title: Downsides of robot-assisted laparoscopic radical prostatectomy: limitations and complications.
abstract: BACKGROUND
  Robot-assisted laparoscopic radical prostatectomy (RALP) using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is now in widespread use for the management of localised prostate cancer (PCa). Many reports of the safety and efficacy of this procedure have been published. However, there are few specific reports of the limitations and complications of RALP.
  
  
  OBJECTIVE
  The primary purpose of this review is to ascertain the downsides of RALP by focusing on complications and limitations of this approach.
  
  
  METHODS
  A Medline search of the English-language literature was performed to identify all papers published since 2001 relating to RALP. Papers providing data on technical failures, complications, learning curve, or other downsides of RALP were considered. Of 412 papers identified, 68 were selected for review based on their relevance to the objective of this paper.
  
  
  RESULTS
  RALP has the following principal downsides: (1) device failure occurs in 0.2-0.4% of cases; (2) assessment of functional outcome is unsatisfactory because of nonstandardised assessment techniques; (3) overall complication rates of RALP are low, although higher rates are noted when complications are reported using a standardised system; (4) long-term oncologic data and data on high-risk PCa are limited; (5) a steep learning curve exists, and although acceptable operative times can be achieved in <20 cases, positive surgical margin (PSM) rates may require experience with >80 cases before a plateau is achieved; (6) robotic assistance does not reduce the difficulty associated with obese patients and those with large prostates, middle lobes, or previous surgery, in whom outcomes are less satisfactory than in patients without such factors; (7) economic barriers prevent uniform dissemination of robotic technology.
  
  
  CONCLUSIONS
  Many of the downsides of RALP identified in this paper can be addressed with longer-term data and more widespread adoption of standardised reporting measures. The significant learning curve should not be understated, and the expense of this technology continues to restrict access for many patients.
authors.affiliation: Department of Urological Oncology, The Peter MacCallum Cancer Centre, Melbourne, Australia. decmurphy@doctors.net.uk
authors.forename: Declan G
authors.initials: DG
authors.lastname: Murphy
authors.forename: Anders
authors.initials: A
authors.lastname: Bjartell
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Ficarra
authors.forename: Markus
authors.initials: M
authors.lastname: Graefen
authors.forename: Alexander
authors.initials: A
authors.lastname: Haese
authors.forename: Rodolfo
authors.initials: R
authors.lastname: Montironi
authors.forename: Francesco
authors.initials: F
authors.lastname: Montorsi
authors.forename: Judd W
authors.initials: JW
authors.lastname: Moul
authors.forename: Giacomo
authors.initials: G
authors.lastname: Novara
authors.forename: Guido
authors.initials: G
authors.lastname: Sauter
authors.forename: Tullio
authors.initials: T
authors.lastname: Sulser
authors.forename: Henk
authors.initials: H
authors.lastname: van der Poel
mesh_terms: D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects* / Q000191:economics; D008297:Male; D011468:Prostatectomy / Q000009:adverse effects* / Q000191:economics / Q000379:methods*; D011471:Prostatic Neoplasms / Q000601:surgery*; D012307:Risk Factors; D012371:Robotics / Q000191:economics