# New Evolution of Robotic Radical Prostatectomy: A Single Center Experience with PERUSIA Technique
## 1 Introduction  
Prostate cancer (PCa) is the second most common malignant neoplasm in the male population. In 2019, the prevalence in the USA was over 3,650,000 cases, while the new diagnoses were 174,950 [1]. However, even more interesting is the estimated prevalence for 2030 of over 5 million cases, which is emblematic of cancer being in continuous evolution [2].  
Radical prostatectomy (RP) is the standard surgical treatment of organ-confined PCa in patients with a life expectancy of at least 10 years [2]. The main objectives of this intervention are first, the eradication of the neoplasm and, secondly, the preservation of urinary incontinence and sexual potency, trying to minimize the rate of peri- and post-operative complications and to guarantee an optimal quality of life. RP can be performed with an open, laparoscopic, or robotic-assisted approach. Thanks to continuous technological progress, over the last few decades, there has been a continuous evolution of surgical techniques that have led to an ever-greater application of laparoscopy first and then of robotics.  
When [PERSON], [PERSON], and [PERSON] standardized laparoscopic RP, described for the first time in 1992 by [PERSON], the advantages of the minimally invasive technique over the traditional one became evident, especially in terms of reduction of intra- and post-operative bleeding, post-operative pain, and length of stay [3, 4, 5]. Since then, thelaparoscopic approach began to be used more and more frequently, so much so that it became the reference technique in high-volume centers. However, laparoscopy was immediately characterized by a long learning curve, and this limited its further spread.  
In 2001, [PERSON] described the first series of robotic-assisted radical prostatectomies (RARP), highlighting their advantages over the laparoscopic approach [6].  
Indeed, the robotic-assisted approach allows maintaining the benefits of laparoscopy, providing additional advantages: the magnification of the operating field thanks to the three-dimensional vision, greater accuracy in dissection and suturing thanks to the EndoWrist(r) technology (Intuitive Surgical Inc., Sunnyvale, CA, USA), which provides seven degrees of freedom of movement to the instruments, control of the camera by the surgeon from the console, and the almost complete elimination of tremor. The main disadvantages are the absence of tactile feedback and the high costs. However, the robotic approach allows you to reproduce the same steps as \"open\" surgery, but with the benefits of minimally invasive surgery, overcoming the limits of laparoscopy: simplifying the learning curve and reducing the surgeon's physical discomfort [7]. All this has led to an increasingly widespread diffusion of robotic surgery, which finds its main indication in RP.  
Urinary incontinence and erectile dysfunction are the main adverse effects of RP and are reported up to 31% and 38% at 12 months, respectively [8; 9]. To improve functional outcomes in the literature, many different nerve-sparing techniques have been described, but the best one is not yet established. In a recent prospective study, we described the PERUSIA technique, an extraperitoneal full nerve-sparing robotic RP, showing its feasibility and safety [10]. In order to reduce injury of the neuro-vascular bundle (NVB), PERUSIA-RP starts with a posterior and median plane; this allows preserving as much as possible neuro-vascular structures lying outside of the Veil of Aphrodite, which becomes a main anatomic landmark. The aim of this retrospective study was to validate the PERUSIA technique as a safe and effective surgical procedure for RP evaluating the peri-operative, oncologic, and functional outcomes.