World J Urol (2015) 33:1095–1102

DOI 10.1007/s00345-014-1393-3

ORIGINAL ARTICLE

Oncologic results, functional outcomes, and complication rates

of robotic‑assisted radical prostatectomy: multicenter experience
in Turkey including 1,499 patients
A. I. Tasci · I. Tufek · E. Gumus · A. E. Canda ·
V. Tugcu · F. Atug · U. Boylu · Z. Akbulut · S. Sahin ·
A. Simsek · A. R. Kural 

Received: 18 March 2014 / Accepted: 24 August 2014 / Published online: 13 September 2014
© Springer-Verlag Berlin Heidelberg 2014

Abstract  PSM rates in pT2, pT3, and pT4 stages were 6.1, 37.1, and
Background  Robot-assisted radical prostatectomy
(RARP) is a rising minimally invasive treatment of local-
ized prostate cancer (PC). We present our multicenter expe-
rience of 1,499 consecutive cases with an analysis of com-
plication rates, oncologic, and functional outcomes.
Patients and methods  From March 2005 through Decem-
ber 2012, details of 1,499 patients were retrospectively ana-
lyzed. Transperitoneal approach using a da-Vinci robotic
system was used to perform RARP. Perioperative charac-
teristics and postoperative oncologic and functional out-
comes are reported.
Results  The mean age was 61.3 years (37–77). Mean
PSA level was 8.3 ng/ml. According to D’Amico classifi-
cation, the percentage of patients with low-, intermediate-,
and high-risk disease cases were 65.0, 30.1, and 4.8 %,
respectively. Mean operative time was 181.9 min. Mean
estimated blood loss was 225.4 cc (30–1,250). Positive sur-
gical margin (PSM) was detected in 212 (14.1 %) patients.
A. I. Tasci · V. Tugcu · S. Sahin · A. Simsek 
Bakirkoy Dr. Sadi Konuk Training and Research Hospital,
Istanbul, Turkey
I. Tufek · A. R. Kural 
Acibadem University School of Medicine, Istanbul, Turkey
E. Gumus · U. Boylu  tive surgical options for managing clinically localized PC,
Umraniye Training and Research Hospital, Istanbul, Turkey
A. E. Canda · Z. Akbulut 
Department of Urology, Ankara Ataturk Training and Research
Hospital, School of Medicine, Yildirim Beyazit University,
Ankara, Turkey
F. Atug (*) 
Bilim University School of Medicine, Istanbul, Turkey
e-mail: fatihatug@hotmail.com
100 %, respectively. The overall complication rate due to
modified Clavien classification was 6.1 %. Mean follow-
up time was 26.7 months. Continence, potency, and bio-
chemical recurrence rates were 88.7, 58.2, and 2.9 %,
respectively.
Conclusions  Our analyses including high-volume centers,
which is the first largest series in Turkey, show that RARP
is a safe procedure, has low PSM rates, high continence,
and potency rates for the treatment of localized PC at expe-
rienced centers.
Keywords  Robotic · Robot-assisted radical
prostatectomy · Radical prostatectomy · Prostate cancer
Introduction
Widespread prostate-specific antigen (PSA) screening,
combined with a reduction in the threshold of indications
for prostate biopsy, has resulted in increased diagnosis
of prostate cancer (PC). This has led to earlier stage and
lower-grade disease detection [1]. This, in order, has led
to an increase in the number of patients for radical pros-
tatectomy (RP). RP remains the standard of care for long-
term cancer control [2]. At present, there are several defini-
including radical retropubic prostatectomy (RRP), laparo-
scopic radical prostatectomy (LRP), and robot-assisted rad-
ical prostatectomy (RARP) [3–6]. Retropubic radical pros-
tatectomy remains the gold standard for organ-confined
PC. However, LRP and RARP have become standards of
care at many centers worldwide [7].
Robot-assisted radical prostatectomy has become a
common approach for the surgical treatment of localized

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1096
disease due to low rates of transfusion, rapid convales-
cence, and adequate short-term functional and oncologic
outcomes [8]. Within the last 10 years, the number of
RARP procedures performed has highly been increased.
Currently, an estimated 80 % of all prostatectomy in the
USA are being performed with the robotic surgery [9].
The aim of the present study was to analyze the perio-
perative outcomes, positive surgical margin (PSM) rates,
complication rates, oncologic and functional outcomes
of the RARP procedures in a multicentre study including
1,499 patients with a median follow-up of 26.7 months in
Turkey.
Patients and methods
Patients
Between March 2005 and December 2012, 1,499 consecu-
tive patients underwent RARP at Bakirkoy Dr. Sadi Konuk
Training and Research Hospital, Acibadem University
School of Medicine, Bilim University School of Medicine,
Umraniye Training and Research Hospital, and Yildirim
Beyazit University, School of Medicine, Ankara Ataturk
Training and Research Hospital, Department of Urology
in Turkey. Patient databases were analyzed retrospectively.
The preoperative risks of PC patients were determined via
the D’Amico classification [10]. Preoperative clinical data
including age, body mass index (BMI), PSA, prostate vol-
ume, biopsy Gleason score, and IIEF-5 (International Index
of Erectile Function Questionnaire) score were evaluated.
Operative parameters were evaluated including neurovascu-
lar bundle (NVB) preservation, pelvic lymph node dissection
(PLND), operative time, and estimated blood loss (EBL).
Lymph node dissection was performed on D’Amico interme-
diate- and high-risk patients. We performed standard PLND.
A nerve-sparing dissection was performed on previously
potent patients without palpable disease or radiological evi-
dence of extracapsular extension. Blood loss was measured
from aspiration materials. The pathologic report included
specimen Gleason score, PSM, and node status. All speci-
mens were evaluated according to the Gleason score, and
pathological staging was based on TNM 2002 classification.
PSM was defined as the presence of tumor at the inked mar-
gin. Perioperative complications were recorded according to
the modification of Clavien–Dindo system [11].
Patients were follow up by PSA levels at week 6 and at
months 3, 6, 9, 12, 18, 24 and annually thereafter. The bio-
chemical recurrence rate (BCR) was defined as two PSA
levels of >0.2 ng/ml after RARP. The definition of conti-
nence was based on the response to the item selected to
reflect the range of incontinence severity by asking the fol-
lowing question ‘‘How many pads per day did you usually
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World J Urol (2015) 33:1095–1102
use to control leakage?’’. Continence was defined as the use
of no pads or only a safety pad usage. Potency was deter-
mined from patients’ reports and IIEF-5 form. Potency was
defined as the ability to achieve and maintain satisfactory
erection firm enough for sexual intercourse with or without
the use of PDE-5 inhibitors.
Surgical procedure
The patients are admitted to the hospital 1 day before the
surgery. A Fleet® enema is administered the evening before
the surgery. Thromboprophylaxis is implemented with low
molecular weight heparin.
Patients underwent RARP with da Vinci-SI or da Vinci-
SI HD system (Intuitive Surgical Inc., Sunnyvale, CA).
Primary access for pneumoperitoneum was performed
using the Veress needle or direct open access via the Has-
son technique. A total of five or six ports were placed. The
first 12-mm port was placed for the camera, which is posi-
tioned at the supraumbilical crase in the midline, and the
others were placed under direct vision by the endoscope.
Port placement, number, and side of trocars for the assis-
tant varied according to surgeon preference. Four EndoW-
rist (Intuitive Surgical) robotic instruments were used:
monopolar curved shears, Maryland bipolar grasper, Pro-
grasp forceps, and large needle drivers. A 0 degree and 30
degree lenses were used. The patient was positioned in the
30° Trendelenburg position. Following inspection of the
peritoneal cavity, dissection technique varied according to
surgeon preference. The following steps performed sequen-
tially: dissection of vesicula seminalis and ductus deferens,
creation of Retzius space, incision of the endopelvic fas-
cia, dorsal vein stitch, bladder neck section, controlling the
lateral pedicles and preservation of the NVBs. The inter-
fascial or intrafascial plane in the posterolateral prostatic
groove was developed using a cautery-free technique until
the apex and urethra were visualized. After exposure of the
prostatic apex, the urethra was transected beyond the apex
of the prostate. In some cases, ductus deferens and vesicula
seminalis dissection were performed after bladder neck
dissection. Lymph node dissection was performed, when
clinically indicated. The urethrovesical anastomosis was
performed using a continuous running suture with V-lock
stitch 3–0 or 3–0 Monocryl sutures tied together. Both
sides of the sutures were passed through the bladder neck
from outside to in at 5 and 7 o’clock positions, respectively.
One continued in an anticlockwise manner, while the other
suture continued clockwise until the 12 o’clock position is
reached. A Foley catheter is placed into the bladder. The
anastomosis is tested for any leaks for 200 ml of saline. A
drain is placed through the left or right 5-mm port into the
pelvis. Trocars removed under direct vision to detect bleed-
ing following decreasing the intraabdominal CO2 pressure.
World J Urol (2015) 33:1095–1102 1097

Table 1  Preoperative characteristics of patients who underwent Table 2  Perioperative parameters of patients who underwent RARP
RARP procedures
Variable Value Variable Value

No. of patients 1,499 Operative time (min) 181.9 ± 71.1

Mean age (years) 61.3 ± 6.8 Estimated blood loss (ml) 225.4 ± 174.5
BMI (kg/m2) 27.3 ± 2.8 Pelvic lymph node dissection, n (%)
Mean PSA (ng/ml) 8.3 ± 5.9  Not performed 1,116 (74.4)
Prostate volume (ml) 50.2 ± 23.7  Unilateral 284 (18.9)
Gleason score 6.3 ± 0.5  Bilateral 100 (6.6)
IIEF-5 score, (%) Neurovascular bundle (NVB) preservation, (%)
 22–25 no erectile dysfunction (ED) 44.1  Not performed 14.3
 17–21 mild ED 29.2  Unilateral 9.6
 12–16 mild to moderate ED 10.1  Bilateral 76.1
 8–11 moderate ED 6.7 Drain extraction time (day) 2.3 ± 1.6
 5–7 severe ED 9.7 Duration of hospital stay (days) 2.9 ± 1.8
D’Amico classification, (%) Urethral catheterization time (days) 7.6 ± 2.2
 Low risk 65.02
 Intermediate risk 30.12
 High risk 4.85 Table 3  Postoperative pathologic stage, Gleason score, positive
Procedure year surgical margin rates, and biochemical recurrence (BCR) rates of
patients who underwent RARP
 2005–2008 181 (12 %)
 2009–2010 503 (33 %) Variable RARP (n = 1,499)
 2011–2012 815 (55 %)
Pathologic stage
 pT2 74.4 %
 PT3a 15.7 %
The specimen was placed in a laparoscopic retrieval bag
 pT3b 8.2 %
and removed by enlarging the umbilical port incision. The
 pT4 0.7 %
fascia at the extraction side and all skin incisions were
Gleason score 6.4 ± 0.4
closed.
Lymph node yield 9.2 (3–18)
Lymph node positivity 7 (1.8 %)
Postoperative care
Positive surgical margins—overall n, (%) 212 (14.14 %)
 pT2 6.1 %
Patients were allowed to take clear fluids following pass-
 pT3 37.1 %
ing flatus and encouraged to mobilize starting from postop-
 pT4 100 %
erative 6 h. The drains were generally removed between 24
Postoperative positive margins by location, (%)
and 48 h postoperatively, and patients were discharged on
 Apex 23.5
48–72 h postoperatively. The urethral catheter was removed
 Bladder neck 8.4
on postoperative day 7–10.
 Anterior and posterior 7.1
Statistical analysis  Seminal vesicles 6.1
 Left and right basis 27.3
All data are presented as mean ± standard deviation (SD).  Multifocal 27.6
The Student’s t test was used to continuous variable, and BCR (n, %) 44 (2.9)
the chi-squared test or Fisher’s exact test was used for eval-
uating categorical variables. P values of <0.05 were consid-
ered statistically significant. (37–77) years, and mean BMI was 27.3 ± 2.8 kg/m2. Mean
preoperative PSA level was 8.3 ± 5.9 ng/ml. Mean preop-
erative Gleason score was 6.3 ± 0.5, mean prostate volume
Results was 50.2 ± 23.7 ml. According to D’Amico classifica-
tion, the percentage of patients with low-, intermediate-,
The preoperative clinical characteristics of the all patients and high-risk disease cases were 65.0, 30.1, and 4.8 %,
are presented in Table 1. Mean patient age was 61.3 ± 6.8 respectively. Mean IIEF-5 scores for no ED, mild ED, mild

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1098 World J Urol (2015) 33:1095–1102

Table 4  Complications of Complication Number of occurrences Clavien grade Incidence, (%)

1,499 robotic-assisted radical
prostatectomy patients
Intraoperative
 Rectal injury 2 – 0.13
 Sigmoid colon injury 2 – 0.13
 Left ureter injury 1 – 0.06
Peri-operative
 Ileus 9 2 0.60
 Blood transfusion 18 2 1.20
 Pulmonary embolus 2 4a 0.13
 Myocardial infarction 2 4a 0.13
 Deep vein thrombosis 3 2 0.20
 Neuropraxia 1 1 0.06
Postoperative (after hospital discharge)
 Anastomotic leakage 21 1 1.40
 Wound infection 6 2 0.40
 Urinary retention 7 1 0.46
 Bladder neck contracture 5 3b 0.33
 Epididymitis 4 2 0.26
 Meatal stenosis 3 2 0.20
 Incisional hernia 3 3b 0.20
 Bowel hernia 1 3b 0.06
 Multiorgan dysfunction 1 4b 0.06
 Death 1 5 0.06

to moderate ED, moderate ED, and severe ED were 44.1,
29.2, 10.1, 6.7, and 9.7 %, respectively.
The perioperative data are listed in Table 2. The mean
operative time was 181.9 ± 71.1 min, and the mean EBL
was 225.4 ± 174.5 (30–1,250) cc during operation. A
nerve-sparing procedure was performed bilaterally in
76.1 % and unilaterally in 9.6 % cases. Lymph node dis-
section was performed in 384 (25.6 %) patients. The mean
drain extraction time was 2.3 ± 1.6 days, and mean hos-
pital stay was 2.9 ± 1.8 days. The urethral catheter was
removed on postoperative day 7.6 ± 2.2.
Postoperative histopathologic outcomes, PSMs, and bio-
chemical recurrence rates BCR are presented in Table 3.
Surgical margins were positive in 212 (14.1 %) patients.
The PSM rates in pT2, pT3, and pT4 stages were 6.1,
37.1, and 100 %, respectively. Among patients with a
PSM, the majority had pathologic T3 disease or T4, and
the percentage with pathologic stage T3 and T4 were sta-
tistically higher than between T2 patients (P < 0.001).
The mean lymph node yield was 9.2 (3–18). The lymph
node positivity was 7 (1.8 %). The mean follow-up was
26.7  ± 18.2 months. There were two deaths in the series,
and none of them were related to PC. Forty-four (2.9 %)
patients had a biochemical recurrence during follow-up.
Comprising one procedure converted to standard lapa-
roscopy due to robotic malfunction, one patient was con-
verted to open surgery. We observed 92 complications due
to modified Clavien–Dindo classification in 84 patients.
Intraoperative complications included two rectal injuries
and two sigmoid colon injuries. These injuries were recog-
nized intraoperatively and repaired primarily. None of these
patients had any problems in the postoperative follow-up.
Classification of the complications according to the modi-
fied Clavien–Dindo grading system is shown in Table 4.
Minor complications (grade 1 and 2) consisted 82.7 % of
all complications. The incidence of severe complications
was 6.9 %. The most common grade 1 complication was
anastomotic leakage (1.4 %), detected on cystography. Pro-
longed ileus and blood transfusion were the most common
grade 2 complications. These patients were managed with
maintenance of intravenous fluids and temporary restriction
of oral intake with resolution of the symptoms or transfu-
sion. Grade 3b complications included five patients with
bladder neck contractures, three patients with incisional
hernias, and one patient with bowel herniation through a
trocar site. Four patients had grade 4a complications. Two
patients presented with acute myocardial infarction on
postoperative day 2. These patients were monitored in the
intensive care unit and managed with clinical treatment.
Another two cases were diagnosed with pulmonary embo-
lism postoperatively. They received heparin and warfarin.
Following treatment, they both recovered without pul-
monary function limitations. There were two cases: mul-
tiorgan dysfunction or death (grade 4b or 5). One patient

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World J Urol (2015) 33:1095–1102 1099
Fig. 1  Return of continence 100
post-RARP 88.7
90
82.1
80
68.6
70
60
50
40
30
20
10.8
10
0
0 pad
had cerebrovascular accident on postoperative day 2. The
patient was treated in accordance with the recommenda-
tions of neurology. The patient’s discharged was planned,
but the patient died on postoperative day 7 for pulmoner
embolus.
At 12 months postoperatively, follow-up data were avail-
able for 1,235 of 1,499 patients (82.3 %). A total of 1,095
patients (88.7 %) were socially dry, as defined by the use
of no pad or safety pad (Fig. 1). The number of patients
requiring more than three pads per day at 12 months was
59 (4.8 %). Fifteen patients underwent insertion of an arti-
ficial urinary sphincter. Of 661 previously potent men, 557
underwent nerve-sparing RARP. At 12 months follow-up,
385 (58.2 %) of previously potent patients were potent with
or without PDE-5 inhibitors.
Discussion
Several treatment options for localized PC are currently
being offered, and the major challenges in caring for men
with newly diagnosed PC is deciding between the many
treatments options available. Since RARP was introduced
in 2000, it has become an important choice for localized
PC [12, 13]. There are several potential advantages of the
robotic approach. RARP is associated with decreased blood
loss and a shorter hospital stay. RARP also appears to offer
faster convalescence when compared to the RP, while still
achieving similar oncologic outcomes [14]. This multicen-
tre study presents the perioperative parameters, postopera-
tive histopathologic outcomes, continence, potency, BCR-
free rate outcome following 1,499 cases of RARP.
In the literature, there are various operation durations
in RARP series. Therefore, it is difficult to compare each
other because of different reporting variables. Patel et al.
3. months
6. months
12. months
13.60
6.4 7.5
3.2 4.7 2.8 4.8
2.3 1.2 2 1.3
1 pad 2 pads 3 pads >3 pads
[15] reported their single surgeon experience of 1,500
RARP procedures. The mean operative time from skin inci-
sion to fasciae closure was 105 min. They also showed a
decrease in the duration from 120 min in the first 300 cases
to 105 min in the last 300 cases of the series. In the series
of Badani et al. [16], they reported their experience with
2,766 RARPs. The mean surgical (from the Veress needle
placement to skin closure) and mean console time were
154 and 116 min, respectively. The authors also reported
that surgical time decreased from 160 to 131 min and con-
sole time from 121 to 97 min in time. In addition, Tasci
et al. [17] reported that their first 112 series mean robotic
console time was 174.7 (75–360) min. In this multicentre
study, the mean operative time was 181.9. These studies
showed operative time is related to the surgeon’s expe-
riences [15, 16]. In the present study, operative time was
relatively longer than that reported in other studies. In our
study, open and laparoscopic surgical experience of the sur-
geon was different. In addition, the time to begin robotic
surgery, case number, and distribution of cases according to
year has varied. Therefore, we were unable to evaluate the
learning curve.
In robotic surgery, intraoperative bleeding is generally
a minor problem due to the elevated intraabdominal pres-
sure by CO2 insufflation [18]. The weighted mean EBL
for current RALP series was 169 mL, with means of 103–
609 mL [19]. Two recent meta-analysis of studies directly
comparing ORP, LRP, and RALP confirmed that RALP
is associated with less operative blood loss and a lower
risk of transfusion than ORP [6, 20]. In the present series,
mean EBL was 225 ml and was comparable with the other
robotic series.
The two most commonly reported oncological outcomes
after RP were PSM and BCR status. PSM status represents
a surrogate marker for surgical quality in organ-confined
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1100
disease and is a risk factor for subsequent BCR. Smith
et al. [21] analyzed the results of 1,747 patients undergoing
radical prostatectomy (RARP in 1,238 and ORP in 509),
selected the last 200 consecutive patients in each group.
The overall incidence of PSM was significantly lower in
RARP compared with ORP (15 vs. 35 %). However, Par-
sons et al. [20] showed that there are no significant differ-
ences in overall risk or incidence of PSM rates between
ORP and LRP or RARP. In present study, PSM rate was
14.1 % (212 cases), and most of them were appeared in
first 700 cases. This result might show that the low PSM
rates are correlated with increasing of surgeon’s experi-
ence although our study includes more than a single con-
sole surgeon. Moreover, previous works demonstrate that
evaluating the margin rates among centers using the same
minimally invasive surgical approach, the results demon-
strate that for laparoscopic RP, PSM rates were higher in
lower-volume centers after adjusting for covariates. For
robot-assisted RP, such trends were less evident, with some
low-volume centers performing very well and others hav-
ing higher PSM rates after adjusting for covariates [22].
Biochemical recurrence after RP is defined as a ris-
ing PSA levels. Following RP, two consecutive values of
PSA > 0.2 ng/ml appear to represent an international con-
sensus defining recurrent cancer. Menon et al. [23] reported
on 1,384 patients who had undergone RARP, adopting
0.2 ng/ml as the definition of PSA recurrence, at a median
follow-up duration of 60.2 months, the authors found 1-,
3-, 5-, and 7-year BCR-free survival rates as high as 95, 90,
87, and 81 %, respectively. Also they reported incidences of
BCR (3.1 %) at a median follow-up 60.2 months. Barocas
et al. [24] compared BCR-free survival of 1,904 patients
who underwent RRP and RARP. The 3-year BCR-free sur-
vival rate was similar between groups when stratified by
known risk factors of recurrence (83–84 %). However, the
study was limited by a median follow-up of <1 year. Soo-
riakumaran et al. [25] reported BCR-free survival outcomes
for 944 men who underwent RARP 5 years ago at single
European center. The BCR-free survival outcome of this
study was 84.8 % at median follow-up, estimated at 5, 7,
and 9 years were 87.1, 84.5, and 82.6 %, respectively. The
authors concluded that RARP has satisfactory medium-
term BCR-free survival. In this study, BCR was detected in
44 (2.9 %) patients in 1-year follow-up.
The role of LND in PC remains a controversial one,
both in terms of the indications and the extent. Most inves-
tigators agree that LND offers significant pathologic and
prognostic information, which affects the use of adjuvant
therapy [26]. The feasibility of LND within RALP is well
established, with several large series demonstrating com-
parable yield and perioperative outcomes to the RRP. Zorn
and colleagues compared 296 RALP patients undergoing
standard PLND (external iliac and obturator fossa) with
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World J Urol (2015) 33:1095–1102
859 patients undergoing RALP alone. The investigators
removed a mean number of 12.5 lymph nodes. The perio-
perative parameters and complications were comparable
between the two groups [27]. We have performed lym-
phadenectomy, when clinically indicated. We performed
standard PLND. Our results have indicated that RPLND
can be effectively and safely performed without a signifi-
cant increase in complications. Moreover, our nodal yield
was comparable to that from previous open, laparoscopic,
and robotic series in which standard-template dissections
were performed. The extent of, and indication for, PLND
has been highly variable among surgeons and institutions.
There is need to studies for consensus in this issue.
Surgical complications after RP have been documented
in various previous series, but few have used standardized
classification system. Clavien et al. [11] proposed a grad-
ing system for surgical complications in 1992 and modi-
fied it in 2004. The updated Clavien–Dindo grading sys-
tem has been used more frequently in recent publications
for complications of RARP [11, 16, 18, 28, 29]. Patel et al.
reported the largest series describing complications follow-
ing RARP according to the Clavien system. They observed
140 complications in 127 patients. Grade 1 and 2 com-
plications comprised >80 % of the complications, and no
cases of multiorgan dysfunction or death were detected
[30]. Badani et al. [16] evaluated 2,766 consecutive RARP
cases and demonstrated that grade 1 and 2 complications
comprised >95 % of the total number of complications.
The overall complication rate was 12.2 %. Novara et al.
[31] reported higher complication rates in 415 consecu-
tive RARP cases. They observed 102 complications in 90
patients (21.6 %). According to the modified Clavien sys-
tem, 41 (10 %) patients had grade 1, 37 (9 %) had grade 2,
11 (3 %) had grade 3, and 1 (0.2 %) had grade 4 complica-
tions. The authors pointed out that the higher complication
rates observed in their series could reflect more rigorous
reporting of the data than in the previous studies. In this
paper, we reported the largest RARP series in Turkey. We
observed 92 complications in 84 patients (6.1 %). Grade 1
and 2 complications occurred 82.7 % of the total number
of complication. In our study, severe complications were
low. Different patient selection criteria and surgical experi-
ence, despite our complications rate, were consistent with
the literature. We believe that with care full patient selec-
tion and increasing experience, the complication rate will
be reduced.
The main objective of performing RARP is cancer
control; however, an important secondary target is the
protection of the quality of the life, like erectile function
and urinary continence. A comprehensive review of the
literature including RRP series published between 1990
and 2005 showed a wide range of estimates after a mini-
mum follow-up of 12 months, with patients who received
World J Urol (2015) 33:1095–1102 1101
bilateral nerve-sparing RRP showing potency rates ranging
from 31 to 86 % [32]. Similar ranges of outcomes from 42
to 76 % were reported after nerve-sparing LRP [6]. With
bilateral extended nerve-sparing RARP and construction
of the so-called Veil of Aphrodite, 80–90 % of patients
can achieve sexual intercourse [33]. It has been proposed
that RARP may prevent damage to the NVB. Tewari et al.
[34] demonstrated better and earlier potency recovery after
RARP compared with RRP. Patients who underwent RARP
showed earlier return of erections as well as a quicker
return to intercourse compared with RRP patients. Novara
et al. [35] demonstrated that age > 60 year and baseline
IIEF-5 score used as continuous variable were independ-
ent predictors of risk of postoperative erectile dysfunction.
Similarly, Shikanov et al. [36] reported in a large cohort
of patients that age, baseline sexual health inventory for
men (SHIM) score, and bilateral nerve sparing were inde-
pendently associated with achieving potency. Our study
showed that postoperative potency rate was 58.2 % with or
without a PDE-5 inhibitor.
The etiology of urinary incontinence following RP has
been attributed to various factors such as patient’s age, det-
rusor dysfunction, insufficiency of the sphincter mecha-
nism, and decreased urethral sensitivity [37]. Continence
rates between RP series have many variations because of
differences of data collection methods and follow-up peri-
ods. Continence rates for RARP series ranged between
38 and 97 % for immediately after catheter removal and
1, 3, 6 and 12 months after RARP [19]. This is related to
improved apical dissection, avoiding the use of monopolar
coagulation, anatomic dissection along the levator muscle,
preservation of the bladder neck, puboprostatic ligaments,
and prostatic fascia. Tewari et al. described an anterior and
posterior reconstruction technique during RARP. They
concluded that the total reconstructive procedure is a safe
and effective way to achieve an early return to continence
after RARP [34]. Similarly, Atug et al. [38] compared the
continence rates of patients who underwent RARP with
total reconstruction and without reconstruction. They
found that the overall continence rates were similar in both
groups at 52 weeks. However, patients in the total recon-
struction group had higher early continence rates than the
other group. The authors concluded that the total recon-
struction procedure is an efficient way to achieve an early
return to continence. In our multicentre series, continence
was defined as no pad or at least one safety pad usage. Our
continence rates were 68.6, 82.1, and 88.7 % at 3, 6, and
12 months after surgery, respectively.
The functional results of the RARP are influenced by
numerous factors including baseline patient characteris-
tics, operation techniques, surgical experience, definition of
potency and continence, and methods used to collect data.
Although the results seem very promising, we hope that
these results will be better by technological advances and
increasing experience. However, these advantages are sup-
ported by the results of an RCT comparing the open, lapa-
roscopic, and robotic techniques.
The data from present multicentre study demonstrated
that blood loss and transfusion rates as well as hospitali-
zation time are very satisfactory and acceptable by RARP
procedure. Concerning oncologic outcomes, PSM, BCR-
free rate, seems to be similar to the RRP literature. Conti-
nence and potency rates are very satisfactory at 12 months
after RARP. As a result, RARP has developed to a new
standard of care. The main limitation of the present study
was the lack of randomization. In our study, patient selec-
tion criteria differ between the centers. Another possible
limitation of the study was that we used interview by dif-
ferent clinicians. In our study, open and laparoscopic surgi-
cal experience of the surgeon was different. Therefore, we
were unable to evaluate the learning curve. Also, we did
not make a cost analysis. The study is limited by the short
follow-up, which can affect BCR-free and functional out-
comes. Prospective, randomized studies with larger sample
sizes with real-matched pairs are needed to evaluate the
outcomes after RARP.
Conflict of interest  The authors declare that they have no conflict
of interest.
Ethical standard  We have been performed in accordance with the
ethical standards laid down in the 1964 Declaration of Helsinki and
its later amendments.
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