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Proper port placement is crucial during conventional laparoscopic surgery. Likewise, during robotic laparoscopic procedures this concept is equally as important. The da Vinci® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) in its current form consists of a patientside cart with arms that dock to trocars that are preplaced by the surgeon. These arms are rather bulky and require sufficient room to maneuver. An effective port placement situates the arms so that they provide excellent intraabdominal instrument mobility while minimizing arm collisions. This chapter will describe some tips on port placement classified by procedure to help surgeons overcome the learning curve of this preliminary but crucial step to robotic urologic procedures.

Initial development of laparoscopic radical prostatectomy (LRP) was based on the experience of a few surgeons with transperitoneal laparoscopic access to the prostate and seminal vesicles. Transperitoneal laparoscopic radical prostatectomy was successfully introduced in routine clinical practice in France following the pioneering work of Gaston and Piéchaud in 1998 (unpublished series). Transperitoneal approach became predominant worldwide and was considered as the gold standard of laparoscopic prostatectomy.

Radical retropubic prostatectomy is one of the most difficult operations in the field of urology. After the procedure was introduced by Millin in 1947, this technique was adopted by others and modified, but never gained widespread popularity because of the significant complications of bleeding, incontinence, and impotence. Although anatomic discoveries by Walsh improved the surgeon’s ability to remove all tumor and have substantially improved other outcomes. Open radical prostatectomy still remains a procedure with significant morbidity.

The task of learning robotic prostatectomy can be quite challenging for both novice and experienced open or laparoscopic surgeons alike. Therefore, prior to the first procedure, much training and planning is required as the entire surgical team prepares for the upcoming challenge. The learning curve to achieve basic competency has been estimated to be between 20 to 25 cases. However, these initial patients are often selected as “ideal candidates” so that the surgical team can ease into the experience. After such cases are performed, the reality of the procedure sets in as one begins to entertain the idea of operating on those with more challenging anatomy.

The robotic-assisted laparoscopic prostatectomy (RALP) has gained rapid acceptance in the urological community due to its documented advantages over standard laparoscopy radical prostatectomy (LRP) and open prostatectomy. This advantage has been most appreciated with regards to the learning curve due to enhanced three-dimensional visualization and instruments that allow six degrees of freedom of motion. These benefits to the surgeon must, however, translate to improved overall outcomes to justify the increased economic burden placed by the robot. In this chapter, we will review the current literature for the peri-operative morbidities of RALP. Due to our extensive experience with pure LRP at Montsouris, the minimally invasive standard to which the RALP must be compared, we will reference the current literature and our own series of both RALP and LRP to make the necessary comparisons for this developing technology.

In 1997, we performed the first standard laparoscopic radical prostatectomy with a posterior approach to the seminal vesicle at the St. Augustin Clinic. After eight years and more than 3000 patients operated on we arrived at a steady state. As a center of excellence, we personally found that it was not possible for our technique to evolve any further. This was secondary to the technical limitations on standard laparoscopy, two-dimensional (2D) vision, counterintuitive motion, and nonwristed instrumentation. The arrival of robotic technology at our institution in January 2006 began a new era in our approach to radical prostatectomy. We thought that the quality of the vision provided by the robot with a three-dimensional (3D) image and the possibility of working using six axis instruments could help us in overtaking the technical limits of laparoscopic surgery.

Whenever a new procedure is introduced, it is imperative that it offers the same or improved outcomes compared to the gold standard. This is especially true when one is dealing with oncologic outcomes. Proponents of robotic surgery are in favor of its three-dimensional (3D) visualization, wristed instruments, finger-controlled movements, seven degrees of freedom (six degrees and freedom of grip) as well as tremor elimination. With these advantages there a is a possibility of increased precision and improved oncologic outcomes. One disadvantage, however, is the lack of tactile feedback.

It is estimated that, in 2005, prostate cancer will be diagnosed in over 232,090 men in the United States and that 30,350 men will die from the disease. Radical retropubic prostatectomy offers an effective cure, but is associated with significant postoperative morbidity, including erectile dysfunction and incontinence. The development of nerve-sparing anatomic prostatectomy by Walsh and colleagues has lead to improved potency rates. However, the results regarding potency preservation published in the literature by many centers are not satisfactory.

The preservation of sexual potency after prostatectomy has always been the topic of much anxiety and debate. While cancer control and urinary continence are of supreme importance, the preservation of sexual function completes the trifecta that both patient and surgeon strive to achieve. Over the decades open nerve sparing radical prostatectomy has continued to evolve from its early rudimentary beginnings into the more refined techniques that we see today. However, while we have seen considerable advances in recent times the limitations in visualization and dissection of the bundle have continued to provide a challenge to even the most experienced surgeon.

The concept of early penile rehabilitation following radical prostatectomy started in the 1990s with the evolution of several dynamic themes regarding prostate cancer diagnosis and management. First, with the maturation of serum prostate-specific antigen (PSA) testing, the detection of lower volume cancers changed the surgical margin rate and the rate of biochemical cures rose substantially, to the 80% to 90% range. The majority of our newly diagnosed tumors were histologic Gleason score 6/7 cancers and were pathologically organ confined. Recent cancer statistics for the year 2006 report that 91% of new prostate cancer cases are expected to be diagnosed at local or regional stages with five-year cancer-specific survivals approaching 100%. A second major theme of the 1990s was the substantial drop in patient age at diagnosis due to earlier screening with serum PSA testing and improved office-based ultrasound-guided biopsy techniques. In fact, the largest increase in prostate cancer incidence during the PSA era occurred in men under the age of 65. The Seattle-Puget Sound Surveillance, Epidemiology and End Results (SEER) cancer registry from 1995 to 1999 reported that 33% of all incident prostate cancer cases are now diagnosed in men under age 65 and this figure will invariably be higher in the subsequent five-year report.