Evolution of Surgical Efficacy and Postoperative Outcomes of a surgeon Throughout the Learning Curve of Laparoscopic Radical Prostatectomy with limited experience of open surgery

Evolution of Surgical Efficacy and Postoperative Outcomes of a surgeon Throughout the Learning Curve of Laparoscopic Radical Prostatectomy with limited experience of open surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evolution of Surgical Efficacy and Postoperative Outcomes of a surgeon Throughout the Learning Curve of Laparoscopic Radical Prostatectomy with limited experience of open surgery Yusuf SENOGLU, Ismail Eyup DILEK, Emre EDIZ, Necati EKICI, Dursun BABA, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7556189/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Feb, 2026 Read the published version in BMC Surgery → Version 1 posted 14 You are reading this latest preprint version Abstract Objective This study aimed to evaluate the learning curve, as well as the oncological and functional outcomes, of a surgeon who initiated laparoscopic radical prostatectomy (LRP) in a low-volume center after limited experience with open radical prostatectomy. Materials and Methods In this retrospective study, 90 patients who underwent LRP were analyzed. For assessing the learning curve, patients were divided chronologically into three groups of 30 each. Demographic data, preoperative prostate specific antigen (PSA), biopsy The international society of urological pathology (ISUP) grade, operative time, intraoperative blood loss, transfusion requirement, length of hospital stay, postoperative catheterization duration, pathological outcomes, and one-year PSA recurrence, continence, and erectile function were evaluated. Results Operative time decreased with experience, reaching a plateau phase after approximately 60 cases (Group 1: 251.3 ± 52.3 min vs. Group 3: 218.7 ± 40.4 min; p = 0.027). Hospital stay also significantly declined with experience (Group 1: 5.5 days vs. Group 3: 4.1 days; p < 0.001). Although a decrease in blood loss was observed, it did not reach statistical significance, and transfusion rates remained minimal (3.3%). The rate of lymph node dissection significantly increased with surgical experience (Group 1: 23.3% vs. Group 3: 56.7%; p = 0.022). No significant differences were observed in early complications or PSA recurrence rates between groups. Erectile function preservation improved from 23.3% in Group 1 to 50.0% in Group 3, whereas continence outcomes remained comparable. Conclusions For surgeons initiating LRP, operative time reaches a plateau after approximately 60 cases, while functional outcomes continue to improve over time. With appropriate training and mentorship, LRP can be safely and effectively performed in low-volume centers with acceptable perioperative and functional results throughout the learning process. Trial registration: Retrospectively registered. Laparoscopy radical prostatectomy learning curve Figures Figure 1 Background Laparoscopic radical prostatectomy (LRP) has revolutionized the field of minimally invasive surgery and has been recognized as a standard surgical procedure in many centers in the modern era. Both laparoscopic and robot-assisted laparoscopic approaches stand out due to advantages such as reduced perioperative complications and shorter hospitalization. ( 1 , 2 ). The learning curve represents a period during which a surgeon demonstrates noticeable improvement in performance parameters as experience accumulates. This improvement continues until a “plateau” phase is reached, at which point the impact of inexperience on outcomes diminishes, and performance stabilizes, with only minor additional gains observed with further case volume. ( 3 ). Although the robot-assisted laparoscopic approach has a shorter learning curve compared to the standard technique, conventional laparoscopy continues to be widely practiced in many countries due to its greater accessibility and cost-effectiveness. Numerous studies in the literature have examined the experiences with laparoscopic radical prostatectomy (LRP). Current evidence indicates that LRP is generally initiated after surgeons have gained experience in open radical prostatectomy (ORP). Furthermore, the majority of these procedures have been reported to be performed by surgeons with prior laparoscopic experience, predominantly in high-volume centers and under the supervision of experienced mentors ( 4 ). However, whether similar learning curves can be reproduced in procedures performed without mentor support or by surgeons working in low-volume centers remains insufficiently addressed in the literature. This study aimed to investigate the learning curve and perioperative outcomes of a surgeon who initiated LRP after limited prior experience with open surgery. Methods Ethical approval for the study was obtained from the Ethics Committee of Düzce University on February 19, 2024 (Decision No: 2024/19). The study was conducted retrospectively, and informed consent was obtained from all patients. A total of 90 patients who were diagnosed with localized prostate cancer and underwent laparoscopic radical prostatectomy (LRP) between March 2021 and January 2024, with a minimum follow-up of one year, were retrospectively evaluated. All patients were chronologically divided into three groups of 30 cases each according to the date of surgery: Group 1 (cases 1–30), Group 2 (cases 31–60), and Group 3 (cases 61–90). The following variables were assessed: demographic characteristics, preoperative total prostate-specific antigen (PSA) level, biopsy and postoperative ISUP grade, operative time, intraoperative blood loss, hemoglobin change, transfusion requirement, length of hospital stay, postoperative urethral catheterization duration, pathological stage, PSA recurrence within one year postoperatively, continence status, and erectile function. After completing his urology residency training, the surgeon worked with a mentor in uro-oncologic surgery for approximately two years. He subsequently gained approximately two years of laparoscopic experience in various urologic procedures. After performing approximately 20 open radical prostatectomies himself, he began performing laparoscopic radical prostatectomy cases. Laparoscopic surgery was performed via a transperitoneal approach with an intra-abdominal pressure of 12 mmHg and the patient positioned in a 30° Trendelenburg orientation. A 10-mm trocar was inserted superior to the umbilicus for the telescope, followed by the placement of two additional 10-mm trocars and two 5-mm trocars under endoscopic guidance. After posterior dissection of the seminal vesicles and prostate, the procedure was continued from the anterior surface of the bladder, and the prostate was excised. Urethrovesical anastomosis was performed in a continuous fashion using a double-armed 3-0 absorbable suture. Intraoperative and early postoperative complications (within 28 days) were classified using the modified Clavien system. Estimated blood loss was calculated by taking into account the volume collected in vacuum canisters. Patients were classified into risk groups based on the EAU prostate cancer risk classification. Those in the intermediate- to high-risk groups underwent lymph node dissection. Prostate volume was measured by MRI. Neurovascular bundles were preserved in appropriate patients, considering local invasion. A 20-Fr urethral catheter was removed between postoperative days 10 and 14. All patients were instructed to perform Kegel exercises before discharge and during follow-up appointments. Continence status was classified into three categories: severe incontinence, mild incontinence, and complete continence. Complete continence was defined as patients who remained completely dry throughout the day. Mild incontinence was defined as patients requiring only a single safety pad or those remaining dry without pad use under medical therapy. Severe incontinence was defined as persistent leakage despite medical treatment or the use of more than two pads per day. Erectile function was defined as the presence of erections sufficient for sexual intercourse at 1 year postoperatively, regardless of the use of supportive therapy. Biochemical recurrence within the first postoperative year was defined as two consecutive serum PSA measurements ≥0.2 ng/mL. Statistical analyses were performed using IBM SPSS Statistics, version 27.0 (IBM Corp., Armonk, NY, USA). Continuous variables with normal distribution were expressed as mean ± standard deviation, while those without normal distribution were presented as median (minimum–maximum). Categorical variables were expressed as number and percentage (n, %). For comparisons between groups, the chi-square (χ²) test was used for categorical variables. One-way analysis of variance (ANOVA) was applied for normally distributed continuous variables, and the Kruskal–Wallis test was used for non-normally distributed variables. In cases where ANOVA revealed significant differences, pairwise comparisons were conducted using the independent-samples t-test, while the Mann–Whitney U test was applied for non-parametric data. Learning curve analyses were performed using GraphPad Prism version 8.0 (GraphPad Software, San Diego, CA, USA). All tests were evaluated at a 95% confidence interval, and a p-value <0.05 was considered statistically significant. RESULTS When demographic and preoperative data were evaluated, the mean age was 66.4 ± 6.9 years and the mean BMI was 26.0 ± 3.6 kg/m². No significant differences were observed between the groups in terms of age and BMI (p=0.403). The mean prostate volume was 49 ± 23.8 cc, with no significant intergroup differences (p=0.065). The distribution of ISUP grades was also comparable across all groups (p=0.589). Detailed preoperative data are presented in Table 1. Table 1. Demographic and preoperative characteristics of the study population Group 1 Group 2 Group 3 Total p value Age(year) 67.1 ±7.3 65.7 ±7.4 66.4 ±6.3 66,4 ± 6,9 0.742 BMI(kg/m²) 26.2 ±3.8 26.5 ±3.7 25.3 ±3.1 26 ± 3,6 0.403 PSA(ng/dl) 8.79 ±6.15 10.8 ±4.88 11.74 ±10.78 10.45± 7.7 0,088 Prostate volume(ml) 55.1 ±28.8 50.8±24.6 41.1±14.4 49 ± 23.8 0.065 Biopsy ISUP Grade (n,%) 0,589 ISUP 1 15,%50 13, %43.3 10, %33.3 38, %42.2 ISUP 2 11, %36.7 11, %36.7 10, %33.3 32, %35.6 ISUP 3 3, %10 3, %10 7, %23.3 13, %14.4 ISUP 4 1, %3.3 2, %6.7 3, %10 6, %6.7 ISUP 5 0 1, %3.3 0 1, %1.1 Data with normal distribution are presented as mean ± standard deviation, while categorical variables are expressed as number (percentage). PSA: Prostate-specific antigen; BMI: Body mass index; ISUP: International Society of Urological Pathology. The mean operative time was 251.33 ± 52.26 minutes in Group 1, 230.9 ± 46.5 minutes in Group 2, and 218.66 ± 40.41 minutes in Group 3 (p=0.027). Post hoc analysis revealed a statistically significant difference between Group 1 and Group 3 (p=0.024). Operative time demonstrated a logarithmic decreasing trend with increasing case numbers (Figure 1). However, only approximately 13% of the reduction in operative time could be attributed solely to case number. The learning curve reached a plateau after around the 60th case (R² = 0.131, curve p < 0.001). Although a decrease in blood loss was observed over time, it did not reach statistical significance (p=0.102). The need for transfusion remained minimal (3.3%). A significant increase was noted in the number of cases in which lymph node dissection was performed as surgical experience increased, with post hoc analysis revealing a significant difference between Group 1 and Group 3 (23.3% vs. 56.7%; p=0.022). Neurovascular bundle preservation was attempted in all surgically eligible patients. Detailed intraoperative data are presented in Table 2. Table 2. Intraoperative data Group 1 Group 2 Group 3 Total p value Operative time (min) 251.33 ±52.26 230.9 ±46.5 218.66 ±40.41 233.6± 48.06 0,027* Post hoc analysis Group 1-2: 0.28 Group 1-3: 0.024* Group 2-3:0.938 Estimated blood loss (mL) 207.03±150.98 185.17±235.38 183 ±122 193.26±169.48 0.102** Hemoglobin change 1.36±0.92 0.84±1.13 0.94±0.88 1.05±0.99 0.09 Blood transfusion requirement (n, %) 1, %3.3 2, %6.6 0 3, %3.3 0.355 Llymph node dissection (n, %) 7 , %23,3 15 , %50 17, %56,7 39 , %43,3 0.022 Chi-square post hoc analysis: A significant difference was observed between Group 1-3. Data are presented as mean ± standard deviation for normally distributed variables, and number (percentage) for categorical variables. Bold italics indicate statistical significance at p<0.05. * One-way ANOVA was used; Bonferroni correction was applied for post hoc testing. ** The Kruskal–Wallis test was used for comparison between the groups. The mean length of hospital stay decreased from 5.5 ± 1.19 days in Group 1 to 4.1 ± 1.24 days in Group 3 (overall mean: 4.8 ± 1.38 days; p<0.001). Post hoc analysis demonstrated a significant difference of 1.4 days between Group 1 and Group 3 (p<0.001). Urethral catheterization times were comparable among the groups (p=0.206). The rates of positive surgical margins were 13.3%, 20.0%, and 3.3% in Groups 1, 2, and 3, respectively (overall 12.2%). Although a numerical decrease was observed in Group 3, the difference was not statistically significant (p=0.140). Postoperative pathological evaluation revealed no significant differences among the groups in terms of ISUP grade distribution (p=0.098) or pathological T stage distribution (p=0.140). Nonetheless, with increasing surgical experience, patients with higher-risk profiles (higher grade and advanced T stage) were more frequently selected for surgery. Detailed postoperative data are presented in Table 3. No significant differences were found among the groups regarding early postoperative complications. A total of 14 patients experienced Clavien Grade I–II complications, and one patient experienced a Clavien Grade III–IV complication. The most common complications included wound infection at the trocar site in five patients, hematuria requiring manual irrigation in three patients, conjunctivitis in two patients, widespread ecchymosis due to bleeding diathesis in one patient, and unexplained tachycardia in two patients. In addition, one patient developed hypoxic pulmonary embolism, which was managed with low-molecular-weight heparin, and another patient developed ileus, which resolved with medical treatment. Table 3. Postoperative outcomes Group 1 Group 2 Group 3 Total p value Length of hospital stay (days) 5.5 ±1.19 4.83 ±1.37 4.1 ±1.24 4.8 ± 1.38 <0.001 Post hoc analysis: Group 1-2: 0.084 Group 1-3: <0.001* Group 2-3:0.135 Urethral catheterization (days) 12.6±1.47 12.03±1.60 12±1.26 12.21±1.47 0.206 Early complications (n, %) 4, %13.3 7, %23.3 4, %13.3 15, %16.7 0.487 Positive surgical margin (n, %) 4, %13.3 6, %20 1, %3.3 11, %12.2 0.140 Prostatectomy-ISUP Grade 0.098 1 (n,%) 3, %10 5, %16.7 3, %10 11, %12.2 2 (n,%) 15, %50 17, %60 14, %46.7 46, %51.1 3 (n,%) 2, %6.7 2, % 6.7 9, %30 12, %14.4 4 (n,%) 4, %13.3 4, %13.3 3, %10 11, %12.2 5 (n,%) 6. %20 2, %6.7 1, %3.3 9, %10 Pathological T stage 0.056 T1 0 2, %6.6 0 2, %2.2 T2 24, %80 20, %66.7 16, %53.3 60, %66.7 T3 5, %16.7 8, %26.7 14,%46.70 27, %30 T4 1,%3.3 0 0 1, %1.1 Values with p < 0.05 are shown in bold italics and considered statistically significant. Normally distributed variables are presented as mean ± standard deviation, and categorical variables as number (percentage). Abbreviations: ISUP, International Society of Urological Pathology. PSA recurrence was observed in 10% of Group 1, 3.3% of Group 2, and 13.3% of Group 3, with no statistically significant difference among the groups (p=0.383). The rate of patients with preserved erectile function was 23.3% in Group 1 and 16.7% in Group 2, increasing to 50.0% in Group 3. Post hoc analysis revealed a significant difference between Group 2 and Group 3 (p=0.012). In terms of continence, no significant differences were observed among the groups (p=0.546). The rates of complete continence were 53.3% in Group 1, 46.7% in Group 2, and 50.0% in Group 3 (overall 50.0%). Mild incontinence was the most common condition, detected in 43.3% of patients. All postoperative outcomes are summarized in Table 4. Table 4. Long-term postoperative outcomes Group 1 Group 2 Group 3 Total p value PSA recurrence 3, %10 1, %3.3 4, %13.3 8, %8.9 0.383 Erectile function 0.012* Present (n, %) 7 ,%23.3 5, %16.7 15, %50 27, %30 Absent (n, %) 23, %76.7 25, %83.3 15, %50 63, %70 Continence 0.546 Severe incontinence (n, %) 3, %10 2, %6.7 1, %3.3 6 ,%6.7 Mild incontinence (n, %) 11, %36.7 14, %46.7 14, %46.7 39, %43.3 Complete continence (n, %) 16, %53.3 14, %46.7 15, %50 45, %50 * Chi-square post hoc analysis: A significant difference was observed between Group 2 and Group 3. DISCUSSION Laparoscopic radical prostatectomy (LRP) has become an established treatment modality for localized prostate cancer with the advancement of minimally invasive surgical techniques. Although robot-assisted surgery has gained popularity, laparoscopic procedures remain widely practiced in developing countries due to their lower cost (5). However, the learning curve of this complex procedure is of critical importance, particularly in low-volume centers, with respect to both surgical experience and patient outcomes (6). The learning curve refers to the process in which a surgeon develops knowledge and skills in performing a specific surgical procedure, leading to progressive improvement in performance over time. The primary challenge during this period is to ensure surgical safety. The initial goal is to optimize perioperative parameters such as operative time, blood loss, and complications. With increasing experience, the focus inevitably shifts toward improving oncological outcomes, including the reduction of positive surgical margins and achieving long-term biochemical recurrence-free survival (3,7). Functional outcomes such as urinary continence and erectile function are also important patient-centered indicators; however, their assessment is more challenging as they require longer follow-up periods. There is considerable variability in the literature regarding the number of cases required to reach the plateau phase of the learning curve, with reports ranging from 40 to 250 procedures (8,9). In our study, a significant reduction in operative time was observed with increasing surgical experience (Group 1: 251.33 minutes vs. Group 3: 218.66 minutes; p=0.027), and the learning curve reached a plateau after approximately the 60th case. This finding is consistent with previous reports in the literature. Studies conducted in low-volume centers have also demonstrated a progressive decline in operative time, with the plateau phase being achieved after approximately 80–100 cases (10,11) . In the international multicenter study by Secin et al., stabilization of the learning curve was reported after 200–250 cases (6,12,13) . The discrepancies among studies support that various factors, such as surgeon experience and center volume, may influence the learning curve of LRP. One of the major advantages of laparoscopic radical prostatectomy over open surgery is reduced blood loss. This benefit is attributed to the more effective control of the dorsal venous complex under magnified vision and the tamponade effect of pneumoperitoneum on venous bleeding (14).There are studies in the literature demonstrating that blood loss decreases with increasing surgical experience. In LRP, mean blood loss has been reported to range between 200–300 mL, with the learning curve reaching a plateau after 80–250 cases (15). In our study, the mean blood loss was approximately 150 mL, and no significant change was observed despite the increasing number of cases. The transfusion rate was 3.3%, which is consistent with the rates reported in the literature (16) . Various lengths of hospital stay have been reported for LRP, with the learning curve reaching a plateau after 25–100 cases. Di Gioia et al. reported a mean hospital stay of 2.15 days and demonstrated a significant reduction as their series progressed (p < 0.001) (12). In an analysis conducted in 2022, the mean length of hospital stay was reported as 5.7 days (2). In our series, the mean length of hospital stay decreased from 5.5 days in Group 1 to 4.1 days in Group 3, and this reduction was found to be statistically significant (p<0.001). Although the literature suggests that catheterization time may be reduced in the later stages of the learning curve due to improved anastomosis quality, no such difference was observed in our series (17). This suggests that the timing of catheter removal is more dependent on institutional protocols and may represent a parameter independent of the learning curve. Different approaches have been reported, with urethral catheterization times ranging between 4 and 14 days (17,18). In future large-cohort studies, postoperative evaluation and individualized catheter removal protocols may be considered to enable a more objective assessment of anastomotic quality. According to current literature, the rate of positive surgical margins (PSM) varies between 17% and 30%. Di Gioia et al. reported an overall PSM rate of 17.08% and identified the D’Amico risk classification as an independent risk factor for PSM occurrence throughout the learning curve. The authors emphasized that the risk of PSM, particularly in the apical and posterolateral regions of the prostate, can be reduced with increasing surgical experience. They also noted that the four apical margin cases observed among the first 20 patients in their series reflected the early phase of the learning curve (12). In the systematic review by Grivas et al., PSM rates in LRP were reported to decrease significantly after 50–60 cases, reaching a plateau phase between 150 and 350 cases (7). In our study, the overall PSM rate was 13% and 20% in Groups 1 and 2, respectively, with a marked improvement observed as experience increased, declining to 3% in the last 30 cases. However, due to the low number of patients with PSM, statistical significance was not achieved. The significant increase in the rate of lymph node dissection with experience (from 23.3% to 56.7%; p=0.022) may be explained by growing confidence in surgical skills and the adoption of a more comprehensive oncological approach. This finding suggests that, as the learning curve progresses, not only technical proficiency but also adherence to oncological principles improves. The primary aim of performing a procedure with a minimally invasive approach is to benefit from advantages such as reduced complications and morbidity, as well as faster recovery compared to conventional procedures. Although LRP is a minimally invasive technique, it may still lead to significant complications and morbidity. Di Gioia et al. reported an overall postoperative complication incidence of 20.41% (49/240). They observed a significant reduction in minor complications classified according to the Clavien–Dindo system (16.25%; p < 0.01), while major complications (4.16%) showed only a decreasing trend (p < 0.18) (12). Penezic et al. reported a Clavien–Dindo grade II complication rate of 7.9% in a series of 63 cases performed by two surgeons (19).In our study, the overall complication rate was 16%, while the rate of major complications was 1%. Biochemical recurrence is one of the most important indicators of oncological success following radical prostatectomy. Reported rates of biochemical recurrence after LRP vary across the literature. In the study by Vickers et al. including 4,702 patients, the 5-year recurrence risk decreased from 17% to 9% with increasing surgical experience (20). An important observation in our study was that, although a numerical increase was noted in Group 3, statistical significance was not reached. This finding may be explained by the tendency to select higher-risk patients for surgery in the later stages of the learning curve. The PSA recurrence rate of 8.9% in our cohort is comparable to the literature and supports the notion that oncological principles were maintained throughout the learning curve. Indeed, our postoperative pathological data further suggest that more complex cases were undertaken as surgical experience advanced. Once surgical safety and oncological control are achieved, one of the most important goals for patients is to obtain acceptable functional outcomes. In a large meta-analysis including 131,350 patients comparing open and minimally invasive techniques, the rates of erectile function at 12 months were reported as 41% for retropubic radical prostatectomy, 55% for laparoscopic radical prostatectomy, and 59% for robot-assisted radical prostatectomy (21). The same meta-analysis also emphasized that the criterion we used in our study—“erections sufficient for sexual intercourse”—is the most widely applied standard in the literature and represents the most appropriate parameter for comparative studies. In our series, a significant improvement in erectile function preservation was observed with increasing experience (Group 1: 23.3% vs. Group 3: 50.0%; p=0.012). This finding suggests that with growing surgical experience, nerve-sparing techniques improve, which in turn positively impacts functional outcomes. Post-prostatectomy incontinence is a multifactorial condition primarily resulting from internal sphincter insufficiency and may coexist with pre-existing or de novo bladder dysfunction (22). Age is a well-established predictor for the development of incontinence, playing a critical role both in the recovery of urinary control and in the presence of preoperative incontinence. In terms of surgical risk factors, surgeon experience and the technique employed have been identified as the most important determinants of postoperative continence outcomes. Preservation or reconstruction of membranous urethral supporting structures—particularly with techniques such as the “Rocco stitch”—has been reported to significantly improve early postoperative incontinence by stabilizing the anatomical position of the urethra during increases in intra-abdominal pressure (23). In our case series, the Rocco stitch was not employed; instead, the dorsal venous complex suture was anchored to the periosteum of the pubic bone for stabilization. Guillonneau et al. reported complete continence rates of 73% at 6 months and 82% at 12 months following surgery (17). In our study, no significant differences were observed among the three groups, with rates of 50% for complete continence and 43.3% for mild incontinence. In the literature, however, the definition and assessment of incontinence vary considerably across studies (24). This likely explains the wide variation in reported rates across different studies. Study Limitations Due to the retrospective design of our study, data were obtained from non-standardized records, which may have increased the likelihood of missing or inconsistent entries. An important limitation in the calculation of operative time was that the duration of lymph node dissection was not excluded from the total operative time. Since the rate of lymph node dissection significantly increased in the later stages of the learning curve (Group 1: 23.3% vs. Group 3: 56.7%), the mean operative times in the second and third groups may, in fact, have been even shorter. In the evaluation of oncological outcomes, positive surgical margin rates and PSA recurrence were not analyzed separately according to pathological T stage. This may have masked the true impact of the learning curve on oncological outcomes. Additionally, factors such as age, the presence of diabetes, and prostate volume are important variables that may influence continence and erectile function, but were not specifically analyzed in this study (25,26). Another limitation of our study is the lack of subgroup analyses for these parameters. Finally, as the study reflects the experience of a single center with a relatively small sample size, the generalizability of our findings is limited. Moreover, the assessment of the learning curve based on only 90 cases may not fully capture the longer learning processes reported in some studies in the literature. Conclusions This study analyzes the LRP learning curve of a surgeon who initiated the procedure with limited prior experience in open radical prostatectomy. Our findings demonstrate that the LRP learning curve can be achieved with acceptable perioperative and functional outcomes. Operative time reached a plateau after approximately 60 cases, while continuous improvement was observed in functional results. With appropriate training and mentorship, LRP can be performed safely and effectively even in low-volume centers. These results are encouraging for the broader adoption of minimally invasive surgery and for improving patient access to prostate cancer treatment. Abbreviations LRP - Laparoscopic Radical Prostatectomy PSA - Prostate Specific Antigen ISUP - The International Society of Urological Pathology ORP - Open Radical Prostatectomy MRI - Magnetic Resonance Imaging EAU - European Association of Urology BMI - Body Mass Index ANOVA - Analysis of Variance PSM - Positive Surgical Margins Fr - French (catheter size) Declarations Ethics approval and consent to participate: The study protocol was approved by the ‘Clinical Research Ethics Committee of Düzce University’ (February 19, 2024; Decision Number: 2024/19) and permission was obtained. Patients’ written consent was obtained and the procedures were in accordance with those outlined by the Declaration of Helsinki. Informed consent forms were obtained from all patients participating in the study. Consent for publication: Not applicable. Availability of data and materials: The data file has been uploaded in the supplementary material section. Competing Interests: The authors declare that they have no competing interests. Funding: This study received no external funding. Authors' contributions: Design: YS, IED Supervision: YS, DB Data Collection - Processing: IED, EE, NE Analysis-Interpretation: IED,ATT Writing: YS, IED. Critical Review: YS, DB, NE Acknowledgements: The author sincerely thanks Prof. Dr. Ali TEKIN, the mentor who provided surgical experience and guidance for the initial laparoscopic and open procedures. Clinical trial number: Not applicable. References Lantz A, Bock D, Akre O, Angenete E, Bjartell A, Carlsson S, et al. Functional and Oncological Outcomes After Open Versus Robot-assisted Laparoscopic Radical Prostatectomy for Localised Prostate Cancer: 8-Year Follow-up. Eur Urol [Internet]. 2021;80(5):650–60.Available from: https://www.sciencedirect.com/science/article/pii/S030228382101928X Moretti TBC, Magna LA, Reis LO. 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Urology. 1997;50(6):854–7. Ma J, Xu W, Chen R, Zhu Y, Wang Y, Cao W, et al. Robotic-assisted versus laparoscopic radical prostatectomy for prostate cancer: the first separate systematic review and meta-analysis of randomised controlled trials and non-randomised studies. Int J Surg. 2023;109(5):1350–9. Ficarra V, Novara G, Artibani W, Cestari A, Galfano A, Graefen M, et al. Retropubic, Laparoscopic, and Robot-Assisted Radical Prostatectomy: A Systematic Review and Cumulative Analysis of Comparative Studies. Eur Urol [Internet]. 2009;55(5):1037–63. Available from: https://www.sciencedirect.com/science/article/pii/S0302283809000499 Guillonneau B, Cathelineau X, Doublet JD, Baumert H, Vallancien G. Laparoscopic radical prostatectomy: assessment after 550 procedures. Crit Rev Oncol Hematol [Internet]. 2002;43(2):123–33. Available from: https://www.sciencedirect.com/science/article/pii/S1040842802000240 Nadu A, Salomon L, Hoznek A, Olsson LE, Saint F, de la TAILLE A, et al. Early removal of the catheter after laparoscopic radical prostatectomy. J Urol. 2001;166(5):1662–4. Penezić L, Kuliš T, Hudolin T, Zekulić T, Saić H, Kaštelan Ž. Laparoskopska radikalna prostatektomija: serija slučajeva jednog centra. Acta Clin Croat. 2022;61(Supplement 3):15–20. Vickers AJ, Savage CJ, Hruza M, Tuerk I, Koenig P, Martínez-Piñeiro L, et al. The surgical learning curve for laparoscopic radical prostatectomy: a retrospective cohort study. Lancet Oncol. 2009;10(5):475–80. Moretti TBC, Magna LA, Reis LO. Erectile dysfunction criteria of 131,350 patients after open, laparoscopic, and robotic radical prostatectomy. Andrology [Internet]. 2024 Nov 1;12(8):1865–71. Available from: https://doi.org/10.1111/andr.13634 Groutz A, Blaivas JG, CHAIKIN DC, Weiss JP, Verhaaren M. The pathophysiology of post-radical prostatectomy incontinence: a clinical and video urodynamic study. J Urol. 2000;163(6):1767–70. Rocco B, Calcagnile T, Assumma S, Sarchi L, Del Nero A, Sangalli M, et al. 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Cite Share Download PDF Status: Published Journal Publication published 06 Feb, 2026 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 16 Sep, 2025 Reviews received at journal 15 Sep, 2025 Reviewers agreed at journal 15 Sep, 2025 Reviewers agreed at journal 15 Sep, 2025 Reviewers agreed at journal 14 Sep, 2025 Reviewers agreed at journal 14 Sep, 2025 Reviews received at journal 14 Sep, 2025 Reviewers agreed at journal 13 Sep, 2025 Reviewers agreed at journal 13 Sep, 2025 Reviewers agreed at journal 13 Sep, 2025 Reviewers invited by journal 13 Sep, 2025 Editor assigned by journal 09 Sep, 2025 Submission checks completed at journal 09 Sep, 2025 First submitted to journal 07 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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DILEK","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYBACNhDBY2DBIMHeAGQBGcRqkWCQ4DkA0iJBpFU8DEAtEgkgJhFa+PgPH5N4UyAhJznz+dUNPwokGPjbuxPwO0wiLU1yjoGEsbR0TtnNHpALz5zdQEALj5k00C+J86Rz0m6APGUgkUtAC//5byAt9fMkz6Td/EOUFoYcNpCWBGkJ9mO3ibNFIs3YEugXw5k9OWy3ZQwkeAj6Rb7/8MMbb/7YyEscP/7sJpAhx9/ei18LELBA44LHAEwSUg4CzB8gNPsDYlSPglEwCkbBCAQAPrQ9Sk3ooBsAAAAASUVORK5CYII=","orcid":"","institution":"KAHTA STATE HOSPITAL","correspondingAuthor":true,"prefix":"","firstName":"Ismail","middleName":"Eyup","lastName":"DILEK","suffix":""},{"id":515715878,"identity":"5fd909fb-b1df-4091-b93f-87782ec0bb60","order_by":2,"name":"Emre EDIZ","email":"","orcid":"","institution":"Duzce University","correspondingAuthor":false,"prefix":"","firstName":"Emre","middleName":"","lastName":"EDIZ","suffix":""},{"id":515715880,"identity":"65e256c4-f16e-484c-b5a9-a3e798f93f8d","order_by":3,"name":"Necati 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06:47:45","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":98002,"visible":true,"origin":"","legend":"","description":"","filename":"6f51348d170c4c129469f3b695f927591structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7556189/v1/36e6ee020a897cdbbadafa74.xml"},{"id":91951629,"identity":"6011ed5e-2690-40a4-a8c6-a96a8189a9eb","added_by":"auto","created_at":"2025-09-23 06:47:44","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":104547,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7556189/v1/12be942d3d85453e44fcdf18.html"},{"id":91956874,"identity":"d79335a1-25e9-487e-a487-4cd40e7441da","added_by":"auto","created_at":"2025-09-23 07:19:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":39804,"visible":true,"origin":"","legend":"\u003cp\u003eLearning curve for laparoscopic radical prostatectomy – analysis of operative time\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7556189/v1/4a21a850460e990641d7fefd.png"},{"id":102234064,"identity":"0ae9aef4-528f-4148-928f-5048e35f7273","added_by":"auto","created_at":"2026-02-09 16:05:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":952795,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7556189/v1/54de1947-16c4-49cd-8ee2-807a88ca8ed7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eEvolution of Surgical Efficacy and Postoperative Outcomes of a surgeon Throughout the Learning Curve of Laparoscopic Radical Prostatectomy with limited experience of open surgery\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eLaparoscopic radical prostatectomy (LRP) has revolutionized the field of minimally invasive surgery and has been recognized as a standard surgical procedure in many centers in the modern era. Both laparoscopic and robot-assisted laparoscopic approaches stand out due to advantages such as reduced perioperative complications and shorter hospitalization. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The learning curve represents a period during which a surgeon demonstrates noticeable improvement in performance parameters as experience accumulates. This improvement continues until a \u0026ldquo;plateau\u0026rdquo; phase is reached, at which point the impact of inexperience on outcomes diminishes, and performance stabilizes, with only minor additional gains observed with further case volume. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Although the robot-assisted laparoscopic approach has a shorter learning curve compared to the standard technique, conventional laparoscopy continues to be widely practiced in many countries due to its greater accessibility and cost-effectiveness. Numerous studies in the literature have examined the experiences with laparoscopic radical prostatectomy (LRP). Current evidence indicates that LRP is generally initiated after surgeons have gained experience in open radical prostatectomy (ORP). Furthermore, the majority of these procedures have been reported to be performed by surgeons with prior laparoscopic experience, predominantly in high-volume centers and under the supervision of experienced mentors (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). However, whether similar learning curves can be reproduced in procedures performed without mentor support or by surgeons working in low-volume centers remains insufficiently addressed in the literature. This study aimed to investigate the learning curve and perioperative outcomes of a surgeon who initiated LRP after limited prior experience with open surgery.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eEthical approval for the study was obtained from the Ethics Committee of Düzce University on February 19, 2024 (Decision No: 2024/19). The study was conducted retrospectively, and informed consent was obtained from all patients. A total of 90 patients who were diagnosed with localized prostate cancer and underwent laparoscopic radical prostatectomy (LRP) between March 2021 and January 2024, with a minimum follow-up of one year, were retrospectively evaluated. All patients were chronologically divided into three groups of 30 cases each according to the date of surgery: Group 1 (cases 1–30), Group 2 (cases 31–60), and Group 3 (cases 61–90). The following variables were assessed: demographic characteristics, preoperative total prostate-specific antigen (PSA) level, biopsy and postoperative ISUP grade, operative time, intraoperative blood loss, hemoglobin change, transfusion requirement, length of hospital stay, postoperative urethral catheterization duration, pathological stage, PSA recurrence within one year postoperatively, continence status, and erectile function.\u003c/p\u003e\n\u003cp\u003eAfter completing his urology residency training, the surgeon worked with a mentor in uro-oncologic surgery for approximately two years. He subsequently gained approximately two years of laparoscopic experience in various urologic procedures. After performing approximately 20 open radical prostatectomies himself, he began performing laparoscopic radical prostatectomy cases.\u003c/p\u003e\n\u003cp\u003eLaparoscopic surgery was performed via a transperitoneal approach with an intra-abdominal pressure of 12 mmHg and the patient positioned in a 30° Trendelenburg orientation. A 10-mm trocar was inserted superior to the umbilicus for the telescope, followed by the placement of two additional 10-mm trocars and two 5-mm trocars under endoscopic guidance. After posterior dissection of the seminal vesicles and prostate, the procedure was continued from the anterior surface of the bladder, and the prostate was excised. Urethrovesical anastomosis was performed in a continuous fashion using a double-armed 3-0 absorbable suture.\u003c/p\u003e\n\u003cp\u003eIntraoperative and early postoperative complications (within 28 days) were classified using the modified Clavien system. Estimated blood loss was calculated by taking into account the volume collected in vacuum canisters.\u003c/p\u003e\n\u003cp\u003ePatients were classified into risk groups based on the EAU prostate cancer risk classification. Those in the intermediate- to high-risk groups underwent lymph node dissection. Prostate volume was measured by MRI. Neurovascular bundles were preserved in appropriate patients, considering local invasion. A 20-Fr urethral catheter was removed between postoperative days 10 and 14. All patients were instructed to perform Kegel exercises before discharge and during follow-up appointments.\u003c/p\u003e\n\u003cp\u003eContinence status was classified into three categories: severe incontinence, mild incontinence, and complete continence. Complete continence was defined as patients who remained completely dry throughout the day. Mild incontinence was defined as patients requiring only a single safety pad or those remaining dry without pad use under medical therapy. Severe incontinence was defined as persistent leakage despite medical treatment or the use of more than two pads per day.\u003c/p\u003e\n\u003cp\u003eErectile function was defined as the presence of erections sufficient for sexual intercourse at 1 year postoperatively, regardless of the use of supportive therapy. Biochemical recurrence within the first postoperative year was defined as two consecutive serum PSA measurements ≥0.2 ng/mL.\u003c/p\u003e\n\u003cp\u003eStatistical analyses were performed using IBM SPSS Statistics, version 27.0 (IBM Corp., Armonk, NY, USA). Continuous variables with normal distribution were expressed as mean ± standard deviation, while those without normal distribution were presented as median (minimum–maximum). Categorical variables were expressed as number and percentage (n, %). For comparisons between groups, the chi-square (χ²) test was used for categorical variables. One-way analysis of variance (ANOVA) was applied for normally distributed continuous variables, and the Kruskal–Wallis test was used for non-normally distributed variables. In cases where ANOVA revealed significant differences, pairwise comparisons were conducted using the independent-samples t-test, while the Mann–Whitney U test was applied for non-parametric data. Learning curve analyses were performed using GraphPad Prism version 8.0 (GraphPad Software, San Diego, CA, USA). All tests were evaluated at a 95% confidence interval, and a p-value \u0026lt;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eWhen demographic and preoperative data were evaluated, the mean age was 66.4 \u0026plusmn; 6.9 years and the mean BMI was 26.0 \u0026plusmn; 3.6 kg/m\u0026sup2;. No significant differences were observed between the groups in terms of age and BMI (p=0.403). The mean prostate volume was 49 \u0026plusmn; 23.8 cc, with no significant intergroup differences (p=0.065). The distribution of ISUP grades was also comparable across all groups (p=0.589). Detailed preoperative data are presented in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Demographic and preoperative characteristics of the study population\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"558\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eGroup 1\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eGroup 2\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eGroup 3\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAge(year)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e67.1 \u0026plusmn;7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e65.7 \u0026plusmn;7.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e66.4 \u0026plusmn;6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e66,4 \u0026plusmn; 6,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.742\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eBMI(kg/m\u0026sup2;)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e26.2 \u0026plusmn;3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e26.5 \u0026plusmn;3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e25.3 \u0026plusmn;3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e26 \u0026plusmn; 3,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.403\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePSA(ng/dl)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e8.79 \u0026plusmn;6.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e10.8 \u0026plusmn;4.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e11.74 \u0026plusmn;10.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e10.45\u0026plusmn; 7.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0,088\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eProstate volume(ml)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e55.1 \u0026plusmn;28.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e50.8\u0026plusmn;24.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e41.1\u0026plusmn;14.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e49 \u0026plusmn; 23.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.065\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eBiopsy\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eISUP Grade (n,%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0,589\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eISUP 1\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e15,%50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e13, %43.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e10, %33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e38, %42.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eISUP 2\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e11, %36.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e11, \u0026nbsp; \u0026nbsp; %36.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e10, %33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e32, %35.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eISUP 3\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e3, %10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3, %10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e7, %23.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e13, %14.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eISUP 4\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e1, %3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2, %6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e3, %10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e6, %6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eISUP 5\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1, %3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1, %1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eData with normal distribution are presented as mean \u0026plusmn; standard deviation, while categorical variables are expressed as number (percentage). PSA: Prostate-specific antigen; BMI: Body mass index; ISUP: International Society of Urological Pathology.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe mean operative time was 251.33 \u0026plusmn; 52.26 minutes in Group 1, 230.9 \u0026plusmn; 46.5 minutes in Group 2, and 218.66 \u0026plusmn; 40.41 minutes in Group 3 (p=0.027). Post hoc analysis revealed a statistically significant difference between Group 1 and Group 3 (p=0.024). Operative time demonstrated a logarithmic decreasing trend with increasing case numbers (Figure 1). However, only approximately 13% of the reduction in operative time could be attributed solely to case number. The learning curve reached a plateau after around the 60th case (R\u0026sup2; = 0.131, curve p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eAlthough a decrease in blood loss was observed over time, it did not reach statistical significance (p=0.102). The need for transfusion remained minimal (3.3%). A significant increase was noted in the number of cases in which lymph node dissection was performed as surgical experience increased, with post hoc analysis revealing a significant difference between Group 1 and Group 3 (23.3% vs. 56.7%; p=0.022). Neurovascular bundle preservation was attempted in all surgically eligible patients. Detailed intraoperative data are presented in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Intraoperative data\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eGroup 1\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eGroup 2\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eGroup 3\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eOperative time (min)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e251.33 \u0026plusmn;52.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e230.9 \u0026plusmn;46.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e218.66 \u0026plusmn;40.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e233.6\u0026plusmn; 48.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0,027*\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePost hoc analysis\u003c/p\u003e\n \u003cp\u003eGroup 1-2: 0.28\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eGroup 1-3:\u003cstrong\u003e0.024*\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eGroup 2-3:0.938\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eEstimated blood loss (mL)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e207.03\u0026plusmn;150.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e185.17\u0026plusmn;235.38\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e183 \u0026plusmn;122\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e193.26\u0026plusmn;169.48\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.102**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eHemoglobin change\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e1.36\u0026plusmn;0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e0.84\u0026plusmn;1.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.94\u0026plusmn;0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1.05\u0026plusmn;0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eBlood transfusion requirement (n, %)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e1, %3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e2, %6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3, %3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.355\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eLlymph node dissection (n, %)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e7 , %23,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e15 , %50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e17, %56,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e39 , %43,3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.022\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eChi-square post hoc analysis: A significant difference was observed between Group 1-3.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as mean \u0026plusmn; standard deviation for normally distributed variables, and number (percentage) for categorical variables. \u003cem\u003eBold italics\u003c/em\u003e indicate statistical significance at p\u0026lt;0.05. * One-way ANOVA was used; Bonferroni correction was applied for post hoc testing. ** The Kruskal\u0026ndash;Wallis test was used for comparison between the groups.\u003c/p\u003e\n\u003cp\u003eThe mean length of hospital stay decreased from 5.5 \u0026plusmn; 1.19 days in Group 1 to 4.1 \u0026plusmn; 1.24 days in Group 3 (overall mean: 4.8 \u0026plusmn; 1.38 days; p\u0026lt;0.001). Post hoc analysis demonstrated a significant difference of 1.4 days between Group 1 and Group 3 (p\u0026lt;0.001). Urethral catheterization times were comparable among the groups (p=0.206).\u003c/p\u003e\n\u003cp\u003eThe rates of positive surgical margins were 13.3%, 20.0%, and 3.3% in Groups 1, 2, and 3, respectively (overall 12.2%). Although a numerical decrease was observed in Group 3, the difference was not statistically significant (p=0.140). Postoperative pathological evaluation revealed no significant differences among the groups in terms of ISUP grade distribution (p=0.098) or pathological T stage distribution (p=0.140). Nonetheless, with increasing surgical experience, patients with higher-risk profiles (higher grade and advanced T stage) were more frequently selected for surgery. Detailed postoperative data are presented in Table 3.\u003c/p\u003e\n\u003cp\u003eNo significant differences were found among the groups regarding early postoperative complications. A total of 14 patients experienced Clavien Grade I\u0026ndash;II complications, and one patient experienced a Clavien Grade III\u0026ndash;IV complication. The most common complications included wound infection at the trocar site in five patients, hematuria requiring manual irrigation in three patients, conjunctivitis in two patients, widespread ecchymosis due to bleeding diathesis in one patient, and unexplained tachycardia in two patients. In addition, one patient developed hypoxic pulmonary embolism, which was managed with low-molecular-weight heparin, and another patient developed ileus, which resolved with medical treatment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Postoperative outcomes\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"595\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eGroup 1\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eGroup 2\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eGroup 3\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTotal\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eLength of hospital stay (days)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e5.5 \u0026plusmn;1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.83 \u0026plusmn;1.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e4.1 \u0026plusmn;1.24\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e4.8 \u0026plusmn; 1.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026lt;0.001\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePost hoc analysis:\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eGroup 1-2: 0.084\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eGroup 1-3:\u003c/em\u003e \u003cstrong\u003e\u003cem\u003e\u0026lt;0.001*\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eGroup 2-3:0.135\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eUrethral catheterization (days)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e12.6\u0026plusmn;1.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e12.03\u0026plusmn;1.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e12\u0026plusmn;1.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e12.21\u0026plusmn;1.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.206\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eEarly complications (n, %)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4, %13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e7, %23.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e4, %13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e15, %16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.487\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePositive surgical margin (n, %)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4, %13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e6, %20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e1, %3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e11, %12.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.140\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eProstatectomy-ISUP Grade\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.098\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e1 (n,%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3, %10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5, %16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e3, %10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e11, %12.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;2 (n,%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e15, %50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e17, %60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e14, %46.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e46, %51.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;3 (n,%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2, %6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2, % 6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e9, %30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e12, %14.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;4 (n,%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4, %13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4, %13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e3, %10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e11, %12.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;5 (n,%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e6. %20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2, %6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e1, %3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e9, %10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePathological T stage\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eT1\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2, %6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e2, %2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eT2\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e24, %80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e20, %66.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e16, %53.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e60, %66.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eT3\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e5, %16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e8, %26.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e14,%46.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e27, %30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eT4\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1,%3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e1, %1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eValues with p \u0026lt; 0.05 are shown in\u0026nbsp;\u003cem\u003ebold italics\u003c/em\u003e\u0026nbsp;and considered statistically significant. Normally distributed variables are presented as mean \u0026plusmn; standard deviation, and categorical variables as number (percentage).\u003cbr\u003eAbbreviations: ISUP, International Society of Urological Pathology.\u003c/p\u003e\n\u003cp\u003ePSA recurrence was observed in 10% of Group 1, 3.3% of Group 2, and 13.3% of Group 3, with no statistically significant difference among the groups (p=0.383).\u003c/p\u003e\n\u003cp\u003eThe rate of patients with preserved erectile function was 23.3% in Group 1 and 16.7% in Group 2, increasing to 50.0% in Group 3. Post hoc analysis revealed a significant difference between Group 2 and Group 3 (p=0.012). In terms of continence, no significant differences were observed among the groups (p=0.546). The rates of complete continence were 53.3% in Group 1, 46.7% in Group 2, and 50.0% in Group 3 (overall 50.0%). Mild incontinence was the most common condition, detected in 43.3% of patients. All postoperative outcomes are summarized in Table 4.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u003c/strong\u003e Long-term postoperative outcomes\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eGroup 1\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eGroup 2\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eGroup 3\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTotal\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cem\u003ePSA recurrence\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3, %10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1, %3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4, %13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e8, %8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e0.383\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cem\u003eErectile function\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.012*\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cem\u003ePresent (n, %)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e7 ,%23.3 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e5, %16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e15, %50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e27, %30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cem\u003eAbsent (n, %)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e23, %76.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e25, %83.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e15, %50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e63, %70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cem\u003eContinence\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e0.546\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cem\u003eSevere incontinence (n, %)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3, %10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2, %6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1, %3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e6 ,%6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cem\u003eMild incontinence (n, %)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e11, %36.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e14, %46.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e14, %46.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e39, %43.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cem\u003eComplete continence (n, %)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e16, %53.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e14, %46.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e15, %50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e45, %50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e Chi-square post hoc analysis: A significant difference was observed between Group 2 and Group 3.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eLaparoscopic radical prostatectomy (LRP) has become an established treatment modality for localized prostate cancer with the advancement of minimally invasive surgical techniques. Although robot-assisted surgery has gained popularity, laparoscopic procedures remain widely practiced in developing countries due to their lower cost (5). However, the learning curve of this complex procedure is of critical importance, particularly in low-volume centers, with respect to both surgical experience and patient outcomes (6). The learning curve refers to the process in which a surgeon develops knowledge and skills in performing a specific surgical procedure, leading to progressive improvement in performance over time. The primary challenge during this period is to ensure surgical safety. The initial goal is to optimize perioperative parameters such as operative time, blood loss, and complications. With increasing experience, the focus inevitably shifts toward improving oncological outcomes, including the reduction of positive surgical margins and achieving long-term biochemical recurrence-free survival (3,7). Functional outcomes such as urinary continence and erectile function are also important patient-centered indicators; however, their assessment is more challenging as they require longer follow-up periods.\u003c/p\u003e\n\u003cp\u003eThere is considerable variability in the literature regarding the number of cases required to reach the plateau phase of the learning curve, with reports ranging from 40 to 250 procedures (8,9). In our study, a significant reduction in operative time was observed with increasing surgical experience (Group 1: 251.33 minutes vs. Group 3: 218.66 minutes; p=0.027), and the learning curve reached a plateau after approximately the 60th case. This finding is consistent with previous reports in the literature. Studies conducted in low-volume centers have also demonstrated a progressive decline in operative time, with the plateau phase being achieved after approximately 80–100 cases (10,11) . In the international multicenter study by Secin et al., stabilization of the learning curve was reported after 200–250 cases (6,12,13) . The discrepancies among studies support that various factors, such as surgeon experience and center volume, may influence the learning curve of LRP.\u003c/p\u003e\n\u003cp\u003eOne of the major advantages of laparoscopic radical prostatectomy over open surgery is reduced blood loss. This benefit is attributed to the more effective control of the dorsal venous complex under magnified vision and the tamponade effect of pneumoperitoneum on venous bleeding (14).There are studies in the literature demonstrating that blood loss decreases with increasing surgical experience. In LRP, mean blood loss has been reported to range between 200–300 mL, with the learning curve reaching a plateau after 80–250 cases (15). In our study, the mean blood loss was approximately 150 mL, and no significant change was observed despite the increasing number of cases. The transfusion rate was 3.3%, which is consistent with the rates reported in the literature (16) .\u003c/p\u003e\n\u003cp\u003eVarious lengths of hospital stay have been reported for LRP, with the learning curve reaching a plateau after 25–100 cases. Di Gioia et al. reported a mean hospital stay of 2.15 days and demonstrated a significant reduction as their series progressed (p \u0026lt; 0.001) (12). In an analysis conducted in 2022, the mean length of hospital stay was reported as 5.7 days (2). In our series, the mean length of hospital stay decreased from 5.5 days in Group 1 to 4.1 days in Group 3, and this reduction was found to be statistically significant (p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003eAlthough the literature suggests that catheterization time may be reduced in the later stages of the learning curve due to improved anastomosis quality, no such difference was observed in our series (17). This suggests that the timing of catheter removal is more dependent on institutional protocols and may represent a parameter independent of the learning curve. Different approaches have been reported, with urethral catheterization times ranging between 4 and 14 days (17,18). In future large-cohort studies, postoperative evaluation and individualized catheter removal protocols may be considered to enable a more objective assessment of anastomotic quality.\u003c/p\u003e\n\u003cp\u003eAccording to current literature, the rate of positive surgical margins (PSM) varies between 17% and 30%. Di Gioia et al. reported an overall PSM rate of 17.08% and identified the D’Amico risk classification as an independent risk factor for PSM occurrence throughout the learning curve. The authors emphasized that the risk of PSM, particularly in the apical and posterolateral regions of the prostate, can be reduced with increasing surgical experience. They also noted that the four apical margin cases observed among the first 20 patients in their series reflected the early phase of the learning curve (12). In the systematic review by Grivas et al., PSM rates in LRP were reported to decrease significantly after 50–60 cases, reaching a plateau phase between 150 and 350 cases (7). In our study, the overall PSM rate was 13% and 20% in Groups 1 and 2, respectively, with a marked improvement observed as experience increased, declining to 3% in the last 30 cases. However, due to the low number of patients with PSM, statistical significance was not achieved. The significant increase in the rate of lymph node dissection with experience (from 23.3% to 56.7%; p=0.022) may be explained by growing confidence in surgical skills and the adoption of a more comprehensive oncological approach. This finding suggests that, as the learning curve progresses, not only technical proficiency but also adherence to oncological principles improves.\u003c/p\u003e\n\u003cp\u003eThe primary aim of performing a procedure with a minimally invasive approach is to benefit from advantages such as reduced complications and morbidity, as well as faster recovery compared to conventional procedures. Although LRP is a minimally invasive technique, it may still lead to significant complications and morbidity. Di Gioia et al. reported an overall postoperative complication incidence of 20.41% (49/240). They observed a significant reduction in minor complications classified according to the Clavien–Dindo system (16.25%; p \u0026lt; 0.01), while major complications (4.16%) showed only a decreasing trend (p \u0026lt; 0.18) (12). Penezic et al. reported a Clavien–Dindo grade II complication rate of 7.9% in a series of 63 cases performed by two surgeons (19).In our study, the overall complication rate was 16%, while the rate of major complications was 1%.\u003c/p\u003e\n\u003cp\u003eBiochemical recurrence is one of the most important indicators of oncological success following radical prostatectomy. Reported rates of biochemical recurrence after LRP vary across the literature. In the study by Vickers et al. including 4,702 patients, the 5-year recurrence risk decreased from 17% to 9% with increasing surgical experience (20). An important observation in our study was that, although a numerical increase was noted in Group 3, statistical significance was not reached. This finding may be explained by the tendency to select higher-risk patients for surgery in the later stages of the learning curve. The PSA recurrence rate of 8.9% in our cohort is comparable to the literature and supports the notion that oncological principles were maintained throughout the learning curve. Indeed, our postoperative pathological data further suggest that more complex cases were undertaken as surgical experience advanced.\u003c/p\u003e\n\u003cp\u003eOnce surgical safety and oncological control are achieved, one of the most important goals for patients is to obtain acceptable functional outcomes. In a large meta-analysis including 131,350 patients comparing open and minimally invasive techniques, the rates of erectile function at 12 months were reported as 41% for retropubic radical prostatectomy, 55% for laparoscopic radical prostatectomy, and 59% for robot-assisted radical prostatectomy (21). The same meta-analysis also emphasized that the criterion we used in our study—“erections sufficient for sexual intercourse”—is the most widely applied standard in the literature and represents the most appropriate parameter for comparative studies. In our series, a significant improvement in erectile function preservation was observed with increasing experience (Group 1: 23.3% vs. Group 3: 50.0%; p=0.012). This finding suggests that with growing surgical experience, nerve-sparing techniques improve, which in turn positively impacts functional outcomes.\u003c/p\u003e\n\u003cp\u003ePost-prostatectomy incontinence is a multifactorial condition primarily resulting from internal sphincter insufficiency and may coexist with pre-existing or de novo bladder dysfunction (22). Age is a well-established predictor for the development of incontinence, playing a critical role both in the recovery of urinary control and in the presence of preoperative incontinence. In terms of surgical risk factors, surgeon experience and the technique employed have been identified as the most important determinants of postoperative continence outcomes. Preservation or reconstruction of membranous urethral supporting structures—particularly with techniques such as the “Rocco stitch”—has been reported to significantly improve early postoperative incontinence by stabilizing the anatomical position of the urethra during increases in intra-abdominal pressure (23). In our case series, the Rocco stitch was not employed; instead, the dorsal venous complex suture was anchored to the periosteum of the pubic bone for stabilization.\u003c/p\u003e\n\u003cp\u003eGuillonneau et al. reported complete continence rates of 73% at 6 months and 82% at 12 months following surgery (17). In our study, no significant differences were observed among the three groups, with rates of 50% for complete continence and 43.3% for mild incontinence. In the literature, however, the definition and assessment of incontinence vary considerably across studies (24). This likely explains the wide variation in reported rates across different studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to the retrospective design of our study, data were obtained from non-standardized records, which may have increased the likelihood of missing or inconsistent entries. An important limitation in the calculation of operative time was that the duration of lymph node dissection was not excluded from the total operative time. Since the rate of lymph node dissection significantly increased in the later stages of the learning curve (Group 1: 23.3% vs. Group 3: 56.7%), the mean operative times in the second and third groups may, in fact, have been even shorter.\u003c/p\u003e\n\u003cp\u003eIn the evaluation of oncological outcomes, positive surgical margin rates and PSA recurrence were not analyzed separately according to pathological T stage. This may have masked the true impact of the learning curve on oncological outcomes.\u003c/p\u003e\n\u003cp\u003eAdditionally, factors such as age, the presence of diabetes, and prostate volume are important variables that may influence continence and erectile function, but were not specifically analyzed in this study (25,26). Another limitation of our study is the lack of subgroup analyses for these parameters. Finally, as the study reflects the experience of a single center with a relatively small sample size, the generalizability of our findings is limited. Moreover, the assessment of the learning curve based on only 90 cases may not fully capture the longer learning processes reported in some studies in the literature.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study analyzes the LRP learning curve of a surgeon who initiated the procedure with limited prior experience in open radical prostatectomy. Our findings demonstrate that the LRP learning curve can be achieved with acceptable perioperative and functional outcomes. Operative time reached a plateau after approximately 60 cases, while continuous improvement was observed in functional results. With appropriate training and mentorship, LRP can be performed safely and effectively even in low-volume centers. These results are encouraging for the broader adoption of minimally invasive surgery and for improving patient access to prostate cancer treatment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eLRP - Laparoscopic Radical Prostatectomy\u003c/p\u003e\n\u003cp\u003ePSA - Prostate Specific Antigen\u003c/p\u003e\n\u003cp\u003eISUP - The International Society of Urological Pathology\u003c/p\u003e\n\u003cp\u003eORP - Open Radical Prostatectomy\u003c/p\u003e\n\u003cp\u003eMRI - Magnetic Resonance Imaging\u003c/p\u003e\n\u003cp\u003eEAU - European Association of Urology\u003c/p\u003e\n\u003cp\u003eBMI - Body Mass Index\u003c/p\u003e\n\u003cp\u003eANOVA - Analysis of Variance\u003c/p\u003e\n\u003cp\u003ePSM - Positive Surgical Margins\u003c/p\u003e\n\u003cp\u003eFr - French (catheter size)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e The study protocol was approved by the ‘Clinical Research Ethics Committee of Düzce University’ (February 19, 2024; Decision Number: 2024/19) and permission was obtained. Patients’ written consent was obtained and the procedures were in accordance with those outlined by the Declaration of Helsinki. Informed consent forms were obtained from all patients participating in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u003cbr\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The data file has been uploaded in the supplementary material section.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;Competing Interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003cbr\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study received no external funding. \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003cbr\u003e\u003cstrong\u003eAuthors' contributions:\u003c/strong\u003e Design: YS, IED Supervision: YS, DB Data Collection - Processing: IED, EE, NE Analysis-Interpretation: IED,ATT Writing: YS, IED. Critical Review: YS, DB, NE\u003cbr\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e The author sincerely thanks Prof. Dr. Ali TEKIN, the mentor who provided surgical experience and guidance for the initial laparoscopic and open procedures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLantz A, Bock D, Akre O, Angenete E, Bjartell A, Carlsson S, et al. Functional and Oncological Outcomes After Open Versus Robot-assisted Laparoscopic Radical Prostatectomy for Localised Prostate Cancer: 8-Year Follow-up. Eur Urol [Internet]. 2021;80(5):650\u0026ndash;60.Available from: https://www.sciencedirect.com/science/article/pii/S030228382101928X\u003c/li\u003e\n\u003cli\u003eMoretti TBC, Magna LA, Reis LO. Surgical Results and Complications for Open, Laparoscopic, and Robot-assisted Radical Prostatectomy: A Reverse Systematic Review. Eur Urol Open Sci [Internet]. 2022;44:150\u0026ndash;61. Available from: https://www.sciencedirect.com/science/article/pii/S2666168322008850\u003c/li\u003e\n\u003cli\u003eBarnaś A, Milecki T, Ida A, Kasperczak M, Lipski A, Antczak A, et al. Learning curve for laparoscopic radical prostatectomy. Wideochirurgia i inne Tech maloinwazyjne = Videosurgery other miniinvasive Tech. 2025 Apr;20(1):69\u0026ndash;75. \u003c/li\u003e\n\u003cli\u003e\u0026Ccedil;elen S, \u0026Ouml;zl\u0026uuml;lerden Y, Mete A, Başer A, Tuncay \u0026Ouml;L, Z\u0026uuml;mr\u0026uuml;tbaş AE. Laparoscopic radical prostatectomy: a single surgeon\u0026rsquo;s experience in 80 cases after 2 years of formal training. African J Urol. 2021;27(1):57. \u003c/li\u003e\n\u003cli\u003eBolenz C, Gupta A, Hotze T, Ho R, Cadeddu JA, Roehrborn CG, et al. Cost Comparison of Robotic, Laparoscopic, and Open Radical Prostatectomy for Prostate Cancer. Eur Urol [Internet]. 2010;57(3):453\u0026ndash;8. Available from: https://www.sciencedirect.com/science/article/pii/S0302283809011506\u003c/li\u003e\n\u003cli\u003eMitre AI, Chammas Jr MF, Rocha Jr JEA, Duarte RJ, Ebaid GX, Rocha FT. Laparoscopic radical prostatectomy: the learning curve of a low volume surgeon. Sci World J. 2013;2013(1):974276. \u003c/li\u003e\n\u003cli\u003eGrivas N, Zachos I, Georgiadis G, Karavitakis M, Tzortzis V, Mamoulakis C. Learning curves in laparoscopic and robot-assisted prostate surgery: a systematic search and review. World J Urol [Internet]. 2022;40(4):929\u0026ndash;49. Available from: https://doi.org/10.1007/s00345-021-03815-1\u003c/li\u003e\n\u003cli\u003eGood DW, Stewart GD, Laird A, Stolzenburg JU, Cahill D, McNeill SA. A critical analysis of the learning curve and postlearning curve outcomes of two experience-and volume-matched surgeons for laparoscopic and robot-assisted radical prostatectomy. J Endourol. 2015;29(8):939\u0026ndash;47. \u003c/li\u003e\n\u003cli\u003eDias JA, Dall\u0026rsquo;oglio MF, Colombo JR, Coelho RF, Nahas WC. The influence of previous robotic experience in the initial learning curve of laparoscopic radical prostatectomy. Int braz j urol. 2017;43:871\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003ePapachristos A, Basto M, Te Marvelde L, Moon D. Laparoscopic versus robotic‐assisted radical prostatectomy: an A ustralian single‐surgeon series. ANZ J Surg. 2015;85(3):154\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eHakimi AA, Blitstein J, Feder M, Shapiro E, Ghavamian R. Direct comparison of surgical and functional outcomes of robotic-assisted versus pure laparoscopic radical prostatectomy: single-surgeon experience. Urology. 2009;73(1):119\u0026ndash;23. \u003c/li\u003e\n\u003cli\u003eDi Gioia RF, Rubinstein M, Velasque L, Rubinstein I. Impact of a low-volume laparoscopic radical prostatectomy learning curve on perioperative outcomes: is it acceptable? J Laparoendosc Adv Surg Tech. 2013;23(10):841\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eSecin FP, Savage C, Abbou C, de La Taille A, Salomon L, Rassweiler J, et al. The learning curve for laparoscopic radical prostatectomy: an international multicenter study. J Urol. 2010;184(6):2291\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eSchuessler WW, Schulam PG, Clayman R V, Kavoussi LR. Laparoscopic radical prostatectomy: initial short-term experience. Urology. 1997;50(6):854\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eMa J, Xu W, Chen R, Zhu Y, Wang Y, Cao W, et al. Robotic-assisted versus laparoscopic radical prostatectomy for prostate cancer: the first separate systematic review and meta-analysis of randomised controlled trials and non-randomised studies. Int J Surg. 2023;109(5):1350\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eFicarra V, Novara G, Artibani W, Cestari A, Galfano A, Graefen M, et al. Retropubic, Laparoscopic, and Robot-Assisted Radical Prostatectomy: A Systematic Review and Cumulative Analysis of Comparative Studies. Eur Urol [Internet]. 2009;55(5):1037\u0026ndash;63. Available from: https://www.sciencedirect.com/science/article/pii/S0302283809000499\u003c/li\u003e\n\u003cli\u003eGuillonneau B, Cathelineau X, Doublet JD, Baumert H, Vallancien G. Laparoscopic radical prostatectomy: assessment after 550 procedures. Crit Rev Oncol Hematol [Internet]. 2002;43(2):123\u0026ndash;33. Available from: https://www.sciencedirect.com/science/article/pii/S1040842802000240\u003c/li\u003e\n\u003cli\u003eNadu A, Salomon L, Hoznek A, Olsson LE, Saint F, de la TAILLE A, et al. Early removal of the catheter after laparoscopic radical prostatectomy. J Urol. 2001;166(5):1662\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003ePenezić L, Kuli\u0026scaron; T, Hudolin T, Zekulić T, Saić H, Ka\u0026scaron;telan Ž. Laparoskopska radikalna prostatektomija: serija slučajeva jednog centra. Acta Clin Croat. 2022;61(Supplement 3):15\u0026ndash;20. \u003c/li\u003e\n\u003cli\u003eVickers AJ, Savage CJ, Hruza M, Tuerk I, Koenig P, Mart\u0026iacute;nez-Pi\u0026ntilde;eiro L, et al. The surgical learning curve for laparoscopic radical prostatectomy: a retrospective cohort study. Lancet Oncol. 2009;10(5):475\u0026ndash;80. \u003c/li\u003e\n\u003cli\u003eMoretti TBC, Magna LA, Reis LO. Erectile dysfunction criteria of 131,350 patients after open, laparoscopic, and robotic radical prostatectomy. Andrology [Internet]. 2024 Nov 1;12(8):1865\u0026ndash;71. Available from: https://doi.org/10.1111/andr.13634\u003c/li\u003e\n\u003cli\u003eGroutz A, Blaivas JG, CHAIKIN DC, Weiss JP, Verhaaren M. The pathophysiology of post-radical prostatectomy incontinence: a clinical and video urodynamic study. J Urol. 2000;163(6):1767\u0026ndash;70. \u003c/li\u003e\n\u003cli\u003eRocco B, Calcagnile T, Assumma S, Sarchi L, Del Nero A, Sangalli M, et al. Posterior reconstruction of the rhabdosphincter. In: Robotic urology. Springer; 2024. p. 537\u0026ndash;43. \u003c/li\u003e\n\u003cli\u003eMoretti TBC, Magna LA, Reis LO. Continence criteria of 193 618 patients after open, laparoscopic, and robot‐assisted radical prostatectomy. BJU Int. 2024;134(1):13\u0026ndash;21. \u003c/li\u003e\n\u003cli\u003eLink BA, Nelson R, Josephson DY, Yoshida JS, Crocitto LE, Kawachi MH, et al. The impact of prostate gland weight in robot assisted laparoscopic radical prostatectomy. J Urol. 2008;180(3):928\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003eIacovelli V, Carilli M, Sandri M, Forte V, Cipriani C, Bertolo R, et al. The role of preoperative prostatic shape in the recovery of urinary continence after robotic radical prostatectomy: a single cohort analysis. Prostate Cancer Prostatic Dis. 2023;26(2):374\u0026ndash;8. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Laparoscopy, radical prostatectomy, learning curve","lastPublishedDoi":"10.21203/rs.3.rs-7556189/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7556189/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study aimed to evaluate the learning curve, as well as the oncological and functional outcomes, of a surgeon who initiated laparoscopic radical prostatectomy (LRP) in a low-volume center after limited experience with open radical prostatectomy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this retrospective study, 90 patients who underwent LRP were analyzed. For assessing the learning curve, patients were divided chronologically into three groups of 30 each. Demographic data, preoperative prostate specific antigen (PSA), biopsy The international society of urological pathology (ISUP) grade, operative time, intraoperative blood loss, transfusion requirement, length of hospital stay, postoperative catheterization duration, pathological outcomes, and one-year PSA recurrence, continence, and erectile function were evaluated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOperative time decreased with experience, reaching a plateau phase after approximately 60 cases (Group 1: 251.3 ± 52.3 min vs. Group 3: 218.7 ± 40.4 min; p = 0.027). Hospital stay also significantly declined with experience (Group 1: 5.5 days vs. Group 3: 4.1 days; p \u0026lt; 0.001). Although a decrease in blood loss was observed, it did not reach statistical significance, and transfusion rates remained minimal (3.3%). The rate of lymph node dissection significantly increased with surgical experience (Group 1: 23.3% vs. Group 3: 56.7%; p = 0.022). No significant differences were observed in early complications or PSA recurrence rates between groups. Erectile function preservation improved from 23.3% in Group 1 to 50.0% in Group 3, whereas continence outcomes remained comparable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor surgeons initiating LRP, operative time reaches a plateau after approximately 60 cases, while functional outcomes continue to improve over time. With appropriate training and mentorship, LRP can be safely and effectively performed in low-volume centers with acceptable perioperative and functional results throughout the learning process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eRetrospectively registered.\u003c/p\u003e","manuscriptTitle":"Evolution of Surgical Efficacy and Postoperative Outcomes of a surgeon Throughout the Learning Curve of Laparoscopic Radical Prostatectomy with limited experience of open surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 06:47:40","doi":"10.21203/rs.3.rs-7556189/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-16T06:22:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-15T14:36:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"329450917247492253530313265414454847384","date":"2025-09-15T14:01:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"150356760547078105039994109526871962466","date":"2025-09-15T12:52:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140519493532544341884153958551672081849","date":"2025-09-15T02:54:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"157784228562994779220253291152578660127","date":"2025-09-14T19:43:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-14T07:20:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"169368564286022493919211009348457358594","date":"2025-09-13T19:58:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"24103869777207404035634590073924823391","date":"2025-09-13T14:04:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"166769599827364329391978647068935105895","date":"2025-09-13T10:07:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-13T09:46:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-09T10:51:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-09T10:51:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2025-09-07T12:21:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8cca1b01-1798-4715-801a-056a5dac088c","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T16:01:57+00:00","versionOfRecord":{"articleIdentity":"rs-7556189","link":"https://doi.org/10.1186/s12893-026-03577-w","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2026-02-06 15:57:46","publishedOnDateReadable":"February 6th, 2026"},"versionCreatedAt":"2025-09-23 06:47:40","video":"","vorDoi":"10.1186/s12893-026-03577-w","vorDoiUrl":"https://doi.org/10.1186/s12893-026-03577-w","workflowStages":[]},"version":"v1","identity":"rs-7556189","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7556189","identity":"rs-7556189","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}