[Abstract] OBJECTIVE: To review the current medical literature on robotic-assisted laparoscopic radical prostatectomy. METHODS: The literature on robotic-assisted laparoscopic radical prostatectomy was searched in MEDLINE using the keywords prostate cancer, radical prostatectomy, robotics, robot assisted, laparoscopy, etc. A preliminary comparison of the clinical outcome of this new technique with that of conventional surgery was also performed. A preliminary comparison was made between this new technique and conventional surgery in terms of clinical outcome and tumor control. RESULTS: A short-term follow-up study showed that robotic-assisted laparoscopic radical prostatectomy achieved the same tumor control as conventional open surgery and pure laparoscopic radical prostatectomy, with the advantages of less trauma, less blood loss, and faster postoperative recovery. Conclusion: Robotic surgical systems have substantially enhanced surgical techniques and provided a platform for more precise surgical techniques to be performed. Robotic-assisted laparoscopic radical prostatectomy is emerging as an important surgical treatment for patients with limited prostate cancer. Keywords: da Vinci, robotics, radical prostatectomy Background Robotic-assisted laparoscopic radical prostatectomy is the newest surgical treatment for limited prostate cancer by combining existing laparoscopic techniques with robotics to perform complex radical prostatectomy. Laparoscopic radical prostatectomy was first reported by Schuessler et al. in 1997. At that time, they concluded that the procedure was feasible and complex, but did not offer significant advantages over traditional open surgery. It was not until 2000 that Guillonneau and Vallancien and Abou et al. reported that this minimally invasive surgical technique for prostate cancer was again resurrected and improved. Subsequent reports of short- and medium-term functional recovery and follow-up of tumor regression with laparoscopic radical prostatectomy have appeared in many medical centers in Europe and the United States, gradually revealing its advantages over traditional open surgery. Despite the large number of physicians interested in this approach, laparoscopic radical prostatectomy has remained unacceptable to the majority of urologists due to the high technical requirements and learning difficulties. The feasibility of robot-assisted laparoscopic radical prostatectomy was first reported in 2000 by 2 French medical centers with experience in laparoscopic radical prostatectomy. However, Menon et al. and Tewari et al. reported initial experience with the da Vinci robot for laparoscopic radical prostatectomy, which was a new chapter in robotic-assisted laparoscopic radical prostatectomy. Since then, many medical research centers in Europe and the United States have started in-depth research in this field. The first laparoscopic radical prostatectomy in China was performed in October 2000 and is now being performed in Guangzhou, Beijing and Shanghai, and is gradually being promoted in many central cities. The main platform consists of four interactive robotic arms and a dual-lens, triple-chip digital camera system; the operating table consists of binoculars, two charge simulation wrists and a foot-operated control panel. The digital camera system provides the surgeon with a perfect ten to one hundred times real-time 3D surgical image, completely avoiding dead spots and helping the surgeon to more easily complete operations such as the identification of small nerves and blood vessels around the prostate and the accurate removal of lesions. The ergonomic table minimizes surgeon fatigue, and the surgeon’s hand movements are transmitted precisely and without delay to the robotic arm inside the patient. The system not only corrects for physiological tremors in the surgeon’s hand to make the operation more stable, but also translates the range of motion in a ratio of 1 to 1, 1 to 3 or 1 to 5. The 7 degrees of motion of the mechanical wrist allow the surgeon to perform more precise surgical operations than is possible with conventional laparoscopic instruments. Prostate cancer is the first malignant tumor in Europe and the United States with the highest incidence and second highest mortality rate in men. With the influence of the European and American lifestyles and the advancement of treatment methods, the incidence rate in China, which was low compared to that in Europe and the United States, is on the rise year by year. In the process of treatment, patients with limited prostate cancer are inevitably faced with a choice of treatment options, and after considering the impact on quality of life, including sexual and urinary function, as well as the side effects of each treatment option, it is only natural to choose the one with lower mortality and less trauma. Currently, radical prostatectomy remains the most effective treatment for limited prostate cancer compared to many other prostate cancer treatment options. However, there are still many long-term complications associated with radical prostate cancer surgery. Only 80% of patients can regain full urinary control after open radical prostatectomy. In terms of sexual function, the recovery rate of erectile function ranges from 13% to 68% in patients with preservation of the unilateral sexual nerve and from 32% to 86% in those with preservation of both sides. Since Walsh proposed the anatomy of radical prostate cancer surgery, surgeons have begun to preserve sexual nerve and sphincter function in a variety of ways. Changes in surgical approach have also affected tumor control. The surgical approach has been shown to be an independent factor in the rate of positive margins, with approximately 28% of patients having positive margins after radical open prostate cancer. a follow-up study by Epstein et al. showed that the 10-year progression-free survival rates were 79.4% and 54.9% for margin-negative and positive patients, respectively. Robotic surgical systems allow for more precise surgical procedures that remove the cancer with maximum protection of sexual function and urinary control. Robotic-assisted radical prostatectomy offers major advantages over traditional open surgery in terms of pain, blood loss, maintenance of anatomical shape, and postoperative recovery. The procedure Robotic-assisted laparoscopic radical prostatectomy can be performed either transperitoneally or directly by an extraperitoneal route. A recent study comparing these two approaches found no statistically significant differences in blood loss, margin positivity, or complications. The extraperitoneal approach is relatively short in terms of operative time, and it does not require opening the peritoneal cavity and confining the anastomotic leak to this extraperitoneal space. However, the restricted space makes the procedure technically more difficult. The patient is placed in the stone position, providing sufficient space for the robotic system to operate between the legs, and the patient’s body is lined and stabilized at the point of compression. Five trocars were placed after the creation of the pneumoperitoneum. The first was a 12-mm diameter trocar in the subumbilical position. Two 8 mm trocars were placed 3 cm below center, approximately 10 cm from the midline, at the outer edge of the rectus abdominis muscle to accommodate the robotic arm, taking special care not to penetrate the inferior abdominal artery during the operation. A fourth 5-mm trocar is placed in the right anterior superior iliac spine to place the auxiliary aspirator. The 5th trocar is optional in the appropriate place. We generally place it over the left anterior superior iliac spine. The camera system used for observation is inserted through the subumbilical trocars, and the surgeon operates primarily through two transrectal trocars. The extraperitoneal route has been described in more detail in the literature, with the following general steps: (1) widening of the extraperitoneal space; (2) pelvic lymph node dissection in preoperative patients with PSA >10 ng/ml and Gleason score >6; (3) access to the Retzius space, dissection of the pelvic floor fascia, severance of the pubic prostatic ligament, and exposure of the prostatic acinus; (4) ligation of the dorsal vein (4) free the vascular nerve bundle; (5) detach the bladder neck; (6) resect the lateral prostatic ligaments and separate the bilateral vascular nerve bundle; (7) sever the dorsal venous plexus and urethra, together with the recto-urethral muscle, and completely free the prostate; (8) remove the prostate specimen from the enlarged subumbilical incision and anastomose the vesicourethra. Routine surgical data According to the literature the operative time for pure laparoscopic radical prostate cancer surgery ranges from approximately 151-288 minutes, whereas the operative time for robot-assisted laparoscopic radical prostate cancer surgery ranges from 141-342 minutes. The transfusion rate for robotic-assisted laparoscopic radical prostatectomy was extremely low, 0-5%, which was significantly better than the 9% transfusion rate for conventional open radical prostatectomy. Positive margins We summarized the positive margins rates for all three, which were mainly related to the pathological grade of the tumor. For open radical prostate cancer, the positive margins rates ranged from 19% to 29% for T2 stage. In contrast, the positive incisional margin rates for patients with stage T2 for pure laparoscopic and robotic-assisted radical prostatectomy ranged from 10% to 23% and 5.7% to 19%, respectively. Complications We summarized some of the major complications in the literature.Gonzalgo et al. recently applied the Claviens classification of complications to summarize laparoscopic radical prostate cancer surgery. This classification was recently updated and applied by Dindo et al. in a summary of complications of a group of laparoscopic prostatectomies. Functional recovery The recovery of urinary control and sexual function in patients undergoing laparoscopic-only and robot-assisted laparoscopic radical prostatectomy was summarized. The results found that traditional open, laparoscopic-only and robotic-assisted approaches were similar in terms of functional recovery, approximately 92% to 98%, while 70% of patients were able to recover sexual function. Learning curve Menon et al. first began to discuss the learning curve for conversion from pure laparoscopy to robotic-assisted prostatectomy. One study showed that physicians with pure laparoscopic skills needed approximately 18 robotic surgical experiences to achieve the original required operative time. Studies have also been reported on how to learn effectively, and on the use of some instrumental methods for surgeons with no laparoscopic experience at all. As for the comparison of pure laparoscopic and robotic-assisted radical prostate cancer surgery. There is only one data set comparing the tumor regression between the two, which resulted in a non-statistically significant difference. The introduction of new instruments and technical tools has made laparoscopic surgery more efficient. Lotan et al. compared the costs of conventional open, pure laparoscopic and robot-assisted laparoscopic radical prostatectomy. The cost of pure laparoscopic surgery was similar to the cost of conventional open surgery. The robotic-assisted procedure was much higher than the first two due to the initial investment and the high maintenance costs. Robotic-assisted laparoscopic radical prostatectomy is gradually replacing traditional open surgery in the surgical management of patients with limited prostate cancer because of its advantages. We believe that with advances in surgical hardware and technology, it will yield better results in tumor control and functional recovery.