Robotic Radical Prostatectomy for Prostate Cancer: Natural Evolution of Surgery for Prostate Cancer?

The prostate gland is a solid one-sided and median organ situated in the male pelvis, under the bladder. Prostatic carcinoma (PCa) is frequently located on the peripheral portion of the gland, so that preoperative imaging starts from endorectal ultrasound. However, the role of multiparametric magnetic resonance imaging is now critical, to guide prostatic biopsy. The indications for robot-assisted radical prostatectomy (RP) (RARP) in PCa treatment are essentially the same as those for open and laparoscopic RP. The robot allows the surgeon to have perfect, less-invasive control of the tissues, increased by 3D vision, working through small cutaneous incisures. Our previous extraperitoneal experience had led us to maintain this approach in RARP. Critical anesthesiologic questions during robotic surgery included a steep Trendelenburg position, restricted access to the patient, and the effects of CO2 insufflation; as a consequence, not every patient can benefit from RARP. Beyond the introduction of robotic surgery the improved knowledge of periprostatic neurovascular structures has permitted the identification of new specific anatomic landmarks and surgical planes between prostate and neurovascular bundles during nerve-sparing procedures, in the continuous attempt to reduce the detrimental effects on sexual function and urinary continence.