Beyond the Learning Curve of the Retzius-sparing Approach for Robot-assisted Laparoscopic Radical Prostatectomy: Oncologic and Functional Results of the First 200 Patients with ≥1 Year of Follow-up

Effects of Retzius sparing on robot-assisted laparoscopic prostatectomy: a systematic review with meta-analysis

BACKGROUND

To comprehensively evaluate the efficacy and safety of Retzius sparing (RS) for men undergoing robot-assisted laparoscopic prostatectomy (RARP).

METHODS

We searched four electronic databases and reference lists of relevant studies for eligible research published before March 11, 2019. After quality assessment, eligible studies were synthesized for relevant outcomes, including positive surgical margin (PSM), continence, incontinence, complication, console time, and hospital stay.

RESULTS

Two randomized clinical trials and four observational studies were included in this study. Quantitative syntheses revealed significantly higher PSM rates in RS-RARP compared with conventional RARP (c-RARP) (odds ratio [OR] 1.68, p = 0.02). Furthermore, we found significantly higher PSM rates at the anterior site in RS-RARP compared with c-RARP (OR 4.34, p = 0.03) and significantly lower incontinence rates in RS-RARP in the first month (OR 0.30, p < 0.001) and 12th month (OR 0.25, p < 0.001).

CONCLUSIONS

Our syntheses revealed higher PSM rates in the RS-RARP group, especially in the anterior aspect. However, RS-RARP had superior functional outcome of urinary continence and lower console time than did c-RARP with equivalent complication rates. Thus, we suggest that operators pay more attention to making clear surgical margins if the lesion is in anterior prostate when performing RS-RARP.

Retzius-sparing robot-assisted radical prostatectomy vs the standard approach: a systematic review and analysis of comparative outcomes

OBJECTIVES

To summarize the current evidence on Retzius-sparing (RS)-robot-assisted radical prostatectomy (RARP) and to compare its oncological, peri-operative and functional outcomes with those of standard retropubic RARP (S-RARP).

MATERIALS AND METHODS

After establishing an a priori protocol, a systematic electronic literature search was conducted in January 2019 using the Medline (via PubMed), Embase (via Ovid) and Cochrane databases. The search strategy relied on the 'PICO' (Patient Intervention Comparison Outcome) criteria and article selection was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only studies reporting the oncological and functional outcomes of RARP (as determined by type of procedure [RS-RARP vs S-RARP]) were considered for inclusion. Risk of bias and study quality were assessed. Finally, peri-operative and functional outcomes were recorded and analysed.

RESULTS

A shorter operating time was associated with RS-RARP (weighted mean difference [WMD] 14.7 min, 95% confidence interval [CI] -28.25, 1.16; P = 0.03), whereas no significant difference was found in terms of estimated blood loss (WMD 1.45 mL, 95% CI -31.18, 34.08; P = 0.93). Also, no significant difference between the two groups was observed for overall (odds ratio [OR] 0.86, 95% CI 0.40, 1.85; P = 0.71) and major (Clavien >3; OR 0.88, 95% CI 0.30, 2.57) postoperative complications; however, the likelihood of positive surgical margins (PSMs) was lower for the S-RARP group (rate 15.2% vs 24%; OR 1.71, 95% CI 1.12, 2.60; P = 0.01). The cumulative analysis showed a statistically significant advantage for RS-RARP in terms of continence recovery at 1 month (OR 2.54, 95% CI 1.16, 5.53; P = 0.02), as well as at 3 months (OR 3.86, 95% CI 2.23, 6.68; P < 0.001), 6 months (OR 3.61, 95% CI 1.88, 6.91; P = 0.001), and 12 months (OR 7.29, 95% CI 1.89, 28.13; P = 0.004).

CONCLUSION

Our analysis confirms that RS-RARP is a safe and feasible alternative to S-RARP. This novel approach may be associated with faster and higher recovery of continence, without increasing the risk of complications. One caveat might be the higher risk of PSMs, and this can be regarded as a current pitfall of the technique, probably related to an expected learning curve.

Robot assisted radical prostatectomy in kidney transplant recipients: surgical, oncological and functional outcomes of two different robotic approaches

Background:

To date, few series on robot-assisted radical prostatectomy (RARP) in kidney transplant recipients (KTRs) have been published.

Purpose:

To report the experience of two referral centers adopting two different RARP approaches in KTRs. Surgical, oncological and functional results were primary outcomes evaluated in the study.

Material and methods:

We retrospectively analyzed data from 9 KTRs who underwent transperitoneal RARP or Retzius-sparing RARP for PCa from October 2012 to April 2016. Data were reported as median and interquartile range (IQR). Pre- and postoperative outcomes were compared by non-parametric Wilcoxon signed-rank test. Significant differences were accepted when p ≤ 0.05. Overall survival was assessed using Kaplan-Meier method.

Results:

Four KTRs underwent a T-RARP and 5 a RS-RARP. Patient median age was 60 (56-63) years. Charlson comorbidity index was 6 (5-6). Preoperative median PSA was 5.6 (5-15) ng / mL. Preoperative Gleason score (GS) was 6 in 5 patients, 7 (3 + 4) in 3, and 8 (4 + 4) in one. Pre- and postoperative creatinine were 1.17 (1.1; 1.4) and 1.3 (1.07; 1.57) mg / dL (p = 0.237), while eGFR was 66 (60-82) and 62 (54-81) mL / min / 1.73m2 (p = 0.553), respectively. One (11.1%) Clavien-Dindo grade II complication occurred. Two extended template lymphadenectomies were performed, both with nodal invasion. These two patients experienced a biochemical recurrence and were subjected to RT. Two patients (22.2%) had PSMs. Median follow-up was 42 months. Seven patients (77.8%) were continent, 5 (55.6%) were potent. Two (22.2%) patients died during follow-up for oncologic unrelated causes.

Conclusions:

Our series suggests that both RARP approaches are safe and feasible techniques in KTRs for PCa.

Validated Prospective Assessment of Quality of Life After Robot-Assisted Laparoscopic Prostatectomy: Beyond Continence and Erections

Continence and erectile function represent major concerns after robot-assisted laparoscopic prostatectomy (RALP), although the analysis of only these results may underestimate the impact of surgery on quality of life (QoL). The aim of the study is to prospectively analyze QoL after RALP according to the validated European Organization for Research and Treatment of Cancer Quality of Life Questionnaire prostate cancer-specific module (EORTC-QLQ-PR25) and C30 and explore risk factors for the deterioration of QoL after surgery. A total of 584 patients undergoing RALP were prospectively enrolled. QoL was assessed with the validated EORTC-QLQ-PR25 and C30. Differences across QoL items were assessed via Wilcoxon rank-sum test and associations between risk factors and QoL scores were tested via univariate and multivariate linear regression analyses. All items of the PR25 questionnaire showed a significant deterioration at 1 month after RALP and began to normalize 3 months after surgery. At 24 months follow-up, urinary, bowel, and sexual activity scores were not significantly different from preoperative scores, while incontinence aid, treatment-related symptoms, and sexual functioning remained significantly worse. Preoperative sexual activity was more important in determining 3-month sexual outcomes than preoperative 5-item version of the International Index of Erectile Function (IIEF-5) or nerve-sparing approach. An overall return to preoperative QoL was registered at 3 months after RALP in global and physical QoL, and most important, global, physical, social, and role-functioning QoL scores were improved at 12 and 24 months compared to preoperative scores. In this prospective study, detailed data on QoL are reported via the EORTC-PR25 and C30 questionnaires. While urinary, bowel, and sexual activity scores return to baseline values 24 months after surgery, incontinence aid, treatment-related symptoms, and sexual functioning may remain significantly deteriorated. Larger studies are needed to validate these findings.

Pain and discomfort after Retzius-sparing robot-assisted radical prostatectomy: a comparative study between suprapubic cystostomy and urethral catheter as urinary drainage

BACKGROUND

The aim of this study is to evaluate differences in discomfort, complications and functional results after Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) according to different urinary drainage: suprapubic tube (SPT) and standard urethral catheter (UC).

METHODS

Prospective, comparative, consecutive, non-randomized study. In all patients with a water-tight anastomosis, no hematuria, obesity, previous suprapubic surgery or history of bladder cancer, a SPT (two-way Foley 14-Fr catheter) was positioned instead of a Foley 18-Fr UC. One week after surgery, an institutional self-compiled questionnaire was administered. The patients were divided into two groups according to the presence of UC or SPT and were compared concerning pain, perioperative results, complications, functional outcomes.

RESULTS

Fifty-six patients with UC and 135 with SPT agreed to participate to the study. Median postoperative pain score was 3 (IQR: 2-5) in UC and 3 (IQR: 1-5) in SPT group (P=0.324); urinary drain-related pain scores were 3 (IQR: 1-5) in UC and 1 (IQR: 0-3) in SPT groups (P<0.001); catheter removal related scores were 1 (IQR: 0-3) and 1 (IQR: 1-3) (P=0.317), respectively. Lastly, 17.8% (UC) and 31.1% (SPT) wore a protection (small or medium pad) while the urinary drainage was in place (P=0.061). No differences related to complications were found (P=0.085); 7.9% of patients in UC group and 4.2% in SPT group (P=0.178) used pads one year after surgery.

CONCLUSIONS

We demonstrated suprapubic tube to be more comfortable than transurethral catheter after RARP, with a possible advantage concerning anastomotic postoperative problems.

Retzius sparing robotic assisted radical prostatectomy vs. conventional robotic assisted radical prostatectomy: a systematic review and meta-analysis

CONTEXT

Retzius sparing robotic assisted radical prostatectomy appears to have better continence rates when compared to conventional robotic assisted radical prostatectomy, however, concern with high positive surgical margin rates exist.

OBJECTIVE

To systematically evaluate evidence comparing functional and oncological outcomes of retzius sparing robotic assisted radical prostatectomy and conventional robotic assisted radical prostatectomy.

EVIDENCE ACQUISITION

The systematic review was performed in accordance with the Cochrane guidelines and the preferred reporting items for systematic reviews and meta-analyses (PRISMA). Bibliographic databases searched were PubMed/MEDLINE, Cochrane central register of controlled trials-CENTRAL (in The Cochrane library-issue 1, 2018). We used the GRADE approach to assess the quality of the evidence.

EVIDENCE SYNTHESIS

The search retrieved 137 references through electronic searches of various databases. Six were included in the review. RS-RALP was associated with better early continence rates (≤ 1 month) (moderate quality evidence) (RR 1.72, 95% CI 1.27, 2.32, p 0.0005) and at 3 months (low quality evidence) (RR 1.39, 95% CI 1.03, 1.88, p 0.03). Time to continence recovery, number of pads used and pad weight are better with RS-RALP. Based on very low quality evidence, RS-RALP did not alter 6 and 12 months continence rates. Based on very low quality evidence, RS-RALP did not alter T2 positive margin rates (RR 1.67, 95% CI 0.91, 3.06, p 0.10) and T3 positive margin rates (RR 1.08, 95% CI 0.68, 1.70, p = 0.75). Short-term biochemical free survival appears to be similar between the two approaches. Based on low-quality evidence, RS-RALP did not alter overall and major complication rates.

CONCLUSIONS

RS-RARP appears to have earlier continence recovery when compared to Con-RARP which does not come at a significant oncologic cost. Whilst there was a trend towards higher PSM rates with RS-RALP, this did not achieve statistical significance. Furthermore this trend appeared to be less pronounced with T3 disease, where the PSM rates are almost similar.

Morphologic changes after bladder neck intussusception in laparoscopic radical prostatectomy contribute to early postoperative continence

PURPOSE

To explore the mechanism and efficacy of the modified bladder neck intussusception in laparoscopic radical prostatectomy (LSRP) on postoperative early continence.

METHODS

We prospectively collected clinical information of prostate cancer patients who underwent LSRP with modified bladder neck intussusception (n = 10) and non-intussusception (n = 10). At postoperative 1 month, the prostate-specific antigen (PSA), pad test, real-time magnetic resonance imaging (rt-MRI), and flow rate were performed. At postoperative 3 months, the PSA, pad test, international prostate symptom score (IPSS), overactive bladder symptom score (OABSS), incontinence questionnaire short form (ICI-Q-SF), and quality of life (Qol) were recorded.

RESULTS

The intussusception and non-intussusception patients had similar baseline characteristics. At postoperative 3 months, intussusception patients had lower OABSS than non-intussusception patients (P = 0.038). The non-intussusception patients suffered from more severe incontinence (P = 0.026). The continence rate of intussusception patients was significantly higher (90% vs. 20%, P = 0.005). And intussusception patients had significantly lower Qol scores (P = 0.038). According to the morphologic analysis by rt-MRI, there were 7/10 non-intussusception patients and 2/10 intussusception patients having funnel-shaped bladder necks at Valsalva movement. The intussusception patients had larger angle between anterior and posterior wall at bladder neck (P = 0.029) and longer length of functional posterior urethra (P = 0.029). During micturition, the intussusception bladder neck was found to move less dynamically on X-axis and Y-axis, but the difference did not reach significance.

CONCLUSIONS

The modified technique of bladder neck intussusception in laparoscopic radical prostatectomy prolongs the length of functional posterior urethra and is effective to improve postoperative early continence.

Predictors for immediate recovery of continence following Retzius-sparing robot-assisted radical prostatectomy: a case-control study

PURPOSE

We evaluated urinary continence in a series of consecutive patients who underwent Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) to identify the preoperative predictors of the return to immediate urinary continence.

METHODS

110 consecutive patients who underwent RS-RARP for clinically localized prostate cancer were retrospectively collected. Patients reported freedom from using safety pad (0 pad/day) within 7 days after removal of urinary catheter were defined as immediate urinary continent.

RESULTS

A total of 85 patients (77.27%) were immediate urinary continent after RS-RARP. Patients with immediate urinary continence were significantly younger (66.92 ± 5.73 vs. 69.68 ± 4.99 years, p = 0.031) than those who were incontinent. Furthermore, the prostate volume was significantly smaller (30.90 vs. 44.60 ml, p = 0.001) and preoperative international prostate symptom score (IPSS) was significantly lower (Mild 76.5% vs. 24.0%, Moderate 20.0% vs. 32.0%, and Severe 3.5% vs. 44.0%, p = 0.000) in patients with immediate urinary continence compared with those who were not. On univariable regression analysis, patient's age (OR 0.907, p = 0.035), prostate volume (OR 0.935, p = 0.000), moderate (OR 0.196, p = 0.007), and severe IPSS (OR 0.025, p = 0.000) (compared with mild IPSS) were independent adverse predictors of immediate urinary continence. On multivariable analysis, prostate volume (OR 0.955, p = 0.032) and severe preoperative IPSS (OR 0.044, p = 0.000) (compared with mild IPSS) were independent adverse predictors of immediate urinary continence after RS-RARP.

CONCLUSIONS

RS-RARP hastens the recovery of urinary continence after surgery. Prostate volume and severe preoperative IPSS were independent adverse predictors of the return to immediate urinary continence.

Use of the IDEAL framework in the urological literature: where are we in 2018?

OBJECTIVES

To assess uptake and application of the IDEAL principles in original surgical procedure- or device-related clinical research studies, as well as its reported relevance as characterized by secondary publications, editorials and reviews.

MATERIALS AND METHODS

IDEAL (Idea, Development, Exploration, Assessment, Long-term study) is a framework that provides stage-specific guidance for surgical innovation and represented a major advance towards raising evidential standards. We performed a comprehensive literature search of all urology-related publications citing one or more of seven key publications on IDEAL in The Lancet and BMJ using multiple databases up to 31 December 2017.

RESULTS

We identified a total of 150 urology-related manuscripts citing IDEAL, of which 83 (55.3%) were original research and 67 (44.7%) were secondary publications. Among the original research articles, 40 (48.2%) did not explicitly apply IDEAL principles or were not surgical innovation studies. The IDEAL phases of the 43 (51.8%) remaining original research studies were IDEAL, in nine (20.9%), 27 (62.8%), four (9.3%), 0 (0%), and three publications (7.0%), respectively. Across IDEAL stages, 30 (75.0%) studies were prospective, 29 (85.3%) reported ethical oversight, and 39 (90.7%) captured treatment-related harms. None of the studies collected information on physician experience.

CONCLUSIONS

The IDEAL framework has found widespread adoption in the urology literature as witnessed by a large number of original manuscripts and secondary publications citing IDEAL; however, its application is largely limited to the early stages of surgical innovation, frequently with inappropriate and incomplete implementation. Further efforts are needed to guide investigators in the optimal use of the IDEAL framework as it relates to surgical innovation in urology.

Simultaneous laparoscopic proctocolectomy (TaTME) and robot-assisted radical prostatectomy for synchronous rectal and prostate cancer

OBJECTIVE

We would like to present a patient with a history of ulcerative colitis suffering from a synchronous rectal and prostate cancer treated with a laparoscopic total proctocolectomy (with TaTME) and Retzius sparing RARP simultaneously.

METHODS

Retzius sparing RARP with bilateral lymph node harvesting was performed first. Afterwards, TaTME was commenced with the placement of a Lonestar^® retractor and GelPort^®. Anterior dissection was troubled unexpectedly by outspoken fibrosis. For that reason, it was completed laparoscopically. We then continued with the laparoscopic total proctocolectomy. Last, a transanal circular stapled ileoanal anastomosis was created and a derivating ileostomy was installed.

RESULTS

Postoperative proctoscopy showed a patent ileoanal anastomosis. After removal of the Foley catheter on day 21, the patient was immediately continent. Prostate specimen revealed a pT2cN1M0 transmural invasive adenocarcinoma with a Gleason score of 7 (3 + 4). Pathology analysis of the rectum revealed a stage IIIc transmural invasive moderately differentiated rectal adenocarcinoma (pT3N2bM0) with free margins. He was referred for adjuvant chemotherapy.

CONCLUSIONS

In this case, the combination of TaTME and Retzius sparing RARP for synchronous rectal and prostate cancer was feasible and safe. We suggest performing the anterior TaTME dissection last, due to disturbing blood flow into the operating field after prostatectomy.

Preservation of continence in radical prostatectomy patients: a laparoscopic surgeon's perspective

Introduction

Preserving continence in patients who underwent radical prostatectomy is of utmost importance. Therefore, modification of surgical technique that would contribute to the regaining of continence with a shortest possible delay after the procedure and adequate evaluation of chances of continence recovery should be considered.

Material and methods

A PubMed database search was performed to review the current literature concerning the physiology and anatomy of sphincter mechanisms, perioperative risk factors, the effects of surgical techniques on post-prostatectomy continence and post-operative management.

Results

Modifications of surgical approach with an aim to minimize damage to the sphincter complex, maintenance of maximal urethral length to enable safe anastomosis, and the reconstruction of the urethral support system appears necessary. The patient should also be informed about the chances of regaining continence after surgery.

Conclusions

There is a need to develop a predictive model to stratify patients according to risk of incontinence and implement adequate action to minimize those risks including preoperative pelvic floor muscle training and/or surgical technique modification.

Robot-Assisted Radical Prostatectomy in a Post-Kidney Transplant Patient: An Initial Case Report in China

OBJECTIVE

Our aim was to evaluate the general applicability, feasibility, and safety of robot-assisted radical prostatectomy (RARP) in Chinese renal allograft patients for prostate cancer removal.

PATIENTS AND METHODS

A 62-year-old patient diagnosed as having biopsy-proven localized prostate cancer in March 2016 who had undergone renal transplant 12 years ago was studied. The preoperative prostate-specific antigen value was determined to be 11.82 ng/mL and the Gleason score was determined to be 3 + 3. The RARP was carried out using a transperitoneal and posterior approach with 5 ports in May 2016. The most important technique was ensuring that the transplanted kidney and ureter remained untouched during the surgery. Only the right obturator lymph nodes were dissected because the renal allograft was overlying the iliac vessels.

RESULTS

The RARP was successfully concluded following 230 minutes with an estimated blood loss of 200 mL. There were no postoperative complications. Final pathology was T2cN0M0, Gleason 3 + 3. Following catheter removal, the patient was completely continent and was discharged with no change in serum creatinine or glomerular filtration rate levels. During a 21-month follow-up, unobstructed urination, no incontinence, no biochemical recurrence, and normal kidney function were observed.

CONCLUSION

RARP in Chinese renal allograft patients is a feasible method that can be accomplished with no injuries to the transplanted kidney or ureter and is achieved with favorable oncological and functional outcomes. In addition, post-kidney transplant male patients are recommended to have routine prostate-specific antigen screening for the early detection of prostate cancer.

Retzius-sparing versus standard robot-assisted radical prostatectomy: a prospective randomized comparison on immediate continence rates

BACKGROUND

Post-prostatectomy urinary incontinence is an adverse event leading to significant distress. Our aim was to evaluate immediate urinary continence (UC) recovery in a single-surgeon prospective randomized comparative study between the traditional robot-assisted laparoscopic radical prostatectomy (TR-RALP) and the Retzius-sparing RALP (RS-RALP), for the treatment of the clinically localized prostate cancer (PCa).

METHODS

102 consecutive PCa patients were prospectively randomized to TR-RALP (57) or RS-RALP (45). Postoperative continence was defined as patient-reported absence of leakage or use of 0 pads/day. The immediate continence rate and 95% confidence interval (CI 95%) were calculated for each treatment. Univariable and multivariate logistic regressions were used to assess predictors of immediate continence following RALP. Continence rates from 1 to 6 months were calculated by Kaplan-Meier curves; log-rank test was used for the curve comparison. Two analyses were performed, considering a per-protocol (PP) population regarding all randomized patients that received nerve-sparing RALP and an Intention-To-Treat (ITT) population regarding all randomized patients that received RALP.

RESULTS

In the PP analysis, the rates of immediate continence were 12/40 (30%) (CI 95% 17-47%) for the TR-RALP and 20/39 (51.3%) (CI 95% 35-68%) for the RS-RALP (p = 0.05). In the ITT analysis, the corresponding rates were 12/57 (21%) (CI 95% 11-34%) for the TR-RALP and 23/45 (51%) (CI 95% 36-66%) for the RS-RALP (p = 0.001). Median time to continence was 21 days for the TR-RALP and 1 day for RS-RALP, respectively (p = 0.02). The relative Kaplan-Meier curves regarding continence resulted statistically different when compared with the log rank test (p = 0.02). In the multivariate analysis, lower age and the Retzius-sparing approach were significantly associated to earlier continence recovery.

CONCLUSIONS

The Retzius-sparing approach significantly reduces time to continence following RALP. Further studies are required to confirm the reproducibility of our results and investigate the role of the RS-RALP as an additional "protective" factor for postoperative continence in the elderly population.

Comparison between a novel knotless technique and the conventional single knot technique of laparoscopic radical prostatectomy by novice laparoscopists

OBJECTIVES

This study aimed to investigate a novel knotless technique for novice laparoscopists in traditional laparoscopic radical prostatectomy.

METHODS

We studied 68 patients who had a novel technique performed in laparoscopic radical prostatectomy (knotless group) and 89 who had the conventional single knot technique (single knot group). The operations were all performed by novice laparoscopists with experience of fewer than 100 cases of laparoscopic radical prostatectomy. Knotless suture of the dorsal vein complex was conducted using a barbed self-retaining suture with three bites at the same location. The knotless urethrovesical anastomosis technique was conducted using a unidirectional single running fashion with a barbed self-retaining suture.

RESULTS

There were no significant differences in the estimated blood loss, complication rate, postoperative hospital stay, anastomotic leakage rate, continence at 6 months after surgery, and positive margin rate between the two groups. The mean anastomotic time (24.9 vs. 44.2 min), operative time (168.1 vs. 201.8 min), and duration of catheter placement (12.8 vs. 19.8 days) were shorter in the knotless group than in the single-knot group.

CONCLUSIONS

The knotless technique of laparoscopic radical prostatectomy is a safe and effective procedure.

Neuro-anatomic basis of potency recovery after radical prostatectomy: an expert's point of view

INTRODUCTION

From 25% to 95% of those who have undergone radical prostatectomy (RP) report erectile dysfunction 12 months after surgery. We attempt a review of the available evidence regarding the anatomy of the cavernous nerves and the surgical refinements to enhance sexual function recovery after surgery.

EVIDENCE ACQUISITION

The PubMed/Medline database was searched. Duplicates were removed. Studies were selected by the authors according to the aim of the present review.

EVIDENCE SYNTHESIS

The cavernous nerves are deemed responsible for erections, but their exact function is still a matter of debate. They do not necessarily have the same distribution in all individuals: in most the cases, these nerves are located posterolaterally, however, it is not uncommon to find some fibers on the anterolateral aspects of the prostate, especially towards the apex. Several technical strategies were proposed in order to intraoperatively identify and spare the neurovascular bundles: despite all efforts, clinical results are still only partially satisfying.

CONCLUSIONS

The recovery of potency is one of the most unpredictable outcomes after RP. The advent of the robotic surgical system seems to have brought a trend towards a faster recovery of erectile function.

Retrograde Release of the Neurovascular Bundle with Preservation of Dorsal Venous Complex During Robot-assisted Radical Prostatectomy: Optimizing Functional Outcomes

BACKGROUND

Robot-assisted laparoscopic radical prostatectomy (RARP) presents consistent oncological outcomes for prostate cancer; yet continence and potency results are not uniform. We present a technical modification for RARP which preserves the nerves and vascular structures anterior to the prostate aiming to optimize functional outcomes.

OBJECTIVE

To present oncological and functional results of a modified technique for RARP.

DESIGN, SETTING, AND PARTICIPANTS

Prospective, noncontrolled case series including 128 consecutive patients undergoing RARP performed by a single surgeon (R.F.C).

SURGICAL PROCEDURE

RARP with retrograde release of the neurovascular bundle and preservation of dorsal venous complex.

MEASUREMENTS

Potency was defined as a Sexual Health Inventory for Men score of ≥17; continence was defined as use of no pads. Oncological results analyzed were positive surgical margins (PSM) rates and biochemical recurrence (BCR)-free survival. BCR was defined as prostate-specific antigen >0.2ng/ml. Complications were graded according to the Clavien-Dindo classification.

RESULTS AND LIMITATIONS

Median patient age was 63.5 yr. Median skin-to-skin time was 78min. Median length of hospital stay was 1 d, with seven patients (5.5%) hospitalized for more than 24h. Median intraoperative bleeding was 200ml and two patients required postoperative blood transfusion (1.6%). Four patients (3.1%) had grade ≥3 complications. Biochemical recurrence (BCR) occurred in nine of 128 patients (7%) and median time to BCR was 6 mo. Overall PSM rate was 13.3% (17 of 128 patients). PSM rate was 9% among patients with pT2 disease (8/89) and 27% in patients with pT3 (9/38). Continence was reached immediately in 85.9% of the patients and 98.4% were continent at1 yr. At 1 mo postoperatively, 60 patients were potent (53%), while 98 patients among 113 (86%) were potent 1 yr after surgery. A limitation of this study is that it was a noncomparative study.

CONCLUSIONS

Retrograde release of the neurovascular bundle with preservation of dorsal venous complex during RARP is safe and associated with excellent oncological and functional outcomes. Future comparative studies are needed.

PATIENT SUMMARY

Robot-assisted radical prostatectomy (RARP) presents consistent oncological outcomes for prostate cancer; yet continence and potency results are not uniform. We present a technical modification for RARP aiming to preserve the nerves and vascular structures anterior to the prostate. We evaluated 128 consecutive patients with clinically localized or locally advanced prostate cancer undergoing RARP with our modified technique of retrograde release of the neurovascular bundles with dorsal vein sparing. We have shown that this technique is safe, effective and associated with early recovery of continence and sexual function after surgery.

Retzius-Sparing Robotic-Assisted Laparoscopic Radical Prostatectomy: A Safe Surgical Technique with Superior Continence Outcomes

PURPOSE

To report early operative outcomes and assess continence in 100 consecutive patients who underwent Retzius-sparing robotic-assisted laparoscopic radical prostatectomy (RALP).

MATERIALS AND METHODS

This was a prospective, single-center, consecutive case series of 100 and 100 patients undergoing a Retzius-sparing and a conventional RALP, respectively, by a single surgeon between March 2015 and April 2017.

RESULTS

Baseline patient characteristics were similar between the two groups. The Retzius-sparing approach required significantly less console time (120.0 minutes vs 144.0 minutes, p < 0.001). There were no differences between intra- and post-operative complication rates, and hospital length of stay was similar in the two groups. Incidence of positive surgical margins was nonsignificantly different between the two groups, with 17% and 13% of pT2 patients and 49% and 48% of pT3 patients in the Retzius-sparing and conventional groups, respectively. Patients in the Retzius-sparing group had significantly superior rates of achieving post-operative urinary continence (log-rank test: p < 0.001), with 20% of patients continent within the first month, compared with 8% of patients in the conventional group. The mean number of pads per day needed at 3, 6, 9, and 12 months post-operatively was also significantly lower in the Retzius-sparing group.

CONCLUSIONS

Retzius-sparing RALP requires shorter console time, is oncologically safe, and leads to significantly superior continence outcomes compared with conventional RALP.

Inseparable interaction of the prostate and inguinal hernia

With an increase in their prevalence, it has become apparent that both benign prostatic hyperplasia and radical prostatectomy for cancer can induce inguinal hernia development. An inguinal hernia is a common late complication following radical prostatectomy, with an occurrence rate of 12-25%. Following radical prostatectomy, the space of Retzius can develop adhesions to surrounding tissue, often causing difficulty during inguinal hernia repair. Conversely, inguinal hernia repair before radical prostatectomy also induces severe adhesions around the space of Retzius and causes difficulty during radical prostatectomy. The association between radical prostatectomy and inguinal hernia development is complex and unclear. Both urologists and surgeons are challenged by this interaction. The surgical approaches for prostate cancer have undergone a major transition from open surgery to robotic surgery, and the treatment of inguinal hernia is also changing. Based on historical trends, several preventive and treatment measures have been proposed, although there is no direct evidence for risk factors that lead to inguinal hernia development. This article focuses on the complex interaction between the prostate and inguinal hernia, and considers preventive measures against inguinal hernia development.

Retzius-sparing robot-assisted radical prostatectomy using the Revo-i robotic surgical system: surgical technique and results of the first human trial

OBJECTIVE

To evaluate the safety and proficiency of the Revo-i^® robotic platform (Meere Company Inc.) in the treatment of prostate cancer (PCa).

PATIENTS AND METHODS

A prospective study was carried out on 17 patients with clinically localized PCa treated between 17 August 2016 and 23 February 2017 at our urology department using the Revo-i. Patients underwent Retzius-sparing robot-assisted radical prostatectomy (RS-RARP). The primary objective was to describe the RS-RARP step-by-step surgical technique using the Revo-i. In addition, the safety of the Revo-i was assessed according to intra-operative and the postoperative complications within 30 days of surgery. Early oncological outcomes were also assessed according to surgical margin status and biochemical recurrence (BCR). Continence was defined as use of no or only one pad. Surgeons' satisfaction with the Revo-i was assessed using the Likert scale.

RESULTS

All surgeries were completed successfully, with no conversion to open or laparoscopic surgery. The median patient age was 72 years. The median docking time, console time, urethrovesical anastomosis time and estimated blood loss were 8 min, 92 min, 26 min and 200 mL, respectively. One patient was transfused intra-operatively as a result of blood loss of 1 500 mL. Postoperatively, two patients received blood transfusion, and there were no other serious/major complications. The median hospital stay was 4 days. At 3 months, four patients had positive surgical margins, one patient had BCR, and 15 patients were continent. Most of surgeons were satisfied with the Revo-i performance.

CONCLUSIONS

The first human study for the treatment of patients with localized PCa using the Revo-i robotic surgical system was carried out successfully. The peri-operative, early oncological and continence outcomes are encouraging. Further prospective studies are warranted to support our preliminary results.

Different approaches to the prostate: The upcoming role of a purpose-built single-port robotic system

With the aim of minimising the patient’s postoperative pain, expediting recovery and improving cosmesis, the idea of performing a laparoscopic procedure through a single abdominal incision was introduced. In the present report, we describe five different access routes to the prostate that may be at the surgeon’s disposal with the potential of decreasing patient’s perioperative morbidity. Robotic radical prostatectomy has been refined and became a standard of care in surgery for localised prostate cancer. The advent of single-port robotic surgery has prompted the re-discovery of different access routes to the prostate and ideally all of them are feasible. The potential for avoiding the abdominal cavity will decrease the surgical morbidity and minimise the surgical dissection. In the near future, each of the described approaches could be chosen on the basis of the patient’s preoperative comorbidities, body habitus, anatomy, and disease characteristics and location.

A Novel Approach for Apical Dissection During Robot-assisted Radical Prostatectomy: The "Collar" Technique

BACKGROUND

Apical dissection in robot-assisted radical prostatectomy (RARP) affects not only cancer control, but also continence recovery.

OBJECTIVE

To describe a novel approach for apical dissection, the collar technique, to reduce apical positive surgical margins (PSMs).

DESIGN, SETTING, AND PARTICIPANTS

A total of 189 consecutive patients (81 in the control group, 108 in the collar technique group) underwent RARP at a single center.

PRIMARY OUTCOME

rates of apical PSMs; secondary outcome: urinary continence.

INTERVENTION

The urethral sphincter complex is incised 2-3mm distally to the apex, to stay farther from it and reduce PSMs; the underlying smooth muscle is exposed and incised closer to the apex to preserve the maximal length of the lissosphincter.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Mann-Whitney U and chi-square tests compared median and proportions between the two groups, respectively. Univariate logistic regression tested the association between technique employed and risk of apical PSMs.

RESULTS AND LIMITATIONS

Fourteen patients (7.4%) revealed apical PSMs (9.9% in the control group, 5.6% in the collar group; p=0.7). When the collar technique was used, significantly lower rates of apical PSMs occurred in pT2 disease (0% vs 7.1%; p=0.03). In case of apical tumor at preoperative magnetic resonance imaging (MRI; n=43), the collar technique determined significantly lower overall (9.7% vs 42%) and apical (3.2% vs 42%) PSMs (all p≤0.02). Continence recovery in the collar and control groups was similar. When preoperative MRI showed an apical tumor, the collar technique had a significantly lower risk of apical PSMs (odds ratio: 0.05, p=0.009).

CONCLUSIONS

The collar technique reduces the rates of apical PSMs in case of apical tumor, preserving the length of the lissosphincter.

PATIENT SUMMARY

We describe a novel approach for apical dissection during robot-assisted radical prostatectomy. Our technique reduces the rates of apical surgical margins in case of apical tumor at preoperative magnetic resonance imaging and leads to optimal continence recovery.

Surgical Techniques to Optimize Early Urinary Continence Recovery Post Robot Assisted Radical Prostatectomy for Prostate Cancer

Purpose of Review

A variety of different surgical techniques are thought to impact on urinary continence (UC) recovery in patients undergoing robot assisted radical prostatectomy (RARP) for prostate cancer. Herein, we review current evidence and propose a composite evidence-based technique to optimize UC recovery after RARP.

Recent Findings

A literature search on studies reporting on surgical techniques to improve early continence recovery post robotic prostatectomy was conducted on PubMed and EMBASE. The available data from studies ranging from randomized control trials to retrospective cohort studies suggest that minimizing damage to the internal and external urinary sphincters and their neural supply, maximal sparing of urethral length, creating a secure vesicourethral anastomosis, and providing anterior and posterior myo- fascio-ligamentous support to the anastomosis can improve early UC recovery post RARP.

Summary

A composite evidence-based surgical technique incorporating the above principles could optimize early UC recovery post RARP. Evidence from randomized studies is required to prove benefit.

Is Retzius-sparing robot-assisted radical prostatectomy associated with better functional and oncological outcomes? Literature review and meta-analysis

Objective

To evaluate the efficiency, safety and clinical outcomes of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) in comparison with the standard RARP.

Methods

A systematic search from Web of Science, PubMed, EMBase, Cochrane Library and Google Scholar was performed using the terms “Retzius-sparing”, “Bocciardi approach” and “robot-assisted radical prostatectomy”. Video articles and abstract papers for academic conferences were excluded. Meta-analysis of interested outcomes such as positive surgical margins (PSMs) and continence recovery was undertaken. A comprehensive literature review of all studies regarding Retzius-sparing (RS) approach was conducted and summarized.

Results

From 2010 to 2017, 11 original articles about RS-RARP approach were retrieved. Of that, only four studies comparing the RS-RARP approach to the conventional RARP were comparable for meta-analysis. Faster overall continence recovery within 1 month after the surgery was noted in the RS group (61% vs. 43%; p = 0.004). PSMs of pT2 and pT3 stages were not significantly different between the groups (10.0% vs. 7.4%; p = 0.39 and 13.1% vs. 9.5%, p = 0.56, respectively). Of all the studies, only one reported sexual recovery outcomes after RS treatment in which 40% of the participants achieved sexual intercourse within the first month.

Conclusion

Though more technically demanding than the conventional RARP, the RS technique is a safe and feasible approach. This meta-analysis and literature review indicates that RS technique, as opposed to the conventional approach, is associated with a faster continence recovery while PSMs were comparable between the two groups. The limitations of observational studies and the small data in our meta-analysis may prevent an ultimate conclusion. Future well-designed RCTs are needed to validate and confirm our findings.

Review of optimal techniques for robotic-assisted radical prostatectomy

PURPOSE OF REVIEW

Robotic-assisted radical prostatectomy has been rapidly adopted and is now the standard of care in the surgical management of prostate cancer. Since the initial description in 2001, the technique has evolved to optimize oncological functional outcomes. Herein, we review key techniques for the robotic-assisted radical prostatectomy.

RECENT FINDINGS

With the current influx of new technology such as focal therapy, stereotactic body radiation therapy and prostate-sparing treatments, there is greater emphasis on maximizing outcomes of robotic-assisted radical prostatectomy. The evidence-based techniques of optimizing oncological outcomes including the lymph node dissection and improving cancer control through minimizing positive surgical margins are reviewed. Improvements in functional recovery has also been seen with technical modifications such as nerve sparing, preservation of the urethral support structures and the bladder neck and the urethra-vesical reconstruction.

SUMMARY

Robotic prostatectomy has demonstrated adequate long-term oncologic success and satisfactory functional recovery. As technology and techniques in robotic-assisted surgery evolve, surgeons will continue to optimize techniques to maximize functional outcome recovery and cancer control. Further studies are actively being conducted to provide level one evidence in multiple aspects of the robotic-assisted radical prostatectomy.

Functional Recovery, Oncologic Outcomes and Postoperative Complications after Robot-Assisted Radical Prostatectomy: An Evidence-Based Analysis Comparing the Retzius Sparing and Standard Approaches

PURPOSE

We report a 1-year update of functional urinary and sexual recovery, oncologic outcomes and postoperative complications in patients who completed a randomized controlled trial comparing posterior (Retzius sparing) with anterior robot-assisted radical prostatectomy.

MATERIALS AND METHODS

A total of 120 patients with clinically low-intermediate risk prostate cancer were randomized to undergo robot-assisted radical prostatectomy via the posterior and anterior approach in 60 each. Surgery was performed by a single surgical team at an academic institution. An independent third party ascertained urinary and sexual function outcomes preoperatively, and 3, 6 and 12 months after surgery. Oncologic outcomes consisted of positive surgical margins and biochemical recurrence-free survival. Biochemical recurrence was defined as 2 postoperative prostate specific antigen values of 0.2 ng/ml or greater.

RESULTS

Median age of the cohort was 61 years and median followup was 12 months. At 12 months in the anterior vs posterior prostatectomy groups there were no statistically significant differences in the urinary continence rate (0 to 1 security pad per day in 93.3% vs 98.3%, p = 0.09), 24-hour pad weight (median 12 vs 7.5 gm, p = 0.3), erection sufficient for intercourse (69.2% vs 86.5%) or postoperative Sexual Health Inventory for Men score 17 or greater (44.6% vs 44.1%). In the posterior vs anterior prostatectomy groups a nonfocal positive surgical margin was found in 11.7% vs 8.3%, biochemical recurrence-free survival probability was 0.84 vs 0.93 and postoperative complications developed in 18.3% vs 11.7%.

CONCLUSIONS

Among patients with clinically low-intermediate risk prostate cancer randomized to anterior (Menon) or posterior (Bocciardi) approach robot-assisted radical prostatectomy the differences in urinary continence seen at 3 months were muted at the 12-month followup. Sexual function recovery, postoperative complication and biochemical recurrence rates were comparable 1 year postoperatively.

Retzius space reconstruction following transperitoneal laparoscopic robot-assisted radical prostatectomy: does it have any added value?

Retzius space sparing (RSS) during laparoscopic robot-assisted radical prostatectomy (RALP) has been offered as an approach that reduces perioperative complications and enables faster gaining of full urinary continence due to bladder anatomy preservation. Retro and transperitoneal techniques have been proposed, whereby RSS has been implemented. We sought to explore whether Retzius space reconstruction (RSR) following transperitoneal RALP will be an advantageous step as well. A prospective registry database of 102 consecutive transperitoneal RALP cases performed by a single surgeon was reviewed. The Retzius space had been opened by dissecting the bladder away from the anterior abdominal wall to the level of both internal rings. In the last 51 cases (RSR group), the peritoneal layer had been sutured back, thus repositioning the bladder back to the anterior abdominal wall and reconstructing the Retzius space. Perioperative factors were analyzed and compared between the two groups. Demographic and perioperative data did not differ between the two groups. RSR group demonstrated shorter length of stay (LOS) compared with the control group (p = 0.01), as well as faster urinary continence recovery (i.e., 0 pads) (p = 0.01). Moreover, lower numbers of Clavien-Dindo class 3 complications and 12 mm port-site hernias (p = 0.03) were seen in the RSR group compared with the control group. RSR following transperitoneal RALP is a simple and efficient step that potentially reduces early and late post-operative complications, shortens LOS and accelerates full urinary continence.

Quantitative assessment of fascia preservation improves the prediction of membranous urethral length and inner levator distance on continence outcome after robot-assisted radical prostatectomy

AIMS

To determine whether preoperative prostate/pelvic anatomical structures and intraoperative fascia preservation (FP) predict continence recovery after robot-assisted radical prostatectomy (RARP).

METHODS

Between January 2012 and March 2016, 439 prostate cancer (PCa) patients with normal preoperative continence were retrospectively included. FP score was defined as the extent of FP from base to apex of the prostate, quantitatively assessed by the surgeon. Anatomical prostate structures were measured on endorectal preoperative Magnetic Resonance Imaging. The International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) was used to assess urinary incontinence (UI). Cox analysis was used to determine predictive factors for early continence recovery. Finally a binary logistic regression analysis was performed to develop a risk calculator.

RESULTS

At a median follow up of 12.1 months 50.8% of men reported UI. In the Cox multivariate analysis longer membranous urethral length (MUL; P < 0.0001; OR 1.309; CI 1.211, 1.415) and shorter inner levator distance (ILD; P < 0.0001; OR 0.904; CI 0.85, 0.961) were predictors of earlier continence recovery. In the multivariate binary logistic regression analysis longer MUL (P < 0.0001; OR 1.565, CI 1.362, 1.798), shorter ILD (P < 0.0001; OR 0.819, CI 0.742, 0.904) and higher FP score (P = 0.024; OR 1.089, CI 1.011, 1.172) were independent predictors of continence outcome. The risk calculator predicted continence recovery between 1.3% and 99%.

CONCLUSIONS

Preoperative longer MUL and shorter ILD, but also intraoperative FP independently improve continence recovery after RARP. The risk calculator could be used to identify patients at high risk of UI.

Precision surgery and genitourinary cancers

The landscape of the surgical management of urologic malignancies has dramatically changed over the past 20 years. On one side, better diagnostic and prognostic tools allowed better patient selection and more reliable surgical planning. On the other hand, the implementation of minimally invasive techniques and technologies, such as robot-assisted laparoscopy surgery and image-guided surgery, allowed minimizing surgical morbidity. Ultimately, these advances have translated into a more tailored approach to the management of urologic cancer patients. Following the paradigm of "precision medicine", contemporary urologic surgery has entered a technology-driven era of "precision surgery", which entails a range of surgical procedures tailored to combine maximal treatment efficacy with minimal impact on patient function and health related quality of life. Aim of this non-systematic review is to provide a critical analysis of the most recent advances in the field of surgical uro-oncology, and to define the current and future role of "precision surgery" in the management of genitourinary cancers.

Urinary continence four weeks following Retzius-sparing robotic radical prostatectomy: The UK experience

Objective:

The purpose of this study was to investigate urinary continence four weeks following Retzius-sparing robot-assisted radical prostatectomy.

Patients and methods:

Forty patients with T2–T3 prostate cancer underwent Retzius-sparing-robot-assisted radical prostatectomy and their results were compared with those from the 40 patients having robot-assisted radical prostatectomy done by the same surgeon immediately prior to the adoption of Retzius-sparing-robot-assisted radical prostatectomy.

Results:

Patients in the two groups had similar age, body mass index, prostate specific antigen, biopsy Gleason sum, clinical stage, d’Amico risk profile, blood loss, prostate weight and post-operative hospital stay. Median operating time (200 (interquartile range=155–266) vs 223 (interquartile range=100–238) min; p=0.05) and catheterisation (8 (interquartile range=8–8) vs 14 (interquartile range=14–14) days; p<0.0001) were shorter in the Retzius-sparing group, many of whom had suprapubic catheters inserted. The overall complication rate was lower in Retzius-sparing patients (2.5% vs 8.0%; p=0.36). Positive surgical margin rates were similar for Retzius-sparing and non-Retzius-sparing patients and decreased with greater experience with the Retzius-sparing technique: 16.7% vs 7.7% for pT2 ( p=0.65) and 31.8% vs 14.3% for pT3 ( p=0.44). Initial prostate specific antigen was <0.1 ng/ml in 97.5% and 100%, respectively ( p=1.00). At four weeks post-operation 0, 1 and 2 pads/day were needed in the Retzius-sparing group in 90.0%, 7.5% and 2.5% of patients, compared to 37.5% ( p<0.0001), 32.5% ( p=0.01) and 30% ( p=0.002) of men having conventional surgery.

Conclusion:

Retzius-sparing-robot-assisted radical prostatectomy is faster than the anterior approach to the prostate, allows a shorter catheterisation time and produces dramatically better continence results at four weeks with 90% of patients being pad-free and 97.5% of patients needing 0–1 pads/day.

Urinary continence recovery after radical prostatectomy - anatomical/reconstructive and nerve-sparing techniques to improve outcomes

In an editorial board-moderated debate format, two experts in prostate cancer surgery are challenged with presenting the key strategies in radical prostatectomy that improve urinary functional outcomes. Dr Bernardo Rocco was tasked with arguing the facts that support the anatomical preservation and reconstruction steps that improve urinary continence. Drs Christian Pavlovich and Sasha Druskin were tasked with arguing the facts supporting neurovascular bundle and high anterior release surgical planes that improve urinary continence. Associate Editor John Davis moderates the debate, and outlines the current status of validated patient questionnaires that can be used to evaluate urinary continence, and recent work that allows measuring what constitutes a 'clinically significant' difference that either or both of these surgical techniques could influence. A review of raw data from a publication from Dr Pavlovich's team demonstrates how clinically relevant differences in patient-reported outcomes can be correlated to technique. A visual atlas is presented from both presenting teams, and Dr Davis demonstrates further reproducibility of technique. A linked video on this concept is available as a supplementary file.

Recovery of urinary continence after radical prostatectomy

INTRODUCTION

In the era of minimally-invasive surgery, urinary incontinence (UI) after radical prostatectomy (RP) still represents a troublesome issue for a considerable rate of patients. Factors associated with the risk of post-RP UI, need to be carefully assessed throughout the overall clinical management process thus including the pre-operative, intra-operative and post-operative setting.

AREAS COVERED

This review analyses current published evidences regarding clinical and surgical aspects associated with urinary continence (UC) recovery after RP. A careful evaluation of patient's clinical characteristics should be carried out before surgery in order to properly counsel the patients regarding the risk of UI. In the last two decades, the advent of robotic surgery has led to an overall improvement of functional outcomes after RP, thanks to the development of different surgical strategies based on either the 'preservation' or the 'reconstruction' of the anatomical elements responsible for urinary continence. Finally, several therapeutic strategies including either a conservative approach, or pharmacological and surgical treatments, should be carefully considered for the post-operative management of UI. Expert commentary: A comprehensive pre-operative patient's clinical assessment, along with a proper and well-conducted surgical procedure and an effective post-operative care management are essential element to achieve a high probability of UC recovery.

Robotic Single-port Surgery: Paving the Way for the Future

Adoption of robotic technology in urology has been widely popularized as it provides considerable advantages over standard techniques, including improved instrument dexterity, three-dimensional high-definition optics, and enhanced ergonomics. As a result, these features have facilitated the adaptation of robotics for laparoendoscopic single-site surgery (LESS) to overcome challenges with clashing, suturing, and intra-abdominal triangulation. Since the inception of robotic LESS by our institution in 2008,(1) many centers have gone on to study this approach in various urologic applications. Herein we discuss the evolution of robotic LESS access, instrumentation, and outcomes with special focus on up-and-coming technology.

A Clinician's Guide to Avoiding and Managing Common Complications During and After Robot-assisted Laparoscopic Radical Prostatectomy

CONTEXT

Robot-assisted radical prostatectomy (RARP) is on the advance globally, and it is essential for surgeons and patients to know the rates of perioperative complications.

OBJECTIVE

To provide evidence-based clinical guidance on avoiding and managing common complications during and after RARP in the context of a comprehensive literature review.

EVIDENCE ACQUISITION

In concordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis 2015 statement guidelines, a literature search of the PubMed database from August 1, 2011, to August 31, 2015, using the predefined search terms robot* AND radical prostatectomy, was conducted. The search resulted in 653 unique results that were subsequently uploaded to DistillerSR (Evidence Partners, Ottawa, Canada) for team-based screening and processing of references.

EVIDENCE SYNTHESIS

Overall, 37 studies met the inclusion criteria and were included. Median rate of overall complication was 12.6% (range: 3.1-42%). Most of the complications were minor (Clavien-Dindo grades 1 and 2). Grade 3 complications comprised the bulk of the major complications with a median rate of 2.7%; grade IV and V complications were exceedingly rare in all reports.

CONCLUSIONS

Despite continued adoption of the RARP technique globally, rates of overall complication remain low. Many of the complications experienced during and after RARP can be mitigated and prevented by experience and the implementation of safe techniques.

PATIENT SUMMARY

Despite continued adoption of the robot-assisted radical prostatectomy (RARP) technique globally, rates of overall and major complications remain low at 12.6% and 2.7%, respectively. Complications can be minimized and successfully managed using established techniques. RARP is a safe and reproducible technique.

Past, present and future of urological robotic surgery

The first urologic robotic program in the world was built at the Vattikuti Urology Institute, Henry Ford Hospital Detroit, Michigan, in 2000 under the vision of surgical innovator, Dr. Mani Menon for the radical prostatectomy. The robot-assisted radical prostatectomy continues being modified with techniques to improve perioperative and surgical outcomes. The application of robotic surgical technique has since been expanded to the bladder and upper urinary tract surgery. The evolution of surgical technique and its expansion of application will continue to improve quality, outcome parameters and experience for the patients.