Scandinavian Journal of Urology. 2014; 48: 252–258

ORIGINAL ARTICLE

Radical prostatectomy: initial experience with robot-assisted laparoscopic procedures at a large university hospital

MIKKEL FODE1,2, JENS SØNKSEN1,2 & HENRIK JAKOBSEN1 1

Department of Urology, Herlev Hospital, Herlev, Denmark, and 2University of Copenhagen, Copenhagen, Denmark

Abstract Objective. The aim of this study was to compare oncological and functional outcomes between robot-assisted laparoscopic radical prostatectomy (RALP) and retropubic radical prostatectomy (RRP) during the initial phase with RALP at a large university hospital. Material and methods. Patient and tumour characteristics, surgeon, nerve sparing, surgical margins and blood loss were recorded prospectively in patients who underwent RRP or RALP between April 2008 and May 2012. Patients filled out the Danish Prostate Symptom Score (DAN-PSS) and International Index of Erectile Function 5 (IIEF-5) questionnaires before surgery and at follow-up and they were asked to report their use of pads/diapers. Potency was defined as an IIEF-5 score of at least 17 with or without phosphodiesterase-5 inhibitors. Patients using up to one pad daily for security reasons only were considered continent. Positive surgical margins, blood loss and functional outcomes were compared between groups. Results. Overall, 453 patients were treated with RRP and 585 with RALP. On multivariate logistic regression analyses, the type of surgery did not affect surgical margins (p = 0.96) or potency at 12 months (p = 0.7). Patients who had undergone RRP had an increased chance of reporting subjective continence at 12 months (odds ratio 2.6, p = 0.014). There was no difference in the proportion of RRP and RALP patients who underwent surgical treatment for incontinence (p = 0.57). On multivariate linear regression analysis, RALP was an independent predictor of a low perioperative blood loss (RRP:RALP ratio = 2.89, p < 0.0001). Conclusions. RALP is a safe procedure with regard to perioperative and oncological results. However, it is important to be aware that functional outcomes may be compromised in the initial phase when introducing RALP.

Key Words: erectile dysfunction, incontinence, prostatectomy, prostatic neoplasm, robotic instrumentation

Introduction Prostate cancer is estimated to affect approximately 900 000 new men worldwide each year [1]. Surgery has been shown to decrease mortality, but can cause functional issues including incontinence and erectile dysfunction [2]. When tumour characteristics allow it, sparing of the neurovascular bundles running in close proximity to the prostate is attempted in order to improve functional outcomes. The first open retropubic radical prostatectomies (RRPs) were performed in Denmark in 1995 and today more than 1000 prostatectomies are performed every year [3]. In recent years, robot-assisted laparoscopic radical

prostatectomy (RALP) has been introduced in an attempt to minimize trauma to nerves and blood vessels. No randomized trials have compared RRP to RALP but a recent series of systematic reviews has shown that RALP may reduce complication rates and improve functional outcomes, without compromising oncological results [4–7]. However, the majority of studies were performed after the initial learning curve with RALP had been overcome. The purpose of this study was to compare outcomes of the initial series of RALP with RRP performed at a large university centre with established experience in RRP. This study is the first of its kind evaluating results from a Danish centre.

Correspondence: M. Fode, Department of Urology, HA54F1, Herlev Hospital, Herlev Ringvej 75, DK-2730 Herlev, Denmark. Tel: +45 38682093. Fax: +45 38684184. E-mail: [email protected]

(Received 3 June 2013; revised 16 October 2013; accepted 18 November 2013) ISSN 2168-1805 print/ISSN 2168-1813 online  2014 Informa Healthcare DOI: 10.3109/21681805.2013.868514

Initial experience with RALP Material and methods The first RALP was performed at the Department of Urology, Herlev University Hospital in April 2008. Prospectively collected data from patients with biopsy-proven, localized prostate cancer who underwent RRP or RALP between April 2008 and May 2012 were used for analyses. In the beginning, patients with the least serious disease were offered RALP instead of the established method with open surgery. This approach was gradually changed and with the majority of data collection there was no specific indication for RALP or RRP. Thus, the type of procedure was chosen based either on availability of surgical time slots or on patient preference. Patients underwent preoperative clinical staging, and preoperative prostate-specific antigen (PSA) levels were measured. Surgeon, degree of nerve sparing and perioperative blood loss were noted in conjunction with the procedure. Nerve sparing was considered and discussed with the patient if there was no palpable tumour in the apex of the prostate, and if the Gleason score was below 9 and the PSA below 20 ng/ml. Relative contraindications against nerve sparing included T2b disease, a PSA value between 10 and 20 ng/ml, Gleason 4 in more than 50% of biopsies, perineural invasion on biopsy and cancer in three biopsies from the same side of the gland. In these cases nerve sparing was only performed in cases with a strong patient preference. Pathological tumour characteristics, prostate volume and any presence of positive surgical margins were recorded after pathological examination of the specimens. The 2002 tumour, node, metastasis (TNM) system was used for clinical and pathological staging. Patients were preoperatively stratified into risk categories according to D’Amico based on Gleason score, tumour stage and PSA values. Lower urinary tract symptoms (LUTS) were assessed by the Danish Prostate Symptom Score (DAN-PSS) [8] and erectile function was assessed by the International Index of Erectile Function 5 (IIEF-5) [9]. Both questionnaires were filled out before surgery and at subsequent followup visits at 3, 6 and 12 months after surgery. Treatments for erectile dysfunction were noted and at each visit patients were asked to rate their continence using a twoitem written questionnaire, which included a subjective four-point incontinence scale ranging from completely dry to severely incontinent and a question on the use of pads/diapers. Data were entered into a database in a continuous fashion as they became available and a chart review was performed to note surgical treatments of incontinence in the study cohort. Patient characteristics were compared using the Wilcoxon–Mann–Whitney test and the chi-squared test. The chi-squared test was used to compare the RALP

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and RRP groups regarding positive surgical margins, potency rates and continence parameters for univariate analyses. Potency was defined as an IIEF-5 score of 17 or above with or without phosphodiesterase-5 (PDE-5) inhibitors, corresponding to no or mild erectile dysfunction [9]. Patients who reported using up to one pad daily for security reasons only were considered continent. A logarithmic transformation of perioperative blood loss values was performed and a two independent samples t test was used to detect differences between groups for univariate analysis. Logistic regression was used to perform multivariable analyses in order to identify independent predictors for oncological outcomes and functional outcomes. A linear regression analysis was performed to identify independent predictors of perioperative blood loss. Type of surgery, age at surgery, D’Amico classification, surgeon, nervesparing status, pathological tumour stage and Gleason score, prostate volume, and tumour volume were included in all multivariate analyses. In the analysis of postoperative erectile function the preoperative IIEF-5 score was also included and the preoperative DAN-PSS was included in analyses related to continence outcomes. Finally, attrition analyses were conducted to assess whether there were differences in patient or tumour characteristics between patients with and without available follow-up data on functional outcomes. Statistical analyses were conducted using SAS version 9.2 (SAS Institute, Cary, NC, USA). The study was approved by the Danish Data Protection Agency. Results Data from 1038 consecutive patients treated by nine different surgeons were registered. Four surgeons had performed both RRP and RALP, three surgeons had performed RRP only and two had performed RALP only. All surgeons were experienced with RRP while only one surgeon had significant RALP experience pre-dating this study. The numbers of procedures performed by each of the nine surgeons are listed in Table I. Overall, 453 patients were treated with RRP and 585 with RALP. In the RRP group median patient age at surgery was 66 years (range 45–76 years) and in the RALP group the median age at surgery was 65 years (range 43–76 years) (p < 0.0001). Patients in the RALP group generally had lower D’Amico risk classification (p < 0.0001), and accordingly lower postoperative Gleason scores (p < 0.0001), pathological tumour stages (p = 0.0027) and tumour volumes (p < 0.0001). Prostate volume did not differ between groups (p = 0.34). Information regarding both clinical and pathological tumour characteristics is listed

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Table I. Number of procedures performed by each of the nine surgeons. Surgeon

RRP

RALP

Total procedures

1

122

330

452

2

99

43

142

3

4

0

4

4

49

0

49

5

0

3

3

6

162

0

162

7

15

173

188

8

2

24

26

9

0

12

12

loss on multivariate analysis, with a ratio between the RRP and the RALP groups of 2.89 (95% CI 2.52–3.3, p < 0.0001). Positive surgical margins were observed in a total of 212 patients (20.5%), comprising 116 patients in the RRP group (25.7%) and 96 patients in the RALP group (16.5%). On univariate analyses the RRP group had a relative risk of positive surgical margins compared to the RALP group of 1.56 (95% CI 1.23–1.99, p = 0.0003). However, on multivariate analyses, with stratification for tumour characteristics, patient characteristics and surgeon, the type of surgery did not affect the surgical margins (p = 0.96). A large tumour volume (p < 0.0001), pathological tumour stage (pT) (p = 0.0051) and a small prostate volume (p = 0.043) were independent predictors of positive surgical margins. Before surgery, 549 patients were sexually active and potent (IIEF-5 score ‡17 with or without PDE-5 inhibitors). There was no difference in preoperative IIEF-5 scores between RRP and RALP patients in this subgroup (p = 0.19). In this group, follow-up data were available for 484 patients (88.2%) at 3 months (192 patients in the RRP group and 292 in the RALP group), 487 patients (88.7%) at 6 months (193 in the RRP group and 294 in the RALP group) and 418 patients (76.1%) at 12 months postoperatively (179 in the RRP group and 239 in the RALP group). However, not all patients had attempted sexual activity at follow-up. At 3 months 267 (55.2%) had been sexually active (112 in the RRP group and 155 in the RALP group), at 6 months 338 (69.4%) had been sexually active (136 in the RRP group and 202 in the RALP group) and at 12 months 324 patients (77.5%) had been sexually active as assessed by the IIEF-5 questionnaire (142 in the RRP group and 182 in the RALP group). At 12 months, 41 (28.9%) of the sexually active patients in the RRP group had regained potency while 66 patients (36.3%) had regained potency in the

RRP = retropubic radical prostatectomy; RALP = robot-assisted laparoscopic radical prostatectomy.

in Tables II,III,IV. In general, the patients in the RRP group had higher preoperative DAN-PSS (p = 0.0004) and lower preoperative IIEF-5 scores (p = 0.0038) compared with RALP patients. In the RRP group, non-nerve-sparing procedures were preformed in 189 patients (41.7%), unilateral nerve sparing was performed in 173 patients (38.2%) and bilateral nerve sparing was achieved in 91 patients (20.1%). In the RALP group, the corresponding numbers were 166 for non-nerve sparing (28.4%), 234 for unilateral nerve sparing (40%) and 185 for bilateral nerve sparing (31.6%). Significantly more patients underwent nerve sparing in the RALP group (p < 0.0001). The median blood loss in the RRP group was 600 ml (range 50–4320 ml) while the median loss in the RALP group was 150 ml (range 5–1500 ml). This translated into significantly less perioperative blood loss in the RALP group, with a ratio between the RRP and the RALP groups of 4.2 [95% confidence interval (CI) 3.8–4.7, p < 0.0001] on univariate analysis. Along with a low prostate volume (p < 0.0001), non-nerve sparing surgery (p < 0.0001) and surgeon (p < 0.0001), RALP remained a predictor of a low perioperative blood Table II. Clinical and pathological tumour characteristics. cT1a

cT1b

cT1c

RRP

2 (0.2)

3 (0.3)

199 (19.2)

81 (6.8)

RALP

0 (0)

1 (0.1)

359 (34.6)

120 (11.6)

Total

2 (0.2)

4 (0.4)

558 (53.8)

201 (19.4)

pT0

pT2a

pT2b

cT2a

pT2c

cT2b

cT2c

cT3a

93 (9)

69 (6.6)

6 (0.6)

72 (6.9)

31 (3)

2 (0.2)

165 (15.9)

100 (9.6)

8 (0.8)

pT3a

pT3b

pT3c

RRP

3 (0.3)

24 (2.3)

13 (1.3)

219 (21.1)

127 (12.2)

56 (5.4)

1 (0.1)

RALP

2 (0.2)

37 (3.6)

13 (1.3)

329 (31.7)

162 (15.6)

40 (3.9)

0 (0)

Total

5 (0.5)

61 (5.9)

26 (2.6)

548 (52.8)

289 (27.8)

96 (9.2)

1 (0.1)

pT4 10 (1) 2 (0.2) 12 (1.2)

Data are shown as n (%). When comparing retropubic radical prostatectomy (RRP) and robot-assisted laparoscopic radical prostatectomy (RALP) patients, patients in the RALP group had both lower overall clinical tumour stages (p < 0.0001) and lower overall pathological tumour stages (p = 0.0027).

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Table III. Gleason scores. Gleason on biopsy 5

6

7 (3 + 4)

7 (4 + 3)

8

9 32 (3.1)

RRP

1 (0.1)

86 (8.3)

169 (16.3)

89 (8.6)

76 (7.3)

RALP

0 (0)

134 (12.9)

300 (28.9)

88 (8.5)

42 (4)

Total

1 (0.1)

220 (21.2)

469 (45.2)

177 (17.1)

21 (2)

118 (11.4)

53 (5.1)

Gleason on specimen 0

5

6

7 (3 + 4)

7 (4 + 3)

8

9 44 (4.2)

RRP

1 (0.1)

10 (1)

57 (5.5)

142 (13.7)

142 (13.7)

54 (5.2)

RALP

0 (0)

16 (1.5)

86 (8.3)

248 (23.9)

163 (15.7)

40 (3.9)

28 (2.7)

Total

1 (0.1)

26 (2.5)

143 (13.8)

390 (37.6)

305 (29.4)

94 (9.1)

72 (6.9)

Data are shown as n (%). When comparing retropubic radical prostatectomy (RRP) and robot-assisted laparoscopic radical prostatectomy (RALP) patients, patients in the RALP group had both lower overall biopsy Gleason scores (p < 0.0001) and lower overall Gleason scores on pathology (p < 0.0001).

RALP group. The corresponding numbers at 3 and 6 months are given in Table V. On univariate analysis there was no statistically significant difference between groups in the proportions of potent patients, at 3 and 12 months (p values of 0.082 and 0.16, respectively), while significantly more patients in the RALP group had regained potency at 6 months (p = 0.019). There was no difference in the use of PDE-5 inhibitors or other erectogenic aids in sexually active patients at any point during follow-up. Multivariate analyses showed no difference between the RRP and RALP groups regarding potency rates among sexually active patients at either 3 months (p = 0.16), 6 months (p = 0.11) or 12 months (p = 0.7). A high preoperative IIEF-5 score (p = 0.0014), younger age at surgery (p = 0.028) and nerve sparing (p = 0.0003) all constituted independent predictors of regained potency at 12 months. Regarding continence, follow-up data were available for 885 patients (85.3%) at 3 months (388 in the RRP group and 497 in the RALP group), 901 patients (86.8%) at 6 months (406 in the RRP group and 495 in the RALP group) and 772 patients (74.4%) at 12 months (366 in the RRP group and 406 in the RALP group). At 12 months, 299 patients (81.7%) in the RRP group and 304 patients (74.9%) in the RALP group Table IV. Median volumes of prostates and tumours. Median prostate volume (ml)

Median tumour volume (ml)

RRP

52 (range 19–211)

7 (range 0–75)

RALP

53 (range 20–149)

6 (range 0–57)

Total

52 (range 19–211)

6 (range 0–75)

When comparing retropubic radical prostatectomy (RRP) and robot-assisted laparoscopic radical prostatectomy (RALP) patients, patients in the RALP group had lower overall tumour volumes (p < 0.0001) while prostate volume did not differ between groups (p = 0.34).

were considered continent according to the questionnaire described above. The corresponding values for 3 and 6 months’ follow-up are shown in Table VI. In the RRP group, 220 out of 366 patients (60%) used no pads at 12 months while 121 patients (33%) used one or two pads and 25 patients (7%) used three or more pads. In the RALP group, 211 out of 406 patients (52%) used no pads at 12 months while 153 patients (38%) used one or two pads and 42 patients (10%) used three or more pads. At the time of data analysis, 23 patients (2.2%) had undergone surgical treatment for their incontinence. Treatments included ProAct devices (n = 18), male slings (n = 3) and artificial sphincters (n = 2). On univariate analysis, more patients in the RALP group reported subjective incontinence than in the RRP group at 12 months, with a relative risk of 1.37 (95% CI 1.04–1.8, p = 0.022). Likewise, patients in the RRP group reported using fewer pads/diapers at this time (p = 0.01). However, at follow-up, there was no difference in the proportion of RRP and RALP patients who had undergone surgical treatment for incontinence (p = 0.4). On multivariate analysis, the type of surgery remained an independent predictor of regaining continence on subjective assessment at 12 months (p = 0.012). Thus, patients who had undergone RRP had an odds ratio of 2.6 (95% CI 1.2–5.4) in favour of feeling continent compared with patients who had undergone RALP. A low preoperative DANPSS score (p = 0.0039), younger age at surgery (p = 0.023) and unilateral or bilateral nerve sparing compared with no nerve sparing (p = 0.033) were also significant predictors of subjective continence. There were no differences in rates of patients who were surgically treated for incontinence between the RALP and RRP groups on multivariate analysis (p = 0.57). Only a high preoperative DAN-PSS score

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Table V. Regained potency among sexually active patients at 3, 6 and 12 months postoperatively. Time-point

Proportion of potent RRP patients

Proportion of potent RALP patients

p (univariate analysis)

p (multivariate analysis)

3 months

14/112 (12.5)

32/155 (20.6)

0.082

0.16

6 months

21/136 (15.4)

53/202 (26.2)

0.019

0.11

12 months

41/142 (28.9)

66/182 (36.3)

0.16

0.7

Data are shown as n (%). Type of surgery, age at surgery, D’Amico classification, surgeon, nerve sparing status, pathological tumor stage and Gleason score, prostate volume, tumor volume, and preoperative IIEF-5 score were included in the multivariate analyses. RRP = retropubic radical prostatectomy; RALP = robot-assisted laparoscopic radical prostatectomy.

(p = 0.015) and a large prostate volume (p = 0.035) were independent predictors of subsequent surgical treatment for incontinence. All independent predictors for the outcomes are given in Table VII. The attrition analyses showed that there were no differences between patients who filled out the questionnaires and those who did not regarding age, tumour characteristics, nerve sparing or preoperative erectile function and LUTS (data not shown). However, the patients who did not fill out the questionnaires had larger prostate volumes, with a median of 54 ml (range 23–211 ml) compared with a median of 52 ml (range 19–176 ml) among patients who did fill out the questionnaire (p = 0.0017). Discussion The outcomes of this study are comparable with those found in the literature. Case series from other highvolume centres have found rates of positive surgical margins between 8.8% [10] and 38.2% [11] for RRP and between 9.4% [12] and 29.3% [13] for RALP. The proportion of patients reported to maintain potency after a radical prostatectomy ranges between about 10% and 90% [14]. This has been attributed to differences in patient populations, erectile function before surgery, surgical techniques, data collection, treatments for erectile dysfunction and especially varying definitions of potency. The present study adopted a definition in which mild erectile dysfunction was included and oral medications were allowed. In the authors’ opinion this situation reflects the

clinical reality following radical prostatectomy. It is important to note that postoperative erectile function could only be evaluated in patients who had attempted sexual activity at follow-up, as this is an inherent weakness of the IIEF-5 questionnaire used in this study. As with erectile dysfunction, incontinence rates after radical prostatectomy vary and are highly dependent on how continence is defined [15]. However, in most publications the rate of incontinence 12 months after surgery is about 20% [16]. As in the majority of the literature, patient self-report was used to define continence. In this study the RALP group had better outcomes regarding surgical margins overall. However, this effect was explained by patient and tumour characteristics, and type of surgery was not an independent predictor of outcomes on multivariate analysis. The independent predictors of oncological outcome in this study have all been found previously, although such predictors vary considerably across studies [7,17]. Blood loss was significantly lower in the RALP group on both univariate and multivariate analyses, which indicates that this method reduces the surgical trauma. This is in concordance with previous studies [4,7,16] and may contribute to the shorter duration of both in-hospital stay and postoperative sick leave for RALP-treated patients [16,18]. There was no difference between RALP and RRP regarding potency rates. These were mainly dependent on nerve sparing. The RALP group had poorer subjective continence outcomes than the RRP group and tended to use more pads/diapers. Even though the

Table VI. Regained continence at 3, 6 and 12 months postoperatively. Time-point

Proportion of continent RRP patients

Proportion of continent RALP patients

p (univariate analysis)

p (multivariate analysis)

3 months

228/388 (58.8)

245/497 (49.3)

0.005

0.0062

6 months

290/406 (71.4)

355/495 (71.7)

0.92

0.29

12 months

299/366 (81.7)

304/406 (74.9)

0.022

0.012

Data are shown as n (%). Type of surgery, age at surgery, D’Amico classification, surgeon, nerve sparing status, pathological tumor stage and Gleason score, prostate volume, tumor volume and the preoperative DAN-PSS were included in the multivariate analyses. RRP = retropubic radical prostatectomy; RALP = robot-assisted laparoscopic radical prostatectomy.

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Table VII. Independent outcome predictors on multivariate analyses. Positive surgical margins

Large tumour volume (p < 0.0001)

High pathological tumour stage (p = 0.0051)

Low prostate volume (p = 0.043)

Low perioperative blood loss

RALP (p < 0.0001)

Low prostate volume (p < 0.0001)

Surgeon (p < 0.0001)

Regained potency at 12 months

Nerve-sparing surgery (p = 0.0003)

Younger age at surgery (p = 0.028)

High preoperative IIEF-5 score (p = 0.0014)

Regained continence at 12 months

RRP (p = 0.012)

Low preoperative DAN-PSS score (p = 0.0039)

Younger age at surgery (p = 0.023)

Surgical incontinence treatment

High preoperative DANPSS score (p = 0.015)

Large prostate volume (p = 0.035)

Non-nerve-sparing surgery (p < 0.0001)

Nerve-sparing surgery (p = 0.033)

RRP = retropubic radical prostatectomy; RALP = robot-assisted laparoscopic radical prostatectomy; DAN-PSS = Danish Prostate Symptom Score; IIEF-5 = International Index of Erectile Function 5.

difference between groups was small in absolute numbers, this finding is surprising as most previous case series have found either similar continence rates between types of surgery or better outcomes with RALP [5,16]. One explanation could be that the present analysis dealt with the first series of RALP-treated patients at this centre, whereas RRP was already an established method at the time of data collection. This possibility is highlighted by the fact that prolonged learning curves have previously been described regarding continence outcomesinRALP [19,20].Furtherdata collection is ongoing and analyses to assess both global and individual learning curves are planned. As the current study was not randomized and as continence outcomes were based on self-report, another explanation relates to patient characteristics, which cannot be controlled for in the analyses. The authors know from clinical experience that many patients prefer RALP, as they believe that it is superior to RRP. It is possible that patients who make an active choice of treatment in this manner have different expectations and are more inclined to report subjective bother postoperatively. This possibility is supported by the finding that rates of subsequent surgical incontinence treatment did not differ between groups. Furthermore, a recent American study found higher expectations regarding some outcome measures in patients undergoing RALP compared with patients undergoing RRP [21]. The present attrition analyses imply that the limited non-compliance with the follow-up questionnaires did not influence outcomes. To date, no randomized trial has compared RRP and RALP and the best comparative evidence comes from prospectively maintained databases such as the one used in this study. However, the major weakness of this study remains the non-randomized design, and the apparent differences in the RRP and RALP groups. In addition, nine surgeons contributed data to the series. This may reduce the reproducibility of the outcomes. Thus, the authors do not claim to hold a universal truth about robotic surgery. However, the

results do reflect the clinical reality with the introduction of RALP at a high-volume centre with RRP experience, which makes them highly relevant. Although long-term follow-up regarding overall and cancer-specific survival is needed, the current data support the safety of RALP, as oncological results were similar to RRP with less perioperative bleeding. Furthermore, postoperative erectile function did not differ between groups. This is especially encouraging since the analysis includes the first RALP procedures at this centre, whereas RRP was an established method from the beginning of data collection. However, postoperative continence was better in the RRP group. This could possibly be explained by higher patient expectations in the RALP group but it is likely that a surgical learning curve plays the most significant role. Further data collection is ongoing to resolve this issue. Nevertheless, it is important to be aware that functional outcomes may be compromised in the initial phase when introducing RALP. Declaration of interest: Mikkel Fode is an advisory board member for Eli Lilly and a speaker for Astellas. Jens Sønksen is an advisory board member and speaker for Eli Lilly, a speaker for Astellas and a shareholder in Multicept. Henrik Jakobsen is a speaker for Astellas and an advisory board member for GlaxoSmithKline.

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Radical prostatectomy: initial experience with robot-assisted laparoscopic procedures at a large university hospital.

The aim of this study was to compare oncological and functional outcomes between robot-assisted laparoscopic radical prostatectomy (RALP) and retropub...
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