# New Evolution of Robotic Radical Prostatectomy: A Single Center Experience with PERUSIA Technique
## 5 Discussion
### PERISIA Technique  
The extraperitoneal approach is less used than the much more common transperitoneal approach, although it allows achieving the same results and provides additional benefits in selected cases. The ideal indications for an extraperitoneal radical prostatectomy are represented by all those conditions that would complicate a transperitoneal radical prostatectomy such as the results of a previous abdominal surgery and obesity [35]. The equivalence of effectiveness between the two approaches has now been demonstrated [36]. The extraperitoneal route, on the other hand, allows reducing operating times and in particular the console time, in which the patient is positioned in Trendelenburg, as well as the complications rate, especially those of low grade [37]. The extraperitoneal route also exploits the peritoneum, which is not violated, as a natural retractor of the intestinal loops and perivascular adipose tissue, which are therefore kept away from the operating field. This allows the operation to be carried out with a less accentuated Trendelenburg position (about 15\({}^{\circ}\) compared to 25-35\({}^{\circ}\) of the transperitoneal route), thus reducing the risk of cardiopulmonary complications, thrombobolic and positional injuries. The preservation of the integrity of the peritoneal cavity also guarantees limiting any blood and/or urine leakage in the extraperitoneal space to minimize the risk of lesions of the intestinal loops. It also ensures an earlier recovery of intestinal activity, a more rapid return to diet and, consequently, a shorter length of stay. The main limitation of this approach is represented by the difficulty in performing an extensive lymphadenectomy. Overall, in our experience, PERUSIA is a safe technique, guaranteeing low peri-operative morbidity, with an overall complications rate of 16%, of which only 2.7% were grade III and none were grade IV and V. No conversion to laparoscopic or traditional surgery was necessary. The overall rate of PSMs was 8.1%, and it is in line with those reported by other authors [22]. However, we would emphasize that 19 out 37 (51.4%) PSMs were focal, and this high rate of focal PSMs in low-risk disease should reduce the prognostic impact of our overall PSMs. Although PSMs have been proved to be associated with BCR, at longer follow-up, this risk should not differ between patients with negative surgical margin and those with PSMs <1 mm [38]. In our series, at median follow up of 47 mo, BCR occurred in 39 out 454 (8.6%) patients. In addition, this finding is in accordance with other experiences. Recently, [PERSON] et al. reported, at median follow up of 60 mo, BCR of 8.2% in a cohort including only low-risk PCa patients who underwent RP with pT2N0R0 [39]. With regard to urinary commence understood as the absence of pads, this outcome, evaluated 24 h after the removal of the catheter, was equal to 58%, while it rose to 85%, 92%, and 96% respectively at 3, 6, and 12 months from intervention. This exciting result may be due to our full nerve-sparing tech nique with complete preservation of the Veil of Aphrodite that allows reducing the damage of intrapelvic nerves supplying the rhabdomyinincter. Recent meta-analysis reported that the degree of preservation of NVB is associated with urinary incontinence in the first postoperative 6 mo [40]. [PERSON] and co-workers demonstrated the same association also in the long term [41]. Furthermore, a conservative management of the dorsal venous complex has a positive effect on the continence recovery. Recently, [PERSON] et al. demonstrated that the dorsal vascular complex overlaps 37% and 30% of the cross-sectional urethral sphincter surface at the prostatic apex and 5 mm distal to the apex, respectively [42]. Our immediate and early continence rate are also due to a \"no-touch\" approach of the Santorini Plexus.