Robot-assisted radical prostatectomy (RARP) is on the advance globally, and it is essential for surgeons and patients to know the rates of perioperative complications.
To provide evidence-based clinical guidance on avoiding and managing common complications during and after RARP in the context of a comprehensive literature review.
In concordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis 2015 statement guidelines, a literature search of the PubMed database from August 1, 2011, to August 31, 2015, using the predefined search terms robot* AND radical prostatectomy, was conducted. The search resulted in 653 unique results that were subsequently uploaded to DistillerSR (Evidence Partners, Ottawa, Canada) for team-based screening and processing of references.
Overall, 37 studies met the inclusion criteria and were included. Median rate of overall complication was 12.6% (range: 3.1–42%). Most of the complications were minor (Clavien-Dindo grades 1 and 2). Grade 3 complications comprised the bulk of the major complications with a median rate of 2.7%; grade IV and V complications were exceedingly rare in all reports.
Despite continued adoption of the RARP technique globally, rates of overall complication remain low. Many of the complications experienced during and after RARP can be mitigated and prevented by experience and the implementation of safe techniques.
Despite continued adoption of the robot-assisted radical prostatectomy (RARP) technique globally, rates of overall and major complications remain low at 12.6% and 2.7%, respectively. Complications can be minimized and successfully managed using established techniques. RARP is a safe and reproducible technique.
Keywords: Robot-assisted radical prostatectomy, Prevention, Management, Complications.
In 2010, an estimated 85% of radical prostatectomies (RPs) performed in the United States were conducted using the robotic platform , and over the last several years robot-assisted radical prostatectomy (RARP) has continued to gain preeminence globally . It is essential for surgeons and patients to be aware of rates of perioperative complications, and several authors have conducted robust systematic reviews concerning this topic , , and . In studies published through 2009 and utilizing the Clavien system, overall RARP complication rates ranged from 12% to 26%, and a meta-analysis of RARP outcomes through 2010 calculated a total perioperative complication rate of 7.8%  and . Most recently, Novara et al. conducted a systematic review of studies through August 2011 specifically evaluating perioperative RARP complications and reported rates of overall complications ranging from 3% to 26% . Therefore, given the rapid diffusion and adoption of this technique, a more contemporaneous assessment of published outcomes is warranted. However, the primary aim of this work is to provide clinicians with an evidence-based resource on how to avoid and manage common complications during and after RARP.
2. Evidence acquisition
We conducted a systematic review according to the Preferred Reporting Items for Systematic Review and Meta-analysis protocols (PRISMA-P) 2015 statement . In compliance with PRISMA-P guidelines, our systematic review protocol was registered online with the International Prospective Registrar of Systematic Reviews (PROSPERO) on October 5, 2015 (registration number: CRD42015026812) and did not duplicate a prior systematic review of perioperative complications following RARP .
We conducted a literature search of the PubMed database from August 1, 2011, to August 31, 2015, using the predefined search terms “robot*” AND “radical prostatectomy.” Our search resulted in 653 unique results that were subsequently uploaded to DistillerSR (Evidence Partners, Ottawa, Canada), an Internet-based software that facilitates team-based screening and processing of references (https://distillercer.com). Four levels of review were undertaken: title screening, abstract screening, manuscript screening, and data extraction.
Two review authors (D.P. and L.C.) independently screened each title and abstract at levels 1 and 2, respectively. Titles consistent with the study aim and abstracts meeting the inclusion criteria were advanced to level 3, if unanimity was not achieved, conflicts were mediated and resolved by a third author (J.D.S.). At level 3, full-text articles were scrutinized to ensure all inclusion criteria were present. At level 4, data were extracted in accordance with desired outcomes. At level 4, reference lists of included studies were reviewed for pertinent references not captured in the literature search.
Studies were considered if published after August 1, 2011, and explicitly reporting perioperative rates of complication (excluding functional outcomes of continence and potency) following at least 100 consecutive RARPs. Both comparative and noncomparative studies were considered for inclusion. Studies reporting outcomes following simple prostatectomy for benign disease were excluded. Studies not in English, abstracts, reports from meetings, comments, and editorials were not considered. When studies reported outcomes from the same institution, only the most recent publication was included, unless reporting a different cohort or complication.
Although the sequential, level-based systematic review technique is commonly used, it is not without limitation. For example, the title of a paper may allude that the work is primarily about functional and oncologic outcomes yet not state explicitly that the text also includes data regarding perioperative complications. In this scenario, works that should be included may inadvertently be excluded. To combat this phenomenon, liberal criteria were used to advance a work from level 1 to 2; however, despite best efforts, some works may be erroneously excluded from this review. Even with this significant limitation, this methodology allows for the inclusion of most of the appropriate texts.
3. Evidence synthesis
3.1. Study selection
Figure 1 depicts the flowchart summarizing this systematic review. Our initial search yielded 659 records of which 10 were duplicates. Two records were added after bibliography review, and reviewers noted an additional two records after submission, resulting in 653 records screened. Adhering to the previously mentioned exclusion criteria, 591 records were excluded. Most of the exclusions were for non–English language, failure to report perioperative rates of complication, or series comprising <100 consecutive cases. Sixty-three full-text articles were assessed; 37 studies were ultimately included , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , and .
3.2. Overall complication rates and rates of complication by Clavien-Dindo classification
Table 1 summarizes the overall complication rates and rates of complication stratified by Clavien-Dindo grade. The median rate of overall complications was 12.6%, with a range of 3.1–42%. Most of the complications in each study were minor (Clavien-Dindo grades 1 and 2). Grade 3 complications comprised the bulk of major complications with a median rate of 2.7% (range: 0–9.5%). Grade 4 (range: 0–1%) and 5 (range: 0–0.5%) complications were exceedingly rare in all reports. Di Pierro et al. reported the highest rate of overall complication, 42% . This group prospectively recorded and reported outcomes of the first 233 RARPs plus extended pelvic lymph node dissection (ePLND) cases performed by a single surgeon with experience in both laparoscopic (>50 cases) and open (>100 cases) approaches . Upon review, the markedly higher rate of overall complication in this report is driven by 47 episodes of “pressure skin redness” recorded as a grade 1 complication. The incidence of “pressure skin redness” ranged from 27% early in their series and dropped to 5% following a technical modification in patient positioning . The authors intentionally reported clinically insignificant events to fully characterize their learning curve, and they note that if these events were excluded, their overall complication rate would drop to 16% .
|Study||Institution||Cases||Study design||Overall complication (%)||Minor complication,1–2 (%)||Major complication, 3–5 (%)||Grade 1 (%)||Grade 2 (%)||Grade 3 (%)||Grade 4 (%)||Grade 5 (%)|
|Ahmed et al. ||George Washington University, USA||1000||Retrospective case series||9.7||5.6||2.7||2.8||0.5|
|Yip et al. ||Chinese University of Hong Kong, Hong Kong|
Prince of Wales Hospital, Hong Kong, Queen Mary Hospital, Hong Kong
Princess Margaret Hospital, Hong Kong
Pamela Youde Nethersole Eastern Hospital, Hong Kong
|235||Retrospective case series||7|
|Bae et al. ||Kyungpook National University, Korea||111||Retrospective comparative||12.6||10.8||1.8||1.8||9||1.8|
|Fuller et al. ||Schulich School of Medicine, Western University, Canada||305||Prospective case series||23||7.5||7.9||7.2||0.3|
|Bouchier-Hayes et al. ||Royal College of Surgeons in Ireland, Ireland||125||Retrospective case series||12.9||4||3.2||5.6|
|Zugor et al. ||Prostate Center Northwest Gronau, Germany; RWTH Aachen University Hospital, Germany||2000||Retrospective comparative||12.7||11.4||1.3|
|Ghazi et al. ||University of Tromso, Norway||1503||Prospective case series||10.0||3.0||4||2.8||0.2||0.1|
|Dogra et al. ||Medanta institute, India|
RML Hospital, India
|190||Retrospective case series||27.4||7.8||9.5||9.5||0.5|
|Ploussard et al. ||Hospital Henri Mondor, France||1009||Retrospective comparative||4.7||0.7||3.6||0.2||0.1|
|Froehner et al. ||Dresden University of Technology, Germany||317||Retrospective comparative||33||3.2|
|Galfano et al. ||Niguarda Ca’ Granda Hospital, Italy||200||Prospective comparative||12.5||11||1.5||1.5|
|Hashimoto et al. ||Tokyo Medical University, Japan||200||Retrospective case series||17.5||17.5||7||10.5|
|Stolzenburg et al. ||University of Leipzig, Germany|
University of Patras, Greece
|100||Retrospective case series||14|
|Liss et al. ||University of California Irvine, USA|
Polisseni Robotic and Minimally Invasive Surgery Center, USA
|1000||Retrospective case series||10.8|
|Brennhovd et al. ||Oslo University Hospital, Norway||1076||Retrospective comparative||3.4||2||0.7||0.6||0.1|
|Sejima et al. ||Totter University Faculty of Medicine, Japan||100||Retrospective case series||30||28||1||1|
|Seo do et al. ||Eulji University, Korea||100||Retrospective case series||17||17|
|Musser et al. ||Memorial Sloan Kettering Cancer Center, USA||651||Retrospective comparative||4.4||3.3||0.3|
|Di Pierro et al. ||Luzerner Kantosspital, Switzerland||233||Prospective case series||42||21||11||10||0.5||0.5|
|Koo et al. ||Yonsei University College, Korea||154||Retrospective comparative||14.3||3.9||1.3||9.1|
|Garate et al. ||Hospital Universitario de Caracas, Venezuela||101||Retrospective case series||13||11||2||2|
|Gu et al. ||University of Oklahoma Health Sciences Center, USA||218||Prospective comparative||9.6|
|Babaian et al. ||University of California Irvine, USA||1000||Retrospective comparative||10.2||2||1||6.7||0.5|
|Gagnon et al. ||Vancouver Prostate Center and Department of Urologic Sciences, Canada||200||Retrospective case series||22||13||7||2|
|Modi et al. ||Rutgers Cancer Institute of New Jersey, USA||751||Retrospective case series||8.5||5.5||0.13||3.1|
|Kumar et al. ||University of Central Florida, USA||800||Retrospective comparative||6.5||4.4||2.1|
|Tasci et al. ||Dr. Sadi Konuk Training and Research Hospital, Turkey; Acibadem University School of Medicine, Turkey; Umraniye Training and Research Hospital, Turkey; Ankara Ataturk Training and Research Hospital, Turkey||1499||Retrospective case series||6.1||1.9||2.9||0.6||0.3||0.1|
|Yumioka et al. ||Totter University, Japan||150||Retrospective comparative||24|
|Morgan et al. ||University of Texas Southwestern Medical Center, USA||381||Retrospective comparative||12.3||2.6||3.6||2.6||1|
|Akand et al. ||Selcuk University, Turkey; Memorial Atasehir Hospital, Turkey; Memorial Antalya Hospital, Turkey||120||Prospective comparative||11.7||5||6.7|
|Wagenhoffer et al. ||Klinikum Ingolstadt, Germany||100||Retrospective case series||11||5||5||1|
3.3. Rates of complications reported by various stratification methods
Table 2 summarizes the complication rates of several studies that stratified their patient cohort by various disease factors, patient attributes, or surgical approaches/techniques. Two reports stratified patients by body mass index (BMI). Bae et al. retrospectively divided patients into two groups and found that patients with a BMI <25 had an overall complication rate of 10.8% compared with 16.2% in patients with a BMI >25 (p = 0.545) . Similarly, Gu et al. prospectively divided patients into three BMI groups and found a lower complication rate in the intermediate group (BMI: 25–30) and higher, yet not statistically significant, rates of complication in the BMI <25 and BMI >30 groups .
|Study||Institution||Total cases||Study design||Stratification method (n)||Overall complication rate (%)||Minor complication, 1–2 (%)||Major complication, 3–5 (%)||Grade 1 (%)||Grade 2 (%)||Grade 3 (%)||Grade 4 (%)||Grade 5 (%)|
|Bae et al. ||Kyungpook National University, Korea||111||Retrospective comparative||BMI <25 (74)|
BMI >25 (37)
|Labanaris et al. ||Prostate Center Northwest Gronau, Germany; RWTH Aachen University Hospital, Germany||2000||Retrospective comparative||Overall patient cohort (2000)|
Age >75 yr (45)
|Ploussard et al. ||Hospital Henri Mondor, France||1009||Retrospective comparative||Laparoscopic extraperitoneal radical prostatectomy (1377)|
Extraperitoneal robotic prostatectomy (1009)
|Zugor et al. ||Prostate Center Northwest Gronau, Germany; RWTH Aachen University Hospital, Germany||2000||Retrospective comparative||Overall patient cohort (2000)|
PSA >20 (147)
|Zugor et al. ||Prostate Center Northwest Gronau, Germany; RWTH Aachen University Hospital, Germany||2000||Retrospective comparative||Overall patient cohort (2000)|
PSA <4.0 (169)
|Brennhovd et al. ||Oslo University Hospital, Norway||1076||Retrospective comparative||D’Amico classification low (227)|
D’Amico classification intermediate (475)
D’Amico classification high (374)
|Froehner et al. a||Dresden University of Technology, Germany||317||Retrospective comparative||Open prostatectomy (2437)|
Robotic prostatectomy (317)
|Galfano et al. ||Niguarda Ca’ Granda Hospital, Italy||200||Prospective comparative||Retzius-sparing first group (100)|
Retzius-sparing second group (100)
|Labanaris et al. ||Prostate Center Northwest Gronau, Germany; RWTH Aachen University Hospital, Germany||370||Retrospective comparative||Prostate volume >100 g (185)|
Prostate volume <50 g (185)
|Babaian et al. ||University of California Irvine, USA||1000||Retrospective comparative||Age <69 yr(868)|
Age >70 yr (129)
|Gu et al. ||University of Oklahoma Health Sciences Center, USA||218||Prospective comparative||BMI <25 (36)|
BMI 25–30 (115)
BMI >30 (67)
|Koo et al. b||Yonsei University College, Korea||154||Retrospective comparative||Men >70 yr, high risk (101)|
Men >70 yr, very high risk (53)
|Musser et al. ||Memorial Sloan Kettering Cancer Center, USA||651||Retrospective comparative||Surgical drain (379)|
No surgical drain (258)
|Akand et al. ||Selcuk University, Turkey; Memorial Atasehir Hospital, Turkey; Memorial Antalya Hospital, Turkey||120||Prospective comparative||Transperitoneal RARP (60)|
Extraperitoneal RARP (60)
|Morgan et al. ||University of Texas Southwestern Medical Center, USA||381||Retrospective comparative||Single console (185)|
Dual console (196)
|Sumitomo et al. ||Aichi Medical University, Japan||154||Retrospective comparative||Experienced open surgeons with >30 robotic prostatectomies (90)|
Experienced open surgeons with <30 robotic prostatectomies (36)
Novice open and robotic prostatectomy surgeons (28)
|Yumioka et al. ||Totter University, Japan||150||Retrospective comparative||No prior abdominal surgery (94)|
Prior abdominal surgery (56)
a Complications stratified as serious, overall, and individual complications, not as major or minor.
b Risk determined based on National Comprehensive Cancer Network criteria.
* Denotes statistical significance.
BMI = body mass index; PSA = prostate-specific antigen; RARP = robot-assisted radical prostatectomy.
Two publications stratified patients by age. Labanaris et al. retrospectively reviewed 2000 cases and found a significantly higher rate of minor complication in patients aged >75 yr but similarly low rates of major complications compared with the entire cohort . Similarly, Babaian et al. retrospectively analyzed 1000 patients and found a significantly higher rate of overall complication in patients aged >70 yr compared with those ≤69 yr (15.4% vs 9.4%; p = 0.042) .
Two reports stratified patients based on risk classification. In a retrospective analysis of 1076 patients, Brennhovd et al. found a significant and progressively higher risk of overall complication with increasing D’Amico classification . In contrast, Koo et al. retrospectively analyzed 154 men >70 yr and found no difference in overall complication rate between men with high-risk and very high-risk prostate cancer .
Two papers compared the robotic approach with previously favored approaches. Ploussard et al. retrospectively compared 1377 pure laparoscopic extraperitoneal RPs with 1009 extraperitoneal RARPs and found no difference in complication rates . Likewise, Froehner et al. retrospectively compared 2437 open RPs with 317 RARPs and found no significant difference in rates of both overall (29.1% vs 33.0%; p = 0.20) and major complications (3.7% vs 3.2%; p = 0.63) .
3.4. Rates of specific intraoperative complications
Table 3 shows rates of specific intraoperative complications. Rates of intraoperative complications (bowel injury, neurapraxia, corneal abrasion, and ureteral injury) were typically <1%. However, Koo et al. reported a 2% incidence of rectal injury in men with high-risk and very high-risk prostate cancer . In the setting of a residency training program, Morgan et al. found a similar 2.2% rate of rectal injury when utilizing a single-surgeon console; however this rate fell to 1.0% when utilizing a dual-console configuration . An exception, Di Pierro et al. reported a high rate of neurapraxia (3.4%), likely secondary to positioning factors, as discussed previously .
|Study||Institution||Cases||Stratification method||Rectal injury||Bowel injury||Neurapraxia||Corneal abrasion||Ureteral injury|
|Hung et al. ||Taichung Veterans General Hospital, Taiwan||288||–||1.0||–||–||–|
|Ahmed et al. ||George Washington University, USA||1000||0.3||0.2||0.2||0.1||0.3|
|Dogra et al. ||Medanta institute, India; RML Hospital, India||190||0.5||–||0.5||–||–|
|Fuller et al. ||Schulich School of Medicine, Western University, Canada||305||–||–||1||–||–|
|Ghazi et al. ||University of Tromso, Norway||1503||0.1||–||0.2||0.5||–|
|Labanaris et al. ||Prostate Center Northwest, Germany||370||–||0.8||–||–||–|
|Ploussard et al. ||Hospital Henri Mondor, France||1009||0.3||0.1||0.1||–||–|
|Yip et al. ||Chinese University of Hong Kong, Hong Kong; Prince of Wales Hospital, Hong Kong; Queen Mary Hospital, Hong Kong; Princess Margaret Hospital, Hong Kong; Pamela Youde Nethersole Eastern Hospital, Hong Kong||235||0.4||–||–||–||–|
|Hashimoto et al. ||Tokyo Medical University, Japan||200||–||–||1.5||–||–|
|Liss et al. ||University of California Irvine, USA; Polisseni Robotic and Minimally Invasive Surgery Center, USA||1000||0.1||–||0.5||0.5||–|
|Babaian et al. ||University of California Irvine, USA||1000||<69 (868)|
|Di Pierro et al. ||Luzerner Kantosspital, Switzerland||233||–||–||3.4||–||0.9|
|Koo et al. ||Yonsei University College, Korea|
|High risk (101)|
Very high risk (53)
|Modi et al. ||Rutgers Cancer Institute of New Jersey, USA||751||0.4||–||–||0.1||–|
|Morgan et al. ||University of Texas Southwestern Medical Center, USA|
|Single console (185)|
Dual console (196)
|Tasci et al. ||Dr. Sadi Konuk Training and Research Hospital, Turkey; Acibadem University School of Medicine, Turkey; Umraniye Training and Research Hospital, Turkey; Ankara Ataturk Training and Research Hospital, Turkey||1499||0.1||0.1||0.1||–||0.1|
|Wagenhoffer et al. ||Klinikum Ingolstadt, Germany||100||1||–||–|
3.5. Rates of specific postoperative complications
Table 4 lists rates of 17 distinct postoperative complications; complication rates were low with a few notable exceptions. Froehner et al. report a 30.9% lymphocele detection rate, from which however only 4.7% required intervention . The authors followed the German S3 guidelines that recommend routine ultrasound lymphocele screening after surgery and intervention in the case of significant compression or thrombosis of major pelvic veins. Four series reported high rates of transfusion ranging from 6.8% to 17% , , , and ; however, each report described an “initial series” and attributed the high transfusion rate to their learning curve. Similarly, other higher than average rates of specific complications were seen in novice robotic surgeons reporting initial outcomes  and . Mortality after RARP was extremely rare and ranged from 0% to 0.13% in reported series.
|Study||Institution||Cases||Stratification method||Urinary retention||UTI||Hematoma||Lymphocele||Transfusion||DVT/PE||Urine/Anastomotic leak||Wound complications||Ileus||SBO||Port site hernia||Meatal/Fossa stenosis||Urethral stricture||BNC||Reoperation||MI||Mortality|
|Kang et al. ||Robert Wood Johnson Medical School, USA||498||–||–||–||–||–||–||–||–||–||–||0.04||–||–||–||–||–||–|
|Ahmed et al. ||George Washington University, USA||1000||1.5||0.2||–||–||1.5||0.5||0.7||–||1||0.1||0.2||0.1||–||–||–||0.1||–|
|Bouchier-Hayes et al. ||Royal College of Surgeons in Ireland, Ireland||125||–||–||–||–||–||–||2.4||–||–||–||–||–||–||3.2||–||–||–|
|Dogra et al. ||Medanta institute, India; RML Hospital, India||190||–||–||–||–||6.8||–||–||0.5||–||4.2||–||–||–||–||2.1||–||–|
|Fuller et al. ||Schulich School of Medicine, Western University, Canada||305||0.3||2.3||–||–||–||0.3||3.9||0.6||3.6||–||2||1||0.3||1.6||–||0.3||–|
|Ghazi et al. ||University of Tromso, Norway||1503||0.8||0.8||1.0||0.6||–||0.8||1.2||0.1||0.1||0.1||–||–||–||1.3||0.3||0.2||0.07|
|Labanaris et al., 2013||Prostate Center Northwest, Germany||370||2.2||5.1||2.4||–||–||–||4.6||–||–||–||–||–||–||–||3.2||–||–|
|Ploussard et al. ||Hospital Henri Mondor, France||1009||–||3.2||1.4||1.1||–||0.2||2.3||–||0.4||–||–||–||–||0.7||–||0.3||0.1|
|Yip et al. ||Chinese University of Hong Kong, Hong Kong; Prince of Wales Hospital, Hong Kong; Queen Mary Hospital, Hong Kong; Princess Margaret Hospital, Hong Kong; Pamela Youde Nethersole Eastern Hospital, Hong Kong||235||–||–||–||0.4||–||1.7||2.6||1.3||–||–||–||–||0.4||–||–||–||0.4|
|Brennhovd et al. ||Oslo University Hospital, Norway||1076||D’Amico classification Low (227)|
D’Amico classification Intermediate (475)
D’Amico classification High (374)
|Froehner et al. ||Dresden University of Technology, Germany||317||–||–||–||30.9||8.9||2.5||–||2.5||–||–||–||–||–||–||0.7||0.3||0.3|
|Galfano et al. ||Niguarda Ca’ Granda Hospital, Italy||200||Retzius sparing first group (100)|
Retzius Sparing second group (100)
|Hashimoto et al. ||Tokyo Medical University||200||4||0.5||2||1.5||–||–||2.5||–||2.5||–||–||–||–||–||–||–||–|
|Liss et al. ||University of California Irvine, USA; Polisseni Robotic and Minimally Invasive Surgery Center, USA||1000||0.3||–||–||0.4||0.4||0.7||0.7||0.4||–||4.1||1.1||–||0.7||–||0.3||–|
|Sejima et al. ||Totter University Faculty of Medicine, Japan||100||–||–||–||2||–||–||5||–||2||–||–||–||–||–||–||–||–|
|Seo do et al. ||Eulji University, Korea||100||–||–||–||–||17||–||–||–||–||–||–||–||–||–||–||–||–|
|Stolzenburg et al. ||University of Leipzig, Germany; University of Patras, Greece||100||–||–||1||2||–||–||11||–||–||–||–||–||–||–||–||–||–|
|Abel et al. ||University of Wisconsin, USA||549||–||–||–||–||–||1.3/0.5||–||–||–||–||–||–||–||–||–||–||–|
|Babaian et al. ||University of California, Irvine, USA||1000||<69 (868)|
|Di Pierro et al. ||Luzerner Kantosspital, Switzerland||233||2.5||4.7||–||4||1.2||1.4||–||–||0.4||–||0.4||–||–||1.3||–||0.4||–|
|Garate et al. ||Hospital Universitario de Caracas, Venezuela||101||–||–||–||–||7.92||–||–||–||–||–||–||–||–||–||–||–||–|
|Gu et al. ||University of Oklahoma Health Sciences Center, USA||218||Normal (36)|
|Koo et al. ||Yonsei University College, Korea||154||High risk (101)|
Very high risk (53)
|Musser et al. ||Memorial Sloan Kettering Cancer Center, USA||651||With drain (379)|
Without drain (258)
|Kumar et al. ||University of Central Florida, USA||800||1.3||–||–||0.13||–||0.4||1.4||0.5||–||–||–||–||–||–||0.3||–||–|
|Modi et al. ||Rutgers Cancer Institute of New Jersey, USA||751||0.27||–||–||0.13||–||–||–||0.27||–||–||–||–||–||1.5||–||–||–|
|Morgan et al. ||University of Texas Southwestern Medical Center, USA||381||Single console (185)|
Dual console (196)
|Sumitomo et al., 2015||Aichi Medical University, Japan||154||Expert open, >30 RARP (90)|
Expert open, <30 RARP (36)
Novice open and RARP (28)
|Tasci et al. ||Dr. Sadi Konuk Training and Research Hospital, Turkey; Acibadem University School of Medicine, Turkey; Umraniye Training and Research Hospital, Turkey; Ankara Ataturk Training and Research Hospital, Turkey||1499||0.5||–||–||–||1.2||0.2/0.1||1.4||0.4||0.6||–||0.2||0.2||–||0.3||–||0.1||0.1|
|Wagenhoffer et al. ||Klinikum Ingolstadt, Ingolstadt, Germany||100||1||–||–||3||–||–||–||–||–||–||–||–||–||–||–||–|
BNC = bladder neck contracture; DVT = deep venous thrombosis; MI = myocardial infarction; PE = pulmonary embolism; RARP = robot-assisted radical prostatectomy; SBO = small bowel obstruction; UTI = urinary tract infection.
3.6.1. Intraoperative complications
18.104.22.168. Robotic malfunction
Like any technology, the robot is subject to failure and malfunction. However, given the delicate nature of surgery and the tool's proximity to the patient, the surgeon and his or her team must be able to troubleshoot any problems quickly and safely to complete the operation without compromising oncologic outcomes or causing harm to the patient. Fortunately, robotic device failures are rare occurrences. In a systematic review, Murphy et al. established that da Vinci robot device failure occurs in only 0.2–0.4% of cases . In an analysis of the US Food and Drug Administration's Manufacturer and User Facility Device Experience 2009–2010 database, 565 device failures were documented, of which 50% were related to the instrument's wrist or tool tip and 31% were cautery related . Although these failures occur rarely, nearly 57% of surveyed RARP surgeons reported experiencing an irrecoverable intraoperative robotic malfunction . Among surgeons faced with device failure before the start of the operation, 58% rescheduled, 5% docked another robot, 19% performed open RP, and 15% proceeded with a straight laparoscopic approach . Conversely, among those surgeons experiencing device failure before completion of the urethrovesical anastomosis, 62% converted to straight laparoscopy and 38% converted to open surgery .
This survey demonstrates that although it is statistically unlikely to experience device failure, a majority of both high- and low-volume RARP surgeons have experienced device failure. Therefore, although all steps should be taken to minimize such an event, the surgeon must always be prepared should device malfunction occur. First, surgeons should be familiar with all components of the device and be appropriately credentialed prior to performing robot-assisted surgery independently  and . Second, systems and checks should be implemented to ensure routine maintenance on all robotic systems, and surgical support staff should evaluate all device components to ensure proper functioning at the onset of each case, prior to the induction of anesthesia  and . Finally, patients must be aware of the rare possibility of device malfunction and understand the need to adopt an alternative surgical approach  and .
Prevention point: Systems should be implemented to ensure routine maintenance of all robotic systems; all device components should be evaluated to ensure proper functioning at the onset of each case, prior to the induction of anesthesia.
22.214.171.124. Access-related complications
Regarding laparoscopic access, a recent systematic review of complications after RARP reported a low incidence of bowel and vascular injuries, 0.07–0.09% and 0.03–0.2%, respectively . Techniques for access include Veress needle placement, direct trocar insertion, minilaparotomy  or Hassan technique , and optical trocar placement . There is wide variation among surgeon preference, yet the available evidence does not demonstrate a superior technique . Thus surgeons should be comfortable with multiple techniques . Some prefer the optical trocar in obese patients because minilaparotomy can be difficult, and other available techniques require blind placement ; however, Veress needle access has been shown to be safe in obese patients . In patients with prior abdominal surgery, risk factors for intra-abdominal adhesions, or umbilical hernia, either the Hassan technique or placement of the Veress needle in the left upper quadrant may be preferable , , and . Confirmation that the trocar is in the correct position should be confirmed by aspiration and then instillation of saline.
Extra caution should be exercised when obtaining access in patients with history of mesh placement for abdominal wall herniorrhaphy given the increased risk of subsequent bowel adhesion. Although these patients can still undergo successful RARP, the surgeon should expect prolonged console times given the need for a more tedious dissection .
Care must also be taken to avoid placing secondary trocars through abdominal wall vasculature. This can be accomplished by dimming operating room lighting and using the laparoscopic camera to transilluminate the abdominal wall . Vascular injuries during access should be managed based on severity. Small nonexpanding hematomas may be outlined with clips and later reassessed at pneumoperitoneum of 5 mm Hg, and if the hematoma expands, it should be explored .
Prevention point: Surgeons should thoroughly review the patient's surgical history and physical examination to choose the best method to obtain access.
126.96.36.199. Nerve injury, rhabdomyolysis, pressure injury, and lower extremity compartment syndrome
Pressure- and positioning-related wounds have been variably reported, with the most thorough assessment performed by Di Pierro and colleagues demonstrating a rate of severe pressure ulcers as high as 3% . Similarly, Mattei et al. found a 5% incidence of severe pressure wounds, with the gluteal region most commonly involved . Pressure-related injuries were largely related to longer operative times and nonmodifiable factors including patient comorbidity and Trendelenburg positioning  and .
In a literature review of brachial plexus injury during laparoscopic/robotic surgery in the Trendelenburg position, steep Trendelenburg positioning, arms extended at ≥90°, and use of shoulder braces are associated with brachial plexus injury  and . Although these injuries are largely self-limited, patients with brachial plexus injury should be referred to physical therapy and treated with nonsteroidal anti-inflammatory medications or neuropathic agents (gabapentin or topiramate)  and . Prevention includes limiting operative time and proper patient positioning. Arms should be tucked at the sides with the palms facing the thigh, and arm boards and shoulder braces should be avoided . To implement proper positioning, many centers now utilize disposable foam padding along with straps and strong tape (Fig. 2).
Pridgeon et al. performed a multicenter retrospective review of 3110 RARP cases and identified nine patients who developed lower extremity compartment syndrome . Risk factors included obesity, prolonged console time (>4 h), and a history of peripheral vascular disease. Prevention requires proper positioning, with the heel supporting most of the pressure and adequate space between the upper calf and the stirrup (when in lithotomy). Early recognition is critical for successful treatment and characterized by the 6 Ps (pain, pressure, paresthesia, pallor, paralysis, and pulselessness) .
Prevention point: Neurapraxia, pressure injury, and compartment syndrome can be avoided with careful attention to proper patient positioning practices.
188.8.131.52. Ocular complications
In our review, five papers documented corneal abrasions with a rate between 0.1% and 0.6% , , , , and . Although occurring at a low rate, corneal abrasion can cause significant discomfort for the patient; use of a transparent occlusive eye dressing rather than tape was demonstrated to eliminate this complication in a single-institution retrospective review . Although no studies of corneal abrasion following RARP examined predictors, a study of 91 064 patients undergoing nonocular surgeries at a major academic center by Lichter et al. described an incidence of 0.13%. Their anesthesia-led protocol for management of postoperative corneal abrasions included stepwise treatment with artificial tears, followed by erythromycin ointment if not effective . With implementation of their protocol, all patients had resolution of their symptoms by postoperative day 1. Patients who experienced corneal abrasions had longer operative times and were older. Prolonged case duration (8–10 h) has been associated with corneal abrasion; however, steep Trendelenburg has not , , and . Steep Trendelenburg positioning during RARP has been shown to increase intraocular pressures significantly and occasionally results in significant yet temporary visual field defects. Thus a theoretical risk of optic nerve hypoperfusion exists, and preoperative ophthalmologic evaluation can be considered in patients with glaucoma and diabetes mellitus at baseline risk of optic nerve injury .
Prevention point: Consider using transparent occlusive eye dressings rather than taping the eyes shut to minimize risk of corneal abrasions.
184.108.40.206. Ureteral injury
Our literature review indicates that ureteral injury occurs in 0.06–0.9% of cases. If ureteral injury is from sharp dissection and noted intraoperatively, it may be primarily repaired. If cautery injury is noted, a retrograde ureteral stent should be placed . These injuries are frequently not recognized intraoperatively, necessitating delayed repair. Ureteral injury commonly occurs during adhesiolysis, bladder neck dissection, vesicourethral anastomosis, or lymphadenectomy, and thus the surgeon should be particularly vigilant about the ureter during these steps . Management depends on the location and severity of injury and may require ureteroneocystostomy  and . Risk factors may include prior pelvic surgery, prior transurethral resection of the prostate (TURP), salvage RP, and extensive adhesiolysis .
220.127.116.11. Rectal injury
Rectal injury is a rare complication during RARP but is associated with significant morbidity, especially if not recognized intraoperatively and repaired. Wedmid et al. reviewed 6650 cases from 11 different surgeons and found an overall incidence of 0.17% . Overall, 73% of cases were identified intraoperatively and managed with a two- to three-layer closure depending on surgeon preference. Three patients had injuries that were not recognized intraoperatively and presented with rectovesical fistula between 2 d and 6 wk later. These patients required ileostomy diversion and delayed repair. Kheterpal et al. published a review of 4400 cases with a 0.2% incidence of rectal injury . All 10 patients in this series were recognized intraoperatively and repaired with 2-0 polyglactin suture in a two-layer fashion. In both series, no patient characteristics predicted rectal injury, and extended catheterization along with watertight urethrovesical anastomosis in cases of rectal injury were emphasized. In addition to a multilayered closure, several authors have reported using an omental flap to reinforce the rectal repair  and .
Many urologists have now moved away from full bowel prep given the rarity of bowel injury and the evidence of safety with less aggressive bowel prep  and . Nonetheless, more aggressive bowel prep may be warranted in men at increased risk of rectal injury, such as men with a history of TURP  and . When possible, patients should wait at least 4–6 wk after prostate biopsy before undergoing RARP because acute prostatic inflammation after biopsy may obliterate surgical planes and increase the risk of rectal injury .
Prevention point: Wait at least 4–6 wk after prostate biopsy before performing robot-assisted radical prostatectomy to allow time for postbiopsy inflammation to subside.
3.6.2. Postoperative complications
18.104.22.168. Small bowel obstruction
Rates of small bowel obstruction (SBO) ranged from 0.1% to 4.2% in the current review. The literature provides little insight into the various causes of SBO post RARP, yet SBOs are likely sequelae of unrecognized intraoperative bowel injury. In a rare instance of SBO 3 mo post RARP, an unhinged Hem-o-Lok vascular clip (Weck; Teleflex Medical, Durham, NC, USA) was the causal agent . A high index of suspicion and early recognition of a possible bowel complication is crucial because laparoscopic bowel injuries may present in an atypical fashion . In the absence of signs/symptoms of peritonitis or bowel strangulation, nonoperative management with tube decompression may be trialed; however, if there is no improvement by day 3–5 of conservative management, the patient should be simulated with a water-soluble contrast medium or evaluated for surgery  and .
22.214.171.124. Pelvic hematoma
In the current review, rates of hematoma ranged from 0.9% to 2.4%. Pelvic hematomas commonly develop in the prostatic resection bed between the rectum and bladder; when sizable, patients present with tenesmus, pelvic pain, hematuria, and in severe cases symptomatic hypovolemia secondary to acute blood loss anemia . Large pelvic hematomas can result in disruption of the urethrovesical anastomosis (UVA) and result in delayed return of normal micturition. Prevention of hematoma primarily depends on meticulous dissection and hemostasis technique .
Kirby et al. have suggested several tips to minimize hematoma formation: clipping the prostatic pedicle to prevent internal iliac bleeding; utilizing the Rocco suture  to minimize the potential space for hematoma formation within the prostatic bed; and finally, spraying a fibrin sealant along the neurovascular bundles and anterior rectal wall prior to the Rocco suture can be considered in higher risk patients . If the patient is hemodynamically unstable, operative exploration is essential to evacuate the hematoma and to identify and repair the origin of bleeding. Kirby et al. successfully managed this complication robotically by evacuating the hematoma and reconstructing the UVA . In most cases, however, hematomas can be managed conservatively with prolonged catheterization and subsequent cystogram to ensure an intact anastomosis .
Prevention point: Pelvic hematoma is prevented by meticulous dissection and hemostasis but can be further minimized by clipping the prostatic pedicle, spraying fibrin sealant along neurovascular bundles, and utilizing the Rocco suture.
The reported rate of lymphocele after RARP largely depends on the method of detection and ranges from 0.1% to 30.9%. A recent systematic review found a 0–8% incidence of symptomatic pelvic lymphocele after RARP with a subsequent 0–5% intervention rate . Lymphoceles are thought to occur secondary to inadequate ligation of lymph channels after pelvic lymph node dissection (PLND) and the inability of collaterals to compensate adequately for the disrupted channels  and . Despite meticulous dissection and ligation, lymphatic channels can often leak fluid for up to 48 h and result in a pelvic fluid collection with subsequent development of a hard fibrous pseudocapsule  and . Lymphoceles become problematic when infection develops or when significant pressure is exerted on surrounding structures. Patients can present with abdominal and leg pain, lower extremity edema, urinary frequency, constipation, ileus, or fever and leukocytosis  and . Although there is no clear threshold size at which a lymphocele becomes problematic, larger lymphoceles exert greater pressure on adjacent structures and thus increasing size results in increased potential morbidity . Although there is clear oncologic benefit to an extended pelvic node dissection (ePLND) , , , and , it has not been fully elucidated if ePLND imposes a greater risk of lymphocele compared with standard PLND. Therefore, given similar rates of overall complications and interventions, ePLND should be performed given superior oncologic control . No definitive link has been found between the extent of lymph node dissection and lymphocele formation, but it is likely that the etiology of increased lymphocele formation in node-positive patients is influenced by surgeon suspicion and consequent aggressive dissection rather than intrinsic factors related to malignant involvement of the nodes  and .
Pharmacologic prophylaxis for deep venous thrombosis (DVT) was previously implicated in lymphocele formation due to possible impairment of lymph coagulative properties; however, no definitive consensus exists, and the benefit of treatment appears to outweigh the possible harms , , and . Similarly, routine pelvic drain placement has not demonstrated decreased lymphocele formation in RARP plus PLND patients , , , and .
Several authors have examined the effect of energy source on subsequent lymphocele formation, and although the overall quality of the evidence is low, bipolar energy and the judicious use of clips has been associated with lower lymphocele rates , , and .
Both symptomatic and asymptomatic lymphoceles are likely to resolve without intervention; however, several treatment options exist if intervention is required . Percutaneous drain placement is the most common initial treatment, but in situations where high output persists despite drainage, a sclerosing agent can be administered. Percutaneous drainage, with optional sclerosis, has been used successfully to resolve 70–100% of symptomatic lymphoceles , , , , , , and . In lymphoceles refractory to percutaneous drainage, minimally invasive marsupialization of the lymphocele cavity was shown to be a safe and definitive intervention .
Prevention point: Consider the use of bipolar energy and judicious use of clips when performing lymph node dissection to minimize lymphocele formation.
126.96.36.199. Deep venous thrombosis and pulmonary embolism
Rates of thromboembolic complication were low in our systematic review ranging from 0.2% to 2.5% , , , and . Nonetheless, similar to lymphocele, the rate of venous thromboembolism (VTE) largely depends on the mechanism of detection. In a recent Chinese study, 109 consecutive patients underwent RARP (utilizing intermittent pneumatic compression devices) and bilateral lower limb Doppler ultrasonographic examination on postoperative day 3, and a high (16.9%) incidence of DVT was found . Only one patient developed an above-knee DVT, and no patient developed a DVT-associated complication .
Risk factors of VTE include older age, elevated BMI, history of prior DVT, current tobacco smoking, and larger prostate volume , , , and . Surgical factors predictive of thromboembolic complications included lymph node dissection, prolonged operative time, need for blood transfusion, longer hospital stay, and reexploration , , , and . Routine use of subcutaneous heparin for VTE prophylaxis has not been shown effective in preventing thromboembolic or increasing bleeding events , , and . Although all patients should receive intermittent pneumatic compression and be encouraged to ambulate early, current evidence only supports use of perioperative prophylactic anticoagulation in patients at high risk of a thromboembolic event , , , and . For these RARP patients at high risk of VTE and without a major bleeding risk, the guidelines recommend extended-duration postoperative low-molecular-weight heparin prophylaxis for a total of 4 wk .
Lower extremity DVT may be suspected based on unilateral lower extremity swelling or pain; however, objective testing is recommended given the inability to make a reliable clinical diagnosis . For patients with low or moderate pretest probability, a highly sensitive D-dimer should be followed by compression ultrasound of the proximal veins; patients with high pretest probability should proceed directly to proximal compression ultrasound . Parenteral anticoagulation should commence once diagnosis of an acute DVT of the lower extremity has been made or immediately if there is high clinical suspicion .
Prevention point: Use of pneumatic compression devices and early ambulation should be encouraged for all robot-assisted radical prostatectomy patients to prevent deep venous thrombosis.
188.8.131.52. Urine leak
Consistent with prior reports, rates of urethrovesical anastomotic leak (UVAL) ranged from 0.5% to 5% in our review  and . Prior research has demonstrated that rates of UVAL are highest in the first 7–10 d postoperatively and decreases thereafter , , and . Both patient factors (obesity, large prostate, and prior prostatic surgery) and technical factors (excessive bleeding, surgeon learning curve, urethral stump length, and integrity of anastomosis during bladder distention) have been implicated as possible risk factors for UVAL . Diagnosis is often based on high drain output, elevated drain creatinine, and symptoms of uroperitoneum. Conventional cystography, computed tomography (CT) cystography, transrectal ultrasound, and a technetium-mercaptoacetyltriglycine-3 renogram have been utilized to diagnose and evaluate UVAL , , and .
In many situations, UVAL is discovered during cystography prior to catheter removal . For most of these leaks, replacement of the catheter alleviates the acute abdominal symptoms, and prolonged catheterization allows for complete resolution of the UVAL. At 3 wk, most leaks will have closed; however, repeat cystography prior to catheter removal is recommended , , , , and . Surgical drains should also be taken off suction, and if no drain was placed intraoperatively or if a urinoma collects, a percutaneous drain can be placed. If these measures fail, nephrostomy placement or reoperation should be considered to repair the UVA . Prevention relies on proper training and execution of anastomotic principles; however, utilization of a fenestrated catheter, fibrin sealants, and oxidized cellulose sponges facilitate a watertight UVA , , and . Fortunately, although UVAL can be troublesome to manage, two retrospective analyses found no long-term impact on erectile function, bladder neck contracture (BNC), or continence  and .
184.108.40.206. Port-site hernia
In our current review, incidence of port-site hernia ranged from 0% to 7% in some specific cohorts; prior reports reported an incidence ranging from 0.4% to 16.7% , , , , and . Port-site hernias may be difficult to detect clinically, but a single-institution retrospective review of 104 patients undergoing robot-assisted urologic surgery (38 RARP patients) found a 6.7% incidence rate of CT-detected clinically occult hernias . Most of them were located at extraction sites or larger port-site locations; thus increased vigilance is required when closing the fascia at these sites .
Concordantly, multiple studies have consistently identified larger prostate size as a primary predictor of incisional hernia , , and . Proposed methods to diminish the incidence of port-site hernia include closing fascia with nonabsorbable suture in an interrupted fashion rather than a running suture line and making transverse port-site incisions rather than traditional vertical incisions  and . After controlling for baseline factors, Beck et al. found that vertical incision resulted in an 11-fold increased hazard of incisional hernia compared with a transverse incision .
Prevention point: In patients with larger prostates, consider utilizing transverse incisions and interrupted closure of the midline fascia to reduce incidence of incisional hernia.
220.127.116.11. Bladder neck contracture
BNC following prostatectomy often presents with obstructive voiding symptoms such as a weak urinary stream and incontinence . Consistent with prior reports, our current review demonstrates an incidence of BNC ranging from 0.3% to 3.2% , , , , , and . Symptoms of BNC often appear early, with many patients reporting symptoms around the fifth month postoperatively , , and . Although the exact etiology of BNC is unknown, several inciting factors have been demonstrated including increased blood loss , Hem-o-Lok clip migration  and , length of time before drain removal  and , and increased operative time . Several authors have implicated Hem-o-Lok clip migration as a cause of BNC, and thus surgeons should minimize clip usage on tissues surrounding the UVA and should take care to remove any loose clips , , , , and .
A recent prospective randomized controlled trial of 62 patients equally randomized to urethral catheterization versus suprapubic catheter (SPT) drainage found a reduced incidence of BNC in the SPT cohort . Thus BNC can be limited with prudent Hem-o-Lok clip utilization and SPT drainage, and notably, most BNCs can been managed successfully with endoscopic interventions .
Prevention point: Avoid Hem-o-Lok clip use on tissues surrounding the urethrovesical anastomosis and consider suprapubic catheter bladder drainage to minimize risk for bladder neck contracture.
The RARP technique has continued to gain in popularity and utilization. Despite the rapid adoption of this technique by surgeons globally, overall complication rates remain low and have been demonstrated to decrease as surgeons move along the learning curve. RARP is a successful operation in that it is reproducible and safe. Many of the complications experienced during and after RARP can be mitigated and prevented by experience and the implementation of particular protocols, as described in this review (Supplementary Table 1). Future efforts should focus on prospective studies and randomized studies attempting to better elucidate methods of avoiding perioperative RARP complications.
Author contributions: Daniel Pucheril 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: Schlomm, Sammon, Montorsi, Bauer.
Acquisition of data: Pucheril, Campbell.
Analysis and interpretation of data: Sammon, Pucheril, Campbell.
Drafting of the manuscript: Pucheril, Campbell, Bauer, Montorsi, Sammon, Schlomm.
Critical revision of the manuscript for important intellectual content: Bauer, Montorsi, Schlomm.
Statistical analysis: Pucheril, Campbell.
Obtaining funding: None.
Administrative, technical, or material support: None.
Supervision: Bauer, Montorsi, Sammon, Schlomm.
Other (specify): None.
Financial disclosures: Daniel Pucheril certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None.
Funding/Support and role of the sponsor: None.
-  Kolkata G. Results unproven, robotic surgery wins converts. New York Times. February 13, 2010. New York Times Web site. http://www.nytimes.com/2010/02/14/health/14robot.html.
-  B.E. Yuh, A. Hussain, R. Chandrasekhar, et al. Comparative analysis of global practice patterns in urologic robot-assisted surgery. J Endourol. 2010;24:1637-1644 Crossref
-  D.G. Murphy, A. Bjartell, V. Ficarra, et al. Downsides of robot-assisted laparoscopic radical prostatectomy: limitations and complications. Eur Urol. 2010;57:735-746 Crossref
-  A. Tewari, P. Sooriakumaran, D.A. Bloch, U. Seshadri-Kreaden, A.E. Hebert, P. Wiklund. Positive surgical margin and perioperative complication rates of primary surgical treatments for prostate cancer: a systematic review and meta-analysis comparing retropubic, laparoscopic, and robotic prostatectomy. Eur Urol. 2012;62:1-15
-  G. Novara, V. Ficarra, R.C. Rosen, et al. Systematic review and meta-analysis of perioperative outcomes and complications after robot-assisted radical prostatectomy. Eur Urol. 2012;62:431-452 Crossref
-  D. Moher, L. Shamseer, M. Clarke, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4:1 Crossref
-  C.F. Hung, C.K. Yang, C.L. Cheng, Y.C. Ou. Bowel complication during robotic-assisted laparoscopic radical prostatectomy. Anticancer Res. 2011;31:3497-3501
-  F. Ahmed, J. Rhee, D. Sutherland, C. Benjamin, J. Engel, H. Frazier II. Surgical complications after robot-assisted laparoscopic radical prostatectomy: the initial 1000 cases stratified by the Clavien classification system. J Endourol. 2012;26:135-139 Crossref
-  J.J. Bae, S.H. Choi, T.G. Kwon, T.H. Kim. Advantages of robot-assisted laparoscopic radical prostatectomy in obese patients: comparison with the open procedure. Korean J Urol. 2012;53:536-540 Crossref
-  D.M. Bouchier-Hayes, K.X. Clancy, K. Canavan, P.J. O’Malley. Initial consecutive 125 cases of robotic assisted laparoscopic radical prostatectomy performed in Ireland's first robotic radical prostatectomy centre. Irish J Med Sci. 2012;181:21-25 Crossref
-  P.N. Dogra, T.D. Javali, P. Singh, et al. Perioperative outcome of initial 190 cases of robot-assisted laparoscopic radical prostatectomy - a single-center experience. Indian J Urol. 2012;28:159-163
-  D.I. Kang, S.H. Woo, D.H. Lee, I.Y. Kim. Incidence of port-site hernias after robot-assisted radical prostatectomy with the fascial closure of only the midline 12-mm port site. J Endourol. 2012;26:848-851 Crossref
-  K.H. Yip, C.H. Yee, C.F. Ng, et al. Robot-assisted radical prostatectomy in Hong Kong: a review of 235 cases. J Endourol. 2012;26:258-263 Crossref
-  V. Zugor, A.P. Labanaris, R.M. Bauer, J.H. Witt. Surgical and oncological outcomes in patients with a preoperative PSA value <4 ng/ml undergoing robot-assisted radical prostatectomy. Anticancer Res. 2012;32:2079-2083
-  V. Zugor, J.H. Witt, A. Heidenreich, D. Porres, A.P. Labanaris. Surgical and oncological outcomes in patients with preoperative PSA >20 ng/ml undergoing robot-assisted radical prostatectomy. Anticancer Res. 2012;32:2091-2095
-  B. Brennhovd, K. Axcrona, S.D. Fossa, K.E. Giercksky, L. Vlatkovic, A.A. Dahl. Robot-assisted radical prostatectomy of clinical high-risk patients with prostate cancer: a controlled study of operative and short-term postoperative events. Scand J Urol. 2013;47:449-455 Crossref
-  M. Froehner, V. Novotny, R. Koch, S. Leike, L. Twelker, M.P. Wirth. Perioperative complications after radical prostatectomy: open versus robot-assisted laparoscopic approach. Urol Int. 2013;90:312-315 Crossref
-  A. Fuller, S.E. Pautler. Complications following robot-assisted radical prostatectomy in a prospective Canadian cohort of 305 consecutive cases. Can Urol Assoc J. 2013;7:116-121
-  A. Ghazi, E. Scosyrev, H. Patel, E.M. Messing, J.V. Joseph. Complications associated with extraperitoneal robot-assisted radical prostatectomy using the standardized Martin classification. Urology. 2013;81:324-331
-  T. Hashimoto, K. Yoshioka, T. Gondo, et al. Learning curve and perioperative outcomes of robot-assisted radical prostatectomy in 200 initial Japanese cases by a single surgeon. J Endourol. 2013;27:1218-1223 Crossref
-  A.P. Labanaris, V. Zugor, J.H. Witt. Robot-assisted radical prostatectomy in patients with a pathologic prostate specimen weight >/=100 grams versus </=50 grams: surgical, oncologic and short-term functional outcomes. Urol Int. 2013;90:24-30 Crossref
-  M.A. Liss, D. Skarecky, B. Morales, K. Osann, L. Eichel, T.E. Ahlering. Preventing perioperative complications of robotic-assisted radical prostatectomy. Urology. 2013;81:319-323 Crossref
-  T. Sejima, T. Masago, S. Morizane, et al. Robot-assisted radical prostatectomy: a case series of the first 100 patients–constitutional introduction and implementation on the basis of comprehensive department of minimal invasive surgery center. BMC Res Notes. 2013;6:436 Crossref
-  Y. Seo do, H.J. Cho, J.M. Cho, J.Y. Kang, T.K. Yoo. Experience with robot-assisted laparoscopic radical prostatectomy at a secondary training hospital: operation time, treatment outcomes, and complications with the accumulation of experience. Korean J Urol. 2013;54:522-526
-  J.U. Stolzenburg, H.A. Qazi, S. Holze, et al. Evaluating the learning curve of experienced laparoscopic surgeons in robot-assisted radical prostatectomy. J Endourol. 2013;27:80-85 Crossref
-  E.J. Abel, K. Wong, M. Sado, et al. Surgical operative time increases the risk of deep venous thrombosis and pulmonary embolism in robotic prostatectomy. JSLS. 2014;18:282-287 Crossref
-  K.N. Babaian, D. Skarecky, M.A. Liss, K. Osann, A. Lusch, T.E. Ahlering. A comparative analysis of complications after robot-assisted radical prostatectomy for men aged </=69 and >/=70 years. J Endourol. 2014;28:1435-1438 Crossref
-  G.B. Di Pierro, J.G. Wirth, M. Ferrari, H. Danuser, A. Mattei. Impact of a single-surgeon learning curve on complications, positioning injuries, and renal function in patients undergoing robot-assisted radical prostatectomy and extended pelvic lymph node dissection. Urology. 2014;84:1106-1111 Crossref
-  L.O. Gagnon, S.L. Goldenberg, K. Lynch, A. Hurtado, M.E. Gleave. Comparison of open and robotic-assisted prostatectomy: the University of British Columbia experience. Can Urol Assoc J. 2014;8:92-97
-  X. Gu, M. Araki, C. Wong. Does elevated body mass index (BMI) affect the clinical outcomes of robot-assisted laparoscopic prostatectomy (RALP): a prospective cohort study. Int J Surg. 2014;12:1055-1060 Crossref
-  K.C. Koo, D.C. Jung, S.H. Lee, et al. Feasibility of robot-assisted radical prostatectomy for very-high risk prostate cancer: surgical and oncological outcomes in men aged >/=70 years. Prostate Int. 2014;2:127-132 Crossref
-  J.E. Musser, M. Assel, G.B. Guglielmetti, et al. Impact of routine use of surgical drains on incidence of complications with robot-assisted radical prostatectomy. J Endourol. 2014;28:1333-1337 Crossref
-  G. Ploussard, A. de la Taille, M. Moulin, et al. Comparisons of the perioperative, functional, and oncologic outcomes after robot-assisted versus pure extraperitoneal laparoscopic radical prostatectomy. Eur Urol. 2014;65:610-619 Crossref
-  M. Akand, T. Erdogru, E. Avci, M. Ates. Transperitoneal versus extraperitoneal robot-assisted laparoscopic radical prostatectomy: a prospective single surgeon randomized comparative study. Int J Urol. 2015;22:916-921
-  J. Garate, R. Sanchez-Salas, R. Valero, R. Matheus, A. Leon, H. Davila. Pentafecta outcomes after robot-assisted laparoscopic radical prostatectomy: first 100 cases in Latinoamerican Hospital. Actas Urol Esp. 2015;39:20-25
-  A. Kumar, S. Samavedi, A.S. Bates, et al. Age stratified comparative analysis of perioperative, functional and oncologic outcomes in patients after robot assisted radical prostatectomy–a propensity score matched study. Eur J Surg Oncol. 2015;41:837-843 Crossref
-  P.K. Modi, Y.S. Kwon, N. Patel, et al. Safety of robot-assisted radical prostatectomy with pneumoperitoneum of 20 mm Hg: a study of 751 patients. J Endourol. 2015;29:1148-1151
-  M.S. Morgan, N.A. Shakir, M. Garcia-Gil, et al. Single- versus dual-console robot-assisted radical prostatectomy: impact on intraoperative and postoperative outcomes in a teaching institution. World J Urol. 2015;33:781-786 Crossref
-  M. Sumitomo, K. Kanao, Y. Kato, et al. Comparative investigation on clinical outcomes of robot-assisted radical prostatectomy between experienced open prostatic surgeons and novice open surgeons in a laparoscopically naive center with a limited caseload. Int J Urol. 2015;22:469-474 Crossref
-  A.I. Tasci, I. Tufek, E. Gumus, et al. Oncologic results, functional outcomes, and complication rates of robotic-assisted radical prostatectomy: multicenter experience in Turkey including 1,499 patients. World J Urol. 2015;33:1095-1102 Crossref
-  R. Wagenhoffer, M. Gruner, J. Schymik, et al. Switching from endoscopic extraperitoneal radical prostatectomy to robot-assisted laparoscopic prostatectomy: comparing outcomes and complications. Urol Int. 2015;95:380-385
-  T. Yumioka, H. Iwamoto, T. Masago, et al. Robot-assisted radical prostatectomy in an initial Japanese series: the impact of prior abdominal surgery on surgical outcomes. Int J Urol. 2015;22:278-282 Crossref
-  A. Galfano, D. Di Trapani, F. Sozzi, et al. Beyond the learning curve of the Retzius-sparing approach for robot-assisted laparoscopic radical prostatectomy: oncologic and functional results of the first 200 patients with >/= 1 year of follow-up. Eur Urol. 2013;64:974-980 Crossref
-  D.C. Friedman, T.S. Lendvay, B. Hannaford. Instrument failures for the da Vinci Surgical System: a Food and Drug Administration MAUDE database study. Surg Endosc. 2013;27:1503-1508 Crossref
-  D. Kaushik, R. High, C.J. Clark, C.A. LaGrange. Malfunction of the Da Vinci robotic system during robot-assisted laparoscopic prostatectomy: an international survey. J Endourol. 2010;24:571-575 Crossref
-  R.J. Sotelo, A. Haese, V. Machuca, et al. Safer surgery by learning from complications: a focus on robotic prostate surgery. Eur Urol. 2016;69:334-344
-  K.R. Ghani, Q.D. Trinh, M. Menon. Vattikuti Institute Prostatectomy-technique in 2012. J Endourol. 2012;26:1558-1565 Crossref
-  H.M. Hasson. A modified instrument and method for laparoscopy. Am J Obstet Gynecol. 1971;110:886-887
-  R. Kassir, P. Blanc, P. Lointier, et al. Laparoscopic entry techniques in obese patient: veress needle, direct trocar insertion or open entry technique?. Obesity Surg. 2014;24:2193-2194 Crossref
-  N. Dunne, M.I. Booth, T.C. Dehn. Establishing pneumoperitoneum: Verres or Hasson? The debate continues. Ann R Coll Surg Engl. 2011;93:22-24 Crossref
-  M. Kosuta, S. Palmisano, G. Piccinni, et al. Safety of Veress needle insertion in laparoscopic bariatric surgery. Surg Laparosc Endosc Percutan Tech. 2014;24:e1-e4 Crossref
-  W. Kim, C. Abdelshehid, H.J. Lee, T. Ahlering. Robotic-assisted laparoscopic prostatectomy in umbilical hernia patients: University of California, Irvine, technique for port placement and repair. Urology. 2012;79 1412.e1–3
-  F.W. Jansen, W. Kolkman, E.A. Bakkum, C.D. de Kroon, T.C. Trimbos-Kemper, J.B. Trimbos. Complications of laparoscopy: an inquiry about closed- versus open-entry technique. Am J Obstet Gynecol. 2004;190:634-638 Crossref
-  C.D. Lallas, M.L. Pe, J.V. Patel, P. Sharma, L.G. Gomella, E.J. Trabulsi. Transperitoneal robotic-assisted laparoscopic prostatectomy after prosthetic mesh herniorrhaphy. JSLS. 2009;13:142-147
-  A. Mattei, G.B. Di Pierro, V. Rafeld, C. Konrad, J. Beutler, H. Danuser. Positioning injury, rhabdomyolysis, and serum creatine kinase-concentration course in patients undergoing robot-assisted radical prostatectomy and extended pelvic lymph node dissection. J Endourol. 2013;27:45-51 Crossref
-  D. Shveiky, J.N. Aseff, C.B. Iglesia. Brachial plexus injury after laparoscopic and robotic surgery. J Minim Invasive Gynecol. 2010;17:414-420 Crossref
-  L. Romanowski, H. Reich, F. McGlynn, M.D. Adelson, P.J. Taylor. Brachial plexus neuropathies after advanced laparoscopic surgery. Fertil Steril. 1993;60:729-732
-  S. Pridgeon, C.V. Bishop, J. Adshead. Lower limb compartment syndrome as a complication of robot-assisted radical prostatectomy: the UK experience. BJU Int. 2013;112:485-488 Crossref
-  D.M. Gainsburg, D. Wax, D.L. Reich, J.R. Carlucci, D.B. Samadi. Intraoperative management of robotic-assisted versus open radical prostatectomy. JSLS. 2010;14:1-5 Crossref
-  J.R. Lichter, L.B. Marr, D.E. Schilling, et al. A Department-of-Anesthesiology-based management protocol for perioperative corneal abrasions. Clin Ophthalmol. 2015;9:1689-1695
-  M.A. Olympio. Postoperative visual loss after robotic pelvic surgery. BJU Int. 2013;112:1060-1061 Crossref
-  M.S. Kim, S.J. Bai, J.R. Lee, Y.D. Choi, Y.J. Kim, S.H. Choi. Increase in intracranial pressure during carbon dioxide pneumoperitoneum with steep trendelenburg positioning proven by ultrasonographic measurement of optic nerve sheath diameter. J Endourol. 2014;28:801-806 Crossref
-  Y. Hoshikawa, N. Tsutsumi, K. Ohkoshi, et al. The effect of steep Trendelenburg positioning on intraocular pressure and visual function during robotic-assisted radical prostatectomy. Br J Ophthalmol. 2014;98:305-308 Crossref
-  Y. Taketani, C. Mayama, N. Suzuki, et al. Transient but significant visual field defects after robot-assisted laparoscopic radical prostatectomy in deep Tendelenburg position. PLoS One. 2015;10:e0123361 Crossref
-  J.K. Jhaveri, F.J. Penna, M. Diaz-Insua, W. Jeong, M. Menon, J.O. Peabody. Ureteral injuries sustained during robot-assisted radical prostatectomy. J Endourol. 2014;28:318-324 Crossref
-  A. Wedmid, P. Mendoza, S. Sharma, et al. Rectal injury during robot-assisted radical prostatectomy: incidence and management. J Urol. 2011;186:1928-1933 Crossref
-  E. Kheterpal, A. Bhandari, S. Siddiqui, N. Pokala, J. Peabody, M. Menon. Management of rectal injury during robotic radical prostatectomy. Urology. 2011;77:976-979 Crossref
-  R. Katz, T. Borkowski, A. Hoznek, L. Salomon, A. de la Taille, C.C. Abbou. Operative management of rectal injuries during laparoscopic radical prostatectomy. Urology. 2003;62:310-313 Crossref
-  D.S. Yee, D.K. Ornstein. Repair of rectal injury during robotic-assisted laparoscopic prostatectomy. Urology. 2008;72:428-431 Crossref
-  R.N. Borland, P.C. Walsh. The management of rectal injury during radical retropubic prostatectomy. J Urol. 1992;147:905-907
-  R.H. McLaren, D.M. Barrett, H. Zincke. Rectal injury occurring at radical retropubic prostatectomy for prostate cancer: etiology and treatment. Urology. 1993;42:401-405 Crossref
-  C.F. Hung, C.K. Yang, Y.C. Ou. Robotic assisted laparoscopic radical prostatectomy following transurethral resection of the prostate: perioperative, oncologic and functional outcomes. Prostate Int. 2014;2:82-89 Crossref
-  G.L. Martin, R.N. Nunez, M.D. Humphreys, et al. Interval from prostate biopsy to robot-assisted radical prostatectomy: effects on perioperative outcomes. BJU Int. 2009;104:1734-1737 Crossref
-  K.R. Ghani, M. Hurwitz, M. Menon. Hem-o-lok clip causing small bowel obstruction after robot-assisted radical prostatectomy. Int J Urol. 2012;19:962-963 Crossref
-  S. Siddiqui, A. Bhandari, M. Menon. Complications of robotic surgery. A. Hemal, M. Menon (Eds.) Robotics in Genitourinary Surgery (Springer-Verlag, London, UK, 2011) 377-390 Crossref
-  S. Di Saverio, F. Coccolini, M. Galati, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg. 2013;8:42 Crossref
-  J.J. Diaz Jr., F. Bokhari, N.T. Mowery, et al. Guidelines for management of small bowel obstruction. J Trauma. 2008;64:1651-1664 Crossref
-  R. Kirby, B. Challacombe, K. Patil, P. Amoroso, P. Dasgupta, J.M. Fitzpatrick. Prevention and management of haematomata after minimally invasive radical prostatectomy. BJU Int. 2011;108:158-159 Crossref
-  R. Kirby, K. Patil, P. Amoroso, B. Challacombe, P. Dasgupta. Avoiding and dealing with the complications of robot-assisted laparoscopic radical prostatectomy. BJU Int. 2010;106:1567-1569 Crossref
-  F. Rocco, L. Carmignani, P. Acquati, et al. Early continence recovery after open radical prostatectomy with restoration of the posterior aspect of the rhabdosphincter. Eur Urol. 2007;52:376-383 Crossref
-  G. Ploussard, A. Briganti, A. de la Taille, et al. Pelvic lymph node dissection during robot-assisted radical prostatectomy: efficacy, limitations, and complications–a systematic review of the literature. Eur Urol. 2014;65:7-16 Crossref
-  W.Y. Khoder, M. Trottmann, A. Buchner, et al. Risk factors for pelvic lymphoceles post-radical prostatectomy. Int J Urol. 2011;18:638-643
-  G.J. Miller, D.J. Howarth, J.C. Attfield, et al. Haemostatic factors in human peripheral afferent lymph. Thromb Haemost. 2000;83:427-432
-  M.L. Lima, C.A. Cotrim, J.C. Moro, R. Miyaoka, C.A. D’Ancona. Laparoscopic treatment of lymphoceles after renal transplantation. Int Braz J Urol. 2012;38:215-221 discussion 221 Crossref
-  M. White, P.R. Mueller, J.T. Ferrucci Jr., et al. Percutaneous drainage of postoperative abdominal and pelvic lymphoceles. AJR. Am J Roentgenol. 1985;145:1065-1069 Crossref
-  U. Capitanio, F. Pellucchi, A. Gallina, et al. How can we predict lymphorrhoea and clinically significant lymphocoeles after radical prostatectomy and pelvic lymphadenectomy? Clinical implications. BJU Int. 2011;107:1095-1101 Crossref
-  A. Naselli, R. Andreatta, C. Introini, V. Fontana, P. Puppo. Predictors of symptomatic lymphocele after lymph node excision and radical prostatectomy. Urology. 2010;75:630-635 Crossref
-  H.J. Lee, C.J. Kane. How to minimize lymphoceles and treat clinically symptomatic lymphoceles after radical prostatectomy. Curr Urol Rep. 2014;15:445 Crossref
-  J. Ji, H. Yuan, L. Wang, J. Hou. Is the impact of the extent of lymphadenectomy in radical prostatectomy related to the disease risk? A single center prospective study. J Surg Res. 2012;178:779-784 Crossref
-  A. Mattei, F.G. Fuechsel, N. Bhatta Dhar, 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;53:118-125 Crossref
-  V. Pagliarulo, D. Hawes, F.H. Brands, et al. Detection of occult lymph node metastases in locally advanced node-negative prostate cancer. J Clin Oncol. 2006;24:2735-2742 Crossref
-  D. Weckermann, R. Dorn, M. Trefz, T. Wagner, F. Wawroschek, R. Harzmann. Sentinel lymph node dissection for prostate cancer: experience with more than 1,000 patients. J Urol. 2007;177:916-920 Crossref
-  B.E. Yuh, N.H. Ruel, R. Mejia, G. Novara, T.G. Wilson. Standardized comparison of robot-assisted limited and extended pelvic lymphadenectomy for prostate cancer. BJU Int. 2013;112:81-88 Crossref
-  D.J. Chalmers, K.R. Scarpato, I. Staff, et al. Does heparin prophylaxis reduce the risk of venous thromboembolism in patients undergoing robot-assisted prostatectomy?. J Endourol. 2013;27:800-803 Crossref
-  R. Tomic, T. Granfors, J.G. Sjodin, L. Ohberg. Lymph leakage after staging pelvic lymphadenectomy for prostatic carcinoma with and without heparin prophylaxis. Scand J Urol Nephrol. 1994;283:273-275
-  M. Araki, M. Manoharan, S. Vyas, A.M. Nieder, M.S. Soloway. A pelvic drain can often be avoided after radical retropubic prostatectomy–an update in 552 cases. Eur Urol. 2006;50:1241-1247 discussion 1246–47 Crossref
-  M. Savoie, M.S. Soloway, S.S. Kim, M. Manoharan. A pelvic drain may be avoided after radical retropubic prostatectomy. J Urol. 2003;170:112-114 Crossref
-  S. Sharma, H.L. Kim, J.L. Mohler. Routine pelvic drainage not required after open or robotic radical prostatectomy. Urology. 2007;69:330-333 Crossref
-  G.N. Box, H.J. Lee, J.B. Abraham, et al. Comparative study of in vivo lymphatic sealing capability of the porcine thoracic duct using laparoscopic dissection devices. J Urol. 2009;181:387-391 Crossref
-  M.A. Orvieto, R.F. Coelho, S. Chauhan, K.J. Palmer, B. Rocco, V.R. Patel. Incidence of lymphoceles after robot-assisted pelvic lymph node dissection. BJU Int. 2011;108:1185-1190
-  O. Akhan, M. Karcaaltincaba, M.N. Ozmen, D. Akinci, D. Karcaaltincaba, A. Ayhan. Percutaneous transcatheter ethanol sclerotherapy and catheter drainage of postoperative pelvic lymphoceles. Cardiovasc Intervent Radiol. 2007;30:237-240 Crossref
-  W. Alago Jr., A. Deodhar, H. Michell, et al. Management of postoperative lymphoceles after lymphadenectomy: percutaneous catheter drainage with and without povidone-iodine sclerotherapy. Cardiovasc Intervent Radiol. 2013;36:466-471 Crossref
-  M.V. Caliendo, D.E. Lee, R. Queiroz, D.L. Waldman. Sclerotherapy with use of doxycycline after percutaneous drainage of postoperative lymphoceles. J Vasc Intervent Radiol. 2001;12:73-77 Crossref
-  A. Chin, N. Ragavendra, L. Hilborne, H.A. Gritsch. Fibrin sealant sclerotherapy for treatment of lymphoceles following renal transplantation. J Urol. 2003;170:380-383 Crossref
-  J.D. Gilliland, J.B. Spies, S.B. Brown, J.M. Yrizarry, L.H. Greenwood. Lymphoceles: percutaneous treatment with povidone-iodine sclerosis. Radiology. 1989;171:227-229 Crossref
-  R.K. Kerlan Jr., J.M. LaBerge, R.L. Gordon, E.J. Ring. Bleomycin sclerosis of pelvic lymphoceles. J Vasc Intervent Radiol. 1997;8:885-887 Crossref
-  J.K. Kim, Y.Y. Jeong, Y.H. Kim, Y.C. Kim, H.K. Kang, H.S. Choi. Postoperative pelvic lymphocele: treatment with simple percutaneous catheter drainage. Radiology. 1999;212:390-394 Crossref
-  O.A. Raheem, W.M. Bazzi, J.K. Parsons, C.J. Kane. Management of pelvic lymphoceles following robot-assisted laparoscopic radical prostatectomy. Urology Ann. 2012;4:111-114
-  T. Patel, W. Kirby, G. Hruby, M.C. Benson, J.M. McKiernan, K. Badani. Heparin prophylaxis and the risk of venous thromboembolism after robotic-assisted laparoscopic prostatectomy. BJU Int. 2011;108:729-732
-  F.P. Secin, T. Jiborn, A.S. Bjartell, et al. Multi-institutional study of symptomatic deep venous thrombosis and pulmonary embolism in prostate cancer patients undergoing laparoscopic or robot-assisted laparoscopic radical prostatectomy. Eur Urol. 2008;53:134-145 Crossref
-  S.Y. Chan, V.F. Leung, C.H. Yee, et al. Incidence of postoperative deep vein thrombosis after robotic-assisted laparoscopic prostatectomy: a prospective study in Chinese patients. Int Urol Nephrol. 2014;46:2139-2142 Crossref
-  S.I. Tyritzis, A. Wallerstedt, G. Steineck, et al. Thromboembolic complications in 3,544 patients undergoing radical prostatectomy with or without lymph node dissection. J Urol. 2015;193:117-125 Crossref
-  M.K. Gould, D.A. Garcia, S.M. Wren, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(Suppl) e227S–77S
-  S.M. Bates, R. Jaeschke, S.M. Stevens, et al. Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(Suppl) e351S–418S
-  C. Kearon, E.A. Akl, A.J. Comerota, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(Suppl) e419S–94S
-  S.I. Tyritzis, I. Katafigiotis, C.A. Constantinides. All you need to know about urethrovesical anastomotic urinary leakage following radical prostatectomy. J Urol. 2012;188:369-376 Crossref
-  T.R. Williams, O.J. Longoria, S. Asselmeier, M. Menon. Incidence and imaging appearance of urethrovesical anastomotic urinary leaks following da Vinci robotic prostatectomy. Abdom Imaging. 2008;33:367-370 Crossref
-  D.P. Dalton, A.J. Schaeffer, J.E. Garnett, J.T. Grayhack. Radiographic assessment of the vesicourethral anastomosis directing early decatheterization following nerve-sparing radical retropubic prostatectomy. J Urol. 1989;141:79-81
-  A.A. Hakimi, D.M. Faleck, S. Sobey, et al. Assessment of complication and functional outcome reporting in the minimally invasive prostatectomy literature from 2006 to the present. BJU Int. 2012;109:26-30 discussion 30
-  S. Kawamoto, M. Allaf, F.M. Corl, T. Feng, J. Yohannan, E.K. Fishman. Anastomotic leak after robot-assisted laparoscopic radical prostatectomy: evaluation with MDCT cystography with multiplanar reformatting and 3D display. AJR Am J Roentgenol. 2012;199:W595-W601 Crossref
-  B. Pogatchnik, S. Monti, D.H. Lewis, D.A. Heinrich, L. Mannelli. Intraperitoneal urine leak after prostatectomy confirmed by 99mTc-MAG3 renogram. Clin Nucl Med. 2014;39:744-746 Crossref
-  O.A. Castillo, C. Alston, R. Sanchez-Salas. Persistent vesicourethral anastomotic leak after laparoscopic radical prostatectomy: laparoscopic solution. Urology. 2009;73:124-126 Crossref
-  V.J. Gnanapragasam, P. Baker, G.P. Naisby, D. Chadwick. Identification and validation of risk factors for vesicourethral leaks following radical retropubic prostatectomy. Int J Urol. 2005;12:948-952 Crossref
-  H.J. Lee, C.I. Shin, S.I. Hwang, et al. MDCT cystography for detection of vesicourethral leak after prostatectomy. AJR Am J Roentgenol. 2008;191:1847-1851 Crossref
-  A.R. Ramsden, G.W. Chodak. Can leakage at the vesico-urethral anastomosis be predicted after radical retropubic prostatectomy?. BJU Int. 2004;93:503-506 Crossref
-  A.J. Ball, K.P. Bordeau, J.W. Davis, R.W. Given, D.F. Lynch, M.D. Fabrizio. Modified running vesicourethral anastomosis after robotically assisted laparoscopic radical prostatectomy: use of solitary Lapra-Ty to secure posterior approximation. Urology. 2005;66:16-18 Crossref
-  E.K. Diner, S.V. Patel, A.M. Kwart. Does fibrin sealant decrease immediate urinary leakage following radical retropubic prostatectomy?. J Urol. 2005;173:1147-1149 Crossref
-  N. Lawrentschuk, D.M. Bolton, D. Angus. Fenestrated urethral catheter to aid anastomotic drainage after radical prostatectomy. Urology. 2005;65:160-162 Crossref
-  D.A. Rebuck, S. Haywood, K. McDermott, K.T. Perry, R.B. Nadler. What is the long-term relevance of clinically detected postoperative anastomotic urine leakage after robotic-assisted laparoscopic prostatectomy?. BJU Int. 2011;108:733-738
-  J.D. Sammon, F. Muhletaler, J.O. Peabody, M. Diaz-Insua, R. Satyanaryana, M. Menon. Long-term functional urinary outcomes comparing single- vs double-layer urethrovesical anastomosis: two-year follow-up of a two-group parallel randomized controlled trial. Urology. 2010;76:1102-1107 Crossref
-  S. Beck, D. Skarecky, K. Osann, R. Juarez, T.E. Ahlering. Transverse versus vertical camera port incision in robotic radical prostatectomy: effect on incisional hernias and cosmesis. Urology. 2011;78:586-590 Crossref
-  A. Chennamsetty, J. Hafron, L. Edwards, et al. Predictors of incisional hernia after robotic assisted radical prostatectomy. Adv Urol. 2015;2015:457305
-  M.C. Christie, J.P. Manger, A.M. Khiyami, A.A. Ornan, K.M. Wheeler, N.S. Schenkman. Occult radiographically evident port-site hernia after robot-assisted urologic surgery: incidence and risk factors. J Endourol. 2016;30:92-96
-  A. Fuller, A. Fernandez, S.E. Pautler. Incisional hernia after robot-assisted radical prostatectomy-predisposing factors in a prospective cohort of 250 cases. J Endourol. 2011;25:1021-1024 Crossref
-  J.S. Parihar, Y.S. Ha, I.Y. Kim. Bladder neck contracture-incidence and management following contemporary robot assisted radical prostatectomy technique. Prostate Int. 2014;2:12-18 Crossref
-  B.N. Breyer, C.B. Davis, J.E. Cowan, C.J. Kane, P.R. Carroll. Incidence of bladder neck contracture after robot-assisted laparoscopic and open radical prostatectomy. BJU Int. 2010;106:1734-1738 Crossref
-  H.J. Cho, T.Y. Jung, D.Y. Kim, et al. Prevalence and risk factors of bladder neck contracture after radical prostatectomy. Korean J Urol. 2013;54:297-302 Crossref
-  G.R. Hanson, E. Odom, L.S. Borden Jr., N. Neil, J.M. Corman. Post-operative drain output as a predictor of bladder neck contracture following radical prostatectomy. Int Urol Nephrol. 2008;40:351-354 Crossref
-  L.P. Msezane, W.S. Reynolds, O.N. Gofrit, A.L. Shalhav, G.P. Zagaja, K.C. Zorn. Bladder neck contracture after robot-assisted laparoscopic radical prostatectomy: evaluation of incidence and risk factors and impact on urinary function. J Endourol. 2008;22:377-383
-  D.R. Webb, K. Sethi, K. Gee. An analysis of the causes of bladder neck contracture after open and robot-assisted laparoscopic radical prostatectomy. BJU Int. 2009;103:957-963 Crossref
-  L. Cormio, P. Massenio, G. Lucarelli, et al. Hem-o-lok clip: a neglected cause of severe bladder neck contracture and consequent urinary incontinence after robot-assisted laparoscopic radical prostatectomy. BMC Urol. 2014;14:21 Crossref
-  K.B. Blumenthal, D.E. Sutherland, K.R. Wagner, H.A. Frazier, J.D. Engel. Bladder neck contractures related to the use of Hem-o-lok clips in robot-assisted laparoscopic radical prostatectomy. Urology. 2008;72:158-161 Crossref
-  C.D. Jaeger, P.A. Cockerill, M.T. Gettman, M.K. Tollefson. Presentation, endoscopic management, and significance of hemostatic clip migration into the lower urinary tract following radical prostatectomy. J Laparoendosc Adv Surg Tech A. 2015;25:800-803
-  R.L. Moser, N. Narepalem. Erosion of Hem-o-Lok clips at the bladder neck after robot-assisted radical prostatectomy. J Endourol. 2009;23:949-951 Crossref
-  A. Martinschek, D. Pfalzgraf, B. Rafail, M. Ritter, E. Heinrich, L. Trojan. Transurethral versus suprapubic catheter at robot-assisted radical prostatectomy: a prospective randomized trial with 1-year follow-up. World J Urol. 2015;34:407-411
-  A.P. Labanaris, J.H. Witt, V. Zugor. Robotic-assisted radical prostatectomy in men ≥75 years of age. Surgical, oncological and functional outcomes. Anticancer Res. 2012;32(5):2085-2089
a VUI Center for Outcomes Research, Analytics and Evaluation, Detroit, MI, USA
b Department of Urology, Ludwig Maximilian University, Munich, Germany
c Department of Urology, University Vita-Salute San Raffaele, Milan, Italy
d Martini-Klinik, Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
Corresponding author. Vattikuti Urology Institute, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48128, USA. Tel. +1 313 916 2062.
© 2016 European Association of Urology, Published by Elsevier B.V.