Search Results (217)

Background/Objectives: Prostate cancer is one of the most common non-skin solid malignancies among male solid organ transplant recipients (SOTRs), in whom radical prostatectomy is technically demanding. We report the first use of indocyanine green (ICG) fluorescence for simultaneous transplanted-ureter identification and renal graft vascular mapping during robot-assisted radical prostatectomy (RARP), and the first use of the CMR Versius^® platform in a SOTR. Methods: Retrospective case series of four consecutive male SOTRs (two renal [RTRs], two hepatic) undergoing RARP. In both RTRs, a dual-route ICG protocol was used on the da Vinci Xi with Firefly^® imaging: pre-docking intraureteral ICG via a ureteral catheter for ureter identification, plus an intravenous ICG bolus for graft vascular mapping and cortical perfusion. One hepatic recipient was operated with the CMR Versius^® system using an infra-umbilical port configuration to avoid the chevron transplant scar. Results: All four procedures were completed robotically without conversion. Median operative time was 176 min and median estimated blood loss 350 mL. Surgical margins were negative (R0) in all four; final pathology was pT3aN0 in three and pT2N0 in one, although in the renal recipients nodal staging reflected a contralateral-only dissection. PSA was undetectable at three months in all patients. One hepatic recipient later developed biochemical recurrence, managed with salvage radiotherapy and androgen deprivation therapy, with subsequent undetectable PSA. One hepatic recipient had a Clavien–Dindo IIIa complication. No graft dysfunction occurred. Conclusions: ICG-guided RARP and the CMR Versius^® platform appear technically feasible in carefully selected solid organ transplant recipients treated at an experienced multidisciplinary centre, with no graft-related complications observed in this small initial series. These preliminary findings require validation in larger, multicenter studies before general safety and oncological efficacy can be established. Full article

Objectives: The objective of this study was to evaluate the efficacy and safety of an autologous vas deferens (AVD) sling for improving early urinary continence after Retzius-sparing robot-assisted radical prostatectomy (RS-RARP). Methods: In this single-center, prospective, randomized trial, 200 patients at high risk for postoperative urinary incontinence were randomized to undergo RS-RARP with or without AVD sling suspension. The primary endpoint was immediate urinary continence, defined as the use of 0–1 safety pads/day within 7 days after catheter removal. Secondary outcomes included continence recovery up to 3 months, EPIC-26 and IPSSs, and subgroup analysis according to the preoperative membranous urethral length (MUL). Multivariable logistic regression was performed to identify predictors of continence recovery. Results: The AVD sling group showed higher immediate (69.0% vs. 55.0%; p = 0.041) and 1-month continence rates (81.0% vs. 67.0%; p = 0.024) than the RS-RARP group. EPIC-26 scores and IPSSs also favored the AVD sling group during the early postoperative period (both p < 0.01). In exploratory subgroup analyses, patients with preoperative MUL < 12 mm appeared to derive greater early continence benefit from the sling procedure. The AVD sling remained independently associated with continence recovery at the immediate (adjusted OR 2.23, p = 0.014) and 1-month (adjusted OR 2.60, p = 0.008) assessments. Differences between groups decreased after postoperative month 2. The operative time was longer in the AVD sling group, whereas complication rates and short-term oncological outcomes were similar between groups. Conclusions: The AVD sling may improve early urinary continence recovery during the first postoperative month after RS-RARP, particularly in high-risk patients with shorter preoperative MUL. Full article

Background/Objectives: Iatrogenic nerve injury is a significant challenge in urologic surgery, with radical prostatectomy posing a high risk due to complex pelvic neural anatomy. Despite advances in robotic-assisted and nerve-sparing techniques, postoperative urinary incontinence and erectile dysfunction remain prevalent, adversely affecting patients’ quality of life and imposing substantial healthcare costs. Methods: A narrative review was conducted using PubMed, MEDLINE, and the Cochrane Library (searches through February 2026) for studies on radical prostatectomy epidemiology, mechanisms of nerve injury, functional outcomes, and economic burden. Emerging intraoperative fluorescence imaging technologies, surgical strategies to mitigate iatrogenic nerve injuries, and the financial costs of post-prostatectomy complications were assessed. Results: Robotic-assisted radical prostatectomy now accounts for >80% of procedures in the United States, and has been associated in observational studies with improved early recovery of erectile function compared with open and laparoscopic approaches. However, the lack of real-time nerve visualization remains a limiting factor. Recent milestones (January 2026) include the Food and Drug Administration Investigational New Drug clearance for the nerve-specific fluorophore LGW16-03 (NerveTrace), which enables real-time identification of sub-millimeter nerve branches, and the 510(k) premarket clearance of Dendrite imaging (November 2025). Conclusions: Enhanced intraoperative nerve discrimination via molecularly targeted imaging has the potential to reduce iatrogenic complications and improve long-term functional and economic outcomes in prostate cancer surgery, although these benefits have yet to be demonstrated in prospective clinical and health-economic studies. Full article

Background/objectives: Prostate cancer is the most common cancer in men over 60 years of age. The development of assisted robotic surgery has improved surgical performance across several variables in dynamic ways, introducing new reconstruction techniques. The present study aims to show differences between Retzius-sparing robotic-assisted prostatectomy vs. Retzius-sparing and posterolateral fascial reconstruction in patients diagnosed with localized prostate cancer. Methods: A retrospective study was performed in a 3-year time period by a single surgeon using the Da Vinci X platform. Two groups were assessed for the study, with and without posterolateral fascial reconstruction. Demographic data were analyzed with central tendency measures, and mean differences were calculated with the Mann–Whitney test and t-test, being significant if p < 0.05. Results: A total of 199 patients were included. The posterolateral reconstruction group had 81 patients, and outcomes saw similar performances to the non-reconstruction group. Urinary continence showed a positive trend of higher percentages in the first week after surgery but had similar results after one year, with no statistically significant differences. Oncologic results and sexual dysfunction showed no statistically significant differences between groups. Conclusions: Posterolateral reconstruction combined with Retzius-sparing radical prostatectomy demonstrated improved continence and was shown to be safe, without increasing overall complications such as bleeding. Full article

Background: Robot-assisted radical prostatectomy (RARP) is the predominant surgical approach for localized prostate cancer in high-volume centers worldwide. However, comprehensive real-world data describing complete institutional transition from open to robotic surgery remain limited. This study evaluated perioperative and early oncological outcomes of a contemporary RARP cohort and characterized the transition from open radical prostatectomy (ORP) to RARP in a European center. Methods: We analyzed 520 consecutive patients who underwent RARP between January 2023 and December 2025. Perioperative, pathological, and biochemical outcomes were assessed. Biochemical recurrence was defined as prostate-specific antigen ≥0.2 ng/mL. Institutional data from 2011 to 2025 were reviewed to evaluate procedural trends and the transition from ORP to RARP. Surgeon-specific and institutional learning curves were analyzed using operative time and linear regression models. Results: Following the introduction of robotic surgery in 2018, annual RARP volume increased from 37 procedures to 205 in 2025. Since 2023, RARP accounted for more than 99% of all radical prostatectomies. Median operative time decreased from 185 min in 2023 to 165 min in 2025, with consistent downward trends observed across all surgeons. Linear regression confirmed progressive improvement in operative efficiency, with learning rates ranging from −0.22 to −0.92 min per case. Estimated blood loss was minimal, no patients required transfusion, and major complications occurred in four patients (0.8%). Hospital stay decreased from 2 days to predominantly 1 day. During follow-up, 36 patients developed biochemical recurrence or PSA persistence. Biochemical recurrence-free survival differed significantly according to pathological stage (log-rank p < 0.001), with 24-month estimates of 93.7%, 91.5%, and 82.1% for pT2, pT3a, and pT3b disease, respectively. Conclusions: RARP provides favorable perioperative safety, minimal morbidity, and favorable early oncological outcomes in a high-volume setting. The complete institutional transition from ORP to RARP, together with demonstrated surgeon-specific and institutional learning effects, supports the feasibility and safety of implementing RARP as the institutional standard within a structured robotic program. Full article

Background/Objectives: Preoperative membranous urethral length (MUL) is a predictor of post-prostatectomy urinary incontinence. However, measurement inconsistencies have hindered the establishment of ethnically specific clinical thresholds. We identified precise and internally validated MUL cutoff values for persistent incontinence at 6 and 12 months in a Korean cohort using a standardized measurement protocol. Methods: We retrospectively analyzed 151 patients who underwent robot-assisted radical prostatectomy (RARP) between 2022 and 2024. Preoperative MUL was measured using a 3-axis cross-reference system (CRS) on 3.0T mpMRI. Continence was defined as 0 or 1 safety pad per day. Independent predictors were identified via multivariable logistic regression, and the optimal cutoff values were determined using the Youden index with 1000-iteration bootstrap validation. Results: Preoperative MUL was significantly longer in continent than in incontinent patients at 6 (16.7 vs. 13.7 mm) and 12 months (16.7 vs. 11.3 mm; both p < 0.001). In the multivariable analysis, MUL was the only significant independent predictor for persistent incontinence (6 months: OR 0.798, p < 0.001; 12 months: OR 0.586, p < 0.001). The univariable AUROCs for predicting persistent incontinence were 0.707 (6 months) and 0.875 (12 months), whereas the multivariable AUROCs were 0.756 and 0.883, respectively. Optimal cutoff values from bootstrap were 14.00 mm (95% confidence interval [CI], 11.43–16.68) for 6-month and 12.60 mm (95% CI, 11.43–14.37) for 12-month persistent incontinence. Conclusions: Using a standardized CRS protocol, this study provides validated population-specific MUL thresholds for predicting persistent incontinence after RARP in Korean men, offering a pragmatic framework for preoperative risk stratification and evidence-based patient counseling. Full article

Background: Preoperative side-specific identification of extracapsular extension (ECE) is important for selecting an appropriate nerve-sparing strategy at radical prostatectomy. Patients with multiparametric magnetic resonance imaging (mpMRI)-defined capsular contact represent a clinically challenging subgroup because contact raises concern for ECE but does not uniformly indicate extraprostatic disease. We aimed to develop a side-specific nomogram for individualized ECE prediction and perform preliminary internal validation in this selected population. Materials and Methods: We retrospectively analyzed 323 prostate lobes from 286 patients with biopsy-proven, non-metastatic prostate cancer and mpMRI-defined capsular contact who underwent robot-assisted radical prostatectomy between 2015 and 2021 at a single institution. The dataset was randomly split into training (70%) and testing (30%) cohorts. Three multivariable logistic-regression models were developed and compared. Discrimination was assessed using the area under the receiver operating characteristic curve (AUC-ROC), calibration by intercept and slope, and clinical utility by decision curve analysis. A nomogram was derived from the best-performing model in the internal split-sample comparison. Results: Side-specific ECE was present in 110/323 lobes (34.1%). Among the candidate models, the forward-selection model showed the most favorable apparent performance, with an AUC-ROC of 0.85 in training and 0.83 in testing, together with good test-set calibration (intercept 0.24; slope 0.97). The final model included a capsular contact length ≥10 mm, percentage tumor involvement in positive biopsy cores, number of positive biopsy cores, and index lesion size. At a 10% predicted risk threshold, 32% of lobes were classified as low risk, with an observed ECE rate of about 5%. Conclusions: We developed a side-specific nomogram tailored to patients with mpMRI-defined capsular contact and performed preliminary internal validation. The model may aid preoperative side-specific risk assessment relevant to nerve-sparing planning, but external validation and assessment of clinical impact are required before clinical adoption. Full article

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