Laparoscopic radical prostatectomy: initial short-term experience

A review of medical robotics for minimally invasive soft tissue surgery

This paper provides an overview of recent trends and developments in medical robotics for minimally invasive soft tissue surgery, with a view to highlight some of the issues posed and solutions proposed in the literature. The paper includes a thorough review of the literature, which focuses on soft tissue surgical robots developed and published in the last five years (between 2004 and 2008) in indexed journals and conference proceedings. Only surgical systems were considered; imaging and diagnostic devices were excluded from the review. The systems included in this paper are classified according to the following surgical specialties: neurosurgery; eye surgery and ear, nose, and throat (ENT); general, thoracic, and cardiac surgery; gastrointestinal and colorectal surgery; and urologic surgery. The systems are also cross-classified according to their engineering design and robotics technology, which is included in tabular form at the end of the paper. The review concludes with an overview of the field, along with some statistical considerations about the size, geographical spread, and impact of medical robotics for soft tissue surgery today.

Robot-assisted extraperitoneal laparoscopic radical prostatectomy: a review of the current literature

Prostate cancer remains a significant health problem worldwide and is the second highest cause of cancer-related death in men. While there is uncertainty over which men will benefit from radical treatment, considerable efforts are being made to reduce treatment related side-effects and in optimizing outcomes. The current gold standard treatment for localized prostate cancer remains open radical prostatectomy. Since the early 1990s, several teams have tried to explore less invasive surgical access. The first robotically assisted laparoscopic prostatectomy (RALP) case was reported in 2000. Enhancement of the ergonomics and optimization of the surgical vision provided by the robotic interface are some of the reasons that explain the worldwide wide spread of RALP. Although this procedure accounted for the vast majority of radical prostatectomies performed in United States, its diffusion is still limited in Europe. The cost for robot purchase and maintenance are obvious limiting factors for its expansion. According to the literature, the operating time and the blood loss are, once the learning curve is completed, similar to those of open or laparoscopic procedures. Hospital stay and time before bladder catheter removal are shorter compared with other approaches. Intermediate oncologic and functional outcomes do not show difference with the open or laparoscopic results. Given that these data are encouraging, the limited follow-up with RALP does not allow drawing any definitive statement in comparison with conventional techniques. The aim of our study was to underline the perioperative, oncologic, and functional outcomes of all extraperitoneal RALP series published.

Laparoscopic extraperitoneal radical prostatectomy: impact of the learning curve on perioperative outcomes and margin status

OBJECTIVE

After improved technical modifications that followed the original reports by pioneering laparoscopic surgeons, the impact of the learning curve has not been objectively assessed for laparoscopic extraperitoneal radical prostatectomy (LERP). In this study, we assessed the impact of the learning curve on operative and oncologic outcomes at a high surgical volume institution.

METHODS AND MATERIAL

We prospectively analyzed 400 consecutive patients with localized prostate cancer treated with LERP between January 2004 and July 2006. Patients were divided into 4 equal groups (1-100, 101-200, 201-300, and 301- 400). Kruskal-Wallis test was performed to determine whether all the preoperative variables were comparable among groups. Fisher's exact test was performed to determine the association of margin status with pathological stage. Chi-square test was performed to determine whether margin status was associated with groups (1 vs. 2, 3, & 4). Wilcoxon rank-sum test was used to determine whether operative time was statistically different in group 1 (1-100) compared with groups 2, 3, and 4.

RESULTS

All groups were comparable with respect to preoperative data. Positive margin rate significantly decreased after the first 200 cases for patients with pT2a-c disease (28.4% to 31.9% vs. 11.6% to 11.5%). Margin status was significantly associated with groups (Group 1 & 3: P=0.0044 and group 1 & 4: P=0.0021). Operative time significantly decreased after the first 100 cases (350 min vs. 218 min, 192 min, and 223 min) (P<0.0001).

CONCLUSIONS

In a tertiary care academic institution, the operative and pathologic outcomes improved significantly with increased surgical experience. At our institution, the operative and pathologic outcomes improved after 100 and 200 cases, respectively.

Laparoscopic extraperitoneal radical prostatectomy: impact of the learning curve on perioperative outcomes and margin status

OBJECTIVE

After improved technical modifications that followed the original reports by pioneering laparoscopic surgeons, the impact of the learning curve has not been objectively assessed for laparoscopic extraperitoneal radical prostatectomy (LERP). In this study, we assessed the impact of the learning curve on operative and oncologic outcomes at a high surgical volume institution.

METHODS AND MATERIAL

We prospectively analyzed 400 consecutive patients with localized prostate cancer treated with LERP between January 2004 and July 2006. Patients were divided into 4 equal groups (1-100, 101-200, 201-300, and 301- 400). Kruskal-Wallis test was performed to determine whether all the preoperative variables were comparable among groups. Fisher's exact test was performed to determine the association of margin status with pathological stage. Chi-square test was performed to determine whether margin status was associated with groups (1 vs. 2, 3, & 4). Wilcoxon rank-sum test was used to determine whether operative time was statistically different in group 1 (1-100) compared with groups 2, 3, and 4.

RESULTS

All groups were comparable with respect to preoperative data. Positive margin rate significantly decreased after the first 200 cases for patients with pT2a-c disease (28.4% to 31.9% vs. 11.6% to 11.5%). Margin status was significantly associated with groups (Group 1 & 3: P=0.0044 and group 1 & 4: P=0.0021). Operative time significantly decreased after the first 100 cases (350 min vs. 218 min, 192 min, and 223 min) (P<0.0001).

CONCLUSIONS

In a tertiary care academic institution, the operative and pathologic outcomes improved significantly with increased surgical experience. At our institution, the operative and pathologic outcomes improved after 100 and 200 cases, respectively.

Transition from pure laparoscopic to robotic-assisted radical prostatectomy: a single surgeon institutional evolution

PURPOSE

To review a single surgeon experience of transitioning to a robotic-assisted laparoscopic prostatectomy program (RALP) with prior pure laparoscopic radical prostatectomy (LRP) experience.

MATERIALS AND METHODS

A retrospective review of surgical results from a single surgeon performing LRP transitioning to RALP was performed. Two hundred five patients undergoing RALP by a single, fellowship-trained, urologic oncologist were analyzed and compared with 45 patients undergoing LRP by the same surgeon. Operative, pathologic, and functional outcomes were evaluated. Validated questionnaires, including the International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF), were utilized for assessing urinary and sexual parameters.

RESULTS

Preoperative parameters (age, PSA, Gleason score) were similar in both RALP and LRP groups. Operative time (190 vs. 299 minutes), estimated blood loss (253 vs. 299 ml), and length of stay (1.6 vs. 2.6 days) were reduced in RALP vs. LRP. Although not statistically significant, there was a trend toward fewer transfusions with RALP (2.0% vs. 4.4%) as well as a lower positive margin rate in organ-confined (pT2) disease (9.8%, RALP vs. 20%, LRP). Continence at 12 months was 94% following RALP as opposed to 82% after LRP. In preoperatively potent men undergoing bilateral nerve sparing procedures, RALP conferred 81% potency at 12 months as opposed to only 62% following LRP.

CONCLUSIONS

The transition from LRP to RALP, in concert with an institutional commitment to a successful robotic surgery program, has yielded superior operative, oncologic, and functional results.

Costs in surgical techniques for radical prostatectomy: a review of the current state

INTRODUCTION

We carried out a mini-review of the literature in order to obtain a snapshot of the present state of the art of surgical techniques costs available for radical prostatectomy.

MATERIALS AND METHODS

We developed a MEDLINE search strategy and one economist assessed the included studies using the NHS EED guidelines for reviewers.

RESULTS

When observing costs by the author, it is possible to trace up a trend line of increasing costs which starts off with RPP, passes through RRP and LRP and ends up with robot-assisted radical prostatectomy. Two studies do not agree with this. One author claims that LRP is less costly than radical retropubic prostatectomy whereas another one agrees on radical perineal prostatectomy and radical retropubic prostatectomy but does not on RAP, which he claims to be less costly.

CONCLUSIONS

The data shown in our study outline a situation by which the observed studies highlight: different costs of the techniques and incapability to achieve a conclusion about the technique with less average costs. These results can be considered in an explorative way and cannot be generalized. They maintain a strictly approximate value in local realities having only an informative purpose.

Overcoming the learning curve for robotic-assisted laparoscopic radical prostatectomy

Robotic-assisted laparoscopic radical prostatectomy (RALP) has been rapidly adopted in the last few years despite having a prolonged learning curve. This article describes the RALP learning curve, reviews in detail the challenging steps of the operation, describes the authors' RALP technique, and concludes with tips to overcome the learning curve.

Comparative effectiveness of prostate cancer surgical treatments: a population based analysis of postoperative outcomes

PURPOSE

Enthusiasm for laparoscopic surgical approaches to prostate cancer treatment has grown despite limited evidence of improved outcomes compared with open radical prostatectomy. We compared laparoscopic prostatectomy with or without robotic assistance vs open radical prostatectomy in terms of postoperative outcomes and subsequent cancer directed therapy.

MATERIALS AND METHODS

Using a population based cancer registry linked with Medicare claims we identified men 66 years old or older with localized prostate cancer who underwent radical prostatectomy from 2003 to 2005. Outcome measures were general medical/surgical complications and mortality within 90 days after surgery, genitourinary/bowel complications within 365 days, radiation therapy and/or androgen deprivation therapy within 365 days and length of hospital stay.

RESULTS

Of the 5,923 men 18% underwent laparoscopic radical prostatectomy. Adjusting for patient and tumor characteristics, there were no differences in the rate of general medical/surgical complications (OR 0.93 95% CI 0.77-1.14) or genitourinary/bowel complications (OR 0.96 95% CI 0.76-1.22), or in postoperative radiation and/or androgen deprivation (OR 0.80 95% CI 0.60-1.08). Laparoscopic prostatectomy was associated with a 35% shorter hospital stay (p <0.0001) and a lower bladder neck/urethral obstruction rate (OR 0.74, 95% CI 0.58-0.94). In laparoscopic cases surgeon volume was inversely associated with hospital stay and the odds of any genitourinary/bowel complication.

CONCLUSIONS

Laparoscopic prostatectomy and open radical prostatectomy have similar rates of postoperative morbidity and additional treatment. Men considering prostate cancer surgery should understand the expected benefits and risks of each technique to facilitate decision making and set realistic expectations.

Early complication rates in a single-surgeon series of 2500 robotic-assisted radical prostatectomies: report applying a standardized grading system

BACKGROUND

Perioperative complications following robotic-assisted radical prostatectomy (RARP) have been previously reported in recent series. Few studies, however, have used standardized systems to classify surgical complications, and that inconsistency has hampered accurate comparisons between different series or surgical approaches.

OBJECTIVE

To assess trends in the incidence and to classify perioperative surgical complications following RARP in 2500 consecutive patients.

DESIGN, SETTING, AND PARTICIPANTS

We analyzed 2500 patients who underwent RARP for treatment of clinically localized prostate cancer (PCa) from August 2002 to February 2009. Data were prospectively collected in a customized database and retrospectively analyzed.

INTERVENTION

All patients underwent RARP performed by a single surgeon.

MEASUREMENTS

The data were collected prospectively in a customized database. Complications were classified using the Clavien grading system. To evaluate trends regarding complications and radiologic anastomotic leaks, we compared eight groups of 300 patients each, categorized according the surgeon's experience (number of cases).

RESULTS AND LIMITATIONS

Our median operative time was 90min (interquartile range [IQR]: 75-100min). The median estimated blood loss was 100ml (IQR:100-150ml). Our conversion rate was 0.08%, comprising two procedures converted to standard laparoscopy due to robot malfunction. One hundred and forty complications were observed in 127 patients (5.08%). The following percentages of patients presented graded complications: grade 1, 2.24%; grade 2, 1.8%; grade 3a, 0.08%; grade 3b, 0.48%; grade 4a, 0.40%. There were no cases of multiple organ dysfunction or death (grades 4b and 5). There were significant decreases in the overall complication rates (p=0.0034) and in the number of anastomotic leaks (p<0.001) as the surgeon's experience increased.

CONCLUSIONS

RARP is a safe option for treatment of clinically localized PCa, presenting low complication rates in experienced hands. Although the robotic system provides the surgeon with enhanced vision and dexterity, proficiency is only accomplished with consistent surgical volume; complication rates demonstrated a tendency to decrease as the surgeon's experience increased.

Laparoscopic radical prostatectomy: a review

INTRODUCTION

We offer an overview of the intra-, peri- and postoperative outcomes of laparoscopic radical prostatectomy (LRP) with the endpoint to evaluate potential advantages of this approach.

MATERIALS AND METHODS

We conducted an extensive Medline literature search (search terms "laparoscopic radical prostatectomy" and "radical prostatectomy") from 1990 until 2007. Only full-length English language articles identified during this search were considered for this analysis. A preference was given to the articles with large series with more than 100 patients. All pertinent articles concerning localized prostate cancer were reviewed.

CONCLUSION

Pure LRP has shown to be feasible and reproducible but it is difficult to learn. Potential advantages over open surgery have to be confirmed by longer-term follow-up and adequately designed clinical studies.

Evaluation of the outcome of laparoscopic radical prostatectomy by a single surgeon: experience with an initial 30 cases

OBJECTIVE

We carried out this study to clarify whether operative methods of laparoscopic prostatectomy (LRP) could become a standard therapy. The purpose was to evaluate the technical feasibility, oncologic effectiveness and perioperative and postoperative morbidity of LRP performed by a general urologist.

PATIENTS AND METHODS

Between June 2004 and May 2006, 30 patients with clinically localized prostate cancer consecutively underwent LRP by a single surgeon. Oncologic data were assessed by histopathological examination and by postoperative prostate-specific antigen (PSA) levels.

RESULTS

Complete laparoscopic removal of the prostate and seminal vesicles was achieved in all 30 patients. The average operation time was 250.9 min (range, 168 to 394 min). The total positive surgical margin rate was 20.7% (6 of 29 cases), with a total PSA recurrence rate was 23.3% (7 of 30 cases), but the frequencies tended to be decreased in the later phase cases. Perioperative complications were encountered in 5 patients; four of these patients were in the initial 10 cases. Two of the 30 cases (6.7%) required a blood transfusion (first case and 11th case). There were three surgical complications, one ureter injury, one rectal injury and one sigmoid serosal injury. The catheter duration intervals were reduced in the later cases.

CONCLUSIONS

From our experience with one surgeon, with whom perioperative complications were concentrated in the initial 10 cases, we conclude that LRP should be performed by experienced surgeons after intensive training.

Reducing blood loss in open radical retropubic prostatectomy with prophylactic periprostatic sutures

OBJECTIVE

To determine whether the placement of small-calibre, rapidly absorbed prophylactic periprostatic sutures before the mobilization of the prostate could reduce blood loss during open retropubic radical prostatectomy (RRP).

PATIENTS AND METHODS

In 2007, during open RRP, we began placing prophylactic haemostatic sutures of 4-0 and 3-0 plain catgut in the anterior portions of the distal neurovascular bundles (NVBs) and lateral to the proximal NVBs and prostate pedicles before initiating the nerve-sparing dissection and mobilizing the prostate gland. To evaluate whether this reduced intraoperative blood loss, we compared estimated blood loss (EBL), non-autologous transfusion rates, and postoperative haemoglobin (Hb) levels between 100 consecutive patients treated immediately before and 100 consecutive patients treated immediately after the adoption of the prophylactic periprostatic suture technique.

RESULTS

Before the use of prophylactic haemostatic sutures, the mean intraoperative blood loss was 1285 mL, and one patient (1%) received an intraoperative non-autologous transfusion. After the adoption of prophylactic sutures, the mean EBL was 700 mL (P < 0.001), and there were no transfusions. The mean Hb concentration the morning after RRP was 10.9 g/dL before and 11.8 g/dL after the initiation of prophylactic haemostatic sutures (P < 0.001).

CONCLUSION

Prophylactic periprostatic haemostatic sutures significantly reduce intraoperative blood loss during open RRP.

Robotic-assisted radical prostatectomy: a review of current outcomes

With the widespread diffusion of the screening for prostate cancer, the disease has been diagnosed more commonly in the organ-confined stage, and in younger and healthier men. For these patients, radical prostatectomy (RP) is still the standard treatment. In an effort to decrease the morbidity associated with open RP, minimally invasive approaches have been described, including robotic-assisted RP (RALP). Almost one decade after the introduction of RALP, large and mature series have now been reported. We reviewed the outcomes of the largest series of RALP published recently. We searched Medline for reports published between 2006 and 2009, to identify articles describing intraoperative data, surgical complications, oncological outcomes, continence and potency rates after RALP. Relevant articles were selected and the outcomes evaluated.

The advanced learning curve in robotic prostatectomy: a multi-institutional survey

Several studies have attempted to define the learning curve associated with robot-assisted laparoscopic prostatectomy (RALP). These studies have focused on the acquisition of skills by novice robotic surgeons. It is unclear, however, if basic proficiency can be equated with satisfactory patient outcomes. We surveyed experienced robotic surgeons with high surgical volume in an attempt to define an "advanced" learning curve, relating to proficiency and outcomes with the robotic procedure. A questionnaire was designed to evaluate the learning curve of the RALP from basic to advanced techniques. High-volume, experienced surgeons were asked to complete this questionnaire on the basis of their personal experience with the RALP procedure. Nine institutions participated in the study accounting for a total case volume of 6,276. Median surgeon experience was 460 cases (range 325-1,500); median total operative and robotic time were 165 and 105 min, respectively. Median time to "basic proficiency" with the robot was 40 cases; proficiency in more challenging cases was approached after a median of 50 cases. Surgical outcomes were deemed satisfactory to the surgeon for continence, potency, and surgical margins after a median of 100, 200, and 300 procedures, respectively. These data confirm previous studies that basic proficiency with the robotic system occurs relatively quickly, after 25-40 cases. Obtaining "satisfactory outcomes" took substantially longer, from 100 to 300 cases. Satisfactory outcomes regarding surgical margins and potency took longer to obtain than continence, likely reflecting the relative complexity of cancer control and nerve-sparing compared with the vesico-urethral anastomosis.

Pathologic outcomes during the learning curve for robotic-assisted laparoscopic radical prostatectomy

OBJECTIVE

We report our initial experience with 62 patients undergoing robotic-assisted laparoscopic prostatectomy (RALP), focusing on the primary parameter of positive surgical margins. The authors demonstrate that excellent oncologic outcomes can be attained with a less steep learning curve than previously hypothesized.

MATERIALS AND METHODS

The first 62 patients undergoing RALP by a single physician (DPD) at our institution between November 2005 and August 2007 were retrospectively assessed. Surgical pathology records were reviewed for Gleason score, pathologic tumor stage, nodal status, location of prostate cancer within the specimen, extracapsular extension, surgical margin status, presence of perineural invasion, tumor volume, and weight of the surgical specimen. Margin status was determined using surgical specimens only, and not intraoperative frozen sections. All cases in this series were completed using the four-arm da Vinci Robotic System (Intuitive Surgical, Sunnyvale, California).

RESULTS

Sixty-one patients had prostate cancer on their final surgical pathology specimens. Pathologic stage T2 and stage T3 patients were 88.7% and 9.7% of all cases, respectively. The pathologic Gleason score was 7 or greater in 62.3%. Our overall positive surgical margin rate was 3.3%. Patients with pathologic T2 and T3 disease had a positive surgical margin rate of 1.8% and 16.7%, respectively.

CONCLUSIONS

Our study suggests that RALP can have equal if not better pathologic outcomes compared to open radical prostatectomy even during the initial series of cases. We argue that the learning curve for RALP is shorter than previously thought with respect to oncologic outcomes, and concerns asserting that lack of tactile feedback leads to poor oncologic outcomes are unfounded.

Laparoscopic radical prostatectomy: oncological and functional results of 126 patients with a minimum 3-year follow-up at a single Chinese institute

In this study we evaluate the oncological and functional results of the largest cohort of patients in China treated by laparoscopic radical prostatectomy (LRP) and with at least 3 years of follow-up. 126 inconsecutive patients (range 56-78 years, median 62.5) who had an LRP were retrospectively analyzed. The mean prostate specific antigen level and Gleason score was 13.4 ng mL(-1) and 6.4, respectively. Twenty-seven patients had unilateral or bilateral nerve preservation and 29 had pelvic lymphadenectomy. Multivariate analysis was used to adjust for differences in clinical and pathological features when comparing the risk for biochemical progression-free survival (bPFS). Urinary continence was assessed by incontinence questionnaire and erectile function by the Sexual Health Inventory for Men score. The mean operative duration was 250 min and blood loss 354 mL. Five patients received blood transfusion and nine had complications, including rectal injury (two), ureteral injury (one), active bleeding (one), bladder neck stenosis (two), paralytic ileus (one), subcutaneous hematoma (one) and port-site hernia (one). The overall positive surgical margin rate was 20.6% and correlated with pathological stage and Gleason score respectively (P = 0.03, P < 0.001 respectively). All patients had >or= 3 years of follow-up (range 3-6.75 years, mean 4.6, median 4.75). At 3 years of follow-up, the overall survival rate was 100% and the bPFS was 81.0% in all patients; 124 patients (98.4%) were continent; 22 of 27 patients (81.5%) who underwent nerve preservation retained erectile function. Our series confirms that LRP is an effective, safe and precise technique at Chinese institution.

Laparoscopic radical prostatectomy: A European virus

The evolution of prostate cancer treatment has now incorporated the principles of minimally invasive surgery. Laparoscopic radical prostatectomy, just like a virus, infected first Europe and three years ago the United States. This European virus has nowadays a potentially widespread application. Oncological efficacy and ability to preserve and improve continence and potency are the factors that will ultimately determine the role of laparoscopic radical prostatectomy and thus the future of this virus infection. This article reviews the current published experience with minimally invasive prostatectomy and provides comparisons to published data on radical retropubic prostatectomy to increase awareness about viability. Some prospective and retrospective non-randomized comparative studies of the two approaches are also included in the present review. The current practice patterns regarding urological laparoscopic surgery and the tendency of the urologic community in Europe and in the United States to establish minimally invasive radical prostatectomy in more urological departments are described.

Introducing a new, simple scoring system to evaluate oncological and functional outcome after radical prostatectomy

OBJECTIVE

To create a scoring system which takes into account oncological outcome and functional results (continence and erectile function) of patients after radical prostatectomy.

MATERIAL AND METHODS

A total of 146 consecutive men underwent radical prostatectomy for localized prostate cancer and were evaluated 1 year after surgery. Biochemical recurrence was defined as a single postoperative prostate-specific antigen (PSA) level of > 0.2 ng/ml. Continence, defined as not using a pad, and potency, defined as the ability to achieve and maintain an erection suitable for sexual intercourse, were evaluated by means of a prospective, self-administered questionnaire. Each patient received 4 points (if PSA was <0.2 ng/ml) or 0 points (if PSA was >0.2 ng/ml) for oncological outcome, 2 points (if continent) or 0 points (if incontinent) for urinary continence and 1 point (if potent) or 0 points (if impotent) for erectile function. The total score was calculated, with higher scores indicating a better outcome. The unique feature of this scoring system is that each individual score represents a particular clinical status regarding oncological and functional outcome.

RESULTS

One year after surgery, 121 (82.8%) patients had PSA levels of <0.2 ng/ml, 103 (70.5%) were continent and 53 (36.3%) were potent. Patients with a total score of > or =4 points had good cancer control and could be further subdivided into those who were continent and potent (7 points; 22.6%), those who were continent but had erectile dysfunction (ED) (6 points; 34.2%), those who were incontinent and potent (5 points; 8.2%) and those who were incontinent and had ED (4 points; 17.8%). Similarly, patients with a score of <4 points had no cancer control and could be further subdivided into those who were continent and potent (3 points; 3.4%), those who were continent but had ED (2 points; 10.3%), those who were incontinent and potent (1 point; 2.1%) and those who were incontinent and had ED (0 points; 1.3%).

CONCLUSIONS

This scoring system includes the three most important outcomes after radical prostatectomy, namely cancer control, continence and erectile function. It may allow us to better evaluate, communicate and compare the results of radical prostatectomy in a multinational, multicenter setting.

Laparoscopic radical prostatectomy: Surgical, oncological and functional outcomes

OBJECTIVE

To report the first results of laparoscopic radical prostatectomy (LRP) at our institution.

MATERIAL AND METHODS

The surgical, functional and oncological outcomes of all patients who underwent LRP at Helsinki University Central Hospital between May 2002 and May 2006 were prospectively evaluated. The first eight patients were operated transperitoneally and the next 72 extraperitoneally.

RESULTS

The mean operative time was 328+/-73 min (range 210-510 min). The mean estimated blood loss was 769+/-906 ml (range 50-5500 ml), and 18 patients (22.5%) had transfusions. The mean catheterization time was 13.2+/-4.0 days (range 9-35 days). Mean hospital stay was 5.7+/-3.1 days (range 3-15 days). Nineteen patients (23.8%) had perioperative complications. The conversion rate to open surgery was 11.3% and 6.3% required an immediate re-operation. Three anastomotic strictures (5.7%) and two cases of ileus (3.8%) were observed. The cancer was intracapsular (pT1-2) in 68 patients (85.0%) and extracapsular (pT3-4) in 12 (15.0%). Positive surgical margins were noted in 20 patients (25.0%) in total: 17.6% of pT1-2 cases and 66.7% of pT3-4 cases. Prostate-specific antigen recurrence (> or =0.2 ng/ml) was noted in 5/53 patients (9.4%), who were followed for >12 months. The continence rate (no daily pad use) was 86.8% and the potency rate was 34.6% at 12 months.

CONCLUSIONS

The surgical, functional and oncological results of our first LRPs compare fairly well with the early experience of others. LRP is feasible outside high-volume centers but the learning curve is expected to be long.

[Prospective study and comparative of surgical and oncologic outcome between laparoscopic and retropubical radical prostatectomy]

INTRODUCTION

Radical prostatectomy (RP) is a potentially healing surgical procedure.

OBJECTIVE

We evaluate and compare the surgical and oncologic outcomes between laparoscopic and retropubical radical prostatectomy in the Urology Department in DIPRECA Hospital.

METHOD

We constructed a nonrandomised, prospective study between january 2003 and march 2007. A total of 115 patients, 56 operated laparoscopically and 59 by retropubical RP. Functional and oncologic results were compared according to standardized variables and their corresponding statistical analysis, for which we used SPSS 12.0 program.

RESULTS

Mean operation time was 202,5 minutes for laparoscopic RP and 150,5 for retropubical RP (p<0.0001). Retropubical RP required more blood transfusions (p<0.0001), longer hospital stay (p=0,0073) and longer need for vesical catheter (p=0,0001) than laparoscopic RP. There were 23 complications, 15 attributable to laparoscopic RP. We found no significant differences in postsurgical sexual function and urinary continence. In respect to the oncologic variables, we found no statistically relevant differences in positive surgical margins nor biochemical relapse during follow up.

CONCLUSION

We found no significant differences between retropubical and laparoscopic RP in the oncologic and functional variables analyzed. Nevertheless, our experience shows a distinct benefit in favour of the laparoscopic approach in relation to bleeding and recovery rate. Though retropubical RP has a shorter operating time, we believe this variable depends on the learning curve still developing for laparoscopic RP. According to our literary review, this is the first publication in Chile that compares both techniques.

Robotic prostatectomy: what we have learned and where we are going

Radical prostatectomy became a mainstay of treatment for prostate cancer in the United States after the pioneering work of Walsh in defining the nerve sparing technique. Efforts to reproduce this operation in a minimally invasive fashion resulted in slow progress that recently have flourished with the application of the daVinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) by Menon and colleagues. This article summarizes the origins of robotic prostatectomy, some of the current data regarding this operation and potential future directions.

Open, laparoscopic and robotic radical prostatectomy: optimizing the surgical approach

As advances in the understanding of prostatic anatomy led to improvements in functional and oncologic outcomes after prostatectomy of the past few decades, advances in technology and surgical technique have made minimally-invasive prostate surgery a reality. Today patients diagnosed with clinically localized prostate cancer have more surgical treatment options than in the past including open, laparoscopic and robot-assisted laparoscopic radical prostatectomy. Advantages and disadvantages exist for each modality and lead to subtle differences in the technical execution of the procedure. Evidence from centers of excellence and from experienced surgeons demonstrates that both laparoscopic and robotic-assisted laparoscopic radical prostatectomy appear to be comparable to outcomes achieved with open radical retropubic prostatectomy series. Individual surgeon skill, experience and clinical judgment are likely the stronger predictors of outcome rather than the technique chosen. However, learning curves, oncologic outcomes and cost-efficacy remain important considerations in the dissemination of minimally-invasive prostate surgery. A greater appreciation of the periprostatic anatomy and further modification of surgical technique will result in continued improvement in functional outcomes and oncological control for patients undergoing radical prostatectomy, whether by open or minimally-invasive surgery.

The "halo effect" in Korea: change in practice patterns since the introduction of robot-assisted laparoscopic radical prostatectomy

Acquisition of the da Vinci surgical system (Intuitive Surgical, Mountain View, USA) has enabled robot-assisted surgery to become an acceptable alternative to open radical prostatectomy (ORP). Implementation of robotics at a single institution in Korea induced a gradual increase in the number of performances of robot-assisted laparoscopic radical prostatectomy (RALP) to surgically treat localized prostate cancer. We analyzed the impact of robotic instrumentation on practice patterns among urologists and explain the change in value in ORP and RALP-the standard treatment and the new approach or innovation of robotic technology. The overall number of prostatectomies has increased over time because the number of RALPs has grown drastically whereas the number of OPRs did not decrease during the period of evaluation. Our experience emphasizes the potential of RALP to become the gold standard in the treatment of localized prostate cancer in various parts of the world.

Advances in robotic prostatectomy

Robotic-assisted laparoscopic prostatectomy (RALP) has emerged as an important treatment option for localized prostate cancer. As such, methods to improve instrumentation, technique, outcomes, and cost require continued investigation. For example, a recently introduced four-armed robotic system has limited the need for bedside assistants, while an enhanced understanding of pelvic anatomy as visualized robotically has led to valuable modifications in operative technique. Increased surgeon experience has decreased perioperative morbidity, and has resulted in short-term pathologic and functional outcomes that compare favorably with open radical prostatectomy. Meanwhile, quality-of-life studies using validated instruments are helping to define the time course of patient recovery. Nevertheless, costs associated with robotic surgery remain daunting. As the follow-up of patients treated with RALP matures, future studies, ideally with a prospective, randomized design, will be needed to establish the long-term oncologic efficacy of the procedure and to evaluate the overall advantages of RALP compared with open surgery.