The evolving landscape of robot-assisted radical prostatectomy: A comprehensive review of surgical techniques

Robot-assisted radical prostatectomy (RARP) has evolved from a novel minimally invasive option to the standard of care for localized prostate cancer. As metrics for success expand to the pentafecta of outcomes, surgical techniques have diversified. This review provides a comprehensive overview of the contemporary RARP landscape, comparing technical modifications aimed at minimizing morbidity and optimizing functional preservation. We systematically reviewed the literature on various RARP approaches, including standard transperitoneal (TP), extraperitoneal (EP), single-port (SP), and transvesical (TV) techniques, and evaluated functional preservation strategies-specifically Retzius-sparing (RS) and intrafascial nerve-sparing approaches-focusing on trade-offs between functional recovery and oncological safety. While TP-RARP remains the standard, EP-RARP offers advantages in patients with prior abdominal surgery by avoiding the peritoneal cavity. The SP platform demonstrates superior pain control and cosmetic results versus multi-port (MP) systems. The novel TV-RARP approach allows exceptionally rapid continence recovery and same-day discharge but is limited by prostate size and lymph node dissection capability. RS-RARP provides significantly higher early continence rates, though this benefit is associated with increased positive surgical margins. Similarly, aggressive nerve-sparing techniques improve potency but require careful risk stratification to ensure oncological control. Surgical experience significantly impacts operative efficiency and margins, though less so for continence. The optimal RARP technique is no longer a single standard but a personalized, evidence-based decision: surgeons should individualize the platform and approach-whether MP, SP, TV, or RS-to the patient's anatomy, cancer risk, and functional priorities to achieve optimal outcomes.