Evaluation of various active surveillance protocols in prostate cancer.

OBJECTIVE: This study aims to investigate whether pathology results obtained by radical retropubic prostatectomy (RRP) were correlated with active surveillance (AS) criteria defined by Klotz, Soloway and D'Amico. MATERIALS AND METHODS: In our clinic we evaluated 211 patients with diagnosis of localized prostate cancer who underwent RRP between 2007 and 2012. AS criteria defined by Soloway (cT ≤ T2, PSA ≤ 15 ng/dl, Gleason ≤ 6), Klotz (cT1c-T2a; if age ≥ 70 PSA ≤ 15 ng/dl, if age < 70 PSA ≤ 10 ng/dl; if age ≥ 70 Gleason ≤ 7(3+4), if age < 70 Gleason ≤ 6) and D'Amico (cT1c-T2a, PSA ≤ 10 ng/dl, Gleason ≤ 6) were used in our study. Pathological stages and Gleason scores were evaluated with coherence to AS protocols, mis-staging rates, biochemical recurrence (BC) of the mis-staged patients and death due to prostate cancer Data was analyzed using NCSS 2007 & PASS 2008 Statistical Software (Utah, USA). Chi square test and Mann-Whitney U test were applied for analyzing qualitative data. Significance was determined as p < 0.05. RESULTS: 137 (64.9%) patients were coherent with Soloway AS criteria, 118 (55.9%) with Klotz AS criteria and 108 (51.1%) with D'Amico AS criteria. Histopathological results of the patients grouped according to Soloway, Klotz and D'Amico AS protocols showed high stage prostate cancer in 40 (29.2%), 32 (27%) and 27 (24.9%) patients, respectively. High grade prostate cancer rates in Soloway, Klotz, D'Amico groups were 55 (40.2%), 46 (38%) and 39 (36.1%); respectively. Misstaging rates of Soloway, Klotz and D'Amico AS protocols were determined as 65 (47.4%), 54 (45.5%) and 46 (42.5%), respectively. In the Soloway group BC rate was 21.9% in those with high stages. Relation between BC and high stage was found to be statistically significant (p < 0.05). CONCLUSION: Misstaging rates were relatively high in the three groups and there was no difference between the three groups in BC rates. Randomized studies with adequate follow up are needed.

The effects of pelvic dimensions on radical retropubic prostatectomy.

INTRODUCTION: To determine the effects of pelvic dimensions on margin status, preoperative and postoperative estimated blood loss (EBL), operative time and transfusion rate (TR) during radical retropubic prostatectomy (RRP). MATERIALS AND METHODS: Data from 94 patients with preoperative prostate MRI were analyzed. Pelvic dimensions, including interspinous distance (ISD), bony (BFW) and soft tissue (SW) pelvic width, apical prostate depth, upper conjugate (UC), lower conjugate (LC) were measured by preoperative MRI. Indexes for pelvic dimensions (PDI), bony width (BWI) and soft-tissue width (SWI) were defined as ISD/AD, BFW/PD, and SW/AD, respectively. As indicators of surgical difficulty, TR and EBL were assessed. SPSS version 17.0 was used for statistical analyses. RESULTS: Correlational analysis revealed no significant relationship between pelvic dimensions and parameters reflecting operative difficulty (p > 0.05). For EBL, there were significant indirect correlations between the BFW/AD, ISD/AD, and SW/AD indexes (p < 0.01, p < 0.01, p < 0.05; respectively). Additionally, the correlations between AD and TR (p < 0.05) and between AD and EBL (p < 0.05) were significant. Consequently, TR was significantly correlated with BFW/AD, ISD/AD and SW/AD (p < 0.01, p < 0.05, p < 0.01; respectively). Correlational analysis revealed that prostate volume (PV) was significantly correlated with EBL and TR (p < 0.01). Multivariate analyses revealed that PV was a significant predictor of TR (p = 0.06). None of the pelvic dimensions were significantly associated with recovery of urinary continence (RUC) (p > 0.05). CONCLUSIONS: Analyses of pelvic dimensions as significant factors influencing operative difficulty during RRP yielded mixed results. PV seems to be the strongest factor related to operative difficulty. Future studies about pelvic dimensions should be conducted.

Comparison of Early Urinary Continence, Oncological Outcomes, and Postoperative Complications in Retzius-Sparing and Standard Approach Robot-Assisted Radical Prostatectomy.

Background: The aim of the study is to compare the results of early urinary continence (UC), pathological results, console time (CT), and perioperative morbidity in patients who underwent transperitoneal robot-assisted radical prostatectomy (TR-RARP) and Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) surgeries in the treatment of clinically localized prostate cancer. Methods: A total of 120 patients, 60 (Group 1) with the TR-RALP technique and 60 (Group 2) with the RS-RALP technique, who had no statistical difference in their preoperative demographic data, were selected retrospectively. Perioperative and postoperative data, and continence rates in the first, third and sixth months were compared between the 2 groups. Results: There was no significant difference between the groups in terms of CT, hemoglobin change, and perioperative and postoperative data. There was a statistically significant difference between the 2 groups in favor of RS-RARP in terms of UC in the first and third months, whereas there was no statistically significant difference between the groups at month 6 (P = .001, P = .002, and P = .245, respectively). Conclusion: This study demonstrates that the RS-RARP technique is a promising approach to achieve early continence without compromising oncological principles and without increased complication rates.

Early outcomes of robotic retroperitoneal partial nephrectomy: evaluating surgical success with margin, ischemia, and complication score.

OBJECTIVE: The objective of this study was to evaluate the minimum number of required cases for successful robotic retroperitoneal partial nephrectomy for an experienced surgeon in transperitoneal robotic surgery. METHODS: Our prospectively collected clinic database was evaluated retrospectively, and 50 patients who underwent robotic retroperitoneal partial nephrectomy by a single experienced surgeon from January 2019 to February 2023 were included in this study. Demographic and perioperative data and R.E.N.A.L. nephrometry scores were noted. margin, ischemia, and complication score was used to predict surgical success. Receiver operating characteristic curve analysis was used to determine how many cases were required to achieve margin, ischemia, and complication score positivity and to apply the off-clamp technique. Also, the first 25 patients were assigned to Group 1 and the second 25 patients to Group 2, and the data were compared between the groups. RESULTS: The patients' demographic data and tumor characteristics were similar in the groups. The off-clamp technique and sutureless technique rates in Group 2 were significantly higher than that in Group 1. Margin, ischemia, and complication score positivity was observed in 60% (n=15) of Group 1 and 96% (n=24) of Group 2. At receiver operating characteristic curve analysis, the 25th and later cases were statistically significant in terms of margin, ischemia, and complication score positivity. In terms of performing surgery with the off-clamp technique, the 28th and subsequent cases were statistically significant. CONCLUSION: A total of 25 or more cases appear to be sufficient to provide optimal surgical results in robotic retroperitoneal partial nephrectomy for an experienced surgeon.

Effect of prostate and bony pelvic dimensions measured by preoperative magnetic resonance imaging on robot-assisted radical prostatectomy.

Bone pelvic dimensions and body habitus may have effects on robot-assisted radical prostatectomy (RARP). In this study, we examined the effects of body mass index, bone pelvis measurements and prostate measurements on console time (CT), decrease in postoperative hemogram level (DHL) and surgical margin(SM) in patients who underwent RARP for clinically localized prostate cancer in our institution. The data of transperitoneal RARP cases performed by a single surgeon between November 2016 and August 2020 were analyzed retrospectively. It was included in 125 patients who met the study criteria. Bone and soft tissue measurements were made on magnetic resonance imaging T2-weighted imaging in the mid-sagittal and transvers plane. In multivariate linear regression analyzes, only soft tissue width/transverse diameter of the prostate and CT were found to be correlated (p = 0.026). For the DHL, no pelvic dimension and body habitus had a significant association on multivariate linear regression analysis. In multivariate analyzes, a statistically significant difference was found only between pathological Gleason Score and SM (p = 0.008). Although we found statistically significant associations between prostate diameters and pelvic bone measurements and operative difficulties, we believe that further studies are needed to confirm these results. Such information can help identify patients with challenging anatomy and can be used in robotic surgery training to achieve optimal patient outcomes after RARP.

The Results of Peritoneal Re-Approximation Methods on Symptomatic Lymphocele Formation in Robot-Assisted Laparoscopic Radical Prostatectomy and Extended Pelvic Lymphadenectomy.

INTRODUCTION: To evlauate role of peritoneal re-approximation methods in the prevention of symphtomatic lymphocele formation in patients underwent transperitoneal robot-assisted laparoscopic prostatectomy (tRALP) and extendeded pelvic lympadenoctomy (ePLND). MATERIALS AND METHODS: Between January 2016 and April 2020, 120 consecutive patients who were administered anterior t-RALP and ePLND were analyzed retrospectively. In group 1 (n = 40), peritoneal approximation was not performed after t-RALP and ePLND application, peritoneal half re-approximation was performed in group 2 (n=40), and peritoneal full re-approximation was performed in group 3 (n=40). Operative parameters and symptomatic lymphocele rates were compared between the groups. RESULTS: There was no statistically significant difference between the groups in terms of mean age, body mass index and prostatespecific antigen levels, Gleason score on biopsy, D'amico risk groups, the mean number of lymph nodes removed, Clavien-Dindo complication grade and mean duration of the surgery. Patients with symptomatic lymphocele in Group 1, Group 2, and Group 3 were found to be 2 (5%), 3 (7.5%) and 5 (12.5%), respectively. There was no statistically significant difference between the groups in terms of symptomatic lymphocele formation. CONCLUSION: Half or full closure of the peritoneum does not affect the symptomatic lymphocele formation in patients who underwent tRALP and ePLND.

Robotic-assisted laparoscopic radical prostatectomy: Initial outcomes of 500 cases.

INTRODUCTION: We aimed to present our experience of robot-assisted laparoscopic radical prostatectomy (RARP). MATERIAL AND METHODS: The study was a retrospective review of 500 patients who underwent RARP between March 2015 and July 2021 in our clinic. A transperitoneal approach was used in all patients. All patients had clinically organ-confined prostate cancer (≤ cT2c). RESULTS: The mean age of the patients was 64.6 ± 5.7 years. The median PSA was 11.4 ng/dL (range 0.3-92.7). The mean operative time was 183.5 min. Positive surgical margin rate was 19.4%. During a mean follow-up of 23.5 months, 96 patients (19.2%) received adjuvant radiotherapy due to the biochemical recurrence and 28 patients (16%) with lymph node positivity received early adjuvant hormone therapy. Considering the continence rates, 69% of the patients were total continence in the 3rd month, while this rate increased to 83 in the 6th month and 91% in the 12th month. CONCLUSION: RARP is a safe and feasible method for experienced centers with patient comfort, surgeon comfort, and successful oncological and functional results.

INTRODUCCIÓN: Nuestro objetivo fue presentar nuestra experiencia de prostatectomía radical laparoscópica asistida por robot (RARP). MATERIAL Y MÉTODOS: El estudio fue una revisión retrospectiva de 500 pacientes que se sometieron a una (RARP) entre marzo de 2015 y julio de 2021 en nuestra clínica. En todos los pacientes se utilizó un abordaje transperitoneal. Todos los pacientes tenían cáncer de próstata limitado al órgano clínicamente (≤ cT2c). RESULTADOS: La edad media de los pacientes fue de 64.6 ± 5.7 años. La mediana de PSA fue de 11.4 ng/dL (rango 0.3-92.7). El tiempo operatorio medio fue de 183.5 min. La tasa de márgenes quirúrgicos positivos fue del 19,4%. Durante un seguimiento medio de 23.5 meses, 96 pacientes (19.2%) recibieron radioterapia adyuvante debido a la recurrencia bioquímica y 28 pacientes (16%) con ganglios linfáticos positivos recibieron terapia hormonal adyuvante temprana. Considerando las tasas de continencia, el 69% de los pacientes tenían continencia total en el 3er mes, mientras que esa tasa aumentó a 83 en el 6° mes y 91% en el 12° mes. CONCLUSIÓN: RARP es un método seguro y factible para centros experimentados con comodidad para el paciente, comodidad para el cirujano y resultados oncológicos y funcionales exitosos.

Is Retzius-sparing robot-assisted laparoscopic radical prostatectomy effective in early continence? A single-center experience of the first 50 patients.

OBJECTIVE: In this study, we aimed to present the perioperative and postoperative outcomes and early continence rates of the first 50 patients who underwent Retzius-sparing robot-assisted laparoscopic radical prostatectomy (RS-RALP) in our clinic for prostate adenocarcinoma. MATERIAL AND METHODS: Between December 2018 and December 2019, 50 patients who underwent RS-RALP by 2 surgeons in our clinic were enrolled in the study. Preoperative, perioperative, and postoperative clinical data were analyzed retrospectively. Procedure-specific complications were graded according to the Clavien-Dindo classification. The continence status of the patients was recorded in the 1st week, 1st month, and 3rd month after catheter removal. Zero pads or 1 safety pad per day was accepted as total continence. RESULTS: The mean age of the patients was 66.6 (57-75) years. According to the D'Amico classification, 36% of patients were at low risk, 48% at intermediate risk, and 16% at high risk. Bilateral or unilateral nerve-sparing procedure was performed in 76% of the patients. There were no intraoperative complications. A total of 9 (18%) patients had a postoperative complication (7 with grade 1, 1 with grade 2, and 1 with grade 3 complications). Whereas 32% of the patients had an extraprostatic extension, 22% had seminal vesicle invasion. The overall positive surgical margin rate was 26%. At 1 week, 1 month, and 3 months after surgery, 64%, 80%, and 92% of men who underwent RS-RALP were continent, respectively. CONCLUSION: Our study showed that this new surgical technique can be a safe and feasible method because high rates of early continence were achieved in the patients who underwent RS-RALP without increasing the risk of complications.

Effects of Listening to Binaural Beats on Anxiety Levels and Pain Scores in Male Patients Undergoing Cystoscopy and Ureteral Stent Removal: A Randomized Placebo-Controlled Trial.

Purpose: To investigate the effects of pure binaural beats on anxiety and pain scores in male patients undergoing diagnostic cystoscopy (DC) and ureteral stent removal (USR) under local anesthesia. Materials and Methods: This was a prospective, randomized placebo-controlled study. Patients in the DC group (DCG) and USR group (USRG) were divided into three subgroups according to interventions applied; DCG-1 and USRG-1, patients listened to binaural beats; DCG-2 and USRG-2, patients listened to classical music; and DCG-3 and USRG-3, patients wore headphones, but were not exposed to audio (control group). The State-Trait Anxiety Inventory (STAI) and Visual Analog Scale (VAS) were used for measuring anxiety and pain scores, respectively. Demographic data, initial STAI, tolerance rate of interventions, terminal STAI (STAI-T), differences of STAI (delta STAI, STAI-D), and VAS scores were compared. Results: Between July 2019 and March 2020, a total of 252 and 159 eligible male patients for DCG and USRG were included, respectively. After exclusions, remaining patients were DCG-1, n = 61; DCG-2, n = 73; DCG-3, n = 75; USRG-1, n = 41; USRG-2, n = 50; and USRG-3, n = 52. The tolerance rate in binaural beat groups was significantly lower than in other groups (p < 0.05 for all). There were significant decreases in terms of STAI-T when DCG-1 and DCG-2 were compared with DCG-3 and USRG-1 and USRG-2 were compared with USRG-3 (p < 0.05 for all). There were significant decreases in STAI-D scores when DCG-1 and DCG-2 were compared with DCG-3 and when USRG-1 and USRG-2 were compared with USRG-3 (p < 0.001 for all). Binaural beat groups had significantly lower VAS scores than other groups and classical music groups had significantly lower VAS scores than control groups (p < 0.05 for all). Conclusions: Listening to pure binaural beats may be a simple and effective method to reduce anxiety levels and pain scores associated with the DC and USR procedures in males.

Preoperative Inflammation Markers and De Ritis Ratio in Predicting Clinical Presentation and Prognosis of Patients with Testicular Germ Cell Tumors.

OBJECTIVE: To evaluate the importance of neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), neutrophil-to-monocyte ratio (NMR) and De Ritis ratio (DRR) in predicting clinical presentation and prognosis of patients with testicular germ cell tumors (TGCTs). STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Antalya Training and Research Hospital Antalya, Turkey, from January 2009 to March 2020. METHODOLOGY: The characteristics and the results of biochemical and pathological examinations of patients who underwent radical orchiectomy were recorded. NLR, LMR, PLR, NMR, and DRR were calculated. The relationship among inflammation markers and DRR and clinical presentation and prognosis of TGCT was evaluated. RESULTS: Data of 99 patients were eligible for the study. Median age was 32 (27-39)  years. Average size of the tumor was 5 (2.7 - 7) cm. Average duration of follow-up was 35.4 (8-62) months. Higher NLR and lower LMR were significantly correlated with higher rates of advanced-stage cancer, metastasis, and retroperitoneal lymph node invasion (RPLNI) (p<0.05). Based on the optimal cut-off values, there was a significantly higher rate of S stage, RPLNI, and metastatic disease in the high NLR group (p<0.05). Kaplan-Meier survival analysis found a statistically significantly lower mean survival rate in the high NLR group (p<0.05). There was no statistically significant difference between the DRR groups in the above-mentioned parameters (p>0.05). CONCLUSION: Preoperative NLR can be used as an inexpensive and easily accessible marker to predict clinical presentation at diagnosis and mortality rates during follow-up of patients with TGCT. Preoperative LMR can also be associated with the clinical picture at the time of diagnosis of TGCT. Key Words: De ritis ratio, Lymphocyte-to-monocyte ratio, Neutrophil-to-lymphocyte ratio, Neutrophil-to-monocyte ratio, Platelet-to-lymphocyte ratio, Testicular  germ cell tumor.

Preoperative Inflammation Markers in Predicting Biochemical Recurrence after Robot-assisted Radical Prostatectomy.

OBJECTIVE: To evaluate the importance of preoperative neutrophil-to-lymphocyte ratio (NLR),  lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), and neutrophil-to-monocyte ratio (NMR) in prostate cancer patients, who underwent robot-assisted radical prostatectomy (RARP). STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Urology Department, Antalya Training and Research Hospital, Turkey, between March 2015 and September 2019. METHODOLOGY: Four hundred and fifty-four patients underwent RARP were scanned. Clinical characteristics and pathological features of patients were recorded. Patients were excluded, if they had persistent PSA; a history of any autoimmune or inflammatory disease; anti-inflammatory agents use; blood transfusion within 3 months; or a follow-up time shorter than 3 months. Systemic inflammation markers were calculated and correlated with patients' data and biochemical recurrence (BCR). Biochemical recurrence was defined as two repetitive measurements of PSA levels ≥0.2 ng/mL at 3  months after the radical prostatectomy. Mann-Whitney U-test, Fisher's exact test, and Pearson Chi-square test, ROC curve, Kaplan-Meier survival analyses, and Cox proportional hazard regression model were used as statistical methods. RESULTS:   Four hundred and two patients were eligible. The median age at RP was 65.5 (61-69) years and median PSA of the patients was 8.3 (5.76-12.61)  ng/ml. Median NLR, LMR, PLR, and NMR were 2 (1.55-2.61), 3.86 (3.14-5), 105.69 (85-134.29), 7.82 (6.25-9.71); and  optimal cut-off values were 2.33, 3.75, 106.6, and 8.75, respectively. Low LMR was found as  an important predictor of biochemical recurrence (hazard ratio, HR=1.769, 95% confidence interval, CI=1.091 - 2.868, p=0.021). A significant association was found between lower LMR and decreased BCR -free survival (p <0.001). CONCLUSION: Pretreatment low LMR might be a simple and inexpensive index, which reflects the host systemic immunity and can predict independently BCR after RARP. Key Words: Biochemical recurrence, Lymphocyte-to-monocyte ratio, Neutrophil-to-lymphocyte ratio, Neutrophil-to-monocyte ratio, Platelet-to-lymphocyte ratio, Prostate cancer.

The effect of peritoneal re-approximation on lymphocele formation in transperitoneal robot-assisted radical prostatectomy and extended pelvic lymphadenectomy.

OBJECTIVE: The objective of the study was to evaluate the effect of peritoneal re-approximation at the end of the procedure in transperitoneal robot-assisted radical prostatectomy (tRARP) and extended pelvic lymphadenectomy (ePLND) on operative, oncologic, and symptomatic lymphocele rates. MATERIAL AND METHODS: A total of 79 patients were included in the study who underwent tRARP and bilateral ePLND performed by two different experienced surgeons. One of the surgeons performed the peritoneal re-approximation (Group 1, n=41) and the other did not re-approximate the peritoneum (Group 2, n=38) at the end of the procedure in tRARP and ePLND. Operative parameters and symptomatic lymphocele rates were compared between the groups. RESULTS: There were no significant differences between the preoperative parameters age, body mass index, and preoperative prostate-specific antigen values (p>0.05). The perioperative parameters were as follows: the operation time and estimated blood loss (EBL) was less, and the number of removed lymph nodes was higher in Group 2. However, only the difference in the EBL was statistically significant (p=0.03). Hospitalization time, symptomatic lymphocele, intervention requiring lymphocele, and complication rates were found to be less in Group 2, but only hospitalization time was statistically significant (p=0.04). Pathological parameters were similar for both groups. There was a significant correlation between lymph node positivity and the presence of symptomatic lymphocele in the correlation analysis (p=0.05). CONCLUSION: It has been shown in this study that the re-approximation of the peritoneum does not provide any additional benefit in terms of complications. Considering that this process also increases the operation time and lymphocele formation, we think there is no need for re-approximation after robot-assisted radical prostatectomy and pelvic lymphadenectomy.

Comparison of a Visual Prostate Symptom Score and International Prostate Symptom Score: A Prospective Multicenter Study and Literature Review.

OBJECTIVE: To evaluate the correlation between Visual Prostate Symptom Score (VPSS) and the International Prostate Symptom Score (IPSS) and uroflowmetry parameters in men with lower urinary tract symptoms (LUTS) with literature review. METHODS: Patients were pooled from 4 different urology clinics in Turkey and divided into 3 groups according to their educational level. The scores of IPSS and the VPSS questionnaire, assistance requirement, and completion time of the questionnaires were recorded. Maximum flow rate (Qmax) and average flow rate (Qave) were determined with uroflowmetry test and the results are recorded. RESULTS: A total of 342 patients were evaluated (group 1, n = 168; group 2, n = 108; group 3, n =66). Median age of all groups was 61 (40-89). There was a significantly higher rate of the completion of VPSS than IPSS without assistance in total (P < .001). Educational level was not found as an independent factor with assistance requirement to complete VPSS while university educational level was found as an independent factor to complete IPSS (odds ratio = 9.735, P < .001).There was a significantly lower completion time for VPSS in all groups when compared to IPSS (P < .001 for all groups). Significant positive correlations were found between VPSS and IPSS questions (P < .001). There were significant negative correlations between total score and weak stream question of VPSS and Qmax and Qave, separately (P < .001). CONCLUSION: VPSS can be more practical than IPSS to evaluate LUTS in men with low educational levels and/or in large populations. Some modifications are needed to increase the availability of VPSS.

Early outcomes of robotic retroperitoneal partial nephrectomy: evaluating surgical success with margin, ischemia, and complication score

SUMMARY OBJECTIVE: The objective of this study was to evaluate the minimum number of required cases for successful robotic retroperitoneal partial nephrectomy for an experienced surgeon in transperitoneal robotic surgery. METHODS: Our prospectively collected clinic database was evaluated retrospectively, and 50 patients who underwent robotic retroperitoneal partial nephrectomy by a single experienced surgeon from January 2019 to February 2023 were included in this study. Demographic and perioperative data and R.E.N.A.L. nephrometry scores were noted. margin, ischemia, and complication score was used to predict surgical success. Receiver operating characteristic curve analysis was used to determine how many cases were required to achieve margin, ischemia, and complication score positivity and to apply the off-clamp technique. Also, the first 25 patients were assigned to Group 1 and the second 25 patients to Group 2, and the data were compared between the groups. RESULTS: The patients' demographic data and tumor characteristics were similar in the groups. The off-clamp technique and sutureless technique rates in Group 2 were significantly higher than that in Group 1. Margin, ischemia, and complication score positivity was observed in 60% (n=15) of Group 1 and 96% (n=24) of Group 2. At receiver operating characteristic curve analysis, the 25th and later cases were statistically significant in terms of margin, ischemia, and complication score positivity. In terms of performing surgery with the off-clamp technique, the 28th and subsequent cases were statistically significant. CONCLUSION: A total of 25 or more cases appear to be sufficient to provide optimal surgical results in robotic retroperitoneal partial nephrectomy for an experienced surgeon.