Robotic Prostatectomy: What We Have Learned and Where We Are Going 1,800 cases overall. In regard to perioperative data, the mean OR time is 120 minutes. We prefer a transperitoneal 6 port approach. The bladder is dropped initially and the dorsal venous complex is divided with a stapler (Fig. 1). The bladder is divided from the prostate and the seminal vesicles are approached anteriorly. The rectum is thoroughly dropped away from the posterior surface of the prostate and the pedicles are controlled with clips (Fig. 2). A running anastomosis is employed for the vesicourethral anastomosis (Fig. 3). We do not routinely leave Jackson Pratt (JP) drains. Patients are discharged on postoperative day #1 96% of the time. Patients are encouraged to ambulate the first night of the operation. Diet is held at clear for the first day and then advanced to a regular diet in the AM. Pain medication consists of toradol around the clock with additional narcotic available on a prn basis. Foley catheters are removed on postoperative day 6 or 7 without cystograms. Patients typically return to work in 2 to 3 weeks and are allowed to assume unrestricted activity by 3 weeks. The major complications rate has been less than 2% consisting of transfusions (10), rectal injury (5), Veress needle injury (1), symptomatic lymphocele requiring drain placement (8), prolonged urine leak requiring drain placement (3), and bladder neck contracture (5). One of these bladder neck contractures has required an open repair. In regard to continence requiring zero pads or a security pad, approximately 20% of patients are continent on catheter removal, 50% by one month and 80% by 3 months. Patients with a preoperative SHIM of 22 or more and aged 55 or less have been able to have successful intercourse with the help of phosphodiesterase5 (PDE5) inhibitors at a rate of 80% by 18 months postoperatively. Our margin rates have steadily been improving. Early in our experience within the first 200 cases, the overall margin rate was 20% with a pT2 margin rate of 10%. However, with consistent communication with our genito urinary (GU) pathologists and technical modifications consisting of an interfascial nerve sparing technique, early retrograde release of the neurovascular bundles and continued use of a stapler for division of the dorsal venous complex, our margin rates for the last 500 cases has been 11% with a pT2 margin rate 4.5% and pT3 margin rate of 35%. Robotic prostatectomy has improved the open approach However, likely the most important factor for success with radical prostatectomy is not so much approach but rather surgeon experience. Scardino has shown the surgeon experi- ence is an independent predictor for success during radical prostatectomy. Eastham et al.19 reported lower positive margins rates are encountered by more experienced surgeons during open radical prostatectomy. When 26 surgeons were examined and patient characteristics such as PSA level, extracapsular extension, Gleason score, surgery date and surgical volume Fig. 1. Photograph of laparoscopic stapler placed across the dorsal venous complex. Fig. 2. The right neurovascular bundle is being dissected away from the prostate in an interfascial technique. Fig. 3. View of the apposition of the bladder to the urethra during vanVelthoven anastomosis. Yonsei Med J http://www.eymj.org Volume 50 Number 2 April 2009 179