How i do it: a survey of practice patterns in robot-assisted radical prostatectomy

Despite the global availability and utilization of robot-assisted radical prostatectomy (RARP), it remains a technically complex operation, with wide variation in training paradigms, surgical technique, and perioperative management. This study examines international RARP practices and aims to identify trends and gaps in clinical practice. A multiple-choice questionnaire consisting of 32 questions was distributed between January and July 2023. A total of 102 responses were received. Responses with ≥ 5 questions with missing data (n = 8) were excluded. Among 94 participants, 91.5% were male, 69.1% practiced outside the United States (US), and 72.3% were fellowship-trained. Most surgeons (79.8%) reported performing ≥ 3 RARPs monthly. About 75% of surgeons reported performing ≥ 90% of their radical prostatectomies (RP) robotically. Seven (7.45%) respondents who reported performing RPs only via laparoscopic or open approach were excluded from subsequent analyses. Regarding the surgical technique, transperitoneal anterior approach was the most preferred (62.1%). For nerve-sparing, the combined antegrade-retrograde approach (43.7%) and the antegrade-only approaches (36.8%) were most common. Approximately half of respondents (51.7%) preferred cut-and-suture ligation for dorsal venous complex control. For pelvic lymph node dissection, standard (44.8%) or limited (29.9%) templates were preferred over the extended (24.1%) template. The most common method for vascular control was clips for vascular pedicle ligation (79.3%). Of the continence-preserving techniques, most respondents agreed on the importance of maximal urethral length preservation (93.1%), bladder neck preservation (80.5%), and posterior reconstruction (64.4%). Postoperatively, most surgeons endorsed early mobilization (92%), early oral nutrition (85.1%), and non-opioid oral analgesia (57.5%). All US-based surgeons reported discharging ≥ 70% of patients on postoperative day 1, whereas discharge patterns varied among non-US surgeons. There are significant global variations in the practice of RARP. These findings point to the potential utility of consensus-driven, evidence-based guidelines to optimize RARP practices worldwide.