The impact of prostate gland weight in robot assisted laparoscopic radical prostatectomy

Urinary symptoms after robotic prostatectomy in men with median lobes

Patients with median lobe enlargement of the prostate have different natural history of lower urinary tract symptoms following robotic prostatectomy as compared with patients without this finding.

Background:

We report on the natural history of lower urinary tract symptoms (LUTS) and urinary continence in patients with median lobe enlargement (MLE) after robotic radical prostatectomy (RP).

Methods:

Patients treated with RP from October 2008 to March 2012 completed American Urological Association symptom index (AUAI) and continence assessments at the preoperative visit and each postoperative visit. Two cohorts were established based on the presence or absence of a median lobe intraoperatively.

Results:

A total of 698 validated questionnaires were completed by 175 patients with a median of 4 AUAI scores per patient. The 36 patients (21%) with MLE required a longer time to achieve urinary continence (P = .05, log-rank test), although ultimately, no difference was seen in long-term continence probability between the two cohorts (P = .63). On multivariate analysis, the presence of a median lobe reduced the odds of early continence recovery (P = .02). By use of a generalized estimating equation, the cohort-average AUAI scores after RP are presented. Patients with MLE had faster improvement in LUTS after surgery, whereas those without MLE had temporary worsening in LUTS before improvement.

Conclusion:

Patients with MLE have a different natural history of LUTS and continence after RP as compared with patients without this finding. Therefore, radiographic or cystoscopic evaluation for the presence of a median lobe before RP may improve patient counseling about urinary outcomes.

Anatomical dimensions using preoperative magnetic resonance imaging: impact on the learning curve of robot-assisted laparoscopic prostatectomy

OBJECTIVE

To evaluate the impact of anatomical dimensions as measured using preoperative magnetic resonance imaging on the outcomes of robot-assisted laparoscopic prostatectomy.

METHODS

We retrospectively reviewed 100 consecutive robot-assisted laparoscopic prostatectomy procedures that were carried out by a single surgeon at the Division of Urology, Department of Surgery, Tottori University Faculty of Medicine, Yonago, Japan. Preoperative clinical data and anatomical measurements, including the calculated prostate volume pelvic cavity index, were determined based on preoperative magnetic resonance imaging, and their effects on console time, estimated blood loss and surgical margin status were compared.

RESULTS

Body mass index, the prostate anteroposterior diameter, and the prostate volume-to-pelvic cavity index ratio were all significantly correlated with console time and estimated blood loss, based on a univariate analysis (P < 0.05). The prostate craniocaudal diameter, prostate transverse diameter and prostate volume also correlated with console time. However, based on the multiple linear regression analysis, only the prostate volume-to-pelvic cavity index ratio was found to be a significant predictor of console time and estimated blood loss. Furthermore, when the 100 total cases were divided into 50 early cases and 50 late cases, the prostate volume-to-pelvic cavity index ratio correlated with console time and estimated blood loss only in the early group, and not in the late group. In contrast, anatomical measurements had no significant effect on surgical margin status.

CONCLUSION

Magnetic resonance imaging can be a valuable adjunct to robot-assisted laparoscopic prostatectomy. Our data show that patients with larger prostates and narrow, deep pelvises might present more difficulty in robot-assisted laparoscopic prostatectomy procedures. However, the present data also show that this problem can be overcome by an experienced operator with improved surgical techniques.

Margini Chirurgici Positivi Dopo una Prostatectomia Radicale

Positive surgical margins after radical prostatectomy

Robotic-assisted laparoscopic simple prostatectomy and bladder diverticulectomy with temporary clamping of internal iliac arteries

The minimally invasive approach for benign prostatic hyperplasia (BPH) is replacing open surgery. Laparoscopic and robotic techniques have benefits in treatment of BPH especially for large prostatic adenoma. We present a case of laparoscopic robotic-assisted simple prostatectomy with bilateral transient occlusion of internal iliac arteries. This could be an optional surgical technique when a significant blood loss is expected, for example in patients with an estimated volume of BPH larger than 100 ml or in patients who cannot suspend antiaggregant therapy. In this case we temporarily occluded the internal iliac arteries bilaterally with Bulldog clamps and the adenoma was enucleated according to Sotelo's laparoscopic robotic-assisted technique. We had optimal results in terms of intraoperative and postoperative outcomes.

[Prevention of postprostatectomy incontinence: etiology and risk factors]

The prevention of postprostatectomy incontinence has always been a challenge for urologists. Improved understanding of male continence and changes in pelvic anatomy after radical prostatectomy and the implementation of new surgical techniques raised hope of reduced incontinence rates. Despite using the full potential of continence-sparing techniques and atraumatic robot-assisted surgery, postprostatectomy incontinence still occurs in 5-20 % of cases. Recently published data showed a trend of improved early return to continence using anterior suspension or posterior reconstruction in robot-assisted prostatectomy. Postprostatectomy incontinence has a negative impact on quality of life and causes high costs of treatment. Therefore, further research in the amelioration of postoperative continence is mandatory.

The effect of prostate weight on the outcomes of robot-assisted radical prostatectomy

OBJECTIVE

The effect of prostate volume on the surgical, functional, and oncological outcomes of robot assisted radical prostatectomy (RARP) was evaluated.

MATERIAL AND METHODS

A total of 180 patients who underwent RARP and had at least a 1-year follow-up were included. The patients were divided into 3 groups based on prostate weight (Group 1: <45 g, Group 2: 45-75 g, and Group 3: >76 g). Erectile function and continence were evaluated at 3, 6, 9, and 12 months postoperatively. The International Index of Erectile Dysfunction (IIEF) score and daily pad usage were evaluated as indicators of erectile function and continence, respectively. The measurement of two prostate-specific antigen (PSA) values over 0.2 ng/mL was considered biochemical disease recurrence.

RESULTS

Patients with larger prostates were older and had a longer operative time and higher PSA level compared with patients with smaller prostates (p<0.05). The positive surgical margin rate was higher in patients with smaller prostates (p=0.06). However, patients with a prostate weight <45 g had higher IIEF scores at 3 and 6 months. IIEF scores were similar at the end of the 1-year follow-up period. Pad usage and time to continence were higher in patients with larger prostates (p>0.05).

CONCLUSION

Although prostate weight affected the surgical outcomes of RARP, the functional and oncological outcomes were similar among all patients. Long-term follow-up is needed to determine their impact on oncological outcomes.

Novel uroflow stop test at time of catheter removal is a strong predictor of early urinary continence recovery following robotic-assisted radical prostatectomy: a pilot study

AIM

To study whether the ability to completely stop urinary flow during voiding at time of catheter removal, measured objectively using uroflowmetry, can predict early recovery of urine continence following robotic-assisted radical prostatectomy (RARP).

MATERIALS AND METHODS

In this pilot study, 108 patients with a minimum of 2 years follow-up, operated by a single surgeon (AEH) were subjected to an uroflowmetry at the time of urethral catheter removal following RARP. Normal Saline (150 ml) was instilled intravesically prior to catheter removal and patients were instructed to attempt to stop urine flow during voiding in uroflowmeter. Two groups were studied, group one with positive Stop Test (n = 80) and group two with negative Stop Test (n = 28). Covariates included age, BMI, IPSS score, PSA, tumor stage, prostate volume, nerve sparing status, and estimated blood loss.

RESULTS

Basic characteristics were not statistically different between both groups. Early continence recovery was significantly higher in group one. Pad-free continence rates in group one and two at 1, 3, 6, 12, 18, and 24 months were 62% vs. 7% (P < 0.001), 85% vs. 28% (P < 0.001), 93% vs. 67% (P 0.001), 93% vs. 82% (P 0.079), 97% vs. 82% (P 0.006), and 97% vs. 85% (P 0.023), respectively. Uroflow Stop Test was the only independent predictor of early urine continence recovery on univariate and multivariate regression analysis [OR 2.87 (95%CI 1.34-4.38, P = < 0.001)].

CONCLUSION

Novel use of uroflowmetry at time of urethral catheter removal is a simple, non-invasive study with independent ability to predict early continence recovery following RARP.

Transurethral marking incision of the bladder neck: a helpful technique in robot-assisted laparoscopic radical prostatectomy involving post-transurethral resection of the prostate and cancers protruding into the bladder neck

Background

Bladder neck transection is one of the most difficult procedures for robot-assisted laparoscopic radical prostatectomy (RALP), particularly in patients who have undergone previous transurethral resection of the prostate (TUR-P), and in those with large median lobes or prostate cancer protruding into the bladder neck. To ensure negative surgical margins and safely preserve the ureteral orifices during bladder neck transection, we propose the use of the transurethral resectoscope for making the incision in the bladder neck before initiating RALP. Thus, we developed a technique for bladder neck transection to facilitate this operation in such patients.

Case presentation

Two Japanese men, aged 61 and 63 years, who were diagnosed with prostate cancer, received a transurethral marking incision of the bladder neck before starting RALP; prostate cancer developed in one patient after TUR-P and the other patient had cancer protruding into the bladder neck. A transurethral resectoscope was used to closely observe the ureteral orifices and bladder necks; the bladder necks were marked to indicate the depth from the mucosa to the muscular layer. During the RALP, the bladder necks were dissected to indicate the depth of the marking incision. The surgical margins were negative and perioperative complications did not occur. The Foley catheters were removed on postoperative day 6, according to the usual protocol. No urinary leakage from the anastomosis sites was observed.

Conclusion

This technique, involving the use of an ordinary transurethral resectoscope, may be an easy procedure to ensure negative surgical margins, safely preserve the ureteral orifices, avoid increasing the bladder neck diameter, and achieve a good quality vesicourethral anastomosis that prevents the risk of suture-related tissue tears.

Positive surgical margins after radical prostatectomy: a systematic review and contemporary update

CONTEXT

The clinical significance of positive surgical margins (PSMs) in radical prostatectomy (RP) specimens and the management of affected patients remain unclear.

OBJECTIVE

To address pitfalls in the pathologic interpretation of margin status; provide an update on the incidence, predictors, and long-term oncologic implications of PSMs in the era of robot-assisted laparoscopic RP (RALRP); and suggest a practical evidence-based approach to patient management.

EVIDENCE ACQUISITION

A systematic review of the literature was performed in April 2013 using Medline/PubMed, Web of Science, and Scopus databases and the Cochrane Database of Systematic Reviews. Studies focusing on PSMs in RP pertinent to the objectives of this review were included. Particular attention was paid to publications within the last 5 yr and those concerning RALRP.

EVIDENCE SYNTHESIS

A total of 74 publications were retrieved. Standardized measures to overcome variability in the pathologic interpretation of surgical margins have recently been established by the International Society of Urological Pathology. The average rate of PSMs in contemporary RALRP series is 15% (range: 6.5-32%), which is higher in men with a more advanced pathologic stage and equivalent to the rate reported in prior open and laparoscopic prostatectomy series. The likelihood of PSMs is strongly influenced by the surgeon's experience irrespective of the surgical approach. Technical modifications using the robotic platform and the role of frozen-section analysis to reduce the margin positivity rate continue to evolve. Positive margins are associated with a twofold increased hazard of biochemical relapse, but their association with more robust clinical end points is controversial. Level 1 evidence suggests that adjuvant radiation therapy (RT) may favorably affect prostate-specific antigen recurrence rates, but whether the therapy also affects systemic progression, prostate cancer-specific mortality, and overall survival remains debatable.

CONCLUSIONS

Although positive margins in prostate cancer are considered an adverse oncologic outcome, their long-term impact on survival is highly variable and largely influenced by other risk modifiers. Adjuvant RT appears to be effective, but further study is required to determine whether early salvage RT is an equivalent alternative.

Preserving continence during robotic prostatectomy

Preservation of postoperative urinary continence remains the primary concern of all men and their surgeons following robot-assisted radical prostatectomy (RARP). Without doubt, continence is the most important quality of life issue following radical prostatectomy. Identification of difficulties and lessons learned over time has helped focus efforts in order to improve urinary quality of life and continence. This review will examine definitions of continence and urinary quality of life evaluation, technical aspects and the impact of patient-related factors affecting time to and overall continence.

Robotic and standard open radical prostatectomy: oncological and quality-of-life outcomes

Prostate cancer is the second leading cause of cancer death among men in the USA. Use of robot-assisted radical prostatectomy (RARP) for the management of localized prostate cancer has increased dramatically in recent years. This review focuses on comparing quality of life following RARP versus retropubic radical prostatectomy. RARP is associated with improved perioperative outcomes, such as reduced blood loss and fewer transfusions. In addition, cancer control after RARP versus retropubic radical prostatectomy is equivalent, with similar incidences of positive surgical margins and comparable early oncological outcomes. RARP appears to provide advantages in recovery of continence, potency and quality of life compared with retropubic radical prostatectomy; however, methodological limitations exist in current literature.

Robotic-assisted radical prostatectomy after the first decade: surgical evolution or new paradigm

Early studies indicate that robotic-assisted radical prostatectomy (RARP) has promising short-term outcomes; however, RARP is beyond its infancy, and the long-term report cards are now beginning. The important paradigm shift introduced by RARP is the reevaluation of the entire open radical prostatectomy experience in surgical technique by minimizing blood loss and complications, maximizing cancer free outcomes, and a renewed assault in preserving quality of life outcomes by many novel mechanisms. RARP provides a new technical “canvas” for surgical masters to create upon, and in ten years, has reinvigorated a 100-year-old “gold standard” surgery.

Robot-assisted laparoscopic radical prostatectomy after previous open transvesical adenomectomy

INTRODUCTION

Robot-assisted laparoscopic radical prostatectomy (RALRP) is one of the best treatment for patients with localized prostate cancer. RALRP is currently performed in patients without previous surgical treatment for benign prostatic hyperplasia. This paper presents a successfully performed RALRP after previous open transvesical adenomectomy (TVA).

CASE REPORT

A 68-year-old patient underwent nerve-sparing RALRP for prostate cancer revealed by transrectal ultrasound guided prostate biopsy, 7 years after TVA.

RESULTS

Postoperatively, a regular diet was allowed on day 1. The Foley catheter was removed on day 7. At 3 months' follow-up, the patient complained of moderate stress incontinence but erectile function was responsive to Tadalafil(®). Serum prostate-specific antigen was undetectable. Quality of life was satisfactory.

CONCLUSIONS

A history of previous prostatic surgery does not appear to compromise the outcome of RALRP. Nerve sparing is still indicated. Long-term follow-up is necessary to define RALRP as a gold standard also in patients with previous TVA.

Impact of prostate volume on oncological and functional outcomes after radical prostatectomy: robot-assisted laparoscopic versus open retropubic

Purpose

We compared the impact of prostate volume on oncological and functional outcomes 2 years after robot-assisted laparoscopic prostatectomy (RALP) and open radical retropubic prostatectomy (ORP).

Materials and Methods

Between 2003 and 2010, 253 consecutive patients who had undergone prostatectomy by a single surgeon were serially followed over 2 years postoperatively. RALP was performed on 77 patients and ORP on 176. The patients were divided into two subgroups according to prostate volume as measured by transrectal ultrasound: less than 40 g and 40 g or larger. Recoveries of potency and continence were checked serially by interview 1, 3, 6, 9, 12, and 24 months postoperatively.

Results

RALP was associated with less blood loss (ORP vs. RALP: 910 mL vs. 640 mL, p<0.001) but a longer operation time (150 minutes vs. 220 minutes, p<0.001) than was ORP. No statistically significant differences were found between the two groups for oncological outcomes, such as positive surgical margin (40% vs. 39%, p=0.911) or biochemical recurrence (12% vs. 7%, p=0.155). The overall functional outcomes showed no statistically significant differences at 2 years of follow-up (continence: 97% vs. 94%, p=0.103; potency: 51% vs. 56%, p=0.614). In the results of an inter-subgroup analysis, potency recovery was more rapid in patients who underwent RALP in a small-volume prostate than in those who underwent ORP in a small-volume prostate (3 months: 24% vs. 0%, p=0.005; 6 months: 36% vs. 10%, p=0.024). However, patients who underwent RALP in a large-volume prostate were less likely to recover continence than were patients who underwent ORP in a large-volume prostate (97% vs. 88%, p=0.025).

Conclusions

Patients can be expected to recover erectile function more quickly after RALP than after ORP, especially in cases of a small prostate volume.

Does the presence of median lobe affect outcomes of robot-assisted laparoscopic radical prostatectomy?

PURPOSE

To determine whether the presence of median lobe (ML) affects perioperative outcomes, positive surgical margin (PSM) rates, and recovery of urinary continence after robot-assisted radical prostatectomy (RARP).

PATIENTS AND METHODS

We analyzed 1693 consecutive patients undergoing RARP performed by a single surgeon. Patients were analyzed in two groups based on the presence or not of a ML identified during RARP. Perioperative outcomes, PSM rates, and recovery of urinary continence were compared between the groups. Continence was assessed using validated questionnaires, and it was defined as the use of "no pads" postoperatively.

RESULTS

A ML was identified in 323 (19%) patients. Both groups had similar estimated blood loss, length of hospital stay, pathologic stage, complication rates, anastomotic leakage rates, overall PSM rates, and PSM rate at the bladder neck. The median overall operative time was slightly greater in patients with ML (80 vs 75 min, P<0.001); however, there was no difference in the operative time when stratifying this result by prostate weight. Continence rates were also similar between patients with and without ML at 1 week (27.8% vs 27%, P=0.870), 4 weeks (42.3% vs 48%, P=0.136), 12 weeks (82.5% vs 86.8%, P=0.107), and 24 weeks (91.5% vs 94.1%, P=0.183) after catheter removal. Finally, the median time to recovery of continence was similar between the groups (median: 5 wks, 95% confidence interval [CI]: 4.41-5.59 vs median: 5 wks, CI 4.66-5.34; log rank test, P=0.113).

CONCLUSION

The presence of a ML does not affect outcomes of RARP performed by an experienced surgeon.

Systematic review and meta-analysis of studies reporting oncologic outcome after robot-assisted radical prostatectomy

CONTEXT

Despite the large diffusion of robot-assisted radical prostatectomy (RARP), literature and data on the oncologic outcome of RARP are limited.

OBJECTIVE

Evaluate lymph node yield, positive surgical margins (PSMs), use of adjuvant therapy, and biochemical recurrence (BCR)-free survival following RARP and perform a cumulative analysis of all studies comparing the oncologic outcomes of RARP and retropubic radical prostatectomy (RRP) or laparoscopic radical prostatectomy (LRP).

EVIDENCE ACQUISITION

A systematic review of the literature was performed in August 2011, searching Medline, Embase, and Web of Science databases. A free-text protocol using the term radical prostatectomy was applied. The following limits were used: humans; gender (male); and publications dating from January 1, 2008. A cumulative analysis was conducted using Review Manager software v.4.2 (Cochrane Collaboration, Oxford, UK) and Stata 11.0 SE software (StataCorp, College Station, TX, USA).

EVIDENCE SYNTHESIS

We retrieved 79 papers evaluating oncologic outcomes following RARP. The mean PSM rate was 15% in all comers and 9% in pathologically localized cancers, with some tumor characteristics being the most relevant predictors of PSMs. Several surgeon-related characteristics or procedure-related issues may play a major role in PSM rates. With regard to BCR, the very few papers with a follow-up duration >5 yr demonstrated 7-yr BCR-free survival estimates of approximately 80%. Finally, all the cumulative analyses comparing RARP with RRP and comparing RARP with LRP demonstrated similar overall PSM rates (RARP vs RRP: odds ratio [OR]: 1.21; p=0.19; RARP vs LRP: OR: 1.12; p=0.47), pT2 PSM rates (RARP vs RRP: OR: 1.25; p=0.31; RARP vs LRP: OR: 0.99; p=0.97), and BCR-free survival estimates (RARP vs RRP: hazard ratio [HR]: 0.9; p=0.526; RARP vs LRP: HR: 0.5; p=0.141), regardless of the surgical approach.

CONCLUSIONS

PSM rates are similar following RARP, RRP, and LRP. The few data available on BCR from high-volume centers are promising, but definitive comparisons with RRP or LRP are not currently possible. Finally, significant data on cancer-specific mortality are not currently available.

Robotic assisted radical prostatectomy in morbidly obese patients: how to create a cost-effective adequate optical trocar

Obesity is a major health issue in modern society, and with the progressive widespread employment of robotic assisted radical prostatectomy (RALP), the urologist-robotic surgeon is increasingly involved in the treatment of obese patients. However, the vast majority of urological departments are not equipped with a complete set of bariatric instruments. One of the potential difficulties of robotic surgery on the morbidly obese patient is the relatively short length of the optical trocar sheath, as the optical robotic arm requires some very valuable centimeters of the sheath to hang onto. This condition may make it impossible to properly reach the peritoneal cavity with the optical trocar during the RALP procedure. We present a series of four morbidly obese patients (BMI ranging from 42.1 to 46.2) with localized prostate cancer treated with RALP. We have developed an effective and "easy-to-implement" solution to the problem of properly elongating the sheath of the optical trocar which involves the use of the plastic cylindrical transparent protective tube of a disposable 26-Ch Amplatz sheath. The Amplatz sheath, with an internal diameter of 13 mm and length of 25 cm, perfectly fits outside of the 13-mm trocar usually employed for the optical trocar. Additionally, the cylindrical tube perfectly fits and hangs onto the robotic optical arm system. Mean operative time was 202.5 min (range 185-220 min). Mean blood loss was 284 mL (range 185-380 mL). Catheterization time and hospital stay were 5 and 6 days, respectively, in all patients. All procedures were safely completed, and no minor or major complications were reported. The optical trocar lengthening technique allowed us to properly perform RALP procedures even in severely morbidly obese patients in an urological setting not equipped for bariatric minimally invasive surgery.

Does size matter? The significance of prostate size on pathologic and functional outcomes in patients undergoing robotic prostatectomy

Background

We examined the effect of prostate weight on perioperative data, and the pathological and functional outcomes of robotic-assisted laparoscopic prostatectomy (RALP).

Patients and methods

Data were available from 716 consecutive patients before, during and after undergoing RALP at one institution. Prostate size was arbitrarily stratified by recorded prostate weight into <50, 50–80 and >80 g, corresponding to small, moderate and large glands, respectively. Perioperative data and the histopathological and functional outcomes were compared across these groups by both univariable and multivariable-adjusted analyses.

Results

Increased prostate size was associated with increased age, preoperative prostate-specific antigen levels, body mass index, operative duration, blood loss, lower biopsy and pathological Gleason scores, and lower pathological staging (P < 0.05). The incidence of extensive positive surgical margins was 14.8%, 9.7%, and 5.3% in small, moderate and large prostates, respectively (P < 0.001). However, after multivariable adjustment, only Gleason score and pathological stage were significantly associated with the incidence of positive margins (P < 0.05); prostate weight was not significantly associated. Overall, 78% and 92% of patients were potent and continent at 12 months, respectively, which was not affected by prostate size.

Conclusion

Patients with larger prostates had favourable pathological outcomes after RALP. When controlling for pathological stage, prostate size was not associated with margin positivity. Functionally, neither continence nor potency at 12 months was affected by prostate size.

Overcoming the challenges of robot-assisted radical prostatectomy

Robot-assisted radical prostatectomy (RARP) is the most commonly performed robotic procedure worldwide and is firmly established as a standard treatment option for localised prostate cancer. Part of the explanation for the rapid uptake of RARP is the reported gentler learning curve compared with the challenges of laparoscopic radical prostatectomy (LRP). However, robotic surgery is still fraught with potential difficulties and avoiding complications while on the steepest part of the learning curve is critical. Furthermore, as surgeons progress there is a tendency to take on increasingly complex cases, including patients with difficult anatomy and prior surgery, and these cases present a unique challenge. Significant intra-abdominal adhesions may be identified following open surgery, or dense periprostatic inflammation may be encountered following TURP; large prostate gland size and median lobes may alter bladder neck anatomy, making difficult subsequent urethro-vesical anastomosis. Even experienced robotic surgeons will be challenged by salvage RARP. Approaching these problems in a structured manner allows many of the problems to be overcome. We discuss some of the specific techniques to deal with these potential difficulties and highlight ways to avoid making serious mistakes.

Positive surgical margins after robotic assisted radical prostatectomy: a multi-institutional study

PURPOSE

Positive surgical margins are an independent predictive factor for biochemical recurrence after radical prostatectomy. We analyzed the incidence of and associative factors for positive surgical margins in a multi-institutional series of 8,418 robotic assisted radical prostatectomies.

MATERIALS AND METHODS

We analyzed the records of 8,418 patients who underwent robotic assisted radical prostatectomy at 7 institutions. Of the patients 323 had missing data on margin status. Positive surgical margins were categorized into 4 groups, including apex, bladder neck, posterolateral and multifocal. The records of 6,169 patients were available for multivariate analysis. The variables entered into the logistic regression models were age, body mass index, preoperative prostate specific antigen, biopsy Gleason score, prostate weight and pathological stage. A second model was built to identify predictive factors for positive surgical margins in the subset of patients with organ confined disease (pT2).

RESULTS

The overall positive surgical margin rate was 15.7% (1,272 of 8,095 patients). The positive surgical margin rate for pT2 and pT3 disease was 9.45% and 37.2%, respectively. On multivariate analysis pathological stage (pT2 vs pT3 OR 4.588, p<0.001) and preoperative prostate specific antigen (4 or less vs greater than 10 ng/ml OR 2.918, p<0.001) were the most important independent predictive factors for positive surgical margins after robotic assisted radical prostatectomy. Increasing prostate weight was associated with a lower risk of positive surgical margins after robotic assisted radical prostatectomy (OR 0.984, p<0.001) and a higher body mass index was associated with a higher risk of positive surgical margins (OR 1.032, p<0.001). For organ confined disease preoperative prostate specific antigen was the most important factor that independently correlated with positive surgical margins (4 or less vs greater than 10 ng/ml OR 3.8, p<0.001).

CONCLUSIONS

The prostatic apex followed by a posterolateral site was the most common location of positive surgical margins after robotic assisted radical prostatectomy. Factors that correlated with cancer aggressiveness, such as pathological stage and preoperative prostate specific antigen, were the most important factors independently associated with an increased risk of positive surgical margins after robotic assisted radical prostatectomy.

The impact of prostate size, median lobe, and prior benign prostatic hyperplasia intervention on robot-assisted laparoscopic prostatectomy: technique and outcomes

BACKGROUND

Large prostate size, median lobes, and prior benign prostatic hyperplasia (BPH) surgery may pose technical challenges during robot-assisted laparoscopic prostatectomy (RALP).

OBJECTIVE

To describe technical modifications to overcome BPH sequelae and associated outcomes.

DESIGN, SETTINGS, AND PARTICIPANTS

A retrospective study of prospective data on 951 RALP procedures performed from September 2005 to November 2010 was conducted. Outcomes were analyzed by prostate weight, prior BPH surgical intervention (n=59), and median lobes >1 cm (n=42).

SURGICAL PROCEDURE

RALP.

MEASUREMENTS

Estimated blood loss (EBL), blood transfusions, operative time, positive surgical margin (PSM), and urinary and sexual function were measured.

RESULTS AND LIMITATIONS

In unadjusted analysis, men with larger prostates and median lobes experienced higher EBL (213.5 vs 176.5 ml; p<0.001 and 236.4 vs 193.3 ml; p=0.002), and larger prostates were associated with more transfusions (4 vs 1; p=0.037). Operative times were longer for men with larger prostates (164.2 vs 149.1 min; p=0.002), median lobes (185.8 vs 155.0 min; p=0.004), and prior BPH surgical interventions (170.2 vs 155.4 min; p=0.004). Men with prior BPH interventions experienced more prostate base PSM (5.1% vs 1.2%; p=0.018) but similar overall PSM. In adjusted analyses, the presence of median lobes increased both EBL (p=0.006) and operative times (p<0.001), while prior BPH interventions also prolonged operative times (p=0.014). However, prostate size did not affect EBL, PSM, or recovery of urinary or sexual function.

CONCLUSIONS

Although BPH characteristics prolonged RALP procedure times and increased EBL, prostate size did not affect PSM or urinary and sexual function.

Correlation between serum prostate-specific antigen and cancer volume in prostate glands of different sizes

OBJECTIVES

To further evaluate the relationship of prostate-specific antigen (PSA) with prostate size and tumor volume in a contemporary surgical series. Although early studies showed a strong correlation between PSA and tumor volume, it has been suggested that PSA is no longer a valid marker for prostate cancer and only correlates with prostate size.

METHODS

From 2003 to 2009, 1234 men with data on prostate weight and total tumor volume underwent radical prostatectomy by a single surgeon. Prostate size was classified into tertiles: small (≤ 41.2 g), medium (41.3-54.5 g), and large (≥ 54.6 g). Pearson correlation coefficients were used to examine the relationship of PSA with prostate size and tumor volume across different prostate sizes.

RESULTS

Median preoperative PSA was 4.9 ng/mL (standard deviation ± 4.6), mean prostate size was 51.7 g, and mean tumor volume was 5.6 cm(3). PSA had a significant correlation with prostate size only at a prostate weight ≥ 54.6 g (P = .02). Regardless of prostate size, PSA had a more robust significant correlation with tumor volume than with prostate size (all P < .0001).

CONCLUSIONS

PSA was significantly correlated with prostate size only in the largest prostate glands, but was significantly associated with tumor volume in small, medium, or large prostates. Thus, PSA continues to be a better marker for tumor volume than for prostate size.

[Does robotics improve laparoscopic radical prostatectomy in complex surgical cases?]

The radical prostatectomy is the main treatment prostate cancer in young men. However in difficult cases, another therapeutic option is often suggested.

OBJECTIVE

Evaluation of the quality of the anastomosis in complex surgical cases by comparing laparoscopic radical prostatectomy (LRP) to robotic assisted radical prostatectomy (RLRP).

MATERIAL

From March 2004 to August 2009, 397 patients underwent radical prostatectomy: 176 LRP and 221 RLRP consecutively by the same surgeon. Antecedents that might have complicated dissection were analyzed: prostatic volume over 80 cc, previous inguinal hernia repair with mesh, previous pelvic surgery, body mass index over 30 and previous trans-urethral resection of prostate.

RESULTS

In a preoperative mode, there was no significant difference between the two groups. A multivariable analysis of the quality of the anastomosis turned to the advantage of the robot (OR=2.56 [95 %CI: 1.28-5.25]), specifically for difficult cases (Odd Ratio=7.736 [95 %CI: 2.689-22.254]).

CONCLUSION

The use of the robot improved the quality of the anastomosis for patients that might have raised technical issues.

Effect of prostate gland size on the learning curve for robot-assisted laparoscopic radical prostatectomy: does size matter initially?

BACKGROUND AND PURPOSE

Widespread introduction of robot-assisted laparoscopic radical prostatectomy (RALRP) has led to multiple surgeons going through the learning curve (LC). One of the recommendations for surgeons on the LC for RALRP is to choose patients with smaller glands. We evaluated our LCs to determine whether prostate size influenced intraoperative outcomes and positive surgical margin rates.

PATIENTS AND METHODS

Data were obtained from a prospective database for the first 154 cases of RALRP performed by a single surgeon. Patients were divided into three groups based on prostate volume (PV): <40 cc (group 1), 40 to 60 cc (group 2), or >60 cc (group 3). PV was estimated by preoperative transrectal ultrasonography (TRUS) and correlated with pathologic weight (PW). Perioperative and immediate postoperative outcomes were evaluated.

RESULTS

A statistically significant difference in total operative times between the groups (206 minutes vs 201 minutes vs 233 minutes for groups 1, 2, and 3, respectively) was noted. With regard to individual intraoperative steps, the bladder neck reconstruction and anastomosis time was longer in group 3. No other statistically significant differences were noted. The Pearson correlation coefficient between PV estimation by TRUS and PW was r = 0.785, and an additional analysis based on PW supports the results of our study.

CONCLUSIONS

Prostate size influenced total operative times and the bladder neck reconstruction and anastomosis time. Our data support the use of preoperative TRUS to estimate PV and recommendations for surgeons starting on their LC to choose glands less than 60 cc.

Downsides of robot-assisted laparoscopic radical prostatectomy: limitations and complications

CONTEXT

Robot-assisted laparoscopic radical prostatectomy (RALP) using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is now in widespread use for the management of localised prostate cancer (PCa). Many reports of the safety and efficacy of this procedure have been published. However, there are few specific reports of the limitations and complications of RALP.

OBJECTIVE

The primary purpose of this review is to ascertain the downsides of RALP by focusing on complications and limitations of this approach.

EVIDENCE ACQUISITION

A Medline search of the English-language literature was performed to identify all papers published since 2001 relating to RALP. Papers providing data on technical failures, complications, learning curve, or other downsides of RALP were considered. Of 412 papers identified, 68 were selected for review based on their relevance to the objective of this paper.

EVIDENCE SYNTHESIS

RALP has the following principal downsides: (1) device failure occurs in 0.2-0.4% of cases; (2) assessment of functional outcome is unsatisfactory because of nonstandardised assessment techniques; (3) overall complication rates of RALP are low, although higher rates are noted when complications are reported using a standardised system; (4) long-term oncologic data and data on high-risk PCa are limited; (5) a steep learning curve exists, and although acceptable operative times can be achieved in <20 cases, positive surgical margin (PSM) rates may require experience with >80 cases before a plateau is achieved; (6) robotic assistance does not reduce the difficulty associated with obese patients and those with large prostates, middle lobes, or previous surgery, in whom outcomes are less satisfactory than in patients without such factors; (7) economic barriers prevent uniform dissemination of robotic technology.

CONCLUSIONS

Many of the downsides of RALP identified in this paper can be addressed with longer-term data and more widespread adoption of standardised reporting measures. The significant learning curve should not be understated, and the expense of this technology continues to restrict access for many patients.

Prostate size is associated with surgical difficulty but not functional outcome at 1 year after radical prostatectomy

PURPOSE

We assessed the impact of prostate size on operative difficulty as measured by estimated blood loss, operating room time and positive surgical margins. In addition, we assessed the impact on biochemical recurrence and the functional outcomes of potency and continence at 1 year after radical prostatectomy as well as postoperative bladder neck contracture.

MATERIALS AND METHODS

From 1998 to 2007, 3,067 men underwent radical prostatectomy by 1 of 5 dedicated prostate surgeons with no neoadjuvant or adjuvant therapy. Pathological specimen weight was used as a measure of prostate size. Cox proportional hazards and logistic regression analysis was used to study the association between specimen weight, and biochemical recurrence and surgical margin status, respectively, controlling for adverse pathological features. Continence and potency were analyzed controlling for age, nerve sparing status and surgical approach.

RESULTS

With increasing prostate size there was increased estimated blood loss (p = 0.013) and operative time (p = 0.004), and a decrease in positive surgical margins (84 of 632 [14%] for 40 gm or less, 99 of 862 [12%] for 41 to 50 gm, 78 of 842 [10%] for 51 to 65 gm, 68 of 731 [10%] for more than 65 gm, p <0.001). Biochemical recurrence was observed in 186 of 2,882 patients followed postoperatively and was not significantly associated with specimen weight (p = 0.3). Complete continence was observed in 1,165 of 1,422 patients (82%) and potency in 425 of 827 (51%) at 1 year. Specimen weight was not significantly associated with potency (p = 0.8), continence (p = 0.08) or bladder neck contracture (p = 0.22).

CONCLUSIONS

Prostate size does not appear to affect biochemical recurrence or 1-year functional results. However, estimated blood loss and operative time increased with larger prostate size, and positive surgical margins are more often observed in smaller glands.

Lymph node dissection during robot-assisted radical prostatectomy: where do we stand?

Since the initial report of robot-assisted laparoscopic prostatectomy (RALP) in 2001, the technique has gained rapid acceptance and utilization. When compared with more traditional forms of surgical intervention, there is still much debate with respect to cost, and impact on potency and continence. Less often is the focus on oncologic outcomes. Pelvic lymph node dissection (PLND) at the time of prostatectomy is an important part of the surgical intervention for prostate cancer and is currently underreported during robotic procedures. Herein, we review the current controversies on the value and extent of PLND and the status of emerging data regarding robot-assisted PLND.

The natural history of voiding function after robot-assisted laparoscopic radical prostatectomy

OBJECTIVES

We report the natural history of voiding function in men with clinically localized prostate cancer after robot-assisted laparoscopic radical prostatectomy (RLRP), describing the trend of functional recovery, which is currently not well described using the robot-assisted laparoscopic approach.

MATERIALS AND METHODS

We determined the impact on voiding function by prospectively evaluating 100 consecutive men who underwent RLRP between May 2005 and December 2006 and compared their reported International Prostate Symptom Score (IPSS) and Quality of Life (QOL) scores at 3, 6, and 12 months with preoperative scores after surgery. Patients with preoperative IPSS of 0-7 and 8-35 were defined as having mild lower urinary tract symptoms (LUTS) and moderate to severe LUTS, respectively.

RESULTS

Continence was achieved in 82%, 87%, and 91% of men at 3, 6, and 12 months after RLRP, respectively. There were statistically and clinically significant improvements in both IPSS and QOL preoperative scores at all studied time points for patients with moderate to severe preexisting LUTS. The mean IPSS scores for these patients preoperatively and at 3, 6, and 12 months after surgery were 14.1, 5.2, 3.0, and 2.9, respectively and the corresponding mean QOL scores were 3.4, 2.1, 1.6, and 1.6, respectively. Patients with mild preexisting LUTS showed no statistically significant improvement in IPSS at 3 and 6 months after surgery but significant improvement was found at 1 year (P = 0.04).

CONCLUSIONS

Good continence recovery is expected in most patients undergoing RLRP. Patients with moderate to severe preexisting LUTS can expect early and clinically significant symptom and QOL improvements after RLRP. Patients with mild preexisting LUTS show significant symptom improvement at 1 year.