Ficarra et al. have published a systematic review and meta-analysis of the studies that have reported outcomes related with erectile function in 2012 [28]. The 12- and 24- month potency rates ranged from 54 to 90% and 63 to 94%, respectively. In this paper, they have covered the RARP series that were published between 2008 and 2011 and included more than 100 patients. Age, baseline erectile function (International Index of Erectile Function (IIEF)-5 score), comorbidities (Charlson score), and extension of the nerve-sparing procedure represented the most important predictors of the risk of postoperative erectile dysfunction.

Furthermore, combination of these variables (age, IIEF score, and Charlson score) within the context of Briganti risk group stratification made it possible to provide a better overview to the patients about what to be expected after RARP in terms of erectile function recovery according to their individual risk category. Low-risk patients’ (age ≤ 60 year, baseline IIEF-6 > 21, and Charlson score ≤ 1) potency rates were 81.9% at 12 months, while the same rate was calculated to be 28.6% among high-risk individuals (age > 70, baseline IIEF-6 score ≤ 10, and Charlson score ≤ 2) [29].

Among the clinical series that included only the bilateral nerve-sparing procedures, 3-, 6-, 12-, and 24-month potency rates were 56%, 69% (50–86%), 74% (62–90%), and 82% (69–94%), respectively [28]. (A)thermal dissection of the neurovascular bundles [30], cold dissection of the cavernous nerve [31], countertraction during the nerve-sparing dissection [32], and the boundaries of the nerve-sparing dissection (intrafascial, interfascial, and extrafascial) represent the most common technical modifications that have been tested in terms of their potential beneficial role regarding postoperative erectile function recovery. Mean potency rates at 3, 6, and 12 months were 44, 50, and 66% (62–75%), respectively, in the clinical series using cautery (monopolar or bipolar) dissection and 52%, 78% (70–86%), and 81% (62–90%), respectively, in the studies using the athermal dissection [28]. Available data seem to support the use of cautery-free dissection or the use of pinpointed low-energy cauterization.

Despite the absence of high-quality level of evidence within this context, cumulative analyses showed better 12-month potency rates after RARP in comparison with RRP (odds ratio [OR], 2.84; 95% confidence interval [CI], 1.46–5.43; p = 0.002). On the other hand, the difference between RARP and LRP remained statistically insignificant (OR, 1.89; p = 0.21) [28].

In the recently published prospective randomized study comparing the outcomes of open versus robotic RP, which represent the relevant paper with the highest level of evidence so far, sexual function scores (sexual domain of EPIC and IIEF) did not differ significantly between the RRP group and the RARP group at 6 weeks postsurgery (30.70 vs. 32.70; p = 0.45) or 12 weeks postsurgery (35.00 vs. 38.90; p = 0.18) [33].

In their systematic review, Ficarra et al. have analyzed 51 articles that reported on urinary continence rates after RARP [34]. If urinary continence was defined more strictly as using no pads at all, the 12-month urinary incontinence rates ranged from 4 to 31%, with a mean value of 16%. However, if the definition was extended to involve a safety pad, then the incidence ranged from 8 to 11%, with a mean value of 9%. Age, body mass index, comorbidity index, lower urinary tract symptoms, and prostate volume were the most important preoperative parameters that influenced the risk of urinary incontinence after RARP. When different surgical approaches were compared in terms of continence recovery, RARP outperformed open (OR, 1.53; p = 0.03) and laparoscopic RP (OR, 2.39; p = 0.006) with a significantly better 12-month continence rate [34]. Approaching extra- or transperitoneally [35], bladder neck preservation [36], hypothermic nerve-sparing dissection using cold irrigation [31], dividing dorsal venous complex via athermal techniques initially and then selectively suture ligating prior to anastomosis [36], barbed versus monofilament sutures for urethrovesical anastomosis [37], and posterior/anterior reconstructions [38] represent the most commonly utilized/tested technical modifications that were employed in an effort to optimize continence recovery post-RARP. Available literature data seems in favor of total reconstruction with a significantly better continence outcome early postoperatively when compared with those who did not undergo such a reconstruction. However, it should be noted that beyond 6 months postoperatively continence rates of those who were reconstructed or not started to overlap.

A recent, prospective, controlled, nonrandomized, multi-institutional trial, comparing open and robotic approaches, showed that continence rates did not differ at 12 months postoperatively [39]. Yaxley et al. reported nonsignificant differences between the urinary function scores (urinary domain of EPIC) of open versus robotic RP at 6 (74.50 vs. 71.10; p = 0.09) and 12 weeks (83.80 vs. 82.50; p = 0.48) postoperatively in their randomized controlled phase 3 study [33]. Functional results of some of the most contemporary RARP series with available data are summarized in Tables 12.2 and 12.3.