Robotic-assisted radical prostatectomy for large-volume prostates (>100 mL): perioperative, functional, and oncologic outcomes from a 5-year multicenter cohort.

Large prostate volume (> 100 mL) remains a technical challenge during robot-assisted radical prostatectomy (RARP), with limited long-term outcome data available in contemporary series. To evaluate perioperative, functional, and oncologic outcomes following RARP in patients with large-volume prostate cancer. A retrospective multicenter cohort study was performed including 201 consecutive patients with prostate volume > 100 mL who underwent RARP between January 2017 and December 2021, with follow-up extending through December 2023. The primary endpoint was biochemical recurrence-free survival (BCRFS). Secondary endpoints included overall survival (OS), cancer-specific survival (CSS), perioperative outcomes, urinary continence recovery, and erectile function recovery. Kaplan-Meier analyses, multivariable Cox proportional hazards regression, and logistic regression analyses were performed. Median prostate volume was 121 mL (IQR 108-142), and median follow-up was 58 months (IQR 46-60). Mean operative time was 121 ± 28 min, while estimated blood loss was 152 ± 70 mL. Major complications (Clavien-Dindo ≥ III) occurred in 4.5% of patients. Positive surgical margins were observed in 15.9%, and pT3 disease was identified in 46.2%. Five-year BCRFS, OS, and CSS were 79.8% and 95.8%, respectively. Urinary continence recovery reached 84.1% at 12 months and 90.6% at 5 years. Erectile function recovery among patients undergoing bilateral nerve-sparing was 48.6% at 12 months and 62.3% at 5 years. On multivariable analysis, Gleason score ≥ 8 (HR 2.63, p < 0.001), pT3 stage (HR 3.02, p < 0.001), and positive surgical margins (HR 2.11, p = 0.01) independently predicted biochemical recurrence. Bilateral nerve-sparing independently predicted improved continence recovery (OR 1.82, p = 0.02). RARP in patients with large-volume prostates is safe and oncologically effective, with favorable long-term functional outcomes. Tumor biology rather than prostate size appears to be the principal determinant of oncologic outcomes.