Difficulties in Robotic-Assisted Nerve-Sparing Radical Prostatectomy

  • Gerald Y. Tan
  • Philip J. DorseyJr.
  • Ashutosh K. TewariEmail author


Serum prostate-specific antigen (PSA) screening, coupled with a rising incidence of needle biopsies in asymptomatic men, have all contributed to prostate cancer becoming the most common cancer in men in the United States1,2 and other parts of the world.3 With increasing evidence of improved long-term survival and progression-free outcomes,4–7 radical prostatectomy has become increasingly popular as the treatment of first choice for organ-confined disease.


  1. 1.
    Penson DF, Rossignol M, Sartor AO, Scardino PT, Abenhaim LL. Prostate cancer: epidemiology and health-related quality of life. Urology. 2008;72(Suppl 6A):3-11.CrossRefGoogle Scholar
  2. 2.
    Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin. 2008;58:71-96.CrossRefPubMedGoogle Scholar
  3. 3.
    Quinn M, Babb P. Patterns and trends in prostate cancer incidence, survival, prevalence and mortality. Part 1: International comparisons. BJU Int. 2002;90(2):162-173.CrossRefPubMedGoogle Scholar
  4. 4.
    Lu-Yao GL, Yao S. Population based study of long-term survival in patients with clinically localized prostate cancer. Lancet. 1997;349:906-910.CrossRefPubMedGoogle Scholar
  5. 5.
    D’Amico DV, Whittington R, Malkowicz SB, et al. Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA. 1998;280(11):969-974.CrossRefPubMedGoogle Scholar
  6. 6.
    Bill-Axelson A, Holmberg L, Ruutu M, et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med. 2005;352(19):1977-1984.CrossRefPubMedGoogle Scholar
  7. 7.
    Bill-Axelson A, Holmberg L, Filen F, et al. Radical prostatectomy versus watchful waiting in localized prostate cancer: the Scandinavian prostate cancer group-4 randomized trial. J Natl Cancer Inst. 2008;100(16):1144-1154.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Su L. Role of robotics in modern urologic practice. Curr Opin Urol. 2009;19:63-64.CrossRefPubMedGoogle Scholar
  9. 9.
    Begg CB, Riedel ER, Bach PB, et al. Variations in morbidity after radical prostatectomy. N Engl J Med. 2002;346(15):1138-1144.CrossRefPubMedGoogle Scholar
  10. 10.
    Bianco FJ Jr, Reidel ER, Begg CB, Kattan MW, Scardino PT. Variations among high volume surgeons in the rate of complications after radical prostatectomy: further evidence that technique matters. J Urol. 2005;173:2099-2113.CrossRefPubMedGoogle Scholar
  11. 11.
    Wilt TJ, Shamliyan TA, Taylor BC, MacDonald R, Kane RL. Association between hospital and surgeon radical prostatectomy volume and patient outcomes: a systematic review. J Urol. 2008;180:820-829.CrossRefPubMedGoogle Scholar
  12. 12.
    Berryhill R Jr, Jhaveri J, Yadav R, et al. Robotic prostatectomy: a review of outcomes compared with laparoscopic and open approaches. Urology. 2008;72:15-23.CrossRefPubMedGoogle Scholar
  13. 13.
    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(5):1037-1063.CrossRefPubMedGoogle Scholar
  14. 14.
    Fischer B, Engel N, Fehr J-L, John H. Complications of robotic-assisted radical prostatectomy. World J Urol. 2008;26:595-602.CrossRefPubMedGoogle Scholar
  15. 15.
    Hu JC, Nelson RA, Wilson TG, et al. Perioperative complications of laparoscopic and robotic assisted radical prostatectomy. J Urol. 2006;175:541-546.CrossRefPubMedGoogle Scholar
  16. 16.
    Yee DS, Ornstein DK. Repair of rectal injury during robotic-assisted laparoscopic prostatectomy. Urology. 2008;72:428-431.CrossRefPubMedGoogle Scholar
  17. 18.
    Guillonneau B, Rozet F, Cathelineau X, et al. Perioperative complications of laparoscopic radical prostatectomy: the Montsouris 3-year experience. J Urol. 2002;167:51-56.CrossRefPubMedGoogle Scholar
  18. 18.
    Bishoff JT, Allaf ME, Kirkels WIM, Moore RG, Kavoussi LR, Schroder F. Laparoscopic bowel injury: incidence and clinical presentation. J Urol. 1999;161:887-890.CrossRefPubMedGoogle Scholar
  19. 19.
    Guillonneau B, Gupta R, El Fettouh H, Cathelineau X, Baumert H, Vallancien G. Laparoscopic management of rectal injury during laparoscopic radical prostatectomy. J Urol. 2003;169:1694-1696.CrossRefPubMedGoogle Scholar
  20. 20.
    Shekarriz B, Upadhyay J, Wood DP. Intraoperative, perioperative and long term complications of radical prostatectomy. Urol Clin North Am. 2001;28:639-653.CrossRefPubMedGoogle Scholar
  21. 21.
    Stolzenburg JU, Rabenault R, Do M, et al. Complications of endoscopic extraperitoneal radical prostatectomy (EERPE): prevention and management. World J Urol. 2006;24:668-675.CrossRefPubMedGoogle Scholar
  22. 22.
    Spaliviero M, Stenberg AP, Kaouk JH, Desai MM, Hammert WC, Gill IS. Laparoscopic injury and repair of obdurator nerve during radical prostatectomy. Urology. 2004;64:1030.CrossRefPubMedGoogle Scholar
  23. 23.
    Sarle R, Tewari A, Hemal AK, Menon M. Robotic–assisted anatomic radical prostatectomy: technical difficulties due to a large median lobe. Urol Int. 2005;74:92-94.CrossRefPubMedGoogle Scholar
  24. 24.
    Meeks JJ, Zhao L, Greco KA, Macejko A, Nadler RB. Impact of prostate median lobe anatomy on robotic-assisted laparoscopic prostatectomy. Urology. 2009;73:323-327.CrossRefPubMedGoogle Scholar
  25. 25.
    Rehman J, Chughtai B, Guru K, Shabsigh R, Samadi DB. Management of an enlarged median lobe with ureteral orifices at the margin of bladder neck during robotic-assisted laparoscopic prostatectomy. Can J Urol. 2009;16:4490-4494.PubMedGoogle Scholar
  26. 26.
    Katz MH, Eng MK, Deklaj T, Zorn KC. Technique for ureteral stent placement during robot-assisted radical prostatectomy: safety measure during vesicourethral anastomosis when ureteral orifices are too close for comfort. J Endourol. 2009;23:827-829.CrossRefPubMedGoogle Scholar
  27. 27.
    El Douaihy Y, Tan GY, Dorsey PJ Jr, Patel ND, Jhaveri JK, Tewari AK. Double pig-tail stenting of the ureters: technique for securing the ureteral orifices during robotic-assisted radical prostatectomy for large median lobes. J Endourol. 2009;23(12):1975-1977.CrossRefPubMedGoogle Scholar
  28. 28.
    Borden LS Jr, Kozlowski PM, Porter CR, Corman JM. Mechanical failure rate of da Vinci robotic system. Can J Urol. 2007;14:3499-3501.PubMedGoogle Scholar
  29. 29.
    Zorn KC, Gofrit ON, Orvieto MA, et al. Da Vinci robot error and failure rates: single institution experience on a single three-arm robot unit of more than 700 consecutive robotic-assisted laparoscopic radical prostatectomies. J Endourol. 2007;21:1341-1345.CrossRefPubMedGoogle Scholar
  30. 30.
    Lavery HJ, Thaley R, Albala D, et al. Robotic equipment malfunction during robotic prostatectomy: a multi-institutional study. J Endourol. 2008;22:2165-2168.CrossRefPubMedGoogle Scholar
  31. 31.
    Magee CC, Pascual M. Update in renal transplantation. Arch Intern Med. 2004;164:1373-1388.CrossRefPubMedGoogle Scholar
  32. 32.
    Campagnari J, Ribeiro L, Mangini M, et al. Localized prostate cancer in patients submitted to renal transplant. Int Braz J Urol. 2002;28:330-334.PubMedGoogle Scholar
  33. 33.
    Marcen R, Pascual J, Tato JL, et al. Renal transplant outcome after losing the first graft. Transplant Proc. 2003;35:1679-1681.CrossRefPubMedGoogle Scholar
  34. 34.
    Jhaveri JK, Tan GY, Scherr DS, Tewari AK. Robotic-assisted laparoscopic radical prostatectomy in the renal allograft transplant recipient. J Endourol. 2008;22:2475-2479.CrossRefPubMedGoogle Scholar
  35. 35.
    Thomas AA, Nguyen MM, Gill IS. Laparoscopic transperitoneal radical prostatectomy in renal transplant recipients: a review of three cases. Urology. 2008;71:205-208.CrossRefPubMedGoogle Scholar
  36. 36.
    Eastham JA, Kattan MW, Rogers E, et al. Risk factors for urinary incontinence after radical prostatectomy. J Urol. 1996;156:1707-1713.CrossRefPubMedGoogle Scholar
  37. 37.
    Sacco E, Prayer-Galetti T, Pinto F. Urinary incontinence after radical prostatectomy: incidence by definition, risk factors and temporal trend in a large series with a long-term follow-up. BJU Int. 2006;97(6):1234-1241.CrossRefPubMedGoogle Scholar
  38. 38.
    Park R, Martin S, Goldberg JD, Lepor H. Anastomotic strictures following radical prostatectomy: insights into incidence, effectiveness of intervention, effect on continence, and factors predisposing to occurrence. Urology. 2001;57:742-746.CrossRefPubMedGoogle Scholar
  39. 39.
    Patil N, Krane L, Javed K, Williams T, Bhandari M, Menon M. Evaluating and grading cystographic leakage: correlation with clinical outcomes in patients undergoing robotic prostatectomy. BJU Int. 2009;103:1108-1110.CrossRefPubMedGoogle Scholar
  40. 40.
    Gnanapragasam VJ, Baker P, Naisby GP, Chadwick D. Identification and validation of risk factors for vesicourethral leaks following radical retropubic prostatectomy. Int J Urol. 2008;12:948-952.CrossRefGoogle Scholar
  41. 41.
    Ramsden AR, Chodak GW. Can leakage at the vesico-urethral anastomosis be predicted after radical retropubic prostatectomy? BJU Int. 2004;93:504-506.Google Scholar
  42. 42.
    Leibovitch I, Rowland RG, Little JS Jr, et al. Cystography after radical retropubic prostatectomy: clinical implications of abnormal findings. Urology. 1995;46:78-80.CrossRefPubMedGoogle Scholar
  43. 43.
    Berlin JW, Ramchandani P, Banner MP, et al. Voiding cystography after radical prostatectomy: normal findings and correlation between contrast extravasation and anastomotic strictures. AJR Am J Roentgenol. 1994;162:87-91.CrossRefPubMedGoogle Scholar
  44. 44.
    Guru KA, Seereiter PJ, Sfakianos JP, Hutson AD, Mohler JL. Is a cystogram necessary after robotic-assisted radical prostatectomy? Urol Oncol. 2007;25:465-467.CrossRefPubMedGoogle Scholar
  45. 45.
    Tan GY, Jhaveri JK, Tewari AK. Anatomic restoration technique (ART): a biomechanics based approach to early continence recovery following minimally invasive radical prostatectomy. Urology. 2009;74(3):492-496.CrossRefPubMedGoogle Scholar
  46. 46.
    Stolzenburg J-U, Wasserschied J, Rabenault R, et al. Reduction in incidence of lymphocele following extraperitoneal radical prostatectomy and pelvic lymph node dissection by bilateral peritoneal fenestration. World J Urol. 2008;26(6):581-586.CrossRefPubMedGoogle Scholar
  47. 47.
    Shaher Z. Port closure techniques. Surg Endosc. 2007;21:1264-1274.CrossRefPubMedGoogle Scholar
  48. 48.
    Brown JA, Elliott DS, Barrett DM. Postprostatectomy urinary incontinence: a comparison of the cost of conservative versus surgical management. Urology. 1998;51(5):715-720.CrossRefPubMedGoogle Scholar
  49. 49.
    van Randenborgh H, Paul R, Kubler H, Breul J, Hartung R. Improved urinary continence after radical retropubic prostatectomy with preparation of a long, partially intraprostatic portion of the membranous urethra: an analysis of 1013 consecutive cases. Prostate Cancer Prostatic Dis. 2004;7:253-257.CrossRefPubMedGoogle Scholar
  50. 50.
    Nyugen L, Jhaveri J, Tewari A. Surgical technique to overcome anatomical shortcoming: balancing post-prostatectomy continence outcomes of urethral sphincter lengths on preoperative magnetic resonance imaging. J Urol. 2008;179:1907-1911.CrossRefGoogle Scholar
  51. 51.
    Steiner MS. Continence-preserving anatomic radical retropubic prostatectomy. Urology. 2000;55:427-435.CrossRefPubMedGoogle Scholar
  52. 52.
    Montorsi F, Salonia A, Suardi N, et al. Improving the preservation of the urethral sphincter and neurovascular bundles during open radical retropubic prostatectomy. Eur Urol. 2005;48:938-945.CrossRefPubMedGoogle Scholar
  53. 53.
    Rocco F, Carmignani L, Aquati P, et al. Restoration of posterior aspect of rhabdosphincter shortens continence time after radical retropubic prostatectomy. J Urol. 2006;175:2201-2206.CrossRefPubMedGoogle Scholar
  54. 54.
    Rocco B, Gregori A, Stener S, et al. Posterior reconstruction of the rhabdosphincter allows a rapid recovery of continence after transperitoneal videolaparoscopic radical prostatectomy. Eur Urol. 2007;51:996-1003.CrossRefPubMedGoogle Scholar
  55. 55.
    Nguyen MM, Kamoi K, Stein RJ, et al. Early continence outcomes of posterior musculofascial plate reconstruction during robotic and laparoscopic prostatectomy. BJU Int. 2008;101:1135-1139.CrossRefPubMedGoogle Scholar
  56. 56.
    Licht MR, Klein EA, Tuason L, Levin H. Impact of bladder neck preservation during radical prostatectomy on continence and cancer control. Urology. 1994;44:883-887.CrossRefPubMedGoogle Scholar
  57. 57.
    Cambio AJ, Evans CP. Minimising postoperative incontinence following radical prostatectomy: considerations and evidence. Eur Urol. 2006;50:903-913.CrossRefPubMedGoogle Scholar
  58. 58.
    Walsh PC, Marschke PL. Intussusception of the bladder neck leads to earlier continence after radical prostatectomy. Urology. 2002;59(6):934-938.CrossRefPubMedGoogle Scholar
  59. 59.
    Srougi M, Paranhos M, Leite KM, Dall’Oglio M, Nesrallah L. The influence of bladder neck mucosal eversion and early urinary extravasation on patient outcome after radical retropubic prostatectomy: a prospective controlled trial. BJU Int. 2005;95(6):757-760.CrossRefPubMedGoogle Scholar
  60. 60.
    Stolzenburg JU, Liatsikos EN, Rabenalt R, et al. Nerve sparing endoscopic extraperitoneal radical prostatectomy – effect of puboprostatic ligament preservation on early continence and positive margins. Eur Urol. 2006;49(1):103-111.CrossRefPubMedGoogle Scholar
  61. 61.
    Tewari AK, Bigelow K, Rao S, et al. Anatomic restoration technique of continence mechanism and preservation of puboprostatic collar: a novel modification to achieve early urinary continence in men undergoing robotic prostatectomy. Urology. 2007;69:726-731.CrossRefPubMedGoogle Scholar
  62. 62.
    Mimic Technologies. dv Trainer brochure. Available at: Accessed July 30, 2009.
  63. 63.
    Sweet RM, McDougall EM. Simulation and computer-animated devices: the new minimally invasive skills training paradigm. Urol Clin North Am. 2008;35:519-531.CrossRefPubMedGoogle Scholar
  64. 64.
    Brown-Clerk B, Siu KC, Katsavelis D, Lee I, Oleynikov D, Stergiou N. Validating advanced robotic-assisted laparoscopic training task in virtual reality. Stud Health Technol Inform. 2008;132:45-49.PubMedGoogle Scholar
  65. 65.
    Tan GY, Goel RK, Kaouk JH, Tewari AK. Technological advances in robotic-assisted laparoscopic surgery. Urol Clin North Am. 2009;36:237-249.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Gerald Y. Tan
    • 1
  • Philip J. DorseyJr.
    • 2
  • Ashutosh K. Tewari
    • 3
    Email author
  1. 1.Department of UrologyTan Tock Seng HospitalJalan Tan Tock SengSingapore
  2. 2.Department of UrologyTulane University School of Medicine, New OrleansLouisianaUSA
  3. 3.Chairman of the Milton and Carroll Petrie Department of Urology at the Icahn School of Medicine at Mount SinaiDepartment of Urology at the Icahn School of Medicine at Mount SinaiNew YorkUSA

Personalised recommendations