irvine, Irvine, CA, USA;eUniversity of Verona, Verona, Italy;fUniversity of California, San Francisco, San Francisco, CA, USA;
gRoyal Melbourne Hospital, Melbourne, Australia;hMemorial Sloan-Kettering Cancer Center, New York, NY, USA;iUniversity of Padua, Padua, Italy;
jFondazione San Raffaele Del Monte Tabor, Milan, Italy;kHenry Ford Hospital, Detroit, MI, USA;lGlobal Robotic Institute, Florida Hospital Celebration
Health, Orlando, FL, USA;mUniversity of Leipzig, Leipzig, Germany;nNetherlands Cancer Institute, Amsterdam, The Netherlands;oUniversity Hospitals
Leuven, Leuven, Belgium;pO.L.V. Clinic, Aalst, BelgiumEUROPEAN UROLOGY 62 (2012) 368–381
available at www.sciencedirect.com
journal homepage: www.europeanurology.com
Article info
Article history:
Accepted May 25, 2012
Published online ahead of
print on June 7, 2012
Keywords:
ConsensusEvidence-based reviewProstateProstate cancerProstatic neoplasm
Prostatectomy
Radical prostatectomyRoboticsRARPRALPRobot-assisted radical
prostatectomy
Robot-assisted laparoscopicradical prostatectomyAbstract
Context: Radical retropubic prostatectomy (RRP) has long been the most common surgical
technique used to treat clinically localized prostate cancer (PCa). More recently, robot-
assisted radical prostatectomy (RARP) has been gaining increasing acceptance among patients
and urologists, and it has become the dominant technique in the United States despite a
paucity of prospective studies or randomized trials supporting its superiority over RRP.
Objective: A 2-d consensus conference of 17 world leaders in prostate cancer and radical
prostatectomy was organized in Pasadena, California, and at the City of Hope Cancer Center,
Duarte, California, under the auspices of the European Association of Urology Robotic Urology
Section to systematically review the currently available data on RARP, to critically assess
current surgical techniques, and to generate best practice recommendations to guide clin-
icians and related medical personnel. No commercial support was obtained for the conference.
Evidence acquisition: A systematic review of the literature was performed in agreement with
the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement.
Evidence synthesis: The results of the systematic literature review were reviewed, discussed,
and refined over the 2-d conference. Key recommendations were generated using a Delphiconsensus approach. RARP is associated with less blood loss and transfusion rates compared
with RRP, and there appear to be minimal differences between the two approaches in terms ofoverall postoperative complications. Positive surgical margin rates are at least equivalent with
RARP, but firm conclusions about biochemical recurrence and other oncologic end points are
difficult to draw because the follow-up in existing studies is relatively short and the overall
experience with RARP in locally advanced PCa is still limited. RARP may offer advantages in
postoperative recovery of urinary continence and erectile function, although there are meth-odological limitations in most studies to date and a need for well-controlled comparative
outcomes studies of radical prostatectomy surgery following best practice guidelines. Surgeon
experience and institutional volume of procedures strongly predict better outcomes in all
relevant domains.
Conclusions: Available evidence suggests that RARP is a valuable therapeutic option for
clinically localized PCa. Further research is needed to clarify the actual role of RARP in
patients with locally advanced disease.
#2012 Published by Elsevier B.V. on behalf of European Association of Urology.
* Corresponding author. Vita Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy.
Tel. +39 022 6437286; Fax: +39 022 6437298.
E-mail address: montorsi.francesco@hsr.it (F. Montorsi).
0302-2838/$ – see back matter #2012 Published by Elsevier B.V. on behalf of European Association of Urology.
http://dx.doi.org/10.1016/j.eururo.2012.05.057

1. Introduction
Radical retropubic prostatectomy (RRP) has long been the
most commonly used surgical approach for patients with
localized prostate cancer (PCa) and a long life expectancy. In
an effort to reduce the morbidity of the procedure, surgeonshave developed new surgical techniques such as laparo-scopic radical prostatectomy (LRP) and, more recently,robot-assisted radical prostatectomy (RARP) [1–5] .
A systematic literature review published in 2009 showed
that laparoscopic techniques were associated with advan-tages in terms of blood loss and transfusion rates comparedwith RRP [6]. At that time, the limited number of studies
comparing RARP with RRP prevented the authors fromdrawing any conclusions about the superiority of one or theother ofthese techniques in terms of oncologic andfunctionaloutcomes.
In this context, and in the absence of any prospective
randomized trial comparing RARP with either RRP or LRP,RARP has become the leading option for treating patientswith clinically localized PCa in the United States, and it hasbeen progressively expanding in other countries.
The systematic reviews presented in this issue of
European Urology suggest that RARP is advantageous in
terms of perioperative outcomes and both urinary conti-nence and potency recovery in comparison with RRP [7–10] .
However, there are a lack of well-controlled prospectivestudies of functional outcomes of RARP compared with RRP.The Pasadena Consensus Panel (PCP) recognized thatrecovery of sexual function and continence following
surgery is influenced by multiple factors including surgical
experience and institutional volume of surgery, level ofpremorbid function in patients, postsurgical rehabilitation,and outcome assessment methods. These factors have notbeen sufficiently controlled in most studies. Although theavailable evidence is still limited, RARP has shown an
impact on cancer control equivalent to RRP.
As a complement to the systematic reviews just men-
tioned, a consensus conference of world leaders in prostate
cancer and radical prostatectomy (RP) was convened inPasadena, California, and at the City of Hope Cancer Center,Duarte, California, in September 2011 under the auspices of
the European Association of Urology (EAU) Robotic Urology
Section. This paper presents the recommendations of thatconference.
2. Evidence acquisition
A systematic review of all published literature related to
RARP was performed in August 2011 using the Medline,Embase, and Web of Science databases. The Medline searchincluded only a free-text protocol using the term radical
prostatectomy across the ‘‘Title’’ and ‘‘Abstract’’ fields of the
records. Subsequently, the following limits were used:
humans; gender (male); publication date from January 1,
2008, to August 2011; and language (English). The searchesof the Embase and Web of Science databases used the samefree-text protocol and the same keywords, applying thesame publication dates.Two authors (G.N. and V.F.) separately reviewed the
records to select the studies comparing RRP with LRP, RRPwith RALP, or LRP with RALP. O ther significant studies
cited in the reference lists of the selected papers were alsoevaluated, as well as studies published after the system-atic search. All noncomparative studies reporting out-comes of RALP on >100 cases were collected and critically
analyzed.
All papers were distinguished according to the 2011 level
of evidence for treatment benefit, as currently described
by the Centre for Evidence Based Medicine at Oxford
University. A total of 44 papers were selected in which RARPwas compared with either RRP or LRP. A total of 136 paperswere included that evaluated some aspect of RARP. Thesystematic reviews complied with the recently reportedPreferred Reporting Items for Systematic Reviews and
Meta-analysis statement [11].
This literature review provided the foundation for the
development of individual presentations by conference
attendees, most of whom presented ancillary literaturereviews and their personal experience on specific subtopics.Over the course of the 2-d conference, systematic reviewdata were presented and considered in three major areas:
(1) patient selection and surgical technique, (2) cancer
control, and (3) complications and sequelae. Followingpresentations of currently available evidence, the PCPdeveloped best practice recommendations in each of theseareas. A multistage Delphi process was used when needed torank recommendations or arrive at consensus on individual
recommendations [12]. Following the conference, panel
members submitted drafts of assigned sections that were
incorporated into a draft manuscript for review by allpanelists. The manuscript was then revised in light of PCPfeedback, and the final version was once again reviewed andapproved by all panel members prior to submission for
publication.
3. Evidence synthesis
3.1. Patient selection and surgical techniques
3.1.1. Patient selection
The indications for RARP, identical to those accepted for RRP
and LRP, are summarized in Table 1 [13–15] . The PCP noted
that certain cases because of their complexity should be
best performed by experienced or very experienced
surgeons ( Table 2 )[16]. For example, patients who have
undergone prior transurethral resection of the prostate(TURP) surgery may present surgical challenges for thenovice RARP surgeon.
3.1.1.1. Indications and technique for nerve-sparing robot-assisted
radical prostatectomy. Deeper insights into the distribution
and course of the cavernous nerves in recent years have
allowed clinicians to increase their knowledge about
prostate anatomy and specifically about the network of
nerves surrounding the prostate, seminal vesicles, andurethral sphincter [17]. These new anatomic concepts have
suggested a role for high incision of the levator ani fasciaEUROPEAN UROLOGY 62 (2012) 368–381 369

that allows preservation not only of the cavernous nerves at
the posterolateral surface of the prostate but also nerve
fibers located along the lateroanterior part of the gland
[18,19] . According to the personal experience of the experts
involved in the Pasadena conference, the better tridimen-sional magnification, scaling of movements, and 7 degreesof freedom associated with the robotic techniques allowsthe extension of the nerve-sparing procedure to be
modulated according to cancer risk stratification, patients’
preoperative characteristics, and patients’ desire to pre-serve erectile function.
A maximum preservation of cavernous nerves (full nerve
sparing), obtained by following the plane between theprostatic capsule and the multilayer tissue of the prostaticfascia, is recommended in sexually active and functional
men without comorbidities and with limited-risk disease. A
less extended nerve-sparing technique (partial nervesparing) within the multilayer tissue of prostatic fasciamight be considered for patients who are at risk ofextracapsular extension but who would still benefit froman anatomic procedure. In patients with preoperativeerectile dysfunction and/or relevant comorbidities as wellas in those not interested in postoperative sexual activity,
preservation of the cavernous nerves should be considered
to facilitate the precise dissection of the external urethralsphincter and to minimize the potential to exacerbatepostoperative urinary incontinence ( Table 3 ).
The PCP recognized that certain PCa patients should
undergo a non–nerve-sparing operation (ie, when the
presenting disease is clearly extraprostatic). Although few
data are available in the literature regarding RARP forunilateral nerve-sparing techniques, participants at the PCPbelieved these techniques can be considered in patientswith monolateral extraprostatic disease. In such cases,partial preservation of the neurovascular bundles limited tothe side with organ-confined disease or no disease may be
indicated.
3.1.1.2. Indications for concomitant pelvic lymph node dissection. As
in the case with RRP, bilateral pelvic lymph node dissection
(PLND) during RARP should be considered for patients withintermediate-risk PCa (cT2a and/or prostate-specific antigen
Table 3 – Indications for nerve-sparing robot-assisted radical prostatectomy
Nerve-sparing
extensionAnatomic planes Categories
Full Plane between the prostatic capsule and
the multilayer tissue of the prostatic fasciaPreoperative potent men without comorbidities
Low-risk localized disease
Partial Planes within the multilayer tissue of prostatic fascia Preoperative potent men without comorbidities
Intermediate- or high-risk localized disease
Minimal Preservation of cavernous nerves running at the
posterolateral surface of the prostatePreoperative patients with erectile dysfunction and/or with comorbidities
Patients not interested in sexual activityTable 1 – Indications for radical prostatectomy according to international guidelines
American Urological
Association, 2007 [20]European Association of Urology, 2011 [34] National Comprehensive Cancer
Network, 2011 [15]
Low-risk localized PCa
Intermediate-risk
localized PCa
High-risk localized PCaLow- and intermediate-risk localized PCa and a lifeexpectancy >10 yr
Patients with stage T1a disease and a life expectancy
>15 yr or GS 7
Selected patients with low-volume high-risk localized PCa
Highly selected patients with very high-risk localized PCa
(cT3b–T4 N0 or any T N1) in the context ofmultimodal treatmentVery low-risk cancer (T1c, GS /C206, PSA <10,<3 positive
prostate biopsy cores, /C2050% cancer in any core) and life
expectancy >20 yr
Low- and intermediate-risk patients with life expectancy
survival >10 yr
High-risk and very high-risk (T3b–4) patients
PCa = prostate cancer; GS = Gleason score; PSA = prostate-specific antigen.
Table 2 – Challenging cases and level of surgeon experience
Level of surgeon experience Challenging cases
Experienced*Obese patients (BMI >30)
Large prostate (prostate volume >70 g)
Previous TURP or other procedure for BPH
Large median lobe
High-risk patients requiring extended pelvic lymph node dissectionPatients with previous pelvic surgery
Very experienced* Salvage robot-assisted radical prostatectomy after radiation therapies, cryotherapy, or high-intensity focused ultrasound
BMI = body mass index; TURP = transurethral resection of the prostate; BPH = benign prostatic hyperplasia.
*The Pasadena Consensus Panel did not reach any consensus about the definition of experienced surgeon (number of procedures needed in an acceptable
period of time). Data from the literature classifies surgeons as high volume ( /C2140 procedures per year) or low volume ( <40 procedures per year) [4].EUROPEAN UROLOGY 62 (2012) 368–381 370

[PSA] 10–20 ng/ml and/or biopsy Gleason score of 7),
high-risk PCa ( >cT2b and/or PSA >20 ng/ml and/or Gleason
score /C218), or patients with /C217% likelihood of having
node metastases according to available nomograms ( Table
4)[14,15,20] . Current National Comprehensive Cancer
Network guidelines [15] recommend a PLND for all risk
categories of PCa if prediction models indicate a 2% risk oflymph node invasion or higher (current American UrologicalAssociation guidelines [20] recommend that PLND generally
be reserved for patients with a higher risk of nodalinvolvement).
The lymph node drainage of the prostate appears to be
wide and bilateral [21]. The primary drainage of the prostate
appears to be in the following order: external and obturator(38%), internal iliac (25%), common iliac (16%), para-aortic/caval (12%), presacral (8%), and inguinal (1%) [21].
An appropriate PLND includes removal of all node-
bearing tissue from an area bounded by the external iliac
artery anteriorly, the pelvic sidewall laterally, the bladder
wall medially, the floor of the pelvis posteriorly, Cooperligament distally, and the common iliac artery/uretercrossing proximally [14,15] . When these anatomic bound-
aries are respected, PLND usually retrieves /C2110 lymph
nodes [22,23] .
Multiple retrospective case series indicate that if the
limits of the node dissection are expanded during RP, anincreased number of lymph nodes are removed and theincidence of positive lymph nodes rises [24,25] . This comes
at the price of increased operative time and slightlyincreased complication rates [24] including lymphocele.
Bader et al. [26] and Briganti et al. [27] showed that men
with a limited number of positive lymph nodes following RPcan have prolonged cancer-specific survival, although mostof these men were treated with adjuvant androgen ablationwith or without external-beam radiation therapy. Thesedata imply that RP is not contraindicated in men thought tobe at significant risk for positive lymph nodes and that an
appropriately performed PLND could, in fact, offer a survival
advantage.
The publications available on RARP (primarily retro-
spective cases series) show that an extended PLND can besafely accomplished at the time of RARP, although in mostof the reported series the number of removed lymph nodeswas small [28]. The PCP agreed that a bilateral extended
PLND is indicated for intermediate- and high-risk patients.A PLND should be considered optional in low-risk patients(D’Amico criteria [29] or N+ risk <3% according to available
nomograms).3.1.2. Patient preparation and anesthesia
There is no medical standard for an optimal time spanbetween biopsy diagnosis and surgery. Many advise aninterval /C214–6 wk [30]. There is no standard practice for
bowel preparation; clinicians should follow their institu-
tional guidelines.
It is standard procedure to advise patients to stop taking
all anticoagulants a week before surgery, although some
emerging evidence suggests that allowing continued low-dose nonsteroidal anti-inflammatory drugs or aspirin is notassociated with the occurrence of bleeding events and couldbe beneficial in preventing serious adverse cardiac throm-
botic events [31].
Concerning medical deep vein thrombosis (DVT) pro-
phylaxis, the incidence of thromboembolic events after
laparoscopic procedures is very low, and data from the mostrelevant multi-institutional observational study do notsupport the routine use of low molecular weight heparin
(LMWH) prophylaxis in patients without risk factors [32].I n
this last category, early mobilization and mechanical
venous thromboembolism (VTE) prophylaxis is adviseduntil mobility is no longer significantly reduced. However,according to the National Institute for Health and ClinicalExcellence (NICE) guidelines, patients with an increased risk
of VTE ( Table 5 ) must be considered for pharmacologic VTE
prophylaxis. The administration of LMWH could be
continued until the patient is no longer at increased riskof VTE (generally 5–7 d) or prolonged for a longer period(28 d after surgery), especially for very high-risk patients(eg, previous VTE) [33].
RARP is a laparoscopic urologic procedure with an open
urinary tract (clean contaminated). Therefore, antibioticprophylaxis (a single perioperative course) using second- orthird-generation cephalosporin is recommended [34]. RARP
is performed using the Trendelenburg position to facilitateexposure of the pelvic area. The degree of Trendelenburginclination is not standardized, and a wide range (between
108and 40 8) is reported in the literature. Patients receiving
RARP in a steep Trendelenburg position for 3–4 h do not
present significant cerebrovascular, respiratory, or hemo-dynamic problems [35,36] . More caution should be
recommended for procedures with a longer operative time,for patients with a American Society of Anesthesiologistsscore /C213, or patients who are obese. A prolonged steep
Trendelenburg position can increase intraocular pressurebut has not been correlated with relevant clinical sequelae[37]. For patients with glaucoma, however, particular
caution should be exercised, and it is recommended thatTable 4 – Currently available guidelines on pelvic lymph node dissection in prostate cancer
Guidelines Indication for PLND Extent of PLND
American Urological Association, 2007 [20] PLND generally reserved for patients with higher risk of nodal involvement Not indicated
European Association of Urology, 2011 [34] Men with intermediate PCa (cT2a, PSA 10–20 ng/ml, biopsy Gleason score 7) or
high risk ( >cT2b, PSA >20 ng/ml, Gleason score 8)Extended
National Comprehensive Cancer
Network, 2011 [15]PLND can be excluded in patients with <7% predicted probability of lymph
node metastases by nomograms, although some patients with nodal metastases
will be missed. An extended PLND is preferred when PLND is performed.Extended
PLND = pelvic lymph node dissection; PCa = prostate cancer; PSA = prostate-specific antigen.EUROPEAN UROLOGY 62 (2012) 368–381 371

ophthalmologic clearance be obtained for such patients
before RARP.
3.1.3. Surgical techniques
RARP is performed using the three- or four-arm da VinciSurgical System (Intuitive Surgical, Sunnyvale, CA, USA).Some surgeons may prefer the four-arm system because itprovides additional stability and dexterity. However, athree-arm robot is an option, and an additional assistantport site can provide additional dexterity.
RARP can be performed using a transperitoneal or
extraperitoneal approach. The former is the most commonlyused and may have advantages in those patients requiringPLND.
Primary access for pneumoperitoneum can be performed
using the Veress needle or direct open access via the Hasson
technique. The camera port should be placed above the
umbilicus except when the distance from the pubis exceeds26 cm. A transverse camera port incision may be consideredan alternative to the standard vertical incision to reduce therisk of camera port site hernia due to specimen extraction,particularly in obese patients and/or patients with largeprostates [38]. Port placement and number of trocars for the
assistant can vary according to surgeon preference, but itmust provide sufficient distance between the camera andworking ports to prevent internal or external collision ofinstruments [39].
The extraperitoneal space is usually entered by making
an incision on the anterior peritoneum superior to the dome
of the bladder and lateral to the medial umbilical ligaments.
Access to the extraperitoneal space can also be obtainedusing the Montsouris approach to the seminal vesicles [40].
Care must be taken to identify and preserve accessorypudendal arteries to reduce potential vascular damage toerectile tissue.
The PCP supported the incision of endopelvic fascia on its
line of reflexion to gain access to the lateral surface of theprostate in close contact with the fibers of the levator animuscles. It was recognized, however, that the dissection ofthe prostate can be completed while leaving the levator anifascia intact.
The dissection of the prostate can be done using an
antegrade (from bladder neck to the apex) or retrograde(from apex to bladder neck) approach. The former is mostpopular and recommended for minimizing bleeding andtraction and optimizing nerve-sparing dissection.A wide bladder neck dissection is not usually recom-
mended with the exception of patients with a large medianlobe. When the bladder neck is widely opened, there is a
need to reconfigure it, and various techniques are available
and deemed equally effective. Similarly, the PCP did notrecommend preservation of the intraprostatic urethra dueto the higher risk of positive surgical margins and noevidence of improvement in the recovery of continence.
During RARP the seminal vesicles can be safely and
precisely removed either entirely or partially according to
the patient’s oncologic status. To avoid injury to cavernous
nerves, the minimal use of cautery and traction in the areaof the seminal vesicles is recommended [41].
Meticulous retroprostatic dissection is essential. In
patients where nerve preservation is advisable, the posteriorlayer of Denonvilliers’ fascia (which contains communicating
nerve fibers) can be left on the rectum; in high-risk patients it
should be included with the specimen [42].
In the last decade, some robotic surgical techniques were
developed with the aim of maximizing the preservation ofthe fibers located within the periprostatic tissue that coversthe lateral and anterior surface of the prostate [19]. Anatomic
studies showed that multiple compartments could bedeveloped from the levator fascia to prostate capsule byentering different fascial planes during surgery [43].
However, the PCP found wide variability and subjectivityamong surgeons regarding these facets of the procedure;hence no recommendation of a standard or preferred fasciaapproach and related surgical techniques was made. It is
suggested that intrafascial and interfascial definitions be
replaced with the newer concept of ‘‘incremental’’ nerve-sparing procedures previously described [44].
During RARP, the cavernous nerves can be damaged by
direct mechanical trauma, traction, or thermal energy.Robotic technology may improve the precision of move-
ments in small and deep spaces, potentially reducing
mechanical, thermal, or traction injury to nerve tissue.Cautery-free dissection is recommended to avoid thermalinjury of cavernous nerves. However, the judicious use ofthermal energy including pinpoint coagulation at lowcautery levels (ie, <30 W) applied briefly (ie, <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.
The puboprostatic ligaments are usually exposed and
divided sharply as they attach to the prostate to gain accessTable 5 – Venous thromboembolism risk factors in candidates for robot-assisted radical prostatectomy
Patient-related factors Surgery-related factors
Active cancer or cancer treatment
Age>60 yr
Known thrombophilia
Obesity
Significant comorbidities (eg, heart disease, metabolic, endocrine, or
respiratory pathologies, acute infection diseases)
Personal history or first-degree relative with history of venous
thromboembolism
Use of hormone replacement therapy
Varicose veins with phlebitisSurgical procedure with a total anaesthetic and surgical time >90 min or
>60 min if the surgery involved the pelvis or lower limb
Expected substantial reduction in mobilityEUROPEAN UROLOGY 62 (2012) 368–381 372

to the dorsal vascular complex (DVC). The DVC is usually
ligated with either one or two interrupted sutures and thendivided using scissors, monopolar electrocautery, or stapler
devices. As an alternative, the DVC can be first divided and
then selectively ligated with a running suture. Afterexposure of the prostatic apex, the urethra must be carefullytransected beyond the apex of the prostate. The urethra isdivided with care taken to avoid injury to the neurovascularbundles and the sphincter. Retroapical transection of theurethra can be considered an option [45].
Posterior musculofascial plate reconstruction (Rocco
stitch) has been proposed to improve the recovery ofurinary continence [46–49] . Although no prospective
randomized trials have proven this hypothesis, there wasunanimous agreement among the PCP that posteriorreconstruction may facilitate performing the urethrovesical
anastomosis and reduce bleeding. This step of the proce-
dure should be considered optional. The posterior recon-struction may be performed either with interrupted suturesor with a running suture, and there is no substantialdifference between the two techniques. Better results werereported when a periurethral suspension stitch [50] or an
anterior reconstruction [51] was added to the Rocco stitch
[52]. The running suture as described by van Velthoven et al.
[53] is the most frequently used technique to perform the
urethrovesical anastomosis. A monofilament suture istypically used for the anastomosis. Barbed sutures havebeen proposed to facilitate the configuration of both theposterior reconstruction and the anastomosis and to reduce
the time needed to complete this step of the procedure [54].
A catheter is placed into the bladder during the
completion of the urethrovesical anastomosis. The anasto-
mosis should be tested intraoperatively by filling thebladder with fluid and checking for leaks. Positioning apercutaneous suprapubic tube drain instead of a trans-
urethral catheter is an option to reduce patient discomfort
[55], but most surgeons select the catheter option.
Concomitant inguinal hernia repair may be considered in
all symptomatic cases [56]. A drain should be positioned
and removed early during the postoperative course insome cases, but it is optional in those cases where there isa very low risk of postoperative hemorrhage or urinary
extravasation. Trocars should be removed under direct
vision to detect bleeding.
A cystogram is recommended before removal of the
urethral catheter in patients at high risk for leakage(ie, previous TURP, salvage RARP), and it should beconsidered optional in all patients except those at high
risk for leakage. Early catheter removal, that is, on
postoperative day 4 or 5, should be considered in thosewith a low risk of extravasation.
3.1.4. Key consensus recommendations
The following recommendations are made with regard topatient selection and surgical technique;
/C15There are no absolute contraindications to RARP.
/C15Obesity, previous abdominal surgery, larger prostate size,
and previous radiation are not absolute contraindicationsfor RARP, although such patients may be best operated onby only experienced clinicians.
/C15A transperitoneal antegrade surgical approach is the most
commonly used.
/C15Robotic techniques have changed the understanding of
prostate anatomy, thus making obsolete some commonlyused terms use as interfascial orintrafascial dissections .
The newer concept of incremental nerve-sparing proce-dures (full, partial, and minimal) should be adopted.
/C15Thermal energy should be used judiciously and with low
cautery levels. Traction of tissues should also be
minimized.
/C15Seminal vesicles can be removed either partially orcompletely during RARP according to the patient’soncologic status.
/C15RARP and RRP have equivalent efficacy for performing
prostatectomy-related extended PLND.
/C15Single running suture is the most frequently used
technique to perform the urethrovesical anastomosis.Monofilament is the standard suture. Barbed suture is anacceptable option.
/C15The use of medical DVT prophylaxis is optional. If used,clinicians should follow NICE or other national guidelines.
3.2. Cancer control
This section reviews the following critical issues related tocancer control and RARP: the suitability of RARP for patientswith high-risk PCa, the prevalence of positive surgicalmargins (PSMs) in RARP, the use of adjuvant therapies
following RARP, and the long-term oncologic efficacy of
RARP.
3.2.1. Biochemical recurrence rates
Long-term data regarding biochemical recurrence of PCaafter RARP are sparse because few centers have beenperforming this procedure >5 yr. Available nonrandomized
comparative studies failed to demonstrate any differencesin the biochemical recurrence-free survival among open RP(ORP), LRP, and RARP. However, they are all hampered by
relatively short follow-up. The most detailed RARP series
that is available reports biochemical recurrence-freesurvival estimates of 95.1%, 90.6%, 86.6%, and 81.0% atfollow-up durations of 1, 3, 5, and 7 yr, respectively (medianfollow-up: 5 yr) [57,58] . The PCP agreed that current
evidence shows that RARP is equivalent to RRP in terms ofbiochemical disease-free survival.
3.2.2. Robot-assisted radical prostatectomy for high-grade
prostate cancer
Despite a trend in recent years toward performing
prostatectomies for more clinically localized, lower gradedisease (driven, in part, by the widespread use of PSAscreening) [59], 20–30% of patients with PCa still present
with high-risk disease as defined by serum PSA, T stage,and/or cancer grade [60]. Such patients are candidates for a
variety of options, most notably neoadjuvant and adjuvantandrogen deprivation combined with well-targeted high-dose radiotherapy or surgery followed selectively byEUROPEAN UROLOGY 62 (2012) 368–381 373

adjuvant therapy. The trend toward more surgical man-
agement of men with such cancers is supported bycontemporary studies that have shown favorable results
in treating high-risk disease with RP [61–63] .Ar e c e n t
comparative effectiveness study assessing >7000 men in
the Cancer of the Prostate Strategic Urologic Research
Endeavor database found tha t men with high-risk PCa had a
lower mortality if they were treated with surgerycompared with radiation or androgen-deprivation therapyalone [61].
This trend for surgical management of high-risk tumors
overlaps with the increasing use of minimally invasive RARPsurgery. The role of RARP in the context of high-risk disease,however, has not been well described to date. The currentliterature on RARP in men with high-risk PCa is sparse butimproving as more centers publish their experience.
On the whole, the available studies suggest that RARP is a
feasible option for men with high-risk PCa and can achieveequivalent oncologic and functional outcomes comparedwith ORP [64]. Several studies have challenged the use of
RARP in high-risk patients, however, suggesting thatcomplication and positive margin rates are too high [65].
After a thorough discussion, the PCP agreed that the findings
could reflect early experience with robotic technology and
surgeons who are still on their learning curve. Studies haveshown that surgical volume and experience generally lead tobetter outcomes [66], and robotic surgery is no exception to
this rule. Therefore, as more men with high-risk PCa movetoward surgery, the choice to use an open versus robotic
approachshould dependon the surgeon and his or herlevel of
comfort and experience with either approach.
3.2.3. Robot-assisted radical prostatectomy and positive
surgical margins
PSMs are defined as tumor at the inked margin of the
prostatectomy specimen. The impact of PSMs on cancer-
related outcome has been studied extensively. A clear
association between PSMs and cancer-specific mortalitywas shown in only a single large population-based study,indicating that patients with PSM had a 1.7-fold higher riskof death compared with those without [67]. Several other
studies demonstrated that PSMs are a risk factor for disease
progression after surgery [68].
The PCP agreed that PSMs should be stratified for
pathologic stage (pT2 vs non–organ confined), location,
number and extent, and Gleason score at the positivemargin. Much evidence suggests that PSMs in pT2 diseaseare, for the most part, iatrogenic and hence potentiallyavoidable [68]. In pathologic pT3 cancers, PSMs are much
more frequently associated with the extent of disease.
Most PSMs are reported to occur at the apex (6%),
posterolaterally adjacent to the neurovascular bundle (NVB)(5%), anteriorly (1–2%), or at the bladder neck (2%) [69].I n
organ-confined disease, the risk of PSMs at the level of theprostatic apex is thought to be increased by the absence of a
visual or pathologic prostatic capsule to serve as a guide.
A positive margin there should not necessarily be consideredas ‘‘surgical failure,’’ as could be the case in T2 elsewhere.Similarly, PSMs adjacent to the NVB may occur whensurgeons attempt to preserve maximum potential sexualfunction. The bladder neck is a relatively unusual site forPSMs because this region is only rarely involved in significant
disease, although when there is extensive disease at the base/
bladder neck, it tends to be higher grade with higher stage(pT4) and with average PSM rates of 50% [68].
The results of the systematic review of oncologic
outcomes in this issue indicate that the average rate ofPSMs in pT2 disease is 8–10% and in pT3 disease is about37% [10]. As with ORP, surgeon experience has been closely
linked to reductions in PSM rates. As surgeons gainexperience, PSMs generally are reduced, which suggestsan iatrogenic role in PSMs. Detailed knowledge of criticalanatomy and techniques was demonstrated to reduceapical, lateral, or bladder neck PSMs in organ-confineddisease [68]. For non–organ-confined disease, it was also
shown that as surgeons gain experience they become betterable to discern which cases need wider excision and also toperform these wider excisions more accurately, both ofwhich tend to reduce the rates of PSMs.
Randomized controlled trials comparing the prevalence
of PSMs following ORP, LRP, and RARP are lacking. However,the available evidence from nonrandomized comparative
studies suggests that PSMs rates are likely to be similar
regardless of the different possible surgical approaches [10].
Specifically, PSM rates ranging from 11% to 38% werereported following RRP, from 12% to 31% following LRP, andfrom 9% to 29% following RARP [68].
3.2.4. Adjuvant and salvage therapies after robot-assisted
radical prostatectomy
Data concerning the use of adjuvant therapies following
RARP are limited. However, some initial population-basedstudies evaluating US patient data from 2003 to 2005suggested that patients treated with minimally invasiveRP (ie, mainly RARP, due to the limited use of LRP in the
United States) were at increased risk of receiving adjuvant
therapies compared with those treated with RRP [70].
Following the publications of these data, some concernsarose that RARP patients may be receiving suboptimaloncologic treatment. However, subsequent Surveillance,Epidemiology and End Results analyses failed to confirm
these earlier data [65,71] , demonstrating that surgical
approach was not associated with any differences in the
risk of adjuvant therapies following RP. In addition, theauthor of the original paper published a letter acknowledgingthe limitations of his study [72].
Conversely, D’Amico risk group, presence of nodal
metastases, PSMs, and surgeon volume were all indepen-
dent predictors of receiving additional cancer therapies
[71]. The PCP agreed that RARP does not expose patients to
an increased risk of adjuvant therapies compared with theother surgical approaches to RP, provided the standardcriteria for patient selection, surgical technique, and lymphnode dissection are used.
3.2.5. Key consensus recommendations
The following recommendations are made with regardingto cancer control:EUROPEAN UROLOGY 62 (2012) 368–381 374

/C15Available data suggest that RARP may also be used in
patients with D’Amico high-risk cancers, provided thatstandard criteria for patient selection, lymph node
dissection, and nerve preservation are fulfilled.
/C15Positive surgical margin rates after RARP are equivalent to
those reported after RRP and LRP.
/C15When appropriately performed, RARP is not associatedwith an increased risk of patients needing adjuvanttherapies.
/C15Biochemical disease-free survival after RARP seems to be
equivalent to other approaches, although existing data
are limited.
/C15RARP is appropriate for those with high-risk disease; thesurgical approach should be determined by the surgeon’sexperience and expertise.
3.3. Functional outcomes and complications of robot-assisted
radical prostatectomy surgery
As with many of the issues discussed thus far in this paper,
high-quality comparative data on surgical complications andsequelae between RARP and RRP are limited, and what dataexist are difficult to interpret because of the lack of
standardized terms and reporting procedures. The risk of
experiencing complications is, of course, related to a range ofrisk factors including age, body mass index, comorbidity,experience of the surgeon, previous lower abdominalsurgery, previous TURP, and previous radiation and/orhormone therapy as well as intraoperative risk factors(prostate volume, median lobe). This section examines the
nature of complications and how they are reported, reviews
the evidence related to the two most pressing functionaloutcomes of RARP (urinary continence and potency), andmakes numerous recommendations for clinical practice andfuture research.
3.3.1. Complications
The PCP agreed that a standardized method to accrue,define, and report complications following RARP is required.Accurate reporting allows physicians to counsel patientsadequately on expected outcomes, and it permits validcomparisons between series and earlier recognition ofpatterns of complications that should prompt changes in
care. The differences currently being reported between
series may simply reflect the diligence of an institution atcollecting and reporting outcomes.
An ad hoc panel of the EAU guidelines office recently
addressed the issue of reporting complications [73].T h e
panel reviewed all the available classification systems for the
reporting of complications and proposed a modification of
the Martin criteria for accurate and comprehensive reportingof surgical outcomes [73]. The PCP recommends that
surgeons be aware of these different instruments and usewhichever one is most relevant to their practice and needs.
The PCP noted that the definition of surgical complication is
still not standardized, although it noted the existence of the
Accordion system, which may serve as a model for a more
widely adopted definition ( Table 6 ). The PCP recognized the
clear distinction, made also by Clavien-Dindo, betweencomplications and sequelae, which are phenomena such asanejaculation that are inherent to the procedure. Likewise,specific postoperative complications of RARP, such as
lymphorrhea, lymphocele, bleeding, pelvic hematoma, urine
leakage, disrupted anastomosis, and penile shortening, needto be defined in a standardized fashion. Nonetheless, the PCPrecommends that complications should be assessed not onlyduring the intraoperative and early postoperative period butalso within 3 mo postsurgery. Results should be available formost patients to be meaningful. For studies of complication
rates following RP surgery, the PCP believes it is critically
important that patients selected for follow-up be represen-tative of all patients receiving treatment at that center andnot a subsample that could be influenced by selection factors.Prospective disease registries should be developed usingphysician-, patient-, and hospital-reported outcomes. These
would be of optimal benefit in assessing the costs and
outcomes of surgery.
It was suggested that a comprehensive report of post-
prostatectomy outcomes may be best represented by thetrifecta concept, that is, measuring the rate of patients who
simultaneously have an undetectable PSA and completerecovery of both urinary continence and erectile function
[74]. A newer, more comprehensive pentafecta approach was
suggested that includes perioperative complications and
PSM rates, a concept the PCP endorsed as more accuratelyreflecting the real conditions facing postoperative patients,although it has not yet been validated [75].
A potential complication of RARP specific to this
procedure is device failure, although such failures appearto be quite rare, occurring in only 34 of 8240 reportedcases (0.4%) in a multi-institutional study [76]. Of these, 24
events were identified preoperatively, leading to cancella-tion of the procedure. Of the 10 device failures thatdeveloped intraoperatively, 8 cases were converted to open
surgery, with 2 converted to a conventional laparoscopic
approach. Smaller studies reported similarly low rates ofdevice failure [77–79] . Most of the adverse events relate
either to broken instrument tips or to failure of electrocau-tery elements.
3.3.2. Urinary incontinence
Urinary incontinence (UI) has been repeatedly shown to beone of the most important factors affecting patient qualityof life (QoL) following RP—more important, in fact, thansexual functioning [80]. Determining whether a patient is
continent, however, is not straightforward. Traditionally, apatient was considered continent if he did not use anysecurity pads [81]. Others used a broader definition of up to
Table 6 – Accordion Severity Grading System
Acomplication is a combination of the following items:
/C15An event unrelated to the purposes of the procedure
/C15An unintended result of the procedure
/C15An event occurring in temporal proximity to the procedure
/C15Something causing a deviation from the ideal postoperative course
/C15An event that induces a change in management
/C15Something that is morbid (ie, causes suffering directly by causing pain
or indirectly by subjecting the patient to additional interventions)EUROPEAN UROLOGY 62 (2012) 368–381 375

one pad per day [82]. It has been shown, however, that
patient QoL is significantly better in patients who are pad
free as compared with those who wear one security pad
[83]. Other studies suggest that significant numbers of
patients who tell their doctor they do not use any pads still
experience leakage of a small or moderate amount of urineat least once a day [84]. The lack of standardization in the
reported literature on UI hampers an accurate assessmentof the prevalence of this common outcome and makes itharder for physicians to help patients set realistic expecta-
tions for their postsurgical experience. The PCP recom-
mended that the definitions for UI be standardized and thata definition of no pads is better correlated with overall QoLthan either zero to one or one pad.
Regardless of the definition, however, it is clear that UI is
a significant consequence of RP. Parker et al. report that at
the 5-yr postoperative mark, only 38% of men returned to
their preoperative continence level [85]. Another study
found that up to 47% of men had worse continence at 1 yrthan they expected preoperatively [86].
An increased age at RARP is the best predictor of UI,
although a number of other significant risk factors havebeen reported ( Table 7 ).
Evidence from the systematic reviews published in this
issue of European Urology suggests that the recovery of
urinary continence following RARP is usually better thanafter RRP [7,87] . Ficarra et al. found better urinary continence
results after 12 mo for RARP patients (97%) compared withRRP patients (88%) [87]. Patients were categorized as
continent if they reported no leak or leaks about once aweek or less. The mean time to continence recovery for RARPpatients was 25 d compared with 75 d for RRP patients(p<0.001). Tewari et al. also showed a more rapid return of
urinary continence for RARP patients, with a median time toreturn of continence for the RARP group of 44 d compared
with 160 d for the RRP group [88].
A single-surgeon study in which continence was defined
as requiring no pads reported similar continence rates for
RARP and ORP (75% vs 76%) [89]. Likewise, Krambeck et al.
found no statistically significant difference in urinarycontinence outcomes between surgical approaches [90].
Using a nonvalidated questionnaire, patients were consid-
ered continent if they reported no urinary leakage or
required only a security pad. Urinary continence at 1 yr was92% for RARP and 94% for RRP ( p= 0.34) [91]. The PCP
recognizes that postoperative recovery of urinary conti-nence may also be influenced by the patient’s preoperativecondition and that available studies do not provide anadequate comparison of postoperative continence rates inpatients treated by RARP versus RRP.
Many different surgical procedures have been identified
that may help maximize the chances for postsurgicalcontinence, and surgeons are encouraged to review thesetechniques [92]. In addition, the PCP recommends that
clinicians counsel patients preoperatively about the poten-tial for UI and the options available for correcting and/orminimizing this potential outcome, such as pelvic floor
exercises, medications, or lifestyle modifications [93].
3.3.3. Sexual dysfunction
As is the case with UI, data comparing outcomes related to
erectile function and other aspects of sexual function afterRARP and RRP are limited by short follow-up times andreports from only a few centers. For example, Krambeck
et al. reported no significant difference in 1-yr potency rates
between RRP and RARP (63% vs 70%; p= 0.08), with potency
defined as erections satisfactory for intercourse with orwithout phosphodiesterase type 5 inhibitors [90]. Tewari
et al. reported a shorter median time to potency recoverywith RARP than with RRP (180 vs 440 d; p<0.05) [88].
A significant advantage for RARP in terms of preserving
erectile function was found by Ficarra et al. in a study thatmeasured erectile function with the International Index ofErectile Function-5. With analysis limited to patientsreceiving bilateral nerve-sparing RP with at least 1 yr offollow-up, 49% of ORP versus 81% of RALP patients werepotent ( p<0.001) [6]. (The analysis adjusted for the effects
of age, preoperative erectile function, and comorbidities.)
The systematic reviews presented in this issue of European
Urology suggest that RARP is advantageous in potency
recovery in comparison with RRP [9]. However, there are a
lack of well-controlled prospective studies of functionaloutcomes of RARP compared with RRP, and the level of
surgeon experience, institutional volume of surgery,
postoperative rehabilitation, and means of outcome assess-ment have varied considerably between studies. The PCPrecognizes that, similar to urinary continence, the postoper-ative recovery of erectile function may be influenced bythe patient’s preoperative condition and postoperative
rehabilitation. The PCP suggested that the goal should be a
return to a patient’s presurgical level of erectile functioning,which requires a careful assessment of patient sexualfunction before surgery. The PCP also suggested that sexualfunctioning is different from, and may be independent of,erectile functioning. Clinicians need to inquire about, andrecord, information from patients about orgasmic function,
libido, and overall sexual satisfaction. In addition, postoper-
ative anejaculation should be discussed with patients, as wellas fertility preservation strategies if those are desired [94].
The PCP recommended specific steps that surgeons can
take to minimize erectile difficulties and other forms ofsexual dysfunction following RARP surgery:
/C15Avoid any use of thermal energy within 5–10 mm of the
neurovascular bundle, especially after the prostaticpedicle has been released.
Table 7 – Risk factors for urinary incontinence following robot-
assisted radical prostatectomy
Increased age
Obesity [81]
Short membranous urethral length on both preoperative and
postoperative endorectal magnetic resonance imaging [97]
Postprostatectomy anastomotic strictures [98]
Low institutional and/or surgeon caseload [99]
Neurovascular bundles not preserved [100]
Bladder neck injured or not preserved [101]
Large prostate [102]EUROPEAN UROLOGY 62 (2012) 368–381 376

/C15Minimize traction during surgery.
/C15Counsel patients regarding the potential sexual compli-
cations of surgery and available options for postsurgical
management.
3.3.4. Key consensus recommendations
The following recommendations are made with regard to
functional outcomes and complications of RARP:
/C15The definition of surgical complications should be stan-
dardized, complications should be assessed in detail from
the intraoperative period until at least 3 mo postoperative-ly, and results should be available in most patients.
/C15Systematic reviews indicate the potential superiority ofRARP for preservation of continence and potency followingRP surgery; however, methodological limitations in most
studies and the lack of prospective randomized trials need
to be considered. Other factors, such as the level of surgeonexperience, means of outcome assessment, premorbidfunction, and postsurgical rehabilitation of the patient, canhave a significant impact on functional outcomes.
/C15Comparative studies of functional outcomes following RPsurgery performed according to best practice guidelines
are needed.
/C15Postoperative anejaculation and fertility preservation
strategies should be discussed with patients, and realisticexpectations should be set regarding a return to conti-nence and baseline potency.
/C15Although the most appropriate way to report composite
outcomes following RP has yet to be standardized, such
reporting should take into account baseline patientcharacteristics, type of surgery, use of adjuvant therapies,and peri- and postoperative complications and sequelae.
3.4. Research needs and priorities
3.4.1. Patient selection and surgical techniques
A number of areas related to patient preparation and
surgical procedures were identified by the PCP as needingfurther research. For example, observational studies areneeded to evaluate the real incidence of VTE in RARP seriesand to identify specific risk factors. Prospective studies are
needed to verify the potential benefit of pharmacologic
prophylaxis for VTE. Anesthesiology procedures are notcurrently standardized and vary widely between hospi-tals. The PCP supports the need to define a RARPanesthesiology standard with particular attention given
to aspects that influence the p ostoperative course as well
as the need for a central venous catheter and pain
management.
The systematic review of the literature revealed that
numerous steps of the surgical procedure are not reported[7–10,95] . This critical aspect can negatively influence the
correct interpretation of reported functional and oncologic
outcomes [96]. It is imperative, therefore, that the main
aspects of surgical procedure be divulged in high-quality
reports of RARP surgery. Table 8 summarizes the proposed
Pasadena criteria for such reporting.
The PCP supported the creation of a survey and resulting
database of surgical techniques currently being used by
RARP surgeons. This could be the first step in creating an
evidence-based classification of surgical variants in fourdifferent categories: recommended, optional, investigational ,
and not recommended.
Few data are available about the most challenging cases
(obese patients, median lobe, large prostate, previous TURP,and salvage RARP). Clinical research should be encouraged to
confirm the safety and effectiveness of RARP for these
particular cases. Comparative studies should be performed toevaluate if robotic technology is able to improve theperioperative, functional, and oncologic outcomes in com-parison with the traditional RRP.
3.4.2. Cancer control
The PCP identified a number of issues related to RP andcancer control that would benefit from further research. Firstwould be the need to study the impact of RARP in largepopulations of high-risk PCa patients where the role of PLNDshould be more important. It is not known whether a type of‘‘positive’’ margin exists that is, in fact, benign, and, if so, what
the pathologic hallmarks of such margins are. It wouldalso be
desirable if the definitions of high-risk, intermediate-risk ,a n d
low-risk prostatectomy patients could be standardized to
allow for more accurate cross-study comparisons. It wasnoted that no studies have yet been conducted on the long-term cost effectiveness of active surveillance versus RRP
versus RARP. Also unknown is whether imaging techniques
such as magnetic resonance imaging, computed tomography,
Table 8 – Essential surgical steps that must be described in the scientific publication (Pasadena criteria)
Initial steps Demolitive steps Reconstructive steps
Robotic arms, no.
Primary access for pneumoperitoneumCamera port placement
Trocars placementRetzius access
Opening the endopelvic fasciaPuboprostatic ligaments management
Bladder neck dissection
Dissection of seminal vesiclesRetroprostatic dissection
Release of NV bundles
Control of prostate vascular pediclesPreservation of NV bundles
Division of DVC
Apical and urethral dissectionPosterior reconstructionAnterior suspensionUrethrovesical anastomosis
NV = neurovascular; DVC = dorsal vascular complex.EUROPEAN UROLOGY 62 (2012) 368–381 377

infrared light–guided utilities, or other types of imaging
facilitate treatment decision making in patients with PCa,regardless of the selected treatment approach. What types
and timing of RP are best for patients requiring multimodal
therapy? And, finally, will new forms of systemic therapy (ie,vaccines, abiraterone, MDV3100, cabazitaxel) improve out-comes? All these issues should be given research priority inthe coming years.
3.4.3. Surgical complications and sequelae
Definitions of erectile function and how to measureit following RP need to be standardized, with the PCPrecommending that researchers report on erectile function at1, 3, 6, 9, and 12 mo postoperatively and yearly thereafterusing well-validated instruments. Results should be availablefor most, if not all, patients in the practice. Data on sexualfunction and continence should be routine data points in
every case.
Most studies of preserving erectile function in men
undergoing prostatectomy have studied younger men with
normal sexual function. Additional research is needed toexplore postoperative outcomes among older men and thosewith less than perfect preoperative erectile function. The role
of penile rehabilitation in the RARP setting should be
assessed.
Finally, the effect of RP on the natural history of lower
urinary tract symptoms (LUTS) has not been widely studied;there is paucity of data assessing LUTS pre- and postopera-tively and on the effect of RP on the natural history of LUTS.This could be addressed by studies evaluating LUTS in these
groups using similar reporting criteria, rather than different
questionnaires, as was the case in most studies to date.
4. Conclusions
RARP has been widely adopted despite an absence of high-
quality randomized controlled clinical trials comparing itwith traditional RRP. A systematic review of the availableevidence suggests that in patients with clinically localizedPCa, RARP is equivalent to RRP in cancer control. Although the
accompanying systematic review indicates that RARP is
advantageous in preservation of continence and potencyrecovery, there are a lack of well-controlled prospectivestudies of functional outcomes of RARP compared with RRP.Future comparisons ideally should be conducted of surgicaloutcomes following RP surgery performed according to best
practice guidelines, as described in the current paper.
Available data suggest that RARP offers advantages inreduced blood loss, lower transfusion rates, and shorterlength of hospital stay than RRP. Likewise, the bestavailable data suggest there are minimal differencesbetween the surgical approaches in terms of overall
postoperative complications. As with RRP, surgeon experi-
ence and institutional volume of procedures stronglyp r e d i c tb e t t e ro u t c o m e sa ta l ll e v e l s .
Author contributions: Francesco Montorsi had full access to all the data
in the study and takes responsibility for the integrity of the data and the
accuracy of the data analysis.Study concept and design: Montorsi, Wilson, Rosen, Ahlering, Artibani,
Carroll, Costello, Eastham, Ficarra, Guazzoni, Menon, Novara, Patel,Stolzenburg, Van der Poel, Van Poppel, Mottrie.Acquisition of data: Montorsi, Wilson, Rosen, Ahlering, Artibani, Carroll,
Costello, Eastham, Ficarra, Guazzoni, Menon, Novara, Patel, Stolzenburg,
Van der Poel, Van Poppel, Mottrie.
Analysis and interpretation of data: Montorsi, Wilson, Rosen, Ahlering,
Artibani, Carroll, Costello, Eastham, Ficarra, Guazzoni, Menon, Novara,
Patel, Stolzenburg, Van der Poel, Van Poppel, Mottrie.
Drafting of the manuscript: Montorsi, Wilson, Rosen, Ahlering, Artibani,
Carroll, Costello, Eastham, Ficarra, Guazzoni, Menon, Novara, Patel,Stolzenburg, Van der Poel, Van Poppel, Mottrie.
Critical revision of the manuscript for important intellectual content:
Montorsi, Wilson, Rosen, Ahlering, Artibani, Carroll, Costello, Eastham,Ficarra, Guazzoni, Menon, Novara, Patel, Stolzenburg, Van der Poel, VanPoppel, Mottrie.
Statistical analysis: None.
Obtaining funding: Wilson.
Administrative, technical, or material support: Rosen, Wilson.
Supervision: None.
Other (specify): None.
Financial disclosures: Francesco Montorsi certifies that all conflicts of
interest, including specific financial interests and relationships andaffiliations relevant to the subject matter or materials discussed in the
manuscript (eg, employment/affiliation, grants or funding, consultan-cies, honoraria, stock ownership or options, expert testimony, royalties,
or patents filed, received, or pending), are the following: Francesco
Montorsi, Giorgio Guazzoni, and Alexandre Mottrie acknowledgereceiving research grants from Intuitive Surgical, Sunnyvale, CA, USA.Walter Artibani was lecturer for Astellas, Ipsen, Zambon. Vincenzo
Ficarra was speaker for Intuitive Surgical, Sunnyvale, CA, USA. Giacomo
Novara was lecturer/advisory board member for Astellas, Eli Lilly, PierreFabre, Provenge, Recordati Int., Takeda.
Funding/Support and role of the sponsor: None.
Acknowledgment statement: Medical writer Stephen R. Braun provided
valuable editorial assistance in the preparation of this white paper. The
Pasadena Consensus Conference was organized by New England
Research Institutes, Inc. (Watertown, MA, USA) and funded entirelythrough a grateful patient donation to City of Hope National Medical
Center (Duarte, CA). No representatives of the company producing the
only robotic system currently on the market attended the conference. Inaddition, no commercial sponsors were accepted in connection with theconference.
References
[1] Park JW, Lee HW, Kim W, et al. Comparative assessment of a single
surgeon’s series of laparoscopic radical prostatectomy: conven-tional versus robot-assisted. J Endourol 2011;25:597–602.
[2] Binder J, Kramer W. Robotically-assisted laparoscopic radical
prostatectomy. BJU Int 2001;87:408–10.
[3] Abbou CC, Hoznek A, Salomon L, et al. Remote laparoscopic radical
prostatectomy carried out with a robot. Report of a case[in French]. Prog Urol 2000;10:520–3.
[4] Pasticier G, Rietbergen JBW, Guillonneau B, Fromont G, Menon M,
Vallancien G. Robotically assisted laparoscopic radical prostatec-
tomy: feasibility study in men. Eur Urol 2001;40:70–4.
[5] Menon M, Shrivastava A, Tewari A, et al. Laparoscopic and
robot assisted radical prostatectomy: establishment of a structured
program and preliminary analysis of outcomes. J Urol 2002;168:
945–9.EUROPEAN UROLOGY 62 (2012) 368–381 378

[6] Ficarra V, Novara G, Artibani W, et al. Retropubic, laparoscopic,
and robot-assisted radical prostatectomy: a systematic review
and cumulative analysis of comparative studies. Eur Urol 2009;55:1037–63.
[7] Novara G, Ficarra V, Rosen R, et al. Systematic review and meta-
analysis of perioperative outcomes and complications after robot-assisted radical prostatectomy. Eur Urol 2012;62:431–52.
[8] Ficarra V, Novara G, Rosen R, et al. Systematic review and meta-
analysis of studies reporting urinary continence recovery afterrobot-assisted radical prostatectomy. Eur Urol 2012;62:405–17.
[9] Ficarra V, Novara G, Ahlering T, et al. Systematic review and meta-
analysis of studies reporting potency rates after robot-assisted
radical prostatectomy. Eur Urol 2012;62:418–30.
[10] Novara G, Ficarra V, Mocellin S, et al. Systematic review and meta-
analysis of studies reporting oncologic outcome after robot-
assisted radical prostatectomy. Eur Urol 2012;62:382–404.
[11] Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Pre-
ferred reporting items for systematic reviews and meta-analyses:the PRISMA statement. Ann Intern Med 2009;151:264–9.
[12] Boulkedid R, Abdoul H, Loustau M, Sibony O, Alberti C. Using and
reporting the Delphi method for selecting healthcare qualityindicators: a systematic review. PLoS One 2011;6:e20476.
[13] Horwich A, Parker C, Bangma C, et al. Prostate cancer: ESMO
clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 2010;21(Suppl 5):v129–33.
[14] Heidenreich A, Bellmunt J, Bolla M, et al. EAU guidelines on
prostate cancer. Part 1: screening, diagnosis, and treatment ofclinically localised disease. Eur Urol 2011;59:61–71.
[15] NCCN guidelines in oncology. Prostate cancer (v1.2011). National
Comprehensive Cancer Network Web site. http://www.nccn.org/
professionals/physician_gls/f_guidelines.asp .
[16] Hu JC, Gold KF, Pashos CL, Mehta SS, Litwin MS. Role of surgeon
volume in radical prostatectomy outcomes. J Clin Oncol 2003;21:401–5.
[17] Walz J, Burnett AL, Costello AJ, et al. A critical analysis of
the current knowledge of surgical anatomy related to optimiza-tion of cancer control and preservation of continence and erec-
tion in candidates for radical prostatectomy. Eur Urol 2010;57:
179–92.
[18] Tewari A, Peabody JO, Fischer M, et al. An operative and anatomic
study to help in nerve sparing during laparoscopic and robotic
radical prostatectomy. Eur Urol 2003;43:444–54.
[19] Savera AT, Kaul S, Badani K, Stark AT, Shah NL, Menon M. Robotic
radical prostatectomy with the ‘‘veil of Aphrodite’’ technique: his-
tologic evidence of enhanced nerve sparing. Eur Urol 2006;49:
1065–74.
[20] American Urological Association. Prostate cancer. Guideline for the
management of clinically localized prostate cancer: 2007 update.American Urological Association Web site. http://www.auanet.
org/content/guidelines-and-quality-care/clinical-guidelines/main-
reports/proscan07/content.pdf .
[21] Mattei A, Fuechsel FG, Bhatta Dhar N, et al. The template of the
primary lymphatic landing sites of the prostate should be revisited:results of a multimodality mapping study. Eur Urol 2008;53:118–25.
[22] Briganti A, Chun FK, Karakiewicz PI, Rigatti P, Montorsi F. Is node-
positive prostate cancer always a systemic disease? Eur Urol 2008;54:243–6.
[23] Heidenreich A, Varga Z, Von Knoblock R. Extended pelvic
lymphadenectomy in patients undergoing radical prostatectomy:high incidence of lymph node metastasis. J Urol 2002;167:1681–6.
[24] Stone NN, Stock RG, Unger P. Laparoscopic pelvic lymph node
dissection for prostate cancer: comparison of the extended and
modified techniques. J Urol 1997;158:1891–4.[25] Allaf ME, Palapattu GS, Trock BJ, Carter HB, Walsh PC. Anatomical
extent of lymph node dissection: impact on men with clinically
localized prostate cancer. J Urol 2004;172:1840–4.
[26] Bader P, Burkhard FC, Markwalder R, Studer UE. Disease progression
and survival of patients with positive lymph nodes after radical
prostatectomy. Is there a chance of cure? J Urol 2009;169:849–54.
[27] Briganti A, Karnes RJ, Da Pozzo LF, et al. Combination of adjuvant
hormonal and radiation therapy significantly prolongs survival ofpatients with pT2-4 pN+ prostate cancer: results of a matched
analysis. Eur Urol 2011;59:832–40.
[28] Briganti A, Karnes JR, Da Pozzo LF, et al. Two positive nodes
represent a significant cut-off value for cancer specific survival
in patients with node positive prostate cancer. A new proposal
based on a two-institution experience on 703 consecutive N+patients treated with radical prostatectomy, extended pelviclymph node dissection and adjuvant therapy. Eur Urol 2009;
55:261–70.
[29] D’Amico AV, Whittington R, Malkowicz SB, et al. Biochemical
outcome after radical prostatectomy, external beam radiationtherapy, or interstitial radiation therapy for clinically localized
prostate cancer. JAMA 1998;280:969–74.
[30] Martin GL, Nunez RN, Humphreys MD, et al. Interval from prostate
biopsy to robot-assisted radical prostatectomy: effects on periop-
erative outcomes. BJU Int 2009;104:1734–7.
[31] Mantz J, Samama CM, Tubach F, et al. Impact of preoperative
maintenance or interruption of aspirin on thrombotic and bleed-ing events after elective non-cardiac surgery: the multicentre,
randomized, blinded, placebo-controlled, STRATAGEM trial. Br JAnaesth 2011;107:899–910.
[32] Secin FP, Jiborn T, Bjartell AS, et al. Multi-institutional study of
symptomatic deep venous thrombosis and pulmonary embolismin prostate cancer patients undergoing laparoscopic or robot-assisted laparoscopic radical prostatectomy. Eur Urol 2008;53:134–45.
[33] National Institute for Health and Clinical Excellence. Venous
thromboembolism: reducing the risk. Reducing the risk of venousthromboembolism (deep vein thrombosis and pulmonary embo-
lism) in patients admitted to hospital. National Institute for Health
and Clinical Excellence Web site. http://www.nice.org.uk/niceme-
dia/live/12695/47195/47195.pdf . Updated March 30, 2010.
[34] Grabe M, Bjerklund-Johansen TE, Botto H, et al. Guidelines on
urological infections. European Association of Urology Web site.http://www.uroweb.org/gls/pdf/Urological%20Infections%202010.pdf.
[35] Park EY, Koo BN, Min KT, Nam SH. The effect of pneumoperito-
neum in the steep Trendelenburg position on cerebral oxygen-
ation. Acta Anaesthesiol Scand 2009;53:895–9.
[36]
Kalmar AF, Foubert L, Hendrickx JFA, et al. Influence of steep
Trendelenburg position and CO2 pneumoperitoneum on cardio-
vascular, cerebrovascular, and respiratory homeostasis duringrobotic prostatectomy. Br J Anaesth 2010;104:433–9.
[37] Awad H, Santilli S, Ohr M, et al. The effects of steep Trendelenburg
positioning on intraocular pressure during robotic radical prosta-tectomy. Anesth Analg 2009;109:473–8.
[38] Beck S, Skarecky D, Osann K, Juarez R, Ahlering TE. Transverse
versus vertical camera port incision in robotic radical prostatec-
tomy: effect on incisional hernias and cosmesis. Urology 2011;78:
586–90.
[39] Buffi N, Cestari A, Lughezzani G, et al. Robot-assisted uretero-
ureterostomy for iatrogenic lumbar and iliac ureteral stricture:technical details and preliminary clinical results. Eur Urol 2011;60:1221–5.
[40] Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy:
the Montsouris technique. J Urol 2000;163:1643–9.EUROPEAN UROLOGY 62 (2012) 368–381 379

[41] Secin FP, Bianco FJ, Cronin A, et al. Is it necessary to remove the
seminal vesicles completely at radical prostatectomy? Decision
curve analysis of European Society of Urologic Oncology criteria.J Urol 2009;181:609–13.
[42] Tewari A, Takenaka A, Mtui E, et al. The proximal neurovascular
plate and the trizonal neural architecture around the prostategland: importance in the athermal robotic technique of nervesparing prostatectomy. BJU Int 2006;98:314–23.
[43] Tewari AK, Yadav R, Takenaka A, et al. Anatomic foundations for
nerve sparing robotic prostatectomy. Correlations between ana-tomic, surgical and ‘real time tissue recognition’ with multiphotonmicroscopy. J Urol 2008;179:462–7.
[44] Tewari AK, Srivastava A, Huang MW, et al. Anatomical grades of
nerve sparing: a risk-stratified approach to neural-hammocksparing during robot-assisted radical prostatectomy (RARP). BJUInt 2011;108:984–92.
[45] Tewari AK, Srivastava A, Mudaliar K, et al. Anatomical retro-apical
technique of synchronous (posterior and anterior) urethral tran-section: a novel approach for ameliorating apical margin positivity
during robotic radical prostatectomy. BJU Int 2010;106:1364–73.
[46] Rocco F, Carmignani L, Acquati P, et al. Restoration of posterior
aspect of rhabdosphincter shortens continence time after radical
retropubic prostatectomy. J Urol 2006;175:2201–6.
[47] Rocco B, Gregori A, Stener S, et al. Posterior reconstruction of the
rhabdosphincter allows a rapid recovery of continence after trans-peritoneal videolaparoscopic radical prostatectomy. Eur Urol
2007;51:996–1003.
[48] Rocco F, Carmignani L, Acquati P, et al. Early continence recovery
after open radical prostatectomy with restoration of the posterior
aspect of the rhabdosphincter. Eur Urol 2007;52:376–83.
[49] Gautam G, Rocco B, Patel VR, Zorn KC. Posterior rhabdosphincter
reconstruction during robot-assisted radical prostatectomy: criticalanalysis of techniques and outcomes. Urology 2010;76:734–41.
[50] Patel VR, Coelho RF, Palmer KJ, Rocco B. Periurethral suspension
stitch during robot-assisted laparoscopic radical prostatectomy:description of the technique and continence outcomes. Eur Urol2009;56:472–8.
[51] Tewari A, Jhaveri J, Rao S, et al. Total reconstruction of the vesico-
urethral junction. BJU Int 2008;101:871–7.
[52] Tan G, Srivastava A, Grover S, et al. Optimizing vesicourethral
anastomosis healing after robot-assisted laparoscopic radical
prostatectomy: lessons learned from three techniques in 1900
patients. J Endourol 2010;24:1975–83.
[53] Van Velthoven RF, Ahlering TE, Peltier A, Skarecky DW, Clayman
RV. Technique for laparoscopic running urethrovesical anastomo-
sis: the single knot method. Urology 2003;61:699–702.
[54] Sammon J, Kim TK, Trinh QD, et al. Anastomosis during robot-
assisted radical prostatectomy: randomized controlled trial com-paring barbed and standard monofilament suture. Urology
2011;78:572–9.
[55] Krane LS, Bhandari M, Peabody JO, Menon M. Impact of percuta-
neous suprapubic tube drainage on patient discomfort after radi-
cal prostatectomy. Eur Urol 2009;56:325–31.
[56] Finley DS, Rodriguez Jr E, Ahlering TE. Combined inguinal hernia
repair with prosthetic mesh during transperitoneal robot assisted
laparoscopic radical prostatectomy: a 4-year experience. J Urol
2007;178:1296–9.
[57] Menon M, Bhandari M, Gupta N, et al. Biochemical recurrence
following robot-assisted radical prostatectomy: analysis of 1384patients with a median 5-year follow-up. Eur Urol 2010;58:838–46.
[58] Suardi N, Ficarra V, Willemsen P, et al. Long-term biochemical
recurrence rates after robot-assisted radical prostatectomy: anal-
ysis of a single-center series of patients with a minimum follow-
up of 5 years. Urology 2012;79:133–8.[59] Schroder FH. Prostate cancer around the world. An overview. Urol
Oncol 2010;28:663–7.
[60] Cooperberg MR, Cowan J, Broering JM, et al. High-risk prostate
cancer in the United States, 1990–2007. World J Urol 2008;26:
211–8.
[61] Cooperberg MR, Vickers AJ, Broering JM, et al. Comparative risk-
adjusted mortality outcomes after primary surgery, radiotherapy,or androgen-deprivation therapy for localized prostate cancer.
Cancer 2010;116:5226–34.
[62] Ploussard G, Masson–Lecomte A, Beauval JB, et al. Radical prosta-
tectomy for high-risk defined by preoperative criteria: oncologic
follow-up in national multicenter study in 813 patients and
assessment of easy-to-use prognostic substratification. Urology
2011;78:607–13.
[63] Lawrentschuk N, Trottier G, Kuk C, et al. Role of surgery in high-risk
localized prostate cancer. Curr Oncol 2010;17(Suppl 2):S25–32.
[64] Silberstein JL, Vickers AJ, Power NE, et al. Pelvic lymph node
dissection for patients with elevated risk of lymph node invasionduring radical prostatectomy: comparison of open, laparoscopic
and robot-assisted procedures. J Endourol 2012;26:748–53.
[65] Hu JC, Gu X, Lipsitz SR, et al. Comparative effectiveness of mini-
mally invasive vs open radical prostatectomy. JAMA 2009;302:
1557–64.
[66] Klein EA, Bianco FJ, Serio AM, et al. Surgeon experience is strongly
associated with biochemical recurrence after radical prostatec-tomy for all preoperative risk categories. J Urol 2008;179:2212–6.
[67] Wright JL, Dalkin BL, True LD, et al. Positive surgical margins at
radical prostatectomy predict prostate cancer specific mortality.J Urol 2010;183:2213–8.
[68] Yossepowitch O, Bjartell A, Eastham JA, et al. Positive surgical
margins in radical prostatectomy: outlining the problem and itslong-term consequences. Eur Urol 2009;55:87–99.
[69] Patel VR, Coelho RF, Rocco B, et al. Positive surgical margins after
robotic assisted radical prostatectomy: a multi-institutional
study. J Urol 2011;186:511–6.
[70] Hu JC, Wang Q, Pashos CL, Lipsitz SR, Keating NL. Utilization and
outcomes of minimally invasive radical prostatectomy. J ClinOncol 2008;26:2278–84.
[71] Williams SB, Gu X, Lipsitz SR, Nguyen PL, Choueiri TK, Hu JC.
Utilization and expense of adjuvant cancer therapies following
radical prostatectomy. Cancer 2011;117:4846–54.
[72] Hu JC, D’Amico AV, Keating NL. Minimally invasive vs open radical
prostatectomy—reply. JAMA 2010;303:619–20.
[73] Mitropoulos D, Artibani W, Graefen M, Remzi M, Roupre ˆt M, Truss
M. Reporting and grading of complications after urologic surgical
procedures: an ad hoc EAU Guidelines Panel assessment and
recommendations. Eur Urol 2012;61:341–9.
[74] Bianco Jr FJ, Scardino PT, Eastham JA. Radical prostatectomy: long-
term cancer control and recovery of sexual and urinary function(‘‘trifecta’’). Urology 2005;66(Suppl):83–94.
[75] Ficarra V, Sooriakumaran P, Novara G, et al. Systematic review of
methods for reporting combined outcomes after radical prosta-
tectomy and proposal of a novel system: the survival, continence,
and potency (SCP) classification. Eur Urol 2012;61:541–8.
[76] Lavery HJ, Thaly R, Albala D, et al. Robotic equipment malfunction
duringroboticprostatectomy:amulti-institutionalstudy.JEndourol
2008;22:2165–8.
[77] Patel VR, Thaly R, Shah K. Robotic radical prostatectomy: out-
comes
of 500 cases. BJU Int 2007;99:1109–12.
[78] Borden LSJR, Koxlowski PM, Porter CR, Corman JM. Mechanical
failure rate of da Vinci robotic system. Can J Urol 2007;14:
3499–501.
[79] Andonian S, Okeke Z, Okeke DA, et al. Device failures associated
with patient injuries during robot-assisted laparoscopic surgeries:EUROPEAN UROLOGY 62 (2012) 368–381 380

a comprehensive review of FDA MAUDE database. Can J Urol
2008;15:3912–6.
[80] Schroeck FR, Krupski TL, Sun L, et al. Satisfaction and regret after
open retropubic or robot-assisted laparoscopic radical prostatec-
tomy. Eur Urol 2008;54:785–93.
[81] Walsh PC, Partin AW, Epstein JL. Cancer control and quality of life
following anatomical radical retropubic prostatectomy: results at10 years. J Urol 1994;152:1831–6.
[82] Eastham JA, Kattan MW, Rogers E, et al. Risk factors for urinary
incontinence after radical prostatectomy. J Urol 1996;156:1707–13.
[83] Liss MA, Osann K, Canvasser N, et al. Continence definition after
radical prostatectomy using urinary quality of life: evaluation
of patient reported validated questionnaires. J Urol 2010;183:
1464–8.
[84] Lee SR, Kim HW, Lee JW, et al. Discrepancies in perception of
urinary incontinence between patient and physician after robotic
radical prostatectomy. Yonsei Med J 2010;51:883–7.
[85] Parker WR, Wang R, He C, Wood Jr DP. Five year expanded prostate
cancer index composite-based quality of life outcomes after pros-tatectomy for localized prostate cancer. BJU Int 2010;107:585–90.
[86] Wittmann D, He C, Coelho M, et al. Patient preoperative expecta-
tions of urinary, bowel, hormonal and sexual functioning do not
match actual outcomes 1 year after radical prostatectomy. J Urol
2011;186:494–9.
[87] Ficarra V, Novara G, Fracalanza S, et al. A prospective, non-ran-
domized trial comparing robot-assisted laparoscopic and retro-pubic radical prostatectomy in one European institution. BJU Int
2009;104:534–9.
[88] Tewari A, Srivasatava A, Menon M. A prospective comparison of
radical retropubic and robot-assisted prostatectomy: experience
in one institution. BJU Int 2003;92:205–10.
[89] Ahlering TE, Woo D, Eichel L, Lee DI, Edwards R, Skarecky DW.
Robot-assisted versus open radical prostatectomy: a comparison
of one surgeon’s outcomes. Urology 2004;63:819–22.
[90] Krambeck AE, DiMarco DS,Rangel LJ, et al. Radical prostatectomy for
prostatic adenocarcinoma: a matched comparison of open retro-pubic and robot-assisted techniques. BJU Int 2009;103:448–53.
[91] Mattei A, Z’brun S, Stucki P, et al. When and how should we test the
tightness of the vesicourethral anastomosis after retropubic radi-cal prostatectomy? Urol Int 2011;86:388–92.[92] Srivastava A, Grover S, Sooriakumaran P, Joneja J, Tewari AK.
Robotic-assisted laparoscopic prostatectomy: a critical analysisof its impact on urinary continence. Curr Opin Urol 2011;21:185–94.
[93] Shamliyan TA, Wyman JF, Ping R, Wilt TJ, Kane RL. Male urinary
incontinence: prevalence, risk factors, and preventive interven-tions. Rev Urol 2009;11:145–65.
[94] Mulhall JP, Bella AJ, Briganti A, McCullough A, Brock G. Erectile
function rehabilitation in the radical prostatectomy patient. In:Montorsi F, Basson R, Adaikan G, et al. editors. Sexual medicine.Sexual dysfunction in men and women. Bristol, UK: Health Publi-cation Ltd.; 2010. p. 1005–46.
[95] Ficarra V, Cavalleri S, Novara G, Aragona M, Artibani W. Evidence
from robot-assisted laparoscopic radical prostatectomy: a system-atic review. Eur Urol 2007;51:45–56.
[96] Murphy DG, Bjartell A, Ficarra V, et al. Downsides of robot-assisted
laparoscopic radical prostatectomy: limitations and complica-tions. Eur Urol 2010;57:735–46.
[97] Mendoza PJ, Stern JM, Li AY, et al. Pelvic anatomy on preopera-
tive magnetic resonance imaging can predict early continenceafter robot-assisted radical pro statectomy. J Endourol 2011;25:
51–5.
[98] Park R, Martin S, Goldberg JD, Lepor H. Anastomotic strictures
following radical prostatectomy: insights into incidence, effec-tiveness of intervention, effect on continence, and factors predis-posing to occurrence. Urology 2001;57:742–6.
[99] Wilt TJ, Shamliyan TA, Taylor BC, MacDonald R, Kane RL. Associa-
tion between hospital and surgeon radical prostatectomy volumeand patient outcomes: a systematic review. J Urol 2008;180:820–8.
[100] Choi WW, Freire MP, Soukup JR, et al. Nerve-sparing technique
and urinary control after robot-assisted laparoscopic prostatec-tomy. World J Urol 2011;29:21–7.
[101] Finley DS, Osann K, Skarecky D, Ahlering TE. Hypothermic nerve-
sparing radical prostatectomy: rationale, feasibility, and effect onearly continence. Urology 2009;73:691–6.
[102] Konety BR, Sadetsky N, Carroll PR, CaPSURE Investigators. Recov-
ery of urinary continence following radical prostatectomy: theimpact of prostate volume—analysis of data from the CaPSUREDatabase. J Urol 2007;177:1423–5.EUROPEAN UROLOGY 62 (2012) 368–381 381