European Urology 44 (2003)

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1 European Urology European Urology 44 (2003) RoboticTechnology and thetranslation of Open Radical Prostatectomy to Laparoscopy: The Early Frankfurt Experience with Robotic Radical Prostatectomy and OneYear Follow-up Wassilios Bentas *, Marc Wolfram, Jon Jones, Ronald Bräutigam, Wolfgang Kramer, Jochen Binder Department of Urology and Pediatric Urology, J.W. Goethe University of Frankfurt, University Hospital Frankfurt am Main, Theodor-Stern-Kai 7, D Frankfurt am Main, Germany Accepted 8 May 2003 Abstract Objective: Laparoscopic radical prostatectomy is a complex procedure and has been standardized only during the last years. The remote controlled da Vinci Surgical System has opened up a new era in minimally invasive surgery. We here present our initial experience with the translation of open retropubic radical prostatectomy to laparoscopic technique using da Vinci and a one year follow-up. Methods: After a period of technical development and training on cadavers, 40 consecutive patients eligible for radical prostatectomy were treated. After port placement, the urologist took control of the 3D 308 laparoscope and the two instrument arms at the da Vinci remote console to perform bilateral pelvic lymph node dissection, radical prostatovesiculectomy and urethrovesical anastomosis. Results: The procedure was completed laparoscopically in all but two patients. Mean procedure time was 8.3 hours and mean intra-operative blood loss 570 ml. Learning curves associated with the use of the da Vinci Surgical System show that there is a 22-minute decrease in time required to perform the radical prostatectomy and lymphadenectomy for each case ( p < 0:0001). Patients recovered rapidly after surgery with early oncological and functional results that were similar to those obtained with our standard radical prostatectomy technique. Conclusions: Remote controlled robotic surgical systems are useful to translate open retropubic radical prostatectomy to laparoscopy. This new technology has the potential to equip the urologist with the microsurgical precision needed to preserve the delicate structural integrity of the pelvic floor in order to improve functional results without compromising the oncological outcome. # 2003 Elsevier Science B.V. All rights reserved. Keywords: Prostate cancer; Radical prostatectomy; Laparoscopy; Telerobotics 1. Introduction The use of laparoscopic radical prostatectomy for treatment of prostatic carcinoma was initially described by Schuessler [1] and, with recent advancements, may prove a viable replacement for the more commonly used open retropubic approach [2,3]. Although laparoscopic * Corresponding author. Tel. þ ; Fax: þ address: bentas@em.uni-frankfurt.de (W. Bentas). surgery provides clear patient benefit through less morbidity, laparoscopic radical prostatectomy using conventional instrumentation is complex, demanding extensive knowledge of topographical anatomy and proficiency with endoscopic suturing and intracorporeal knot tying. While laparoscopic radical prostatectomy is slowly becoming more common, it seems evident that the introduction of simpler and more enabling endoscopic techniques is needed for laparoscopy to overtake open surgery as the primus modus of radical prostatectomy /$ see front matter # 2003 Elsevier Science B.V. All rights reserved. doi: /s (03)

2 176 W. Bentas et al. / European Urology 44 (2003) We recently evaluated the da Vinci TM Surgical System, a comprehensive robotic endoscopic surgical device, for laparoscopic radical prostatectomy. The da Vinci has been used extensively in Europe since 1998, primarily by cardiothoracic surgeons interested in introducing minimally invasive techniques to cardiac surgery. Our objective was to evaluate whether the da Vinci Surgical System could be effectively used to facilitate performance of laparoscopic procedures in urology. We chose laparoscopic prostatectomy mainly because this procedure requires precise endoscopic visualization and meticulous suturing in a very limited pelvic space. The procedures were performed by two surgeons skilled in the open technique but with only limited expertise in conventional laparoscopy (cryptorchidism, lymphocele fenestration, pelvic lymphadenectomy, occasional simple nephrectomy). This report covers our initial experience with laparoscopic radical prostatectomy using the da Vinci in a first series of 40 patients and a one year follow-up. 2. Materials and methods 2.1. Population Between May 2000 and May 2001, 40 consecutive patients with clinically localized (stage T1b, T1c, T2a and T2b), non-metastatic prostate cancer who were eligible for radical prostatectomy and gave informed consent underwent laparoscopic resection of the prostate using the da Vinci Surgical System. All men underwent extensive pre-operative clinical characterization, which included digital rectal examination (DRE), serum prostate specific antigen (PSA) and ultrasound-guided needle biopsy. Scintigraphy was performed to rule-out bone metastasis for men with a serum PSA value exceeding 10 ng/ml. Histological assessment with assignment of the Gleason score was done for all pre- and intra-operative specimens. There were no selection criteria like age, body mass index or prior operations. Laparoscopic pelvic lymphadenectomy was performed in all patients. Pre-operative characteristics including age, serum PSA concentration, Gleason score, prostate volume and clinical staging are shown in Table 1. Three patients had previously undergone transurethral resection of the prostate (TURP) and 11 had received at least one course of neoadjuvant endocrine therapy. 10 patients had previous abdominal operations Operative procedure The da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA, USA) incorporates three robotic arms, one holding a novel dual channel endoscope and two holding the endoscopic instruments, which are controlled through manipulation of two master controls mounted on the surgeon s console, where the surgeon sits and operates during the procedure. Surgeon manipulation of the controls is managed by a processor that filters, scales and relays the exact motion of the surgeon s hands and fingers to the endoscopic instruments. There is no measurable delay between movement of the surgeon controls and the mirrored movement of the instruments. Tremors and minor, insignificant movements of the surgeon controls Table 1 Demographic and pre-operative characteristics of 40 cases Mean SD Range Age (years) (45, 72) BMI (kg/m 2 ) (20.7, 31.4) Pre-operative PSA (ng/ml) (0.5, 53.0) Prostate Volume (ml) (15, 100) Gleason Score (2, 9) Frequency Rate (%) Clinical TNM Stage n (%) T1a/1b 3 (7) T1c 16 (40) T2a 14 (35) T2b 7 (18) that are commonly encountered while holding instruments, particularly during protracted procedures, are eliminated by the processor. The integrated architecture of the instruments and system allow 7 degrees of freedom which is more than allowed by the human hand. The two images of the dual channel endoscope are fused providing the surgeon with a magnified, resolute stereovision image of the operative field. We used a laparoscopic technique for radical prostatectomy, which was a modification of our open retropubic radical prostatectomy technique to accommodate use of the da Vinci Surgical System. The patient was placed in the dorsal supine position with the upper limbs placed at their sides and lower limbs in abduction to provide access for the patient side system of the da Vinci. A 2.5 cm sub-umbilical, midline laparotomy was made to, first, facilitate digital guidance of subsequent insertion for two 8 mm cannulae for the da Vinci endoscopic tools positioned pararectally and bilaterally and, second, to act as a port for insertion of the endoscope. The laparotomy was temporarily closed around the endoscope for maintenance of the pneumoperitoneum. Two additional 10 mm cannulae to be used for additional non-da Vinci laparoscopic instruments, e.g., large clip applier, suction/irrigator and large graspers, were placed medial to either iliac crest. The prostatectomy was conducted as a combined Walsh retrograde and Campbell antegrade procedure. Briefly, the first portion of the procedure was always bilateral pelvic lymphadenectomy and frozen section of the lymph tissue to evaluate nodal status. The lymphadenectomy was followed by dissection of the urachus to open the Retzius space, preparation and lateral incision of the endopelvic fascia, dissection of the puboprostatic ligaments and preparation of the prostatic apex, ligation of the venous plexus, dissection of the urethra, incision of Denonvilliers fascia and ascending preparation of the dorsal aspect of the prostate, dissection of the bladder neck, descending dissection of ducts, seminal vesicles and lateral pedicle, disposition of the prostate in a laparoscopy organ bag, reconstruction of the bladder neck and vesiculourethral anastomosis, transurethral insertion of a foley catheter, insertion of a silicone drain, removal of the organ bag through the midline laparotomy, and finally wound closure. All radical prostatectomy specimens were sent to the Pathology Department for evaluation Post-operative care Post-operative care consisted of standard analgesia and antithrombotic agents as indicated, suction drainage, urine cultures as indicated, early ambulation, and serum PSA at post-operative day 14, which is our standard routine. Patients were either discharged

3 following removal of the urinary catheter or discharged with the urinary catheter in place. A self-administered questionnaire was sent out with questions regarding post-operative problems, potency and continence status 11 to 23 months after surgery (median follow-up 15 months). Follow-up visits in our outpatient department and at the office of referring urologists were evaluated. W. Bentas et al. / European Urology 44 (2003) Data analysis Generalized estimating equations were used to study the learning curve associated with use of the da Vinci Surgical System for radical prostatectomy and lymphadenectomy. This modelling method accounts for the correlation structure involved with repeated measures (i.e., surgery times) for a given surgeon performing this surgical procedure. This model includes as parameters the case number and the surgeon (entered as a single parameter) since the intercepts of both learning curves are different (i.e., they do not have the same baseline surgical experience). Operative times were recorded for the total procedure ( skin-toskin ), including the installation of the robotic system, and for duration of the endoscopic procedure, i.e., the da Vinci time. Additional information was obtained characterizing intra-operative blood loss, complications, reoperations, conversions, transfusions, length of hospitalization, and catheterization time. Complications were scored according to the severity criteria of Dillioglugil [4]. Data were analyzed using a standardized statistical package (SAS, Cary, NC, USA). Fig. 1. Learning curves. Operative time of two urologists for the endoscopic procedure, i.e. da Vinci system time. Procedure time J.B. (trend ). Procedure time W.K. (trend ). 3. Results The operative morbidity among the 40 patients is shown in Table 2. The average total operative time ( skin-to-skin ) was 9:9 2:8 hours (range: ) while the average time of use for the da Vinci was 8:3 2:1 hours (range: ). The first case in the series of 40 represented the longest duration, i.e., 15.5 and 13.0 hours for total operative and da Vinci time, respectively. Learning curves for the surgeons, graphically depicted in Figs. 1 and 2, show that total operative ( skin-to-skin ) time as well as da Vinci use time decreases with accumulation of experience by the surgeons. Analysis of generalized estimating equations demonstrates that for every da Vinci Surgical System case there is a 21.6-minute decrease in time required to perform the radical prostatectomy and lymphadenectomy (p < 0:0001). There is no difference in the slope of the learning curves between surgeons (p ¼ 0:14). The average intra-operative blood loss was 570:4 499:9 ml (range: ) requiring 7 intraand 6 post-operative transfusions, a total rate of 32.5%. Fig. 2. Learning curves. Operative time of two urologists for the complete procedure including port placement and system set-up, i.e. total operative time. Procedure time J.B. (trend ). Procedure time W.K. (trend ). Intra- and post-operative complications are listed on Table 3. There were no intra- or post-operative deaths. We experienced four (10%) intra-operative adverse events and one reoperation: A trocar injury to an epigastric artery necessitated open revision on postoperative day 1, an intra-operative partial injury of the obturator nerve, and two instances of hemostatic complications at the dorsal vein complex. None of these operative consequences were associated with use of Table 2 Operative morbidity Mean operating time skin-to-skin SD (hours) Conversion rate (%) Mean blood loss SD (mls) Transfusion rate (%) Mean catheterization SD (days) Mean hospitalization SD (days) (5) (32.5)

4 178 W. Bentas et al. / European Urology 44 (2003) Table 3 Complications rates and severity score for da Vinci assisted radical prostatectomies Complications Rate (%) Severity score Pulmonary embolism 2 (5) 4 Deep vein thrombosis 1 (3) 3 Obturator nerve injury 1 (3) 3 Trocar injury to epigastric artery 1 (3) 3 Venous plexus bleeding 2 (5) 2 Urinary tract infection 2 (5) 2 Prolonged anastomotic leak 4 (10) 2 the da Vinci system. There were two conversions: the first case was converted to a laparotomy to complete the urethrovesical anastomosis after the protracted operative time and associated blood loss. Case number 14 was converted to a laparotomy after the cautery hook dispatched from the instrument and could not be located laparoscopically between the small bowel. A serious post-operative complication was pulmonary embolism in two patients, the other major complication was one deep vein thrombosis. Minor postoperative complications were urinary tract infection in two patients and a prolonged anastomotic leak with conservative treatment in four patients. None of the post-operative complications observed in this evaluation was related to use of da Vinci. Table 4 shows the early oncological results as regarding to histopathological evaluation of the prostate and the serum PSA at post-operative day 14. Positive resection margins were found in 2 (8%) of 25 patients with pt2 tumors and in 10 (67%) of 15 patients with pt3 tumors. The average Gleason score was 6:3 1:3 (range 3 9). Serum PSA concentration decreased to 0:32 0:48 ng/ml ranging from undetectable to 2.14 ng/ml. Table 4 Post-operative oncologic results Pathological staging Rate (%) N ¼ 40 pt2a 7 (18%) pt2b 18 (45%) pt3a 9 (22%) pt3b 6 (15%) R1 Total 12 (30%) pt2 2 (8%) pt3 10 (67%) Mean SD Range Gleason score (3, 9) Serum PSA Post-Op Day 14 (ng/ml) (0.01, 2.14) The average number of days of catheterization for subjects in this study was 16:7 9:3 days (range: 5 49). The average length of hospitalization was 17:1 6:8 days (range: 6 32). Eight patients were discharged home with the bladder catheter in place. The post-operative continence status was available in 38 subjects 11 to 23 months after surgery. 26 (68%) were completely continent without pads after a median of 2 months (range 0 to 7 months). Twelve (32%) patients still used pads. Of these patients six (16%) used one pad a day for safety reasons. Three patients used one or two pads for mild stress incontinence, three patients needed three or four pads for severe stress incontinence. 37 of these 38 patients were potent before radical prostatectomy. At one year follow-up, all of these patients reported a reduction of erectile function. Eight patients had regained sexual activity but required assistance. 4. Discussion Over the last decade, several groups in the United States and Europe have made significant progress towards development of useful and practical procedures for performance of radical prostatectomy using conventional laparoscopic techniques [5 7]. While there may be distinct patient benefits associated with laparoscopic excision of this poorly accessible organ, including shorter recovery and fewer operative complications, there are nonetheless some surgical impediments to laparoscopic radical prostatectomy, including surgeon training, learning curves, fatigue, and visualization. Furthermore, there is no single urological procedure comparable in frequency to e.g. cholecystectomy or gynaecological procedures, consequently limiting urological experience in laparoscopic surgery. Thus, one must be aware that conventional laparoscopic radical prostatectomy is a technically challenging and physically strenuous procedure, even for surgeons with advanced laparoscopic experience. In this situation, the use of a robotic telesurgical system was deemed to be attractive to reduce technical difficulties, particularly for us as surgeons with limited experience in urological laparoscopy. Our report of 40 consecutive robotic radical prostatectomies performed by two separate urologists in one institution shows that this procedure developed rapidly which is best exemplified by the dramatic improvements in operative time over only a few procedures. Our average operative times decreased 22 minutes per procedure which included pelvic lymphadenectomy in all cases to a mean duration of approximately 4 5 hours. Other groups with much more expertise in laparoscopic

5 W. Bentas et al. / European Urology 44 (2003) surgery reported on mean operation times from 270 to 472 minutes for the first laparoscopic radical prostatectomies [8,9] However, in these series, pelvic lymphadenectomy was not performed routinely, and no data is available about the average operative time of the first 10 or 20 patients of the individual surgeon [7,10]. The extensive operative times in our early series reflect the fact that these were the first procedures of this kind worldwide and thus, for example, no outside proctoring was available. There is little doubt that increasing experience with this operative techniques will lead us to operation times which are competitive with those of open surgery [11]. Furthermore, the delicate wristed instruments that had been available for the first series of patients were not yet optimized for use by urologists for procedures as radical prostatectomy since they had been developed mainly for cardiac surgery. The da Vinci system proved to be a safe device. There was only one specific complication related to the use of the da Vinci which has never been described in conventional laparoscopic prostatectomy, the dispatchment of a hook which was lost between the small bowel and was only recovered after converting. Emergency conversions were never required. However, in this case, the patient side cart of the da Vinci system could have been disconnected and pulled back from the operating table in approximately 30 seconds. Blood loss is commonly lower during laparoscopic procedures as compared to open surgery. In our series, the average intra-operative blood loss accounted to 558 ml. The peri- and post-operative transfusion rate was 32.5%. This rate was similar to the rate of 30% in Rassweiler s patient group but significantly higher than the transfusion rates of 2% in Türk s series or of 10% reported by Jacob et al. [7,9,10]. Besides representing our early learning period, this high transfusion rate may be attributed to the operative technique we followed in this first series, which was an ascending-descending approach that is also been employed by Rassweiler, while the others follow the descending technique described by Vallancien and Guilloneau which may provide a better bleeding control. Considering the innovative nature of this technique, there was a low intra-operative complication rate and no mortality in this series. However, there were serious post-operative complications (two pulmonary embolisms and one deep vein thrombosis) which must be attributed to the prolonged operative time. Our two early surgical conversions can be explained by lack of experience, as the rate has decreased and none of the last 26 patients had to be converted or re-operated upon. This compares favourably to 5 conversions in Guillonneau s first series of 40 laparoscopic radical prostatectomies. The long duration of post-operative bladder drainage and the rate of 10% prolonged urinary leakage has also been observed by other authors in their early experience with laparoscopic prostatectomy and has been attributed to excessive coagulation of the bladder neck [7]. Other putative reasons could be that either too little urethral tissue was included in the suture (due to magnification) or that knots were tied too tightly (due to lacking of force feedback). With growing experience, these problems have decreased. In our series, the length of hospital stay was directly related to the urinary catheter time. Patients usually decided to remain in hospital until all catheters were removed, even though they would have been able to leave the hospital earlier. Also, we did not encourage earlier dismissal as a longer observation period was deemed to be advantageous following a novel procedure. Finally, our insurance system does not yet give financial incentives to discharge patients early. Histopathology of the prostate specimen may give important clues as to the oncological value of a procedure. The tumor was classified pt2 in 62.5% and pt3 in 37.5% of the patients. Positive resection margins were found in 8% of patients with pt2 tumors and in 67% of patients with pt3 tumors. These results are consistent with those obtained by retropubic or perineal radical prostatectomy [12]. Larger series of conventional laparoscopic radical prostatectomies showed positive resection margins of 2 17% in pt2 and 20 84% in pt3 tumors [7,8,10]. Thus, we conclude that our learning curve was not associated with a marked compromise in local tumor control. However, we are sure that better results can be expected with improved surgical experience and development of suitable instruments. Specific da Vinci related limitations when performing prostatectomy in pt3 tumors were not observed. Collection of functional data is hampered by the surgeon s subjectivity in interpretation of post-operative continence status. Therefore, we send a self-administered questionnaire to our patients which they filled out at home. 68% our patients were completely dry, day or night. 16% used one pad per day for safety without stress incontinence episodes. Large series with over 100 conventional laparoscopic prostatectomies reported on continence rates of 76 to 95% six to 12 months postoperatively [5 7]. Our results after 40 procedures again reflect our learning curve. As for the oncological results, we are certain that functional results as continence will improve with further experience. Concerning post-operative potency status we must emphasize that preservation of neurovascular bundles was not our intention in this first series. Excellent magnified visualization and meticulous dissection and suturing should

6 180 W. Bentas et al. / European Urology 44 (2003) Table 5 Scope of robotic procedures at Dept. of Urology and Pediatric Urology, Frankfurt University Procedure Radical prostatectomy Radical cystoprostatectomy and ileal neobladder (Hautmann) Dismembered pyeloplasty Retrocaval ureter, ureteroureterostomy Adrenalectomy Nephrectomy Retroperitoneal lymph node dissection enable us to achieve functional and oncological results superior to other techniques. Given the novelty of our experience with robotically assisted laparoscopic prostatectomy, it is clearly premature to draw conclusive inferences regarding specific patient outcome parameters. Nevertheless, this study demonstrates that a robotically-assisted stereoendoscopic device is available, practical for use in radical prostatectomy. With only limited experience in laparoscopy, we performed 40 laparoscopic radical prostatectomies just by applying our well known techniques from open surgery. Complications were acceptable, the operative time was steadily decreasing and, as the foremost objective, a good treatment of the specific disease process was attained. Although costly, use of the da Vinci Surgical System has some potential advantages over conventional laparoscopic surgery in urology. Our initial experience with robotic assisted laparoscopic radical prostatectomy in 40 patients has demonstrated that: (1) visualization is clearly improved by the InSite Vision System through three-dimensional vision, 10-fold magnification and infinitely variable positioning of the 30 degree endoscope by the urologic surgeon; (2) handling of the laparoscopic tools is greatly facilitated by the degrees of freedom available with the Endowrist instrument technology which enables the surgeon to dissect, suture and tie knots endoscopically as is done in open surgery; (3) improved surgical dexterity can probably be improved by increasing the number of available Endowrist instruments; (4) the laparoscopic procedure can be performed in a relaxed working position at the console with harmonious control of two surgical instruments and the camera position; and, (5) there is a minimal learning curve to be negotiated in initial use of da Vinci and that the surgeon does not need extensive laparoscopic training to rapidly become a proficient user of the system. Considering the absence of haptic feedback using the da Vinci Surgical System, an increased potential for adjacent organ damage could be conceivable. In our experience, the absence of haptic feedback is more than equalized by the excellent visualization. While laparoscopic skill is probably not a disadvantage when starting robotic surgery, it is curious that certain features of the robotic system, as wristed instruments and 3D vision tend to be appreciated more by open surgeons. Whether the da Vinci system is of benefit for surgeons experienced in laparoscopy remains debatable. First reports show that experienced laparoscopists performed their first robotic radical prostatectomies with little problems [13,14]. Further developments regarding minimalization, optimalization of instruments, and cost reduction are required. The potential of this novel technique is definitely its great surgical accuracy. Given the intricacy and complexity of the pelvic anatomy, it is probable that use of this technology will help the surgeon to preserve delicate structural integrity, thereby preserving erectile function and minimizing blood loss. The forecast that preservation of anatomy and operative time could be improved with increasing experience has been met, as data from the Detroit group [15] and our own with at present 100 robotic prostatectomies (not yet published) show. At the same time, robotic technology has enabled us to translate various other ablative and reconstructive procedures in the retroperitoneum and the small pelvis to laparoscopy which were previously all standard open procedures (Table 5). References [1] Schuessler WW, Schulam PG, Clayman RV, Kavoussi LR. Laparoscopic radical prostatectomy: initial short-term experience. Urology 1997;50: [2] Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: the Montsouris technique. J Urol 2000;163: [3] Abbou CC, Salomon L, Hoznek A, Antiphon P, Cicco A, Saint F, et al. Laparoscopic radical prostatectomy: preliminary results. Urology 2000;55: [4] Dillioglugil O, Leibman BD, Leibman NS, Kattan MW, Rosas AL, Scardino PT. Risk factors for complications and morbidity after radical retropubic prostatectomy. J Urol 1997;157: [5] Rassweiler J, Sentker L, Seemann O, Hatzinger M, Rumpelt HJ. Laparoscopic radical prostatectomy with the Heilbronn technique: an analysis of the first 180 cases. J Urol 2001;166: [6] Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: the Montsouris experience. J Urol 2000;163: [7] Türk I, Deger IS, Winkelmann B, Roigas J, Schönberger B, Loening SA. Laparoscopic radical prostatectomy. Experience with 145 procedures. Urologe A 2001;40: [in German]. [8] Guillonneau B, Cathelineau X, Barret E, Rozet F, Vallancien G. Laparoscopic radical prostatectomy: technical and early oncological assessment of 40 operations. 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7 W. Bentas et al. / European Urology 44 (2003) [9] Jacob F, Salomon L, Hoznek A, Bellot J, Antiphon P, Chopin DK, et al. Laparoscopic radical prostatectomy: preliminary results. Eur Urol 2000;37: [10] Rassweiler J, Sentker L, Seemann O, Hatzinger M, Stock C, Frede T. Heilbronn laparoscopic radical prostatectomy. Technical aspects and experience with 125 cases. Eur Urol 2001;40: [11] Guilleneau B, Cathelineau X, Doublet JD, Vallancien G. Laparoscopic radical prostatectomy: the lessons learned. J Endourol 2001; 15: [12] Lance RS, Freidrichs PA, Kane C, Powell CR, Pulos E, Moul JW, et al. A comparison of radical retropubic with perineal prostatectomy for localized prostate cancer within the Uniformed Services Urology Research Group. BJU Int 2001;87:61 5. [13] Rassweiler J, Frede T, Seemann O, Stock C, Sentker L. Telesurgical Laparoscopic Radical Prostatectomy. Initial Experience. Eur Urol 2001;40: [14] Pasticier G, Rietbergen JB, Guillonneau B, Fromont G, Menon M, Vallancien G. Robotically assisted laparoscopic radical prostatectomy: feasibility study in men. Eur Urol 2001;40:70 4. [15] Menon M, Shrivastava A, Tewari A, Sarle R, Hemal A, Peabody JO, et al. Laparoscopic and robot assisted radical prostatectomy: establishment of a structured program and preliminary analysis of outcomes. J Urol 2002;168:945 9.