Early continence assessment in retzius sparing robot Assisted radical prostatectomy using CMR versius® robotic surgical system

Since the introduction of the da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA, USA), the trend of minimally invasive surgery has accelerated. Recently, Intuitive Surgical launched the new da Vinci Xi platform and a prototype of a single-port surgical system. Other platforms from other robotic companies are on the horizon. The multiport surgical robotic ALF-X system (SORAR SpA, Milan, Italy) was initially introduced for gynecological surgery and was recently assessed in a preclinical animal study of robot-assisted partial nephrectomy (RPN) [1,2]. The ALF-X robot consists of a remote-controlled unit with a haptic handle, a three-dimensional high-definition monitor, an infrared eye-tracking system, and four detached robotic arms. The haptic feedback allows the surgeon to feel the force and resistance to the tissue. The surgeon can move the camera by gaze, and the system includes a large set of reusable instruments. Other manufacturers include Medrobotics (Raynham, MA, USA), which received U.S. Food and Drug Administration clearance for the Flex Robotic System in July 2015. The Flex Robotic System provides surgeons with single-site access visualization of hard-to-reach anatomical locations. Titan Medical (Toronto, ON, Canada) is a public company based on Single Port Orifice Robotic Technology. The system utilizes a 25-mm single-access port that contains two articulating instruments and a three-dimensional high-definition camera. The Korean domestic manufacturer Meree Company has developed the REVO I robot system. A clinical trial for the REVO I robot has been planned to supplement the global market. Meanwhile, the Korean national evidence-based health care collaborating agency (NECA) published a preliminary report on the clinical feasibility and cost-effectiveness of robot-assisted radical prostatectomy (RARP) from a total of five high-volume centers to provide fundamental data for instituting the national health policy. Concerning oncological outcomes, there were no significant differences in biochemical recurrence or the positive surgical margin rate. Concerning functional outcomes, RARP revealed the highest continence rate of 88.7% and 95.3% achievement of complete continence at postoperative 3 months and 3 years, respectively. Concerning cost analysis of the robotic system, with a threshold value of 30.5 million Korean won (KRW; 27,000 US dollars [USD]), a cost-effectiveness analysis of purchase among RARP, laparoscopic radical prostatectomy, and open radical prostatectomy (ORP) showed that RARP was not yet cost-effective. RARP could be cost-effective if the expenses could be reduced by 8.3 million KRW (7,400 USD). The effectiveness of the system could not offset the costs, because there was no significant difference in effectiveness among the different procedures, and the robotic cost of RARP was significantly more than that of the other procedures. However, owing to the short term of 1 year of data used for the cost-effectiveness analysis, long-term prospective study is necessary for further high-quality analysis. Recently, high-quality evidence is emerging comparing robotics with its traditional counterparts. In a study of RARP, Wallerstedt et al. [3] performed a prospective comparative trial of ORP versus RARP in a Swedish group of 14 centers including a total of 2,506 patients. The study was conducted prospectively over a 3-year period with patient-reported outcome measurement. The RARP group had less perioperative bleeding and shorter hospital stays. Reoperation during the hospital stay and seeking health care for cardiovascular reasons were more frequent after ORP. Haglind et al. [4] performed a prospective, controlled, nonrandomized trial evaluating urinary incontinence and erectile dysfunction in a total of 14 centers in Sweden including 2,625 patients and concluded that RARP was beneficial in preserving erectile function compared with ORP, with no statistically significant differences in continence or surgical margins. In an analysis of RPN, Choi et al. [5] performed a systematic review and meta-analysis of 23 studies and 2,240 patients. The authors concluded that RPN is more favorable than laparoscopic partial nephrectomy (LPN) in terms of a lower conversion rate to radical nephrectomy, more favorable renal function, a shorter length of hospital stay, and a shorter warm ischemia time. Potretzke and Bhayani [6] wrote an editorial comment on our previous article [5]. The authors mentioned the superior outcomes of RPN and the efficiency of excision and suturing. The true value of RPN is in its feasibility, accessibility, and learning curves, and the procedure competing with RPN now is not LPN, but rather radical nephrectomy, ablation, and observation. There will be more new robotic platforms, and new prospective randomized data will become available. The Korean Journal of Urology hopes to continue to share this knowledge on recent updates in robotic minimally invasive surgery and to enhance future perspectives on robotic minimally invasive surgery.

Robotic surgical systems have revolutionized minimally invasive procedures, offering enhanced three-dimensional visualization, high precision, and stable operation, particularly beneficial for radical prostatectomy. However, high costs have hindered the adoption of robot-assisted radical prostatectomy (RARP) in grassroots hospitals in China. This retrospective study aimed to evaluate the efficacy and safety of the EDGE Surgical Robotic System in performing RARP. A total of 129 patients who underwent RARP at our center between November 2023 and March 2025 were analyzed, with outcomes assessed including port placement to docking time, operative time, estimated blood loss, complications, pathological results, safety indicators, length of hospital stay, catheterization duration, postoperative PSA level, and early urinary continence recovery rate. All surgeries were completed successfully without conversion to laparoscopic or open procedures, with a mean setup time of 36.9min, operative time of 176.3min, and estimated blood loss of 128.1 mL. The positive surgical margin (PSM) rate was documented at 31.0%, with an average hospital stay of seven days and catheterization duration of 15.4 days. Importantly, no safety incidents were reported, and the average total cost of hospitalization and operative cost was CNY ¥59854.8 (USD $8287.8) and ¥36,249.2 (USD $5,019.26), respectively, indicating a cost-effective approach. While the study's retrospective design is a limitation, the findings provide preliminary evidence that the EDGE Surgical Robotic System is a safe and economically viable alternative for RARP, paving the way for broader implementation in similar healthcare settings.

Minimally Invasive Radical Prostatectomy

MP46-14 LOOKING BEYOND CANCER DETECTION: IS TEMPLATE BIOPSY BETTER THAN TRUS BIOPSY IN PLANNING NERVE SPARING ROBOTIC RADICAL PROSTATECTOMY IN THE MULTIPARAMETRIC MRI ERA?

Variations Among Individual Surgeons in the Rate of Positive Surgical Margins in Radical Prostatectomy Specimens

To evaluate the positive surgical margin rates and locations in radical prostatectomy among three surgical approaches, including open radical prostatectomy, laparoscopic radical prostatectomy and robot-assisted radical prostatectomy. We retrospectively reviewed clinical outcomes at our institution of 450 patients who received radical prostatectomy. Multiple surgeons were involved in the three approaches, and a single pathologist conducted the histopathological diagnoses. Positive surgical margin rates and locations among the three approaches were statistically assessed, and the risk factors of positive surgical margin were analyzed. This study included 127, 136 and 187 patients in the open radical prostatectomy, laparoscopic radical prostatectomy and robot-assisted radical prostatectomy groups, respectively. The positive surgical margin rates were 27.6% (open radical prostatectomy), 18.4% (laparoscopic radical prostatectomy) and 13.4% (robot-assisted radical prostatectomy). In propensity score-matched analyses, the positive surgical margin rate in the robot-assisted radical prostatectomy was significantly lower than that in the open radical prostatectomy, whereas there was no significant difference in the positive surgical margin rates between robot-assisted radical prostatectomy and laparoscopic radical prostatectomy. In the multivariable analysis, PSA level at diagnosis and surgical approach (open radical prostatectomy vs robot-assisted radical prostatectomy) were independent risk factors for positive surgical margin. The apex was the most common location of positive surgical margin in the open radical prostatectomy and laparoscopic radical prostatectomy groups, whereas the bladder neck was the most common location in the robot-assisted radical prostatectomy group. The significant difference of positive surgical margin locations continued after the propensity score adjustment. Robot-assisted radical prostatectomy may potentially achieve the lowest positive surgical margin rate among three surgical approaches. The bladder neck was the most common location of positive surgical margin in robot-assisted radical prostatectomy and apex in open radical prostatectomy and laparoscopic radical prostatectomy. Although robot-assisted radical prostatectomy may contribute to the reduction of positive surgical margin, dissection of the bladder neck requires careful attention to avoid positive surgical margins.

Robot-assisted radical prostatectomy (RARP) is the standard surgical treatment for localized prostate cancer in the United States. After more than a decade of experience with the robotic approach, its oncological safety has been confirmed with margins positivity comparable to the open approach. Large scale RARP series yielded positive surgical margin (PSM) rates between 9 and 19%. PSM rates are strongly associated with preoperative disease characteristics (i.e., PSA, Gleason score, and clinical stage). As more patients with intermediate and high risk disease undergo RARP, the overall rates of PSM may potentially increase. While PSMs have been repeatedly shown to predict biochemical recurrence (BCR), their impact on more meaningful outcomes, such as the development of metastatic disease and cancer-specific mortality is not completely clear. Gleason score at PSM and PSM margins length are important features of PSM that seems to have influence on the long term impact of PSM. Various surgical techniques and tailoring nerve preservation based on disease severity appear to improve cancer control during RARP. Post radical prostatectomy radiation therapy (RT) also improves oncological outcomes. Level I evidence from open radical prostatectomy literature, demonstrated improved biochemical recurrence-free, metastasis-free, and overall survival when adjuvant radiation therapy was given to patients with adverse pathological features, including PSMs. Yet, the optimal timing of when to deliver additional RT is still unknown and awaits the results of several randomized clinical trials.

103 Background: There is no clear evidence to support one form of surgical approach over another with regards radical prostatectomy. The aim of this study was to analyze the literature available between 2002 and 2008 and compare positive surgical margin and complication rates for open retropubic, laparoscopic, and robotic radical prostatectomy. Methods: A total of 110,016 patients formed the basis of this meta-analysis, representing the largest compilation of radical prostatectomy patients in the literature. Summary data were abstracted on year of publication, pre-operative patient characteristics, positive surgical margins, estimated blood loss, blood transfusions, conversions, length of hospital stay, and total intra- and peri-operative complications, with a further 21 individual perioperative complications selected a priori for abstraction and analysis. Results: The open and laparoscopic surgical groups had similar overall positive surgical margin rates, with the robotic group having lower rates. Both minimally invasive approaches showed significantly lower estimated blood loss and rate of blood transfusions, and a shorter length of hospital stay when compared to an open approach. A further decrease in these parameters was seen when robotic assistance was used. Total complication rates were highest for the open approach, intermediate for the laparoscopic cohort, and lowest for the robotic group. For the individual complication analysis, the rates for death, readmission, reoperation, ureteral, bladder, and rectal injury, ileus, pneumonia, fistula, and wound infection showed significant differences between groups. Conclusions: Robotic assisted laparoscopic radical prostatectomy has overall lower perioperative morbidity and improved early oncologic outcomes compared to conventional laparoscopic or open approaches. Further studies comparing longer term oncologic and functional outcomes, as well as cost-benefit comparisons are needed before making recommendations for or against a specific type of surgery. [Table: see text]

Retzius Sparing Radical Prostatectomy Versus Robot-assisted Radical Prostatectomy: Which Technique Is More Beneficial for Prostate Cancer Patients (MASTER Study)? A Systematic Review and Meta-analysis

IntroductionThe coming decade will see the emergence of many surgical robotic systems that need to prove their cost‐effectiveness and clinical usability to gain the trust of robotic surgeons worldwide. Herein, we provide a concise review of the currently available robotic systems. Since the da Vinci Surgical System's patent expired and its market monopoly ended, many robotic surgical systems have, and will continue to, enter the market. Central to this is the challenge of gaining the trust of robotic surgeons in a cost‐effective manner. However, the cumulative robotic surgical experience of Intuitive Surgical over these years—which has proven itself clinically and technically—is a great challenge for new surgical robots.MethodsThis was a non‐systematic review of the literature, conducted through the PubMed search engine, using the following words: “Da Vinci,” “robotic surgical system,” and “new robotic surgical device.” Further information was obtained from the robotic system companies’ official websites and press releases.ConclusionsThe open robotic market carries great challenges for new robotic surgical systems, especially when following well‐established da Vinci Surgical System. Surgeons’ trust, clinical publications, technical support, and market distribution all represent separate challenges that require address.

Rates of Positive Surgical Margins and Their Effect on Cancer-specific Mortality at Radical Prostatectomy for Patients With Clinically Localized Prostate Cancer.

BackgroundIntrafascial prostatectomy was a modified technique from the conventional nerve-sparing surgery in order to improve patients’ post-surgical continence and erectile function; however, ongoing controversy exists regarding the oncological safety of this technique. In this study we aimed to provide a critical and pooled analysis based on published literatures regarding the oncological outcomes after intrafascial nerve-sparing prostatectomy.MethodsDatabase searches were performed for published articles till June 2018 on PubMed. Three reviewers screened fulfilled papers and extracted data independently. Main outcome was the positive surgical margins (PSMs) rates stratified by pathological stages. We performed both one-arm and comparative meta-analysis to evaluate the oncological safety of intrafascial technique. Moreover, we built meta-regression models to assess the confounding factors.ResultsWe retrieved a total of 117 records after electronic search, of which 21 studies were finally included in this review. There were 15 controlled studies and 6 surgical series. Our one-arm meta-analysis demonstrated that the total PSM rates after intrafascial techniques ranging from 2.2 to 35%, with a pooled rate of 14.5% on average (480 of 3151 patients, 95% confidence interval[CI]: 11.2–17.5%). Meta-regression model showed that patients’ age, pT2 cancer percentage and Selection Score of Oncological Safety (SSOS) were significantly associated with total PSM rate; moreover, each 1 point of SSOS could decrease the total PSM rate by 1.3% on average. Comparative meta-analysis demonstrated that there was no significant difference between intra- and inter-fascial group regarding PSM rates.ConclusionsWith stringent case selection and when performed by experienced surgeons, intrafascial prostatectomy could offer an acceptable or, at least, equivalent PSM rate compared with the conventional interfascial approach. Preoperative SSOS more than 7 points could be considered as an indication of intrafascial radical prostatectomy.

Operator is an Independent Predictor of Detecting Prostate Cancer at Transrectal Ultrasound Guided Prostate Biopsy

The Impact of Positive Surgical Margins on Mortality Following Radical Prostatectomy During the Prostate Specific Antigen Era

Does body mass index have an impact on the rate and location of positive surgical margins following robot assisted radical prostatectomy?