Outcomes Of Robot-assisted Laparoscopic Prostatectomy Research Articles

Impact of frozen section on long-term outcomes in robot-assisted laparoscopic prostatectomy.

To compare 1-year functional and 5-year oncological outcomes of men undergoing robot-assisted laparoscopic prostatectomy (RALP) with neurovascular structure-adjacent frozen-section examination (NeuroSAFE) with those in men undergoing RALP without NeuroSAFE (standard of care [SOC]). Men undergoing RALP in our centre between 1 January 2009 and 30 June 2018 were enrolled from a prospectively maintained database. Patients were excluded if they had undergone preoperative therapy or postoperative adjuvant therapy or were enrolled in clinical trials. Patients were grouped based on use of NeuroSAFE. Follow-up was censored at 5 years. The primary outcome was difference in time to biochemical recurrence (BCR) on multivariable analysis, defined as prostate-specific antigen (PSA) >0.2 ng/L on two consecutive measurements. Secondary outcomes were difference in 1-year erectile dysfunction and incontinence. In the enrolment period, 1199 consecutive men underwent RALP, of whom 1140 were eligible, including 317 with NeuroSAFE and 823 with SOC. The median PSA follow-up was 60 months in both groups. Rates of 5-year BCR were similar on Kaplan-Meier survival curve analysis (11% vs 11%; P = 0.9), as was time to BCR on multivariable Cox proportional hazards modelling (hazard ratio 1.2; P = 0.6). Compared with the SOC group at 1 year, the NeuroSAFE group had similar unadjusted rates of incontinence (5.1% vs 7.7%) and lower unadjusted impotence (57% vs 80%). On multivariable analysis, NeuroSAFE patients had equivalent risk of incontinence (odds ratio [OR] 0.59, 95% CI 0.17-1.6; P = 0.4) but significantly reduced risk of erectile dysfunction (OR 0.37, 95% CI 0.22-0.60; P < 0.001). For men undergoing RALP, compared with SOC, NeuroSAFE patients had equivalent time to BCR and risk of 1-year incontinence, and significantly lower risk of 1-year erectile dysfunction.

Association of Crowd-Sourced Assessment of Technical Skills and Outcomes of Robotic-assisted Radical Prostatectomy

ObjectiveTo investigate if use of the Crowd-Sourced Assessment of Technical Skills (CSATSTM) platform and video peer review with constructive feedback is associated with improvement in technical skill and patient outcomes for robotic-assisted laparoscopic prostatectomy (RALP). MethodsFive fellowship-trained urologists voluntarily submitted RALP cases for CSATSTM Global Evaluative Assessment of Robotic Skills (GEARS) scoring and expert narrative review between April 15, 2022 - April 30, 2023. Surgeon-selected and randomly-selected cases were reviewed. Surgeons underwent local peer review of videos with constructive feedback. Change in GEARS scores and frequency of post-operative outcomes over the 12-month periods before and during the study were analyzed in logistic regression models. Bias was assessed with sensitivity analysis comparing surgeon-selected to randomly-selected cases. ResultsGEARS scores for randomly-selected versus surgeon-selected cases did not differ significantly. Overall GEARS score correlated positively with annual surgical RALP volume (r=0.39, p=0.003) and negatively with years in practice (r=-0.34, p=0.01). After adjusting for confounders, there was no significant improvement in overall GEARS Score (0.01±0.02/month, p=0.48); but likelihood of sepsis (Odds Ratio 0.07, 95% CI 0.01-1.00, p=0.05) and pelvic fluid collection (Odds Ratio 0.09, 95% CI 0.01-0.99, p=0.049) were significantly decreased during the intervention period (n=165) compared to the prior 12 months (n=144). No outcome increased in likelihood (p>0.05). ConclusionsIntegration of CSATSTM and local video peer review is associated with significant improvement in patient outcomes after RALP, despite no significant change in surgeons’ GEARS scores. This is the first study demonstrating improvement in patient RALP outcomes after implementation of such a paradigm in practicing surgeons.

Robot-assisted versus three-dimensional laparoscopic radical prostatectomy: 12-month outcomes of a randomised controlled trial.

To compare functional and oncological outcomes of robot-assisted laparoscopic prostatectomy (RALP) to three-dimensional laparoscopic radical prostatectomy (3D-LRP) at 12 months after surgery. Prospective randomised single-centre study of 145 consecutive men referred to radical prostatectomy in a tertiary referral centre in Finland. Patients were randomised 1:1 to the RALP (N = 75) and 3D-LRP (N = 70) groups. The primary outcome was urinary continence evaluated with the Expanded Prostate Cancer Index Composite 26-item version (EPIC-26) incontinence domain score at 12 months after surgery. Secondary outcomes included the use of protective pads at 12 months after surgery, EPIC-26 domain scores of irritative/obstructive, bowel, sexual and hormonal symptoms, positive surgical margin (PSM) rate, and biochemical recurrence (BCR). Complication frequency within the 3-month period after surgery was evaluated according to Clavien-Dindo classification. Statistical significance between groups was analysed using Mann-Whitney, chi-square and Fisher's exact tests. The trial was terminated after interim analysis based on no statistically significant difference in EPIC-26 urinary incontinence domain scores. Altogether 145 patients of the target accrual of 280 patients were recruited. Postoperative continence at 12 months after surgery according to the EPIC-26 incontinence domain was 79.25 in both groups (P = 0.4). Between group difference was -5.8 (95% confidence interval -15.2 to 3.6). There was no statistically significant difference in the rates of PSM or BCR between the two surgical modality groups. We were unable to demonstrate a difference between the RALP and 3D-LRP groups for functional and oncological outcomes at 12 months after surgery.

“Robotic fatigue?” – The impact of case order on positive surgical margins in robotic-assisted laparoscopic prostatectomy

PurposeMultiple robotic-assisted surgeries are often performed within a single operating day; however, the impact of this practice on patient outcomes has not been examined. We aim to determine whether outcomes for robotic-assisted laparoscopic prostatectomy (RALP) differed when performed sequentially. Materials and methodsA multi-institutional, retrospective cohort study was conducted involving a total of 8 academic centers between years 2015 and 2018. Participants were adult males undergoing RALP for localized prostate cancer on operative days in which 2 RALP cases were performed sequentially by the same resident-attending team. The primary outcome of the study was presence of positive surgical margin (PSM). Secondary outcomes were lymph node yield, operative time, and estimated blood loss. The primary analysis was a random effects meta-analysis model for PSM. ResultsOverall, 898 RALP cases (449 sequential pairs) were included in the study. There was no significant difference in PSM rate (27.2% vs. 30.3%, P= 0.338) between first and second case groups, respectively. Utilizing random effects meta-analysis, the second case cohort had no increased risk of PSM (OR 0.761.231.97, P= 0.40). Higher blood loss was noted in the second case cohort (186.7 ml vs. 221.7 ml, P = 0.002). Additionally, factors associated with PSM were increasing prostate specific antigen, higher percent tumor involvement, extraprostatic extension, and seminal vesicle invasion. ConclusionCase sequence was not associated with PSM, lymph node yield, or operative time for RALP. Disease specific factors and institutional experience are associated with increased risk for positive surgical margin which can aid providers in scheduling of patients.

Real-time assessment of learning curve for robot-assisted laparoscopic prostatectomy.

The learning curves analysed to date for robot-assisted laparoscopic prostatectomy are based on arbitrary cut-offs of the total cases. We analysed a large dataset of robot-assisted laparoscopic prostatectomies from a single centre between 2008 and 2019 for assessment of the learning curve for perioperative outcomes with respect to time and individual cases. A total of 1,406 patients were evaluated, with mean operative time 198.08 minutes and mean console time 161.05 minutes. A plot of operative time and console time showed an initial decline followed by a near-constant phase. The inflection points were detected at 1,398 days (308th case) for operative time and 1,470 days (324th case) for console time, with a declining trend of 8.83 minutes and 7.07 minutes, respectively, per quarter-year (p<0.001). Mean estimated blood loss showed a 70.04% reduction between the start (214.76ml) and end (64.35ml) (p<0.001). The complication rate did not vary with respect to time (p=0.188) or the number of procedures (p=0.354). There was insufficient evidence to claim that the number of operations (p=0.326), D'Amico classification (p=0.114 for intermediate versus low; p=0.158 for high versus low) or time (p=0.114) was associated with the odds of positive surgical margins. It takes about 300 cases and nearly 4 years to standardise operative and console times, with a requirement of around 80 cases per annum for a single surgical team in the initial years to optimise the outcomes of robot-assisted laparoscopic prostatectomy.

Patient-reported outcomes after surgery or radiotherapy for localised prostate cancer: a retrospective study.

To compare the intermediate-term outcomes and patient-reported outcomes of robot-assisted laparoscopic prostatectomy (RALP) and radical external beam radiotherapy (RT) in Chinese patients with localised prostate cancer. This was a retrospective study of patients with localised prostate cancer diagnosed between 2010 and 2011 and treated with either RALP or RT. Baseline patient and disease characteristics, post-treatment complications, and latest disease status were retrospectively collected from hospital records. For assessment of patient-reported outcomes, the Chinese version of the Expanded Prostate Cancer Index Composite (EPIC) questionnaire was completed by the patients. Ninety three patients aged 58 to 84 years were recruited. Thirty patients were treated by RALP (32.3%), whereas 63 received RT (67.7%). The RALP group had significantly lower baseline prostate-specific antigen levels than the RT group (P<0.001). More patients who underwent RALP reported urinary incontinence (70.0% vs 3.2%, P<0.001), whereas more patients who underwent RT reported other voiding symptoms (87.3% vs 50.0%, P<0.001) and perirectal bleeding (36.5% vs 0%, P<0.001) during follow-up. Of the 85 patients who were still alive at the time of the study, 52 (61.2%) returned completed questionnaires. Patients who underwent RALP had poorer median (interquartile range) EPIC urinary summary scores than patients who underwent RT [81.5 (18.3) vs 88.9 (17.9), P=0.016]. Urinary function [75.9 (20.4) vs 93.6 (16.2), P<0.001] and incontinence [60.5 (31.8) vs 91.8 (14.5), P<0.001] were also significantly worse in the RALP group. The bowel and sexual domain scores were similar between the two groups. We found that RALP and RT were associated with different patterns of complications and patient-reported outcomes. Urinary incontinence was much more prevalent in the patients treated surgically. This may significantly affect patients' quality of life.

Retrospective Cohort Analysis from a High-Volume Center of Prognostic Factors Affecting Biochemical Relapse in Patients with Encapsulated, Margin-Negative, Isolated Seminal Vesicle Invasion After Robot-Assisted Laparoscopic Prostatectomy: A Novel Study.

Purpose: Specimen pathology findings collectively impact the long-term outcomes of robot-assisted laparoscopic prostatectomy. Since seminal vesicle invasion (SVI) is an important independent predictor of biochemical recurrence (BCR), this study was designed to evaluate the influence of isolated SVI in the absence of capsular/margin invasion on BCR. Material and Methods: Pathology reports of 2009 robot-assisted laparoscopic prostatectomy specimens were analyzed retrospectively excluding capsular breach and/or margin-positive cases to include 1409 patients in the study. Factors predicting SVI and BCR in this select group of patients were assessed and statistically analyzed. Survival analysis for PSA (prostate-specific antigen) failure probability and binomial regressions for variable predictability were performed. Results: The African American race was associated with SVI (p < 0.05). PSA had a directly proportional correlation with the occurrence of SVI and BCR. SVI was found to be an independent predictor of BCR, leading to higher odds of BCR at 5 years (odds ratio [OR] 8.2, 95% confidence interval [CI] 4.5-14.6, p < 0.0001). When the seminal vesicle was invaded, the specimen Gleason grade group (SGGG; OR 1.9, 95% CI 1.02-3.7, p = 0.04), PSA (OR 1.2, 95% CI 1.01-1.4, p = 0.03), and BMI (body mass index) (OR 1.2, 95% CI 1.04-1.5, p = 0.01) predicted BCR. Seminal vesicle involvement was not found in SGGG 1. Risk stratification of significant predictors of BCR with isolated SVI identified a subgroup with BMI ≤27.9 kg/m2, PSA ≤8.6 ng/mL, and SGGG 2, which had a significantly better prognosis (p = 0.029, log-rank test). Conclusions: Seminal vesicles are infrequently involved with SGGG 1. Select groups of patients with isolated SVI who have low-grade disease with relatively lower PSA and BMI do not have an aggressive biological behavior and are unlikely to have a BCR, thereby circumventing unnecessary adjuvant therapy with its attendant side effects. The BMI significantly predicted PSA failures and should be considered as an additional risk assessment tool.

SC216 - The evolution of practice patterns and its impact on perioperative outcomes in robot-assisted laparoscopic prostatectomy (RALP) based on analysis of a single-surgeon series of 10,000 cases

SC216 - The evolution of practice patterns and its impact on perioperative outcomes in robot-assisted laparoscopic prostatectomy (RALP) based on analysis of a single-surgeon series of 10,000 cases

PE14 - The effect of USPSTF recommendation on post-operative outcomes in Robot-assisted laparoscopic prostatectomy (RALP) based on analysis of a single surgeon series

PE14 - The effect of USPSTF recommendation on post-operative outcomes in Robot-assisted laparoscopic prostatectomy (RALP) based on analysis of a single surgeon series

Outcomes of robotic-assisted laparoscopic prostatectomy versus open prostatectomy in surgical intervention of localized prostate cancer

An informed consent conversation regarding robotic-assisted laparoscopic prostatectomy versus open prostatectomy in patients with localized prostate cancer.

MP60-04 LONG-TERM ONCOLOGICAL AND FUNCTIONAL OUTCOMES OF HIGH-RISK PROSTATE CANCER FOLLOWING ROBOT-ASSISTED LAPAROSCOPIC PROSTATECTOMY: MINIMUM FOLLOW-UP OF 10 YEARS

INTRODUCTION AND OBJECTIVES:Data on long-term oncological and functional outcomes of robot-assisted laparoscopic prostatectomy (RALP) beyond 10 years are sparse. We aimed to interrogate our prospec...

PT373 - The effect of US Preventive Services Task Force’s screening recommendation on trifecta and pentafecta outcomes in robot-assisted laparoscopic prostatectomy based on analysis of a single-surgeon series

PT373 - The effect of US Preventive Services Task Force’s screening recommendation on trifecta and pentafecta outcomes in robot-assisted laparoscopic prostatectomy based on analysis of a single-surgeon series

Short interval of biopsy to robotic-assisted laparoscopic radical prostatectomy does not render any adverse effects on the perioperative outcomes.

The aim of our study was to investigate the effects of prostate biopsy on perioperative outcomes of robotic-assisted laparoscopic prostatectomy (RALP).A total of 181 patients who underwent the RALP in our institution have been retrospectively reviewed, patients were divided into different groups according to the interval of biopsy to RALP and core numbers of biopsy. Perioperative outcomes including estimated blood loss (EBL), operative time (OT), surgical margin status, postoperative drainage, hospital stay, and perioperative complications were served as endpoints.Interval of biopsy to RALP was not significantly correlated with any perioperative outcomes, while the biopsy core numbers had significant correlation with the EBL. In logistic regression analysis, the biopsy core numbers were associated with higher risk of positive surgical margins. Body mass index (BMI) was also a significant factor related to OT.Delay of the RALP after biopsy was not applicable in the era of RALP and surgeons could be more freely in selecting the time of RALP. Besides, further studies should focus on how to improve the diagnostic efficiency of prostate cancer without increasing the incidence of surgical complications.

Evolution of the Surgical Technique to Improve Functional Outcomes in Robot-Assisted Laparoscopic Prostatectomy (RALP): A Single Centre Experience of Over 500 Cases

Evolution of the Surgical Technique to Improve Functional Outcomes in Robot-Assisted Laparoscopic Prostatectomy (RALP): A Single Centre Experience of Over 500 Cases

Urinary Continence after Robot-Assisted Laparoscopic Radical Prostatectomy: The Impact of Intravesical Prostatic Protrusion.

PurposeTo assess the impact of intravesical prostatic protrusion (IPP) on the outcomes of robot-assisted laparoscopic prostatectomy (RALP).Materials and MethodsThe medical records of 1094 men who underwent RALP from January 2007 to March 2013 were analyzed using our database to identify 641 additional men without IPP (non-IPP group). We excluded 259 patients who presented insufficient data and 14 patients who did not have an MRI image. We compared the following parameters: preoperative transrectal ultrasound, prostate specific antigen (PSA), clinicopathologic characteristics, intraoperative characteristics, postoperative oncologic characteristics, minor and major postoperative complications, and continence until postoperative 1 year. IPP grade was stratified by grade into three groups: Grade 1 (IPP≤5 mm), Grade 2 (5 mm<IPP≤10 mm), and Grade 3 (IPP>10 mm).ResultsOf the 821 patients who underwent RALP, 557 (67.8%) experienced continence at postoperative 3 months, 681 (82.9%) at 6 months, and 757 (92.2%) at 12 months. According to IPP grade, there were significant differences in recovering full continence at postoperative 3 months, 6 months, and 12 months (p<0.001). On multivariate analysis, IPP was the most powerful predictor of postoperative continence in patients who underwent RALP (p<0.001). Using a generalized estimating equation model, IPP also was shown to be the most powerful independent variable for postoperative continence in patients who underwent RALP (p<0.001).ConclusionPatients with low-grade IPP have significantly higher chances of recovering full continence. Therefore, the known IPP grade will be helpful during consultations with patients before RALP.

The impact of days off between cases on perioperative outcomes for robotic-assisted laparoscopic prostatectomy.

To examine the effect of days off between cases on perioperative outcomes for robotic-assisted laparoscopic prostatectomy (RALP). We analyzed a single-surgeon series of 2036 RALP cases between 2003 and 2014. Days between cases (DBC) was calculated as the number of days elapsed since the surgeon's previous RALP with the second start cases assigned 0 DBC. Surgeon experience was assessed by dividing sequential case experience into cases 0-99, cases 100-249, cases 250-999, and cases 1000+ based on previously reported learning curve data for RALP. Outcomes included estimated blood loss (EBL), operative time (OT), and positive surgical margins (PSMs). Multiple linear regression was used to assess the impact of the DBC and surgeon experience on EBL, OT, and PSM, while controlling for patient characteristics, surgical technique, and pathologic variables. Overall median DBC was 1 day (0-3) and declined with increasing surgeon case experience. Multiple linear regression demonstrated that each additional DBC was independently associated with increased EBL [β = 3.7, 95% CI (1.3-6.2), p < 0.01] and OT [β = 2.3 (1.4-3.2), p < 0.01], but was not associated with rate of PSM [β = 0.004 (-0.003-0.010), p = 0.2]. Increased experience was also associated with reductions in EBL and OT (p < 0.01). Surgeon experience of 1000+ cases was associated with a 10% reduction in PSM rate (p = 0.03) compared to cases 0-99. In a large single-surgeon RALP series, DBC was associated with increased blood loss and operative time, but not associated with positive surgical margins, when controlling for surgeon experience.

Outcomes of Robot-Assisted Laparoscopic Prostatectomy with a Posterior Approach to the Seminal Vesicle in 300 Patients.

Background. The goal of this study was to analyze the perioperative outcomes of robot-assisted laparoscopic radical prostatectomies (RALPs) performed at our center. Methodology. We retrospectively reviewed 300 consecutive patients with clinically localized prostate cancer who underwent RALP with a posterior dissection approach to the seminal vesicle between May 2011 and November 2013. The mean patient age was 67.2 ± 5.5 years (range: 41–78 years), and the mean prostate-specific antigen (PSA) concentration, at diagnosis of prostate cancer, was 9.16 ± 6.50 ng/mL (range: 2.20–55.31 ng/mL). Results. The median duration of robotic surgery was 160 min (mean: 165 ± 40 min; range: 75–345 min). Median estimated blood loss, including that in urine, was 200 mL (mean: 277 ± 324 mL; range: 4–3250 mL). Intraoperative and immediate postoperative complications occurred in 3.0% of patients; 4 patients required allogeneic blood transfusion. As a measure of patient continence, 82.4% did not use more than 1 absorbent pad in 24 h, at 6 months postoperatively. Conclusion. RALP with an initial posterior dissection to the seminal vesicle was a safe and efficient method for controlling prostate cancer, even in these initial cases.

Does elevated body mass index (BMI) affect the clinical outcomes of robot-assisted laparoscopic prostatectomy (RALP): A prospective cohort study

Objectives: With the prevalence of obesity in the United States, a significant proportion of robot-assisted laparoscopic prostatectomy (RALP) candidates have an elevated body mass index (BMI). We determine if this impacts on the clinical outcomes of RALP. Methods: 218 consecutive patients underwent RALP were identified from a prospectively maintained RALP database recorded and compared for their demographics, clinical outcomes and adverse events in normal weight (BMI <25 kg/m2), overweight (BMI ≥25 and <30 kg/m2) and obese (BMI ≥30 kg/m2) groups. Results: 36 normal weight, 115 overweight and 67 obese patients were identified. There were no significant differences in demographic data among the three groups except for mean BMI (23.1 vs. 27.5 vs. 32.8 kg/m2, p < 0.001). The median operative time was longer in obese patients compared to both overweight (210 vs. 189 min, p = 0.031) and normal weight (210 vs. 177 min, p = 0.008) patients. There were no significant differences in median estimated blood loss, mean prostate volume, positive surgical margin rate and time to continence without pads. The median urethral catheter duration and hospitalization were similar in all groups. Patients with elevated BMI had a significantly higher median Gleason score (p = 0.046) and incidence of pathologic T3 disease (p = 0.038). The incidence of adverse events was low and there were no significant differences among the three groups (p > 0.05).Conclusions: Elevated BMI appears to increase the RALP operative time, but has little impact on other intraoperative parameters, clinical outcomes or patient morbidity. RALP is a safe and effective procedure in patients with elevated BMI.

Anatomical dimensions using preoperative magnetic resonance imaging: impact on the learning curve of robot-assisted laparoscopic prostatectomy.

To evaluate the impact of anatomical dimensions as measured using preoperative magnetic resonance imaging on the outcomes of robot-assisted laparoscopic prostatectomy. We retrospectively reviewed 100 consecutive robot-assisted laparoscopic prostatectomy procedures that were carried out by a single surgeon at the Division of Urology, Department of Surgery, Tottori University Faculty of Medicine, Yonago, Japan. Preoperative clinical data and anatomical measurements, including the calculated prostate volume pelvic cavity index, were determined based on preoperative magnetic resonance imaging, and their effects on console time, estimated blood loss and surgical margin status were compared. Body mass index, the prostate anteroposterior diameter, and the prostate volume-to-pelvic cavity index ratio were all significantly correlated with console time and estimated blood loss, based on a univariate analysis (P < 0.05). The prostate craniocaudal diameter, prostate transverse diameter and prostate volume also correlated with console time. However, based on the multiple linear regression analysis, only the prostate volume-to-pelvic cavity index ratio was found to be a significant predictor of console time and estimated blood loss. Furthermore, when the 100 total cases were divided into 50 early cases and 50 late cases, the prostate volume-to-pelvic cavity index ratio correlated with console time and estimated blood loss only in the early group, and not in the late group. In contrast, anatomical measurements had no significant effect on surgical margin status. Magnetic resonance imaging can be a valuable adjunct to robot-assisted laparoscopic prostatectomy. Our data show that patients with larger prostates and narrow, deep pelvises might present more difficulty in robot-assisted laparoscopic prostatectomy procedures. However, the present data also show that this problem can be overcome by an experienced operator with improved surgical techniques.

Impact of prostate weight on perioperative outcomes of robot-assisted laparoscopic prostatectomy with a posterior approach to the seminal vesicle

BackgroundTo determine the effect of prostate weight on the preoperative and postoperative outcomes of robotic-assisted laparoscopic radical prostatectomy with a posterior approach to the seminal vesicle.MethodsThis retrospective study examined prospectively collected data on 219 robotic-assisted laparoscopic radical prostatectomies performed from May 2011 to February 2013. Patients were divided into four groups based on pathologic prostate weight: <30 g, 30–49 g, 50–79 g, and ≥80 g. Continence and sexual function were assessed using validated questionnaires.ResultsOf the 219 patients, 19, 143, 51, and 6 had prostates weighing <30 g, 30–49 g, 50–79 g, and ≥80 g, respectively. Significant differences were found between the preoperative Gleason scores, total operative times, and robotic times of the groups. Both estimated blood loss and anastomosis time tended to be greater in the higher prostate weight groups, but the differences were not significant. No significant differences were observed in transfusion rate, length of catheterization, complication incidence, or positive surgical margins. The return of urinary function, as determined by questionnaire scores, was not affected by prostate weight.ConclusionsRobotic-assisted laparoscopic radical prostatectomy can be performed safely and with similar perioperative outcomes, regardless of prostate weight. Indeed, oncological outcome, urinary continence, and complications were similar across the prostate weight groups, suggesting that robotic-assisted laparoscopic radical prostatectomy with a posterior approach to the seminal vesicle may be performed effectively on men with large prostates, despite greater surgical times.