Robotic surgery in urologic oncology: gathering the evidence

In less than a decade, the widespread application of robotic technology to the field of urologic oncology has permanently altered the way urologists approach malignancy. The short-term benefits of minimally invasive surgery using robotic assistance (i.e., decreased blood loss, improved convalescence and ergonomic appeal), as well as a broad marketing campaign, have helped the technology gain traction in the field of urology. Although the long-term benefits of its use in urologic surgery are less clear and the costs of robotic surgery are consistently greater than those of other approaches, the numbers of prostate, kidney and bladder cancer cases continue to rise. Identifying transferable surgical processes of care that matter most for each of the robotic cases in urologic oncology (e.g., prostatectomy, cystectomy and partial nephrectomy) is a next step toward broadly improving the quality of urologic cancer care. To this end, urologic professional societies and their surgeons should aim to identify underwriters for and participate in large clinical registries and surgical quality collaboratives.

Does robotic technology mitigate the challenges of large prostate size?

OBJECTIVES

For radical prostatectomy, the advantages of robotic surgery may facilitate precise dissection and improve functional outcomes. However, patients with larger prostates may still pose increased challenges because of impaired visualization and mobility in the pelvis. For this reason, we undertook a study to better understand the relationships between large prostate size and robotic prostatectomy outcomes with respect to intraoperative and pathologic factors.

METHODS

Patients undergoing robotic-assisted radical prostatectomy from 2003 to 2008 at our institution were included in this retrospective study. Prostate size was categorized into 3 groups (< 50, 50-100, > 100 g). We compared surgical and quality of life (Expanded Prostate Cancer Index Composite [EPIC] scores) outcomes among groups using generalized linear models and chi-square testing.

RESULTS

Patients with the largest prostates had longer operative times (> 100 vs < 50 g, 250 vs 232 minutes, P < .01) and more blood loss (> 100 vs < 50 g, 250 vs 155 mL, P = .01). Conversely, these patients had fewer positive surgical margins and lower Gleason sums (both P < .01). Despite worse baseline irritative symptoms (> 100 vs < 50 g, 79.7 vs 90.0, P < .001) and sexual function (> 100 vs < 50 g, 38.2 vs 77.9, P < .001), these differences resolved at 3 months (P = .92, P = .88, respectively). Recovery of continence was relatively sluggish compared with that in patients with the smallest prostates (> 100 vs < 50 g; 44.0, 62.2, P = .03).

CONCLUSIONS

Not surprisingly, larger prostate size was associated with increased operative times and blood loss, although of questionable clinical significance. While these patients appeared to benefit regarding irritative symptoms, recovery of continence was delayed. Longer follow-up is needed to further assess recovery.

The role of lymphovascular space invasion in renal cell carcinoma as a prognostic marker of survival after curative resection

OBJECTIVES

Lymphovascular invasion (LVI) correlates with adverse outcomes in numerous malignancies. However, its role in predicting outcomes in RCC is unclear. Herein, we evaluated what effect LVI had on metastasis free survival (MFS), disease-specific survival (DSS), and overall survival (OS) in patients with RCC treated with surgical excision.

METHODS

Eight hundred forty-one consecutive patients who underwent partial or radical nephrectomy from 1989 to 2004 were identified. Pathologic and gross features examined were LVI, subtype, Fuhrman grade, stage, and size. Age and gender were also analyzed. Slides were re-reviewed by a single pathologist (MS). Variables with P < 0.1 on univariate analysis were incorporated in a Cox proportional hazards multivariate model. MFS, DSS, and OS were described for patients with and without LVI using the Kaplan-Meier method, and compared with the log-rank test.

RESULTS

LVI was seen on H and E stained slides in 91 patients (11%); 120 (14%) developed metastatic disease, 91 (11%) died of RCC, and 306 (36%) died during a median follow-up of 61 months. While on univariate analysis, LVI was strongly associated with decreased MFS, DSS, and OS (P < 0.0001), on multivariate analysis, LVI was no longer statistically significant for MFS, DSS, and OS with a HR of 0.976 (95% CI: 0.583-1.63; P = 0.93), 0.96 (95% CI: 0.542-1.69; P = 0.88), and 1.24 (95% CI: 0.869-1.77; P = 0.24).

CONCLUSIONS

We found LVI to be associated with worse MFS, DSS, and OS on univariate analysis, but not on multivariate analysis for patients with nonmetastatic RCC. In contrast to previously reported studies, LVI may not be an independent prognostic variable in patients with localized RCC.

Transobturator sling with intraoperative cough test is effective for patients with low valsalva leak point pressure

OBJECTIVE

The transobturator sling (TOS) is safe and effective for the treatment of female stress urinary incontinence (SUI). Controversy exists regarding its efficacy in patients with low valsalva leak point pressure (VLPP), a marker of intrinsic sphincter deficiency (ISD). We review our experience of TOS in the treatment of women with SUI and low VLPP.

METHODS

Patients diagnosed with stress or mixed incontinence treated with TOS were identified by retrospective review. All procedures were performed with local anesthesia and intravenous sedation. Stress incontinence and VLPP were determined preoperatively with urodynamic testing. Chart review identified demographics, perioperative variables, complications, and subjective cure. Low VLPP was defined as VLPP less than 60 cm H2O.

RESULTS

From November 2003 to February 2006, 151 consecutive women underwent TOS. Twenty-seven patients were excluded who exhibited incontinence with cough but not valsalva on preoperative urodynamic testing. Of the remaining 124 patients, 29% had low VLPP and 71% had higher VLPP. There was no difference in subjective cure between patients with low (94%) and higher VLPP (84%) overall (p = 0.12) or in patients with 12 months or more of follow-up (93% versus 79%, p = 0.40). Patients with low VLPP were more likely to be older (p = 0.036), and have pure SUI (p = 0.019).

CONCLUSIONS

TOS is effective for patients with low VLPP. Women with SUI and ISD without a fixed urethra should be considered candidates for TOS. The use of intravenous sedation during sling placement allows the surgeon to perform an intraoperative cough test, permitting tensioning of the TOS in relation to the patient's ISD.