Platinum Priority – Collaborative Review – Prostate Cancer Editorial on pp. x–y of this issue Downsides of Robot-assisted Laparoscopic Radical Prostatectomy: Limitations and Complications Declan G. Murphy a,b, *, Anders Bjartell c , Vincenzo Ficarra d , Markus Graefen e , Alexander Haese e , Rodolfo Montironi f , Francesco Montorsi g , Judd W. Moul h , Giacomo Novara d , Guido Sauter i , Tullio Sulser j , Henk van der Poel k a Department of Urological Oncology, The Peter MacCallum Cancer Centre, Melbourne, Australia b Australian Prostate Cancer Research Centre, Epworth Richmond, Melbourne, Australia c Division of Urological Cancers, Department of Clinical Sciences, Lund University, Malmo, Sweden d Department of Oncological and Surgical Sciences, Urology Clinic, University of Padua, Padua, Italy e Martini-Clinic, Prostate Cancer Centre, University Medical Centre Eppendorf, Hamburg, Germany f Section of Pathological Anatomy, Polytechnic University of the Marche Region, Ancona, Italy g Universita Vita-Salute San Raffaele, Via Olgettina 60, 20132 Milan, Italy h Division of Urologic Surgery, Duke Prostate Centre, Duke University, Durham, NC, USA i Institute of Pathology, University Medical Centre Eppendorf, Hamburg, Germany j Department of Urology, University Hospital Zurich, University of Zurich, Switzerland k Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands EUROPEAN UROLOGY XXX (2009) XXX–XXX available at www.sciencedirect.com journal homepage: www.europeanurology.com Article info Article history: Accepted December 10, 2009 Published online ahead of print on  Keywords: da Vinci Complications Continence Erectile function Laparoscopic Prostate cancer Radical prostatectomy Robotic Abstract Context: Robot-assisted laparoscopic radical prostatectomy (RALP) using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is now in widespread use for the management of localised prostate cancer (PCa). Many reports of the safety and efficacy of this procedure have been published. However, there are few specific reports of the limitations and complications of RALP. Objective: The primary purpose of this review is to ascertain the downsides of RALP by focusing on complications and limitations of this approach. Evidence acquisition: A Medline search of the English-language literature was performed to identify all papers published since 2001 relating to RALP. Papers providing data on technical failures, complica- tions, learning curve, or other downsides of RALP were considered. Of 412 papers identified, 68 were selected for review based on their relevance to the objective of this paper. Evidence synthesis: RALP has the following principal downsides: (1) device failure occurs in 0.2–0.4% of cases; (2) assessment of functional outcome is unsatisfactory because of nonstandardised assessment techniques; (3) overall complication rates of RALP are low, although higher rates are noted when complications are reported using a standardised system; (4) long-term oncologic data and data on high-risk PCa are limited; (5) a steep learning curve exists, and although acceptable operative times can be achieved in <20 cases, positive surgical margin (PSM) rates may require experience with >80 cases before a plateau is achieved; (6) robotic assistance does not reduce the difficulty associated with obese patients and those with large prostates, middle lobes, or previous surgery, in whom outcomes are less satisfactory than in patients without such factors; (7) economic barriers prevent uniform dissemination of robotic technology. Conclusions: Many of the downsides of RALP identified in this paper can be addressed with longer-term data and more widespread adoption of standardised reporting measures. The significant learning curve should not be understated, and the expense of this technology continues to restrict access for many patients. # 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. The Peter MacCallum Cancer Centre, St Andrews Place, Melbourne, Victoria 3002, Australia. Tel. +61 39936 8032; Fax: +61 39429 4683. E-mail address: decmurphy@doctors.net.uk (D.G. Murphy). EURURO-3303; No of Pages 12 Please cite this article in press as: Murphy DG, et al. Downsides of Robot-assisted Laparoscopic Radical Prostatectomy: Limitations and Complications, Eur Urol (2009), doi:10.1016/j.eururo.2009.12.021 0302-2838/$ – see back matter # 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2009.12.021