Search Results (230)

Background: Pathological T0 (pT0) prostate cancer following radical prostatectomy is uncommon, and its prognostic significance remains unclear, particularly after neoadjuvant hormonal therapy (NHT). We investigated the incidence of pT0 disease in a multicenter Japanese cohort and described postoperative biochemical recurrence (BCR) outcomes. Methods: This retrospective study analyzed 3079 patients who underwent robot-assisted radical prostatectomy at nine Japanese centers between 2011 and 2021. Patients were classified as having pT0 or non-pT0 disease. Because only four pT0 cases occurred without NHT, these are summarized descriptively. Exploratory Kaplan–Meier and log-rank analyses of biochemical recurrence-free survival (BRFS) were performed for the NHT subgroup. Results: Twenty-seven pT0 cases (0.9%) were identified, and 85.2% were identified after NHT. Overall, 399 patients (13.0%) developed BCR. Among patients who did not undergo NHT, the 1- and 2-year BRFS rates were 100% and 100%, respectively, in the pT0 group and 92.4% and 88.1%, respectively, in the non-pT0 group. In the NHT subgroup, the corresponding rates were 92.9% and 92.7%, versus 91.8% and 85.5%, respectively (p = 0.651). Conclusions: pT0 disease after robot-assisted radical prostatectomy is rare and occurs predominantly after NHT. Given the possibility that late-onset recurrences may have been overlooked, the results of this trial should be understood as providing evidence from the short- to intermediate-term perspective. Full article

Background: Predicting postoperative recurrence of prostate cancer (PCa) after robot-assisted radical prostatectomy (RARP) remains challenging. Endogenous testosterone density (ETD) has emerged as a potential biomarker, though its exact prognostic value remains underexplored in specific surgical cohorts. To evaluate preoperative ETD, the ratio of endogenous testosterone to prostate volume (PV; mL), as a predictor of both unfavorable tumor grade and disease progression in clinically localized low-grade (ISUP 1) and high-grade (ISUP 4/5) prostate cancer (PCa). Methods: Between November 2014 and December 2019, 186 patients were selected according to the study criteria. Statistical methods evaluated associations of ETD with study endpoints. Results: In the surgical specimen, 63 cases (33.9%) were low grade (ISUP 1) and 123 (66.1%) high grade (ISUP 4/5). Median (IQR) follow-up was 40 (25–50). PCa progression occurred in 48 subjects (25.8%). Patients presenting with increased ETD levels above 10 ng/(mL × dL) were more likely to associate with high-grade cancer in the surgical specimen (OR = 2.098; 95% CI: 1.028–4.124; p = 0.021) than to undergo disease progression (HR 2.278; 95%CI: 1.258–4.124; p = 0.007). Conclusions: Preoperative ETD was an independent parameter for stratifying clinically localized PCa. ETD levels increased according to the risk of unfavorable tumor grade and disease progression. Full article

Objective: To evaluate the early oncological outcomes of patients treated with robot-assisted radical prostatectomy for prostate cancer with multiple PIRADS lesions at baseline mpMRI in a tertiary referral center. Methods: Data of consecutive patients undergoing robot-assisted radical prostatectomy between 2020 and 2022 at a high-volume tertiary referral center were prospectively collected. mpMRI data was evaluated by two expert uro-radiologists at our center. All patients received an MRI–ultrasound fusion biopsy. Results: Overall, 286 patients with multiple PIRADS lesions treated with robot-assisted radical prostatectomy at a tertiary referral center were included. Unilateral and bilateral nerve-sparing were achieved in 63 (22.3%) and 124 (43.1%) patients, respectively. Median age was 69 years (IQR: 64–72), while median Charlson Comorbidity Index was 3 (IQR: 2–4). The presence of two PIRADS lesions was found in the 81.8% of cases, while 18.2% presented with three or more. Bilateral lesions were observed in 67.4% of cases. The dominant lesion was PIRADS 4 in 57.3% and PIRADS 5 in 32.3% of cases, with a median diameter of 12 mm (IQR: 10–17). Pathological upstaging to pT3 occurred in 61% of patients. Overall, 9.8% of cases exhibited positive surgical margins (PSMs), most of them single and limited in extent. Postoperative major complications were recorded in 6.3% of patients. At a median follow-up of 18 months (IQR: 6–29), biochemical recurrence (BCR) occurred in 8% of patients. Patients with PIRADS 5 lesions experienced shorter BCR-free survival compared to those with PIRADS 3–4. On multivariable Cox regression, PIRADS 5 independently predicted biochemical recurrence (HR: 2.52; 95% CI: 1.10–5.80; p = 0.029), after adjustment for age, number of lesions, and nerve-sparing status, with the performance of nerve-sparing not associated with an increased risk of recurrence, including in patients with multifocal disease. Conclusions: Nerve-Sparing Robot-Assisted Radical Prostatectomy in patients with multiple PIRADS lesions achieves encouraging short-term oncologic outcomes, with biochemical recurrence-free survival exceeding 84% at 3 years, despite high rates of multifocality and pathological upstaging. Full article

Objectives: Recently, the Hugo RAS System has been introduced on the market and features a modular design comprising four separate, independent arm carts. In this study we aim to identify the number of consecutive robotic-assisted radical prostatectomies (RARP) required to achieve optimal docking time with this new robotic platform. Methods: Data from 68 patients who underwent RARP with the New Hugo RAS System were analyzed. A three-arm setting was used in every case. The docking was executed by the same urology resident who had successfully completed the training course as a bed assistant provided by Medtronic at the ORSI Academy in Aalst, Belgium. Statistical analysis included univariate linear regression to evaluate the association between the number of consecutive procedures (independent variable) and docking time (dependent variable). Additionally, a cumulative sum (CUSUM) analysis was conducted to assess the learning curve, identifying the point at which docking time stabilized. Results: The analysis included 68 patients. The median “skin to skin” operative time was 198 min (IQR 90–375), with a total console time median of 150 min (IQR 60–335) and a docking time median of 5 min (IQR 4–13). Linear regression analysis showed a significant negative correlation between the number of procedures performed and docking time (p < 0.0017), indicating that increased experience correlates with reduced docking time. CUSUM analysis revealed that after the sixth procedure, docking time consistently declined, suggesting that the learning curve for achieving optimal docking time was reached around this point. Conclusions: These findings suggest that, despite being a new platform with four independent arms, the Hugo RAS System allows for a brief docking time to be achieved with just a few procedures, thus not impacting the overall duration of the surgical procedure. Full article

Introduction: Late functional outcomes remain major determinants of quality of life after robot-assisted radical prostatectomy (RARP). Although several baseline and perioperative factors have been linked to postoperative stress urinary incontinence (SUI) and erectile dysfunction (ED), their cumulative effect remains incompletely characterized in large real-world cohorts. Materials and Methods: This retrospective single-center study included 862 consecutive patients undergoing RARP for localized prostate cancer. All endpoints were assessed at a fixed 12-month follow-up visit; therefore, a median follow-up beyond this predefined time point was not applicable. Outcomes were derived from patient-reported information documented during routine follow-up and comprised pad use, ED, and urethral anastomotic stricture. Age, body mass index (BMI), console time, estimated blood loss, and prostate weight were selected a priori based on clinical relevance and uniform availability and were analyzed using univariable and multivariable logistic regression. A simple exploratory composite risk score (0–5 points) was constructed by assigning one point for each predefined adverse factor. Results: At 12 months, 50.0% of patients were pad-free, 85.6% achieved social continence (0–1 pad/day), 14.5% had clinically significant incontinence (>1 pad/day), 71.5% had chart-documented ED, and 1.0% developed urethral anastomotic stricture. In multivariable analysis, age (OR 1.039, 95% CI 1.018–1.059) and prostate weight (OR 1.011, 95% CI 1.004–1.018) independently predicted SUI, while age was the only independent predictor of ED (OR 1.029, 95% CI 1.007–1.050). No predictor of stricture was identified. The composite score showed an exploratory dose–response association with SUI (OR 1.364 per point, 95% CI 1.208–1.541; AUC 0.597) and a weaker association with ED (OR 1.149, 95% CI 1.007–1.313; AUC 0.540). Conclusions: A simple composite score may provide pragmatic exploratory grouping of SUI risk after RARP, but discrimination is modest and interpretation is limited by non-validated outcome assessment and the absence of major confounders, including nerve-sparing status and baseline functional measures. Full article

Background: Robot-assisted laparoscopic radical prostatectomy (RALP) requires prolonged steep Trendelenburg positioning, which increases intraocular and intracranial pressure. Although transient visual field defects have been documented after RALP using objective perimetric testing, data on patient-reported visual outcomes remain limited. We hypothesized that intraoperative optic nerve sheath diameter (ONSD) measurements and hemodynamic variables would be associated with postoperative patient-reported visual symptoms. Methods: This prospective, single-center observational cohort study enrolled consecutive adult patients undergoing RALP between March and September 2023 at Ospedale Santo Stefano, Prato, Italy. Patients with pre-existing glaucoma, ocular disease, or intracranial hypertension were excluded. Intraoperative ONSD was measured by transorbital ultrasound at three time points: before Trendelenburg (t1), 30 min after Trendelenburg (t2), and at end of Trendelenburg (t3). Postoperative visual symptoms were assessed at ≥1 month follow-up using the validated Catquest-9SF questionnaire. Rasch analysis converted ordinal responses to interval-level measures. Logistic regression explored associations between visual complaints and intraoperative predictors (Rasch scores, lowest mean arterial pressure [MAP], maximum ONSD). Results: Fifty-five patients were enrolled. Six patients (10.9%) reported new subjective visual symptoms at follow-up. Rasch-transformed scores were associated with the presence of these symptoms (coefficient 1.38; p < 0.05). Lowest intraoperative MAP (p = 0.081) and maximum ONSD (p = 0.811) did not reach statistical significance as independent factors. Conclusions: Patient-reported visual symptoms occurred in approximately 11% of patients after RALP. Postoperative Rasch-transformed visual function scores correlated with these complaints. While intraoperative ONSD was not associated with visual outcomes, the potential role of intraoperative hypotension requires further investigation in larger, powered cohorts. Full article

Background: Prostate cancer (PCa) imposes a substantial global health burden, with robot-assisted radical prostatectomy (RARP) established as the gold standard for localized disease. While da Vinci^® Xi maintains market dominance, Toumai^® MT-1000 offers a potentially cost-competitive alternative lacking prospective validation. Objective: To evaluate perioperative safety, oncologic quality (primary endpoint: positive surgical margins), early functional recovery (continence), and surgeon learning curve between Toumai^® MT-1000 (T-RARP) and da Vinci^® Xi RARP (DV-RARP) performed in high-volume European practice. Materials and Methods: This is a prospective single-center comparative study carried out at Policlinico Gemelli, Rome (May–November 2025), enrolling 80 patients with localized or locally advanced PCa, elected for radical prostatectomy and casually allocated to receive surgery with Toumai or the da Vinci robotic platform. The primary endpoint was the comparison of positive surgical margin (PSM) rates. Secondary endpoints included the comparison of operative time (skin-to-skin), estimated blood loss, length of hospital stay, 45-day postop outcomes, specifically Clavien–Dindo complications, urinary continence recovery (0–1 pad/day), and IIEF-5 scores. Learning curve was evaluated through the cumulative summation (CUSUM) analysis of operative times and linear regression of operative times (n = 80 cases). The analyses used STATA 19 with two-sided tests at p < 0.05 significance. Results: Baseline characteristics showed balance between cohorts (p > 0.05 for most covariates). Perioperative outcomes proved equivalent: median operative time (OT) was 192.5 min (IQR 165–230) for Toumai^® versus 183.5 min (IQR 147–225) for da Vinci^® Xi (p = 0.38); estimated blood loss (EBL) was 150 mL in both groups (p = 0.87); length of hospital stay (LOS) was 2 days in both groups (p = 0.92). PSM rates were identical at 17.5% (p = 0.79). Continence recovery reached 72.5% versus 80% (p = 0.43). Complications (Clavien–Dindo ≥ II) occurred in 7.5% versus 12.5% of cases (p = 0.45). The CUSUM analysis demonstrated operative time proficiency after only four procedures; operative time regression showed no significant trend (p = 0.38). Conclusions: Toumai^® MT-1000 demonstrates similar performance to da Vinci^® Xi across different RARP quality metrics, with no detectable learning curve for surgeons previously experienced with da Vinci. These findings support a safe integration of cost-effective platforms into clinical practice, pending multicenter randomized confirmation. Full article

Introduction: Nerve-sparing (NS) during robot-assisted radical prostatectomy (RARP) plays a critical role in postoperative functional recovery, particularly urinary continence and erectile function. Despite the importance of precise neurovascular bundle (NVB) preservation, intraoperative assessment of NS quality remains largely subjective and lacks standardized evaluation tools. The aim of this study was to develop and preliminarily evaluate a structured intraoperative scoring system designed specifically for assessing NS quality during RARP. Methods: A novel 10-point intraoperative NS scoring system (NSQ Score) based on five domains was developed: dissection plane, bleeding control, bundle manipulation, continuity of dissection, and symmetry. Each parameter was rated on a 0–2 scale. Thirty robot-assisted radical prostatectomy (RARP) procedures performed in 2024 were randomly selected from a prospectively maintained institutional surgical video archive. Cases were not pre-filtered based on tumor stage, surgical difficulty, or intraoperative complexity. High-definition video recordings of the nerve-sparing phase were anonymized and independently evaluated by three experienced observers blinded to patient outcomes and to each other’s assessments. Inter-rater agreement was analyzed using weighted Cohen’s kappa statistics with quadratic weights, complemented by exact and near-agreement proportions. Cluster bootstrap resampling was applied to account for bilateral observations. Results: A total of 48 evaluable observations were analyzed. The overall inter-rater agreement demonstrated a weighted kappa of 0.41 (95% CI 0.36–0.48), indicating fair-to-moderate agreement among reviewers. Exact agreement occurred in 43% of observations, while near-agreement (allowing one ordinal level difference) reached 98%. Among individual parameters, symmetry demonstrated the highest reliability with substantial agreement (κ = 0.70; 95% CI 0.58–0.81). Other domains showed fair agreement, including intraoperative bleeding (κ = 0.36), continuity of dissection (κ = 0.39), bundle manipulation (κ = 0.34), and dissection plane (κ = 0.27). Agreement levels were comparable between left- and right-sided dissections. Conclusions: We propose a novel structured intraoperative scoring system for evaluating nerve-sparing quality during RARP. The scale is simple, procedure-specific, and feasible for structured postoperative or video-based assessment. Preliminary results demonstrate fair-to-moderate inter-rater reliability with very high near-agreement, supporting the feasibility of this tool for clinical use. The proposed scoring system may facilitate standardized training, objective performance assessment, and future studies correlating intraoperative NS quality with functional outcomes. Full article

Introduction: Post-prostatectomy incontinence (PPI) remains a major functional concern after robot-assisted radical prostatectomy (RARP). Posterior musculofascial reconstruction (PMFR) has been shown to facilitate early urinary continence (EUC), but variations in technique may further improve outcomes. We evaluated whether a modified vesicourethral anastomosis (VUA) incorporating simultaneous PMFR with a single barbed suture [pontine VUA (P-VUA)] may facilitate continence recovery compared with the standard Van Velthoven anastomosis (ST-VUA). Materials and Methods: This prospective study included patients undergoing RARP between January 2021 and December 2023. Allocation was based on surgeon preference. UC was defined as the use of no pads or one dry safety pad per day and was assessed at 10, 30, 90, 180, and 365 days after catheter removal. Multivariable logistic regression was performed to evaluate factors associated with 30-day continence. Time to continence was additionally analyzed using Kaplan–Meier methods. Results: This prospective comparative study included 157 patients undergoing robot-assisted radical prostatectomy (RARP) between January 2021 and December 2023 (76 ST-VUA, 81 P-VUA). Baseline and pathological characteristics were comparable between groups. Catheterization time was significantly shorter in the P-VUA group (5.0 ± 1.1 vs. 6.7 ± 1.4 days, p < 0.001). Continence rates were higher in the P-VUA group at 10 days (72.8% vs. 55.3%, p = 0.03), 30 days (84.0% vs. 68.4%, p = 0.035), 90 days (92.6% vs. 76.3%, p = 0.007), 180 days (93.8% vs. 82.9%, p = 0.044), and 365 days (97.5% vs. 86.8%, p = 0.015). Kaplan–Meier analysis demonstrated a shorter time to continence in Group P (log-rank p = 0.0037). In multivariable analysis, P-VUA was independently associated with higher odds of 30-day continence (OR 6.38, 95% CI 2.08–19.63, p = 0.001). Conclusions: The study suggests that the P-VUA technique was associated with faster recovery of urinary continence compared with ST-VUA in this prospective, non-randomized cohort. These findings support the hypothesis that integrating anatomical reconstruction principles into the anastomotic step may enhance functional outcomes after RARP. However, the results should be interpreted with caution, given the study design and sample size, and require confirmation in larger, preferably randomized studies. Full article

Background: Arytenoid cartilage dislocation (ACD) is a rare but clinically significant complication of endotracheal intubation that may be misdiagnosed as transient vocal cord paralysis. The potential role of prolonged surgical positioning in ACD remains underrecognized. Methods: A 63-year-old male developed left posterior ACD following robot-assisted radical prostatectomy (RARP) performed in a steep Trendelenburg position for 3.5 h. Intubation was successfully achieved on the first attempt using a video laryngoscope with full glottic visualization and no apparent airway trauma. Postoperatively, the patient developed persistent dysphonia, dysphagia, aspiration, and tongue deviation. Initial flexible laryngoscopy suggested left vocal cord paralysis, whereas direct laryngoscopy on postoperative day 6 confirmed posterior arytenoid dislocation. Urgent closed reduction was performed, followed by structured voice therapy, which resulted in substantial functional recovery. Discussion: This case illustrates that ACD may occur despite technically optimal and atraumatic intubation and should be interpreted as reflecting a temporal association rather than a definitive causal relationship. Prolonged steep Trendelenburg positioning and extended operative duration may be considered potential contributing biomechanical factors, possibly mediated by venous congestion, mucosal edema, altered endotracheal tube dynamics, and cumulative shear stress on the cricoarytenoid joint. However, these mechanisms remain interpretive and hypothesis-generating. Conclusions: Prolonged steep Trendelenburg positioning and extended operative duration may represent possible contributing biomechanical factors in ACD, even in the setting of atraumatic intubation. Early laryngeal evaluation and timely reduction remain essential for optimal functional recovery. Full article

Purpose: the prognostic value of positive surgical margins (PSMs) after radical prostatectomy (RP) remains debated, particularly when distinguishing focal from extensive involvement. Moreover, the interaction between margin status and other adverse pathological features, such as tumour stage, grade, and nodal status, is not fully defined. The study aims to evaluate the impact of focal and extensive PSMs on biochemical recurrence-free survival (BCRFS), stratified by pathological stage, Gleason grade, and nodal involvement. Methods: we retrospectively analyzed 1258 patients who underwent robot-assisted RP between 2017 and 2023, evaluating BCRFS as primary endpoint. Survival was analyzed using Kaplan–Meier and log-rank tests across margin categories (negative, focal, extensive). Analyses were stratified by pT stage (pT2–pT3b), ISUP grade (<3 vs. ≥3), and nodal status (pN0/pNx vs. pN+). Median follow-up was 39 months (IQR 24–62), and 5-year BCRFS was used as the reference endpoint. Results: median age was 68 years and median PSA 6.9 ng/mL. Stage distribution: pT2 56.4%, pT3a 29.8%, pT3b 13.6%; 16.6% were pN+. ISUP grade ≥ 3 was observed in 60.6%. Overall, 20.3% developed biochemical recurrence. In pT2 tumours or primary Gleason pattern 3, focal PSMs showed 5-year BCRFS of 88–90%, very similar to negative margins (91–93%) and clearly better than extensive PSMs (~72%). In pT3 tumours or primary Gleason pattern 4, focal PSMs showed 5-year BCRFS of ~55–60%, similar to extensive PSMs (~40–50%) and significantly worse than negative margins (78% in pT3a and 65% in pT3b, p < 0.01). In N + 5-year BCRFS was similarly poor in negative (~45%), focal (~42%), and extensive margins (~40%, p = 0.455). Conclusions: the prognostic impact of positive surgical margins depends on tumour biology. In organ-confined or ISUP ≤ 2 disease, focal PSMs show recurrence rates similar to negative margins and may be managed with observation. In locally advanced or ISUP ≥ 3 tumours, both focal and extensive PSMs carry a markedly higher risk of biochemical recurrence and might suggest an early intervention. PSMs lose discriminatory value in node-positive patients. Full article

Background/Objectives: Urinary continence recovery after robot-assisted radical prostatectomy (RARP) follows a progressive trajectory that is often simplified into binary outcomes. Modeling continence recovery as an ordered process may better reflect post-operative functional patterns and identify clinically relevant predictors. Methods: We retrospectively analyzed 180 patients undergoing extraperitoneal single-port RARP. At 6 months, continence recovery was classified into three ordered categories: early continence, late continence, and persistent incontinence. Multivariable ordinal logistic regression was used to identify independent predictors of continence recovery. The primary model included nerve-sparing (NS) status, postoperative complications, age, and prostate volume. Sensitivity analyses were performed by sequentially replacing prostate volume with body mass index, surgical case number, or preoperative prostate-specific antigen (PSA). An interaction between NS and age group was also tested. Results: NS surgery was the factor most strongly associated with favorable continence recovery (p < 0.001), followed by absence of post-operative complications (p = 0.003). Younger age and larger prostate volume were also independently associated with improved continence recovery. Sensitivity analyses confirmed the robustness of the primary model, as replacement of prostate volume with body mass index, surgical case number, or PSA did not improve model performance and did not alter the effect of NS surgery. No significant interaction between NS and age group was observed. Conclusions: Continence recovery after extraperitoneal RARP is primarily associated with NS surgery and an uncomplicated post-operative course, with age and prostate volume providing additional refinement. Modeling continence as an ordinal outcome offers a clinically meaningful framework for evaluating functional recovery after prostatectomy. Full article

Background: The perioperative period in cancer surgery is characterized by transient metabolic and inflammatory perturbations that may influence early postoperative biochemical dynamics. Surgical stress induces insulin resistance, hyperglycemia, cytokine activation, and metabolic shifts that interact with tumor cell signaling pathways. Intravenous lidocaine has been associated with anti-inflammatory and systemic stabilizing effects beyond analgesia. We investigated whether perioperative lidocaine administration during robotic-assisted radical prostatectomy (RARP) is associated with early postoperative prostate-specific antigen (PSA) dynamics within the context of perioperative metabolic–inflammatory modulation. Methods: In this single-center retrospective cohort study, 180 patients undergoing RARP for localized or locally advanced prostate cancer were stratified according to perioperative intravenous lidocaine exposure. The primary endpoint was undetectable PSA (<0.1 ng/mL) at 6–12 weeks postoperatively. Secondary endpoints included PSA detectability at 3 and 6 months and time to first detectable PSA. Multivariable logistic and Cox regression models were adjusted for established oncologic risk factors. Perioperative glycemic variation, intraoperative lactate dynamics, and postoperative IL-6 levels were analyzed as indicators of stress-induced metabolic activation. Results: Lidocaine exposure was independently associated with higher odds of undetectable PSA at 6–12 weeks (OR 2.10, 95% CI 1.15–3.85) and at subsequent time points. In Cox analysis, lidocaine was associated with a reduced hazard of PSA detectability (HR 0.58, 95% CI 0.37–0.92). Patients receiving lidocaine demonstrated significantly attenuated perioperative hyperglycemia, lower lactate elevation, and reduced IL-6 response. Conclusions: Perioperative intravenous lidocaine administration during RARP was associated with more favorable early PSA dynamics and attenuation of perioperative metabolic–inflammatory activation. Given the retrospective and non-randomized design of the study, these findings should be interpreted as associative and hypothesis-generating, and warrant confirmation in prospective controlled investigations. Full article

Minimally invasive surgical therapies (MISTs), such as Rezūm™ Water Vapor Therapy, are emerging treatment options for benign prostatic obstruction (BPO). When prostate cancer is subsequently diagnosed, radical prostatectomy may still be indicated. However, evidence regarding intraoperative challenges and the surgical and functional outcomes of robot-assisted radical prostatectomy (RARP) following Rezūm remains limited. We report the first documented case of RARP following Rezūm in a 68-year-old man. He initially underwent Rezūm for symptomatic BPO. Due to rising PSA, a suspicious lesion on MRI, and a biopsy-confirmed high-risk prostate carcinoma, radical surgery was performed. Intraoperatively, dense fibrosis and altered tissue planes required precise dissection and a level 2 bilateral nerve-sparing approach. A systematic review revealed no previously published cases of RARP after Rezūm. On the other hand, RARP after transurethral resection of the prostate (TURP) is associated with increased operative time, blood loss, and bladder neck reconstruction, though late continence and biochemical recurrence rates are similar to those in treatment-naïve patients. In conclusion, RARP after ablative BPO therapies is feasible but may present unique technical challenges. Larger prospective studies are needed to develop standardized management strategies. Full article

Background/Objectives: Robotic-assisted radical prostatectomy (RARP) is a standard treatment for localized and locally advanced prostate cancer; however, optimizing oncologic control while preserving urinary continence and erectile function remains challenging. Advances in preoperative imaging, molecular diagnostics, artificial intelligence (AI), and intraoperative assessment have the potential to refine surgical planning and execution. This review summarizes contemporary evidence on advanced imaging and intraoperative technologies used to optimize RARP outcomes. Methods: A narrative literature review was conducted of English-language studies published between 2015 and 2025 using PubMed/MEDLINE, Scopus, and Google Scholar. Studies evaluating multi-parametric and bi-parametric MRI, prostate-specific membrane antigen-based positron emission tomography/computed tomography (PSMA PET/CT), AI-assisted tumor modeling, and intraoperative histologic or molecular imaging techniques in the context of robotic-assisted radical prostatectomy were included. Evidence from randomized controlled trials, prospective and retrospective studies, technical feasibility reports, and expert consensus statements was reviewed. Results: MRI remains central to anatomic mapping and local staging but consistently underestimates true tumor extent, with implications for margin control. AI-assisted platforms improve tumor contouring accuracy and may meaningfully influence surgical decision-making. PSMA-based imaging enhances detection of extra-prostatic extension and nodal disease and shows early promise for ex vivo and intraoperative guidance. Intraoperative margin assessment techniques are supported by randomized evidence demonstrating improved functional outcomes without compromising short-term oncologic safety and emerging digital histologic technologies offer scalable alternatives for real-time margin evaluation. Conclusions: Integration of advanced anatomic, molecular, and intraoperative imaging technologies represents an evolving multimodal paradigm in RARP. Combined use of MRI, PSMA-based imaging, AI-assisted modeling, and rapid histologic assessment may enable more precise, individualized surgery that balances oncologic control with functional preservation. Further validation is required to define optimal implementation in routine clinical practice. Full article