Technique Selection for Robot-Assisted Radical Prostatectomy: A Multi-Institutional Survey in Japan

Since Japan's public insurance covered robot-assisted radical prostatectomy (RARP) in 2012, it has become standard. Despite widespread use, variability exists among surgeons in approaches, nerve-sparing, lymph node dissection (LND), and postoperative management. This study examined the practices of surgical technique selection, energy settings, and postoperative management in RARP across Japan to identify standardization opportunities.

A 50-item questionnaire was distributed between October and December 2023 to physicians performing robotic surgeries at 44 institutions affiliated with Kyoto University and other universities. The survey addressed the surgeons' experience, robotic platforms, energy settings, surgical approaches, LND, anastomosis, complication prevention, and postoperative management. Responses from 147 physicians were analyzed.

All respondents used the da Vinci system, with the half of institutions performing over 50 RARP annually. Most surgeons preferred the transperitoneal approach (over 80%) and standard LND (65.7%), while 20% performed an extended pelvic lymph node dissection. Monopolar and bipolar energies were set to Effects 3 and 4, respectively. Barbed sutures were used for anastomosis in 90% of the cases with posterior wall reconstruction. Drains were placed in 70% of the cases, and catheters were removed on postoperative days 5-7 in over 90%. Variations were noted in dorsal venous complex management, nerve-sparing, hernia prevention, and imaging before catheter removal.

This survey revealed the diversity of RARP techniques and postoperative protocols among Japanese surgeons. While fundamental elements, such as LND templates and barbed anastomosis, have converged, significant procedural variability persists. A two-tiered educational model, which standardizes essential safety techniques while allowing case-specific flexibility, may promote consistent nationwide RARP practices.