title: How to optimize patient selection for robot-assisted radical prostatectomy: functional outcome analyses from a tertiary referral center.
abstract: BACKGROUND
  The role of surgical approach on functional outcomes recovery in prostate cancer (PCa) patients treated with bilateral nerve-sparing radical prostatectomy (BNSRP) is still debated. In this study, we examine the association between the surgical approach and functional outcomes after BNSRP.
  
  
  METHODS
  The study included 609 patients treated with robot-assisted radical prostatectomy (RARP) or open radical prostatectomy (ORP) between June 2008 and January 2011. Erectile function recovery was defined as an International Index of Erectile Function-Erectile Function domain (IIEF-EF) score ≥22. Urinary continence recovery was defined as being completely pad-free over a 24-hour period. Patients were stratified according to their probability of postoperative erectile dysfunction and urinary incontinence, according to previously published predictive models. Multivariable logistic regression tested the association between the surgical approach and functional outcomes recovery in the overall population after stratifying patients according to their risk of erectile dysfunction and urinary incontinence.
  
  
  RESULTS
  Patients treated with RARP had higher 2-year erectile function (52.1% vs 67.8%; P<0.001) and urinary continence (72.0% vs 87.4%; P<0.001) recovery rates as compared to their ORP counterparts. After stratification according to the erectile dysfunction risk, RARP led to higher erectile function recovery rates in the low- and intermediate-risk erectile dysfunction groups (all P<0.001).This did not hold true, however, in patients at high risk of erectile dysfunction (P=0.5). Similarly, when patients were stratified according to their urinary incontinence risk, RARP was associated with a higher probability of urinary continence recovery in the very low, low, and intermediate risk groups only (all P<0.001). This did not hold true, however, in the group of men at high risk of postoperative urinary incontinence (P=0.8).
  
  
  CONCLUSIONS
  RARP leads to higher urinary continence and erectile function recovery rates compared with ORP. Not all patients benefit from this approach to the same extent, however. Accurate preoperative patient selection would result in substantial savings for the health care system.
authors.affiliation: 1 Urological Research Institute, Vita-Salute San Raffaele University , San Raffaele Scientific Institute, Milan, Italy .
authors.forename: Giorgio
authors.initials: G
authors.lastname: Gandaglia
authors.forename: Nazareno
authors.initials: N
authors.lastname: Suardi
authors.forename: Andrea
authors.initials: A
authors.lastname: Gallina
authors.forename: Emanuele
authors.initials: E
authors.lastname: Zaffuto
authors.forename: Vito
authors.initials: V
authors.lastname: Cucchiara
authors.forename: Damiano
authors.initials: D
authors.lastname: Vizziello
authors.forename: Shahrokh
authors.initials: S
authors.lastname: Shariat
authors.forename: Francesco
authors.initials: F
authors.lastname: Cantiello
authors.forename: Rocco
authors.initials: R
authors.lastname: Damiano
authors.forename: Giorgio
authors.initials: G
authors.lastname: Guazzoni
authors.forename: Francesco
authors.initials: F
authors.lastname: Montorsi
authors.forename: Alberto
authors.initials: A
authors.lastname: Briganti
mesh_terms: D000368:Aged; D007172:Erectile Dysfunction / Q000209:etiology; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D059351:Organ Sparing Treatments / Q000379:methods*; D018579:Patient Selection; D010410:Penile Erection / Q000502:physiology*; D011184:Postoperative Period; D011468:Prostatectomy / Q000009:adverse effects / Q000379:methods*; D011471:Prostatic Neoplasms / Q000601:surgery; D020127:Recovery of Function / Q000502:physiology*; D012044:Regression Analysis; D012371:Robotics / Q000592:standards*; D062606:Tertiary Care Centers; D014549:Urinary Incontinence / Q000209:etiology