Early Experience of the Single-Port Robotic Transvesical Radical Prostatectomy: Case Series

Article information

J Urol Oncol. 2024;22(3):188-195
Publication date (electronic) : 2024 November 30
doi : https://doi.org/10.22465/juo.244800740037
Department of Urology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
Corresponding author: Jae Hoon Chung Department of Urology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22 Gwanpyeong-ro, 170beon-gil, Dongan-gu, Anyang 14068, Korea Email: dr.jhchung@gmail.com
Received 2024 August 20; Revised 2024 October 20; Accepted 2024 October 28.

Abstract

Purpose

This study evaluated the feasibility and safety of single-port transvesical robotic radical prostatectomy.

Materials and Methods

Four patients underwent a transvesical robotic radical prostatectomy using a singleport robotic system. The procedure involved a 2.5-cm suprapubic incision to access the anterior bladder wall, which was incised by approximately 2 cm. Utilizing a floating-docking technique.

Results

All surgeries were successfully completed without the need for additional ports or open conversion. Intraoperative complications were not observed. The median (interquartile range, IQR) console time was 159 (96–198) minutes. The median (IQR) estimated blood loss was 350 (300–700) mL. The median (IQR) duration for Foley catheter removal and patient discharge postsurgery was 7.5 (6–10) days. None of the patients experienced total incontinence after Foley catheter removal, and at 1-month postsurgery, all patients used only a safety pad. Pathology revealed positive surgical margins in 2 patients (both with pT3a and pT3b), with one of these patients having a persistent prostate-specific antigen level of 0.48 ng/mL at 1-month postsurgery. Additionally, 2 patients experienced gross hematuria within 2-week postdischarge.

Conclusion

This series demonstrates that single-port robotic transvesical radical prostatectomy is a feasible procedure with favorable perioperative functional outcomes. This offers the advantage of rapid continence recovery without oncological disadvantages.

INTRODUCTION

In recent years, the treatment of prostate cancer has predominantly involved surgical intervention, with robotic surgery becoming the standard approach because of its superior outcomes compared to traditional open or laparoscopic approaches [1,2]. These outcomes encompass not only the treatment success rate of prostate cancer but also the functional recovery rates, including urinary incontinence and erectile dysfunction [3]. In particular, urinary incontinence poses a substantial issue that affects patients’ quality of life by necessitating the use of adult diapers or causing an inability to control urination [4]. Although robotic surgery significantly reduces these complications and enhances recovery prospects compared with other surgical methods, it cannot guarantee full continence recovery. Moreover, patients cannot avoid the severe urinary incontinence in the early postoperative period.

To address these challenges, ongoing advancements and innovations in robotic surgical techniques have been developed. Techniques such as bladder neck preservation, neurovascular bundle sparing (NVBS), maximal urethral length preservation, and anterior and posterior reconstruction of the prostate have been introduced and are currently being implemented [5,6]. Despite these techniques, the recovery of continence and reduction of urinary incontinence remain areas that require improvement. Approximately 15% of patients continue to require the use of adult diapers 1-year postsurgery or undergo artificial urinary sphincter implantation [7]. To achieve better functional outcomes, the Retzius-sparing technique, which approaches the prostate posteriorly without detaching the bladder from the abdominal wall, has gained increasing attention. This method reportedly improves the early postoperative continence outcomes [8,9]. However, a notable drawback is the increased rate of positive surgical margins, which can reach up to 40% compared to the traditional 15% [10]. This is primarily due to the limited visibility of the prostate contour during the procedure and the constrained movement of surgical instruments.

To overcome these limitations, transvesical single-port robotic prostatectomy has been introduced [11]. This surgical approach allows for surgery without detaching the bladder from the abdominal wall and provides a traditional operative view. This method demonstrated excellent early continence, rapid recovery, and reduced hospital stay. Moreover, a reasonable positive surgical margin rate of 15% was maintained [12].

Currently, there are no reported cases of this surgery performed in Korea. Therefore, this study aimed to evaluate the feasibility and safety of this procedure. Moreover, oncological and functional outcomes were assessed.

MATERIALS AND METHODS

1. Patients

Four patients underwent transvesical robotic radical prostatectomy using the single-port robotic system between May 2024 and July 2024 by a single surgeon at a single institution. All patients had clinically localized prostate cancer. The inclusion criteria were as follows: (1) prostate cancer patients aged ≥40 years; (2) patients with localized or locally advanced prostate cancer who were candidates for radical prostatectomy (cT2–T3a); and (3) patients eligible for general anesthesia. The exclusion criteria were as follows: (1) patients with severe benign prostatic hyperplasia (BPH) with a prostate volume of ≥80 mL; (2) patients with a history of previous surgery or procedure for BPH; (3) patients unable to void normally due to neurological issues; (4) patients with lymph node metastasis; (5) patients with urethral stricture; and (6) patients who had been treated with neoadjuvant androgen deprivation therapy.

During the same period, 11 patients underwent robotic radical prostatectomy for prostate cancer. Among them, 7 patients underwent the transperitoneal multiport approach. Two patients had severe BPH with a prostate volume >80 mL, 3 patients were needed maximal NVBS due to good preoperative erectile function, and 2 patients underwent the transperitoneal multiport approach due to the institution’s operation schedule.

2. Operation Technique

The procedure involved a 2.5-cm suprapubic skin incision to access the anterior bladder wall. The anterior wall of the bladder was incised to approximately 2 cm. The patients were placed in the Trendelenburg position and robot docking was performed using the floating-docking technique (Fig. 1). The cart approach was performed at a slight diagonal angle from the patient’s leg direction, and docking was accomplished by manually adjusting boom rotation. For the instrument setup, the camera was positioned at the top; Maryland bipolar forceps were used in arm 1, Cadiere forceps in arm 2, and monopolar curved scissors in arm 3 (Fig. 2). Continuous suction was achieved using a homemade device constructed from an endotracheal tube, and the AirSeal system (Conmed, FL, USA) was used to maintain a constant pneumovesicum. The pneumovesicum pressure was maintained at 10 mmHg and reduced to 4–6 mmHg during anastomosis (Fig. 2).

Fig. 1.

Skin incision and floating-docking technique. (A, C) The procedure involved a 2.5-cm suprapubic skin incision. (B) The floating-docking technique.

Fig. 2.

Docking and setting. Homemade continuous suction, constructed from an endotracheal tube. The AirSeal system (Conmed, FL, USA) was used.

Port placement was performed and the posterior bladder neck was dissected after identification of the bilateral ureteral orifices. Following identification of the vas deferens and seminal vesicles, the vas deferens were transected and the seminal vesicles were dissected. The posterior plane was accessed by incising the Denonvilliers fascia, continuing towards the prostatic apex. At this stage, the degree of NVBS was determined by choosing either the interfascial or the extrafascial plane. An anterior bladder mucosal incision was then made. The endopelvic fascia and puboprostatic ligaments were then identified and excised. Pedicle dissection was performed using the Hem-o-lok robotic clips with bipolar energy. The urethra was identified and transected to ensure maximum preservation of length. Vesicourethral anastomosis was initiated at the 6 o’clock position and continued in the laterosuperior direction by using a double-arm barbed suture. The sutures were tied together at the top position. A Foley catheter was inserted into the bladder and ballooning was performed with distilled water. Finally, the specimen was extracted from a single-port site by using a lap bag (Fig. 3).

Fig. 3.

Surgical techniques. (A) Port placement. (B) Posterior bladder neck incision. (C) Dissection of the vas deferens and seminal vesicles. (D) Incising the Denonvilliers fascia. (E) Anterior bladder mucosal incision. (F) Dissection to endopelvic fascia and puboprostatic ligaments. (G–I) Pedicle dissection and neurovascular bundle sparing. (J and K) Urethra dissection. (L and M) Vesicourethral anastomosis. (N) The specimen was extracted.

3. Feasibility, Safety, and Efficacy

All patients underwent preoperative diagnostic evaluations, including prostate magnetic resonance imaging, abdominal and chest computed tomography, and whole body bone scans for the clinical staging of prostate cancer. We assessed baseline characteristics, such as age, prostate specific antigen (PSA) level, clinical stage, Gleason score, and the presence of neoadjuvant therapy before surgery. To evaluate the feasibility of the surgery, we analyzed the total operation time, console time, and performance of NVBS. Pathological reports, including pathological stage, Gleason score, and margin status, were analyzed. PSA levels 1 month after surgery were also assessed. To assess safety, we assessed the pre- and postoperative levels of hemoglobin, hematocrit, blood urea nitrogen (BUN), and creatinine and evaluated intraoperative and perioperative complications. The efficacy of surgery was assessed by evaluating the duration until fluid and food intake, Foley catheterization duration, and length of hospital stay. Pad usage, including the quantity used, was evaluated 1-month postsurgery.

RESULTS

1. Feasibility of the Surgical Approach

All surgeries were completed successfully without the need for additional ports or conversion to open surgery, demonstrating the technical feasibility of the approach. The median operative time was 188.5 minutes, with console times ranging from 96 to 198 minutes (median, 159 minutes), and NVBS was achieved bilaterally in all cases.

Two patients had positive surgical margins, both with locally advanced pathological stages (pT3a and pT3b) and high Gleason scores (4+3 and 4+4). Lymphovascular invasion was observed in 1 patient, correlating with a higher pT3b stage.

PSA levels were measured 1-month postsurgery to assess biochemical recurrence risk. Three patients achieved PSA levels <0.01 ng/mL. However, 1 patient with a positive margin and pT3b stage presented a persistent PSA level of 0.48 ng/mL, necessitating further monitoring and potential adjuvant therapy.

2. Safety Outcomes

The estimated blood loss was minimal, with a median of 300 mL, and no patient required perioperative transfusion. The median hemoglobin decrease was 1.2 g/dL, and the median hematocrit reduction was 3.5%. BUN and creatinine levels remained stable preoperatively and on the day after the surgery.

Intraoperative complications were not observed. Postoperative complications included 2 cases of gross hematuria, which occurred within 2-week postdischarge. Both patients were managed conservatively without the need for further intervention.

3. Efficacy

All patients had fluid intake a day after surgery, and 2 patients advanced a full diet on the same day. The other 2 patients had a full diet 2 days after surgery as their own want. The median Foley catheter indwelling time was 7.5 days and the day when the Foley catheter was removed, the patients were discharged.

None of the patients experienced total incontinence after removal of the Foley catheter. One patient showed immediate continence, whereas the others showed continence during straining. One month after surgery, all the patients required only a safety pad. Mild stress urinary incontinence was noted when standing or coughing in 2 patients (Table 1).

Outcomes

DISCUSSION

This study investigated the feasibility, safety, and potential efficacy of transvesical single-port robotic prostatectomy in the treatment of clinically localized prostate cancer. As the first report of this surgical technique in Korea, our findings provide evidence supporting innovative approaches for prostate cancer surgery.

The completion of all surgeries without the need for any additional ports or conversion to open surgery demonstrates the technical feasibility of the transvesical single-port approach. The median console time of 159 minutes (96–198 minutes) was longer than that reported for established robotic techniques [13]. However, these cases were the initial experiences of single-port robotic surgery. The median resection time was 106 minutes (72–127 minutes), and the anastomosis time was 33.5 minutes (14–53 minutes). The most time-consuming procedures was anterior resection and anastomosis. In anterior resection, there was an event which was dissection between the transition zone and the peripheral zone. However, after lateral dissection, an optimal surgical plane was obtained. The surgical planes become obvious once the learning curve is overcome. When anastomosis was performed, the bladder mucosa was not considered intact in 2 cases. The Foley catheter period was extended in these patients. Cystography was performed 2 days after the resolution of gross hematuria, and the Foley catheter was removed. In anastomosis, optimal anastomosis can be expected by reducing the pneumovesicum pressure. However, there were difficulties in the early stage of pressure setting, and there were no problems when the pressure was lowered to 4–6 mmHg [14]. The single-port approach can be integrated into surgical practice without significant increases in operative time. However, the success of this technique may depend on the surgeon’s experience with robotic systems [15].

Conventional robot-assisted laparoscopic prostatectomy has a surgical margin positivity rate of approximately 15%–20% [16]. In our study, the positive margin rate was 50%; however, cases of margin involvement were diagnosed as locally advanced prostate cancer (pT3a and pT3b). Two patients with localized prostate cancer had a PSA level <0.01 ng/mL at 1 month after surgery. However, in this study, oncological outcomes, such as margin status or PSA persistence, could not be assessed in very small cases. Retzius-sparing robotic prostatectomy is associated with a higher positive surgical margin rate in anterior tumors [17]. However, transvesical single-port robotic prostatectomy allows for the preservation of anterior structures to the greatest extent possible while providing flexibility in choosing dissection above or below the dorsal venous complex. Additionally, maximal urethral length sparing can be performed selectively. Consequently, contraindications for anterior tumors may not be necessary in this approach.

Transvesical single-port robotic prostatectomy demonstrated a favorable safety profile, with blood loss and no intraoperative complications. Two cases of gross hematuria occurred postoperatively, both of which were resolved with conservative management. The single-port technique does not introduce additional risks compared to traditional multiport robotic prostatectomy [18].

A notable feature of the transvesical singleport approach is the preservation of the anatomical structures that are critical for urinary continence. By avoiding dissection of the Retzius space, this technique minimizes trauma to the surrounding tissues, potentially facilitating the early recovery of urinary function [19,20]. In this study, none of the patients experienced immediate total incontinence after catheter removal. All patients showed stress-induced urinary incontinence after Foley removal. Moreover, the requirement for only a safety dry pad 1-month postsurgery suggests that the single-port technique may facilitate early recovery of urinary function, potentially improving patients’ quality of life in the immediate postoperative period.

Currently, no long-term follow-up data are available on continence rates for single-port transvesical radical prostatectomy. For conventional robotic prostatectomy, a urinary continence rate of approximately 90% has been reported [21]. Thus, in the case of long-term follow-up, it is likely that there will be no significant difference in continence rates when compared with the conventional approach. However, continence may decline over time postrecovery, especially in elderly patients who are likely to experience poorer outcomes [22]. Therefore, a high rate of early recovery is expected to benefit overall continence and improve quality of life; however, it is crucial to confirm these findings through long term follow-up in future studies.

The small sample size and short follow-up period limited the generalizability of our results. Further research involving larger multicenter trials with extended follow-up periods is essential to validate the feasibility and safety of the transvesical single-port approach and to explore its long-term oncological and functional outcomes. Since this was my initial attempt, patients with good preoperative sexual function who could undergo interfacial NVBS were treated using a conventional approach during the study period.

Moreover, the learning curve associated with this novel technique warrants further consideration. Successful implementation of the single-port approach in clinical practice requires surgeons to acquire specific skills and experience, which may initially limit its widespread adoption. Future studies should focus on defining the learning curve and identifying strategies to facilitate the transition to single-port robotic prostatectomy in surgeons accustomed to conventional techniques.

CONCLUSIONS

In conclusion, transvesical single-port robotic prostatectomy is a feasible and potentially promising surgical option for the management of clinically localized prostate cancer. This technique offers the potential for improved early functional outcomes, particularly urinary continence, without compromising oncological integrity. However, further research is needed to establish its role within the broader context of prostate cancer surgery, and to ensure that it can be safely and effectively implemented in diverse clinical settings. Continuing to explore and refine innovative surgical approaches can enhance the quality of care for patients with prostate cancer and improve their postoperative quality of life.

Notes

Grant/Fund Support

This research was supported by Hallym University Research Fund 2024 (HURF-2024-01).

Research Ethics

This study was performed in accordance with applicable laws and regulations, good clinical practice, and ethical principles described in the Declaration of Helsinki. The Institutional Review Board (IRB) of the Hallym University Sacred Heart Hospital approved the present study (IRB No. 2024-08-003). The requirement for informed consent from the participants was waived by the IRB.

Conflicts of Interest

The authors have nothing to disclose.

Author Contribution

Conceptualization: JHC; Data curation: JHC, HK; Formal analysis: JHC; Funding acquisition: JHC; Methodology: JHC, HK; Project administration: JHC; Visualization: JHC; Writing - original draft: JHC; Writing - review & editing: WJB, CYO, JSC

References

1. Saika T, Miura N, Fukumoto T, Yanagihara Y, Miyauchi Y, Kikugawa T. Role of robot-assisted radical prostatectomy in locally advanced prostate cancer. Int J Urol 2018;25:30–5.
2. Pansadoro V, Brassetti A. Extrafascial robot-assisted laparoscopic radical prostatectomy in locally advanced prostate cancer. Minerva Chir 2019;74:78–87.
3. Kitamura K, China T, Nagata M, Isotani S, Muto S, Sakamoto Y, et al. Prediction of recovery time of urinary incontinence following robot-assisted laparoscopic prostatectomy. Int J Urol 2023;30:77–82.
4. Chen Y, Hao H, Chen S, Chen X, Liu Y, Zhang M, et al. Insights into urinary incontinence after robot-assisted radical prostatectomy: urgent urinary incontinence or stress urinary incontinence. World J Urol 2023;41:3635–42.
5. Mac Curtain BM, Sugrue DD, Qian W, O’Callaghan M, Davis NF. Membranous urethral length and urinary incontinence following robot-assisted radical prostatectomy: a systematic review and metaanalysis. BJU Int 2024;133:646–55.
6. Arenas-Gallo C, Shoag JE, Hu JC. Optimizing surgical techniques in robot-assisted radical prostatectomy. Urol Clin North Am 2021;48:1–9.
7. Johnson A, Mossack S, Tsambarlis P. Artificial urinary sphincters for moderate post-prostatectomy incontinence: current research and proposed approach. Cancers (Basel) 2023;15:4424.
8. Fonseca J, Froes G, Moraes-Fontes MF, Rebola J, Lúcio R, Almeida M, et al. Urinary continence recovery after Retzius-sparing robot-assisted radical prostatectomy in relation to surgeon experience. J Robot Surg 2023;17:2503–11.
9. Kadono Y, Nohara T, Kawaguchi S, Makino T, Naito R, Kadomoto S, et al. Comparison of postoperative urinary continence and incontinence types between conventional and Retzius-sparing robot-assisted radical prostatectomy. Neurourol Urodyn 2023;42:1411–20.
10. Barakat B, Othman H, Gauger U, Wolff I, Hadaschik B, Rehme C. Retzius sparing radical prostatectomy versus robot-assisted radical prostatectomy: which technique is more beneficial for prostate cancer patients (MASTER Study)? A systematic review and metaanalysis. Eur Urol Focus 2022;8:1060–71.
11. Kaouk J, Sawczyn G, Wilson C, Aminsharifi A, Fareed K, Garisto J, et al. Singleport percutaneous transvesical simple prostatectomy using the SP robotic system: initial clinical experience. Urology 2020;141:173–7.
12. Ramos-Carpinteyro R, Ferguson EL, Chavali JS, Geskin A, Kaouk J. First 100 cases of transvesical single-port robotic radical prostatectomy. Asian J Urol 2023;10:416–22.
13. Song W, Lee SW, Chung JH, Kang M, Sung HH, Jeon HG, et al. Relationship between robotic-assisted radical prostatectomy and retropubic radical prostatectomy in the learning curve of a single surgeon as a novice in radical prostatectomy: a retrospective cohort study. Int J Surg 2020;81:74–9.
14. Kaouk J, Beksac AT, Abou Zeinab M, Duncan A, Schwen ZR, Eltemamy M. Single port transvesical robotic radical prostatectomy: initial clinical experience and description of technique. Urology 2021;155:130–7.
15. Ramos-Carpinteyro R, Ferguson EL, Chavali JS, Geskin A, Soputro N, Kaouk J. Single-port transvesical robot-assisted radical prostatectomy: the surgical learning curve of the first 100 cases. Urology 2023;178:76–82.
16. Bravi CA, Dell’Oglio P, Piazza P, Scarcella S, Bianchi L, Falagario U, et al. Positive surgical margins after anterior robot-assisted radical prostatectomy: assessing the learning curve in a multi-institutional collaboration. Eur Urol Oncol 2024;7:821–8.
17. Oshima M, Washino S, Nakamura Y, Konishi T, Saito K, Miyagawa T. Retzius-sparing robotic prostatectomy is associated with higher positive surgical margin rate in anterior tumors, but not in posterior tumors, compared to conventional anterior robotic prostatectomy. Prostate Int 2023;11:13–19.
18. Carlos AF, Dario VM, Popescu RI, Mariela C, Venancio CA. Robot-assisted radical prostatectomy (RARP) trifecta learning curve for surgeons with previous experience in laparoscopy. Medicina (Kaunas) 2024;60:1032.
19. Rosenberg JE, Jung JH, Edgerton Z, Lee H, Lee S, Bakker CJ, et al. Retzius-sparing versus standard robotic-assisted laparoscopic prostatectomy for the treatment of clinically localized prostate cancer. Cochrane Database Syst Rev 2020;8:CD013641.
20. Dalela D, Jeong W, Prasad MA, Sood A, Abdollah F, Diaz M, et al. A pragmatic randomized controlled trial examining the impact of the Retzius-sparing approach on early urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol 2017;72:677–85.
21. Ficarra V, Borghesi M, Suardi N, Naeyer GD, Novara G, Schatterman P, et al. Long-term evaluation of survival, continence and potency (SCP) outcomes after robot-assisted radical prostatectomy (RARP). BJU Int 2013;112:338–45.
22. Prabhu V, Sivaraja G, Taksler GB, Laze J, Lepor H. Long term continence outcomes in men undergoing radical prostatectomy for clinically localized prostate cancer. Eur Urol 2014;65:52–7.

Article information Continued

Fig. 1.

Skin incision and floating-docking technique. (A, C) The procedure involved a 2.5-cm suprapubic skin incision. (B) The floating-docking technique.

Fig. 2.

Docking and setting. Homemade continuous suction, constructed from an endotracheal tube. The AirSeal system (Conmed, FL, USA) was used.

Fig. 3.

Surgical techniques. (A) Port placement. (B) Posterior bladder neck incision. (C) Dissection of the vas deferens and seminal vesicles. (D) Incising the Denonvilliers fascia. (E) Anterior bladder mucosal incision. (F) Dissection to endopelvic fascia and puboprostatic ligaments. (G–I) Pedicle dissection and neurovascular bundle sparing. (J and K) Urethra dissection. (L and M) Vesicourethral anastomosis. (N) The specimen was extracted.

Table 1.

Outcomes

Variable Case #1 Case #2 Case #3 Case #4
Baseline characteristic
 Age (yr) 69 68 62 63
 BMI (kg/m2) 26.75 23.11 25.19 27.65
 Underlying disease None Subarachnoid hemorrhage Diabetes mellitus Hypertension
 ASA PS classification grade II III II II
 Previous abdominal surgery None None Cholecystectomy None
 5ARI administration No No Yes No
 IPSS 32 14 10 14
 QoL 5 4 1 3
 IIEF-5 2 19 10 3
Preoperative parameter
 Initial PSA 9.93 20.5 1.45 6.02
 Prostate volume (mL) 36 24 36 27.4
 cT stage T2c T2c T2a T2b
 Gleason score 4+5 4+3 4+4 4+3
 Positive cores 9/12 12/12 1/13 4/12
 Highest tumor proportion in core 90% 100% 15% 90%
 PIRADS 5 5 4 4
 Size of index lesion Diffuse Diffuse 1 1.4
 No. of PIRADS 3 to 5 Diffuse Diffuse 1 1
Surgical and oncological outcome
 Operative time/console time (min) 205/167 216/151 215/198 115/96
 Estimated 300 700 300 400
 NVBS Bilateral Bilateral Bilateral Bilateral
 pT stage T3a T3b T2a, ductal adenocarcinoma T3a
 Gleason score 4+3 4+4 4+4 4+3
 Tumor volume 100% 100% 2% 12%
 Margin involvement Positive Positive Negative Negative
 Lymphovascular invasion Negative Positive Negative Negative
 Complications Gross hematuria None Gross hematuria None
Safety and functional outcome
 Preoperative Hb/Hct 15.7/45.1 13.6/39.5 15.3/44 14.3/43.7
 POD#1 Hb/Hct 13.8/40.9 13.2/38.7 13.2/37.5 13.8/40.9
 Preoperative BUN/Cr 17.2/1.02 19/0.73 19.9/1.12 8.8/0.93
 POD#1 BUN/Cr 10/0.85 14/0.76 10.5/1.07 10/0.94
 SOW POD #1 POD #1 POD #1 POD #1
 Diet POD #1 POD #2 POD #1 POD #2
 Foley removal/discharge POD #10 POD #6 POD #8 POD #7
 PSA at 1 mo 0.01 0.48 <0.01 <0.01
 Incontinence at 1 mo When standing up Safety pad When coughing Safety pad

BMI, body mass index; ASA PS, American society of anesthesiologists; 5ARI, 5-alpha reductase inhibitor; IPSS, International Prostate Symptom Score; QoL, quality of life; IIEF-5, international index of erectile function; PSA, prostate-specific antigen; PIRADS, prostate imaging reporting & data system; NVBS, neurovascular bundle sparing; Hb, hemoglobin; Hct, hematocrit; POD, postoperative day; BUN, blood urea nitrogen; Cr, creatinine; SOW, sips of water.