Functional outcomes following robotic prostatectomy using athermal, traction free risk-stratified grades of nerve sparing

Nerve-sparing techniques in robot-assisted radical prostatectomy - anatomical approach

INTRODUCTION

Nerve-sparing (NS) techniques in robot-assisted radical prostatectomy (RARP) are foundational to preserving sexual function and urinary continence in prostate cancer (PCa) patients.

AREAS COVERED

This article aims to classify nerve-sparing (NS) techniques in RARP based on an anatomical approach to the prostate. We have identified three main NS approaches in RARP: anterior, lateral, and posterior. The anterior approach, which involves early retrograde nerve release, improves early potency rates. The lateral approach, using hybrid techniques and extra-fascial dissection, provides clear nerve visualization and reduces nerve injuries, enhancing continence and potency recovery. The posterior approach, particularly the hood technique, effectively preserves periurethral structures, leading to high continence rates within a year post-surgery. The posterior approach effectively balances nerve preservation with cancer control.

EXPERT OPINION

Re-classifying NS techniques in RARP based on an anatomical approach optimizes patient outcomes and the surgeon choice. A personalized approach to those techniques improves functional recovery and maintains oncological safety in PCa surgery. Further studies are needed to confirm those findings and refine the selection criteria.

Outcomes after precision prostatectomy: safety, efficacy and transference of skills

PURPOSE

Precision Prostatectomy (PP) is a viable treatment option for men with unilateral dominant cancer who are interested in preserving functional outcomes. To date, the data published about the outcomes of this technique has come from a single center only (Henry Ford - HF). We present the surgical, functional, and oncological outcomes of the first series of patients to undergo PP outside of HF, to demonstrate the safety and reproducibility of the technique.

METHODS

Between 2022 and 2023, PP was offered to select patients who were interested in preserving their functional status. Men who underwent PP were followed at 3 monthly intervals; information regarding their functional status was simultaneously obtained. Men who had biochemical recurrence were advised to undergo remnant biopsy. If residual cancer was detected, then remnant removal was performed.

RESULTS

The median age and median PSA of the study group was 63 years and 6.89 ng/ml respectively. The median operative and console times were 196.5 and 154 minutes. No intra-operative complications were noted. Three patients had a total of three post-operative complications. Three patients had biochemical recurrence; cancer was not detected in any of these patients on postoperative biopsies of the prostatic remnant. At 12 months, 91% of patients reported using 0 pads/day and 90.9% of pre-operatively potent patients were potent at 12 months.

CONCLUSION

PP is a safe and reproducible technique that can ensure cancer control and preservation of functional status in select patients. Further studies with large sample sizes and longer follow-up are required to ascertain the long-term outcomes of this surgical technique.

The Association Between Low Preoperative Serum Testosterone and Post-radical Prostatectomy Urinary Function

OBJECTIVE

To determine if hypogonadism leads to delayed urinary function recovery post-radical prostatectomy (RP) by studying the effect of preoperative factors including age, membranous urethral length, radiation therapy, and Body Mass Index on urinary continence in patients with or without hypogonadism.

MATERIALS AND METHODS

We identified 1209 patients treated by RP with both pretreatment T and post-treatment urinary outcome. We assessed whether there was an association between low preoperative T level (prenoon T ≤ 300 ng/dL) and continence (using ≤1 pad/d) at 6 and 12months post-RP. Patient-reported continence was used when available, otherwise, surgeon-assessed continence was used. Logistic regression models were used, adjusted for age at RP and nerve-sparing status.

RESULTS

Median age at RP was 61 (Intraquatile Range (IQR) 56, 66), 92% of patients had at least one nerve spared and 99% were continent at baseline. Continence in patients with low T was nonsignificantly lower at 6months (odds ratio 0.69, 95% confidence interval 0.44, 1.06; P = .10) and nonsignificantly higher at 12months (odds ratio 1.07, 95% confidence interval 0.71, 1.58; P = .8). Sensitivity analyses excluding patients with preoperative metastasis or treated with androgen deprivation therapy (ADT) and including testosterone as a continuous predictor were consistent with the primary analysis; similarly finding no evidence of an association.

CONCLUSION

Although we cannot rule out an effect on early continence, overall the evidence does not suggest that low serum testosterone adversely impacts urinary function recovery after RP. This finding can be used to counsel patients enrolled in neoadjuvant ADT trials or those patients undergoing RP who have had prior ADT, such as in the setting of oligometastatic disease.

The Expanding Utility of Robotic-Assisted Flap Harvest in Autologous Breast Reconstruction: A Systematic Review

The expansion of robotic surgery has led to developments in robotic-assisted breast reconstruction techniques. Specifically, robotic flap harvest is being evaluated to help maximize operative reliability and reduce donor site morbidity without compromising flap success. Many publications are feasibility studies or technical descriptions; few cohort analyses exist. This systematic review aims to characterize trends in robotic autologous breast reconstruction and provide a summative analysis of their results. A systematic review was conducted using PubMed, Medline, Scopus, and Web of Science to evaluate robot use in breast reconstruction. Studies dated from 2006 to 2022 were identified and analyzed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Full-text, peer-reviewed, English-language, and human subject studies were included. Non-breast reconstruction articles, commentary, expert opinion, editor's letter, and duplicate studies were excluded. A total of 17 full-text articles were analyzed. The two robotic breast procedures identified were the deep inferior epigastric perforator (DIEP) and the latissimus dorsi (LD) flap. Results showed comparable complication rates and increased operative times compared to NSQIP data on their corresponding open techniques. Additional findings reported in studies included patient reported outcomes, incision lengths, and downward trends in operative time with consecutive procedures. The available data in the literature confirms that robotic surgery is a promising alternative to traditional open methods of breast reconstruction following mastectomy.

Multiparametric MRI for Staging of Prostate Cancer: A Multicentric Analysis of Predictive Factors to Improve Identification of Extracapsular Extension before Radical Prostatectomy

Simple Summary

In this multicentric study, we tested the accuracy of multiparametric magnetic resonance imaging (mpMRI) in detecting extracapsular extension (ECE) out of the prostate in order to plan surgical sparing of neurovascular bundles in radical prostatectomy. Univariate and multivariate logistic regression analyses were performed to identify other risk factors for ECE. We found that it has a good ability to exclude extracapsular extension but a poor ability to identify it correctly. Risk factors other than mpMRI that predicted ECE were as follows: prostatic specific antigen, digital rectal examination, ratio of positive cores, and biopsy grade group. We suggest that using mpMRI exclusively should not be recommended to decide on surgical approaches.

Abstract

The correct identification of extracapsular extension (ECE) of prostate cancer (PCa) on multiparametric magnetic resonance imaging (mpMRI) is crucial for surgeons in order to plan the nerve-sparing approach in radical prostatectomy. Nerve-sparing strategies allow for better outcomes in preserving erectile function and urinary continence, notwithstanding this can be penalized with worse oncologic results. The aim of this study was to assess the ability of preoperative mpMRI to predict ECE in the final prostatic specimen (PS) and identify other possible preoperative predictive factors of ECE as a secondary end-point. We investigated a database of two high-volume hospitals to identify men who underwent a prostate biopsy with a pre-biopsy mpMRI and a subsequent RP. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of mpMRI in predicting ECE were calculated. A univariate analysis was performed to find the association between image staging and pathological staging. A multivariate logistic regression was performed to investigate other preoperative predictive factors. A total of 1147 patients were selected, and 203 out of the 1147 (17.7%) patients were classified as ECE according to the mpMRI. ECE was reported by pathologists in 279 out of the 1147 PS (24.3%). The PPV was 0.58, the NPV was 0.72, the sensitivity was 0.32, and the specificity was 0.88. The multivariate analysis found that PSA (OR 1.057, C.I. 95%, 1.016–1.100, p = 0.006), digital rectal examination (OR 0.567, C.I. 95%, 0.417–0.770, p = 0.0001), ratio of positive cores (OR 9.687, C.I. 95%, 3.744–25.006, p = 0.0001), and biopsy grade in prostate biopsy (OR 1.394, C.I. 95%, 1.025–1.612, p = 0.0001) were independent factors of ECE. The mpMRI has a great ability to exclude ECE, notwithstanding that low sensitivity is still an important limitation of the technique.

Indications for nerve-sparing surgery for radical prostatectomy: Results from a single-center study

Purpose

To explore the clinical indications of using the nerve-sparing technique in radical prostatectomy.

Patients and methods

We retrospectively analyzed the clinical and pathological data of 101 patients who underwent radical prostatectomy (RP) at our institution. Twenty-five patients underwent open surgery, and 76 patients underwent laparoscopic surgery. The biochemical recurrence (BCR) rate was analyzed by the method of Kaplan–Meier. The distance between the ipsilateral neurovascular bundles (NVBs) and foci of prostate tumor (N-T distance) was measured in postoperative specimens. We defined the N-T distance >2 mm as the threshold to perform nerve-sparing (NS) in RP. Through logistic regression analysis, we determined the preoperative clinical indications for the nerve-sparing technique in RP.

Results

The average BCR-free survival time was 53.2 months in these 101 patients with RP, with the 3- and 5-year BCR-free rates being 87.9% and 85.8%, respectively. The N-T distance was measured in 184 prostate sides from postoperative specimens of 101 patients. Univariate analysis showed that the percent of side-specific biopsy cores with cancer (≥1/3), maximum tumor length in biopsy core (≥5 mm), average percent involvement of each positive core (≥50%), PI-RADS score, and prostate MP-MRI imaging (extra-capsular extension) were associated with the N-T distance (p < 0.003). Furthermore, the percent of side-specific biopsy cores with cancer (≥1/3) (OR = 4.11, p = 0.0047) and prostate MP-MRI imaging (extra-capsular extension) (OR = 3.92, p = 0.0061) were found to be statistically significant independent predictors of the N-T distance in multivariate analysis.

Conclusions

The clinical indications of nerve-sparing RP were <1/3 side-specific biopsy cores with cancer and no extra-capsular extension by prostate MP-MRI examination.

Continence definition and prognostic factors for early urinary continence recovery in posterior rhabdosphincter reconstruction after robot-assisted radical prostatectomy. Post-hoc analysis of a randomised controlled trial

INTRODUCTION

Urinary incontinence after radical prostatectomy (RP) is an adverse event with high impact on patient's quality of life. Nowadays there is no standardized method for urinary continence measurement. Posterior rhabdosphincter reconstruction (PRR) is a surgical step that can improve early urinary continence after RP. Our objective was to analyse different continence definitions and predictors of urinary continence recovery after robot-assisted RP (RARP).

MATERIAL AND METHODS

We conducted a double-blind, randomised controlled trial (NCT03302169) including 152 consecutive patients with localized prostate cancer subjected to RARP. Patients were randomised to single urethrovesical anastomosis (control arm) or PRR before urethrovesical anastomosis (PRR arm). Urinary continence was measured with the EPIC-26 and ICIQ-SF validated questionnaires, and pad use (0-1 pads and no pads), at 7, 15, 30, 90, 180 and 365 days after catheter removal. Prognostic factors for early urinary continence recovery were analysed.

RESULTS

72 patients were included in the control arm and 80 in the PRR arm. Baseline characteristics were similar between arms, except body mass index, which was higher in PRR arm. "No pad" was the only definition assessing the benefit of PRR at 30 days, 33.8% in PRR arm and 18.1% in control arm, p = 0.022; and at 90 days, 58.8 and 43.1% respectively, p = 0.038. Questionnaires did not detect differences in terms of continence recovery. PRR was the only predictor for early continence recovery, p = 0.03.

CONCLUSIONS

PRR increased early urinary continence recovery after RARP. Continence definition was critical to assess benefit. The only predictive factor for early continence recovery was PRR.

Development of New Comorbidities in Patients Awaiting Urinary Incontinence Surgery Following Radical Prostatectomy

OBJECTIVE

To examine the incidence and factors associated with the development of new comorbidities in men undergoing anti-incontinence surgery after prostate cancer (PCa) surgery. Post-prostatectomy incontinence (PPI) may deter men from engaging in physical activities and increase the risk of developing comorbidities after prostatectomy.

METHODS

Patients undergoing surgery for PPI from 2006 to 2019 were identified. A retrospective review was performed to document patient characteristics noted at the time of PCa surgery and compare these with parameters recorded at the time of anti-incontinence surgery.

RESULTS

A total of 229 patients were included. Mean age was 68.8 years at time of incontinence surgery. Median duration of incontinence was 3.5 ± 4.6 years. There was a significant increase in CCI comorbidities between PCa surgery and PPI surgery (2.7 ± 1.5 vs 4.1 ± 1.9, P < .0001). Almost half of patients (45.2%) developed a new comorbidity while awaiting incontinence surgery including an increase in the incidence of diabetes (21.9% vs 12.7%; p<0.0001), hypertension (56.2% vs 36.7%; P < .0001), coronary artery disease (14.6% vs 8.9%; P = .008) and arrhythmia (11.0% vs 3.8%; P = .008). On multivariable analysis, duration of incontinence was significantly associated with development of new comorbidities (O.R. 1.2, P = .01) while age (P = .20) and incontinence severity (P = 1.0) were not. There was no change in weight (P = .34), obesity (P = 1.0) or BMI (P = .18) between PCa surgery and PPI surgery.

CONCLUSION

Patients with PPI appear at risk of developing new comorbidities while awaiting anti-incontinence surgery. Strategies which expedite return of continence for example, early surgical intervention, may facilitate resumption of physical activity and minimize the risk of future comorbidity.

The Use of Augmented Reality to Guide the Intraoperative Frozen Section During Robot-assisted Radical Prostatectomy

BACKGROUND

Multiparametric magnetic resonance imaging (mpMRI) can guide the surgical plan during robot-assisted radical prostatectomy (RARP), and intraoperative frozen section (IFS) can facilitate real-time surgical margin assessment.

OBJECTIVE

To assess a novel technique of IFS targeted to the index lesion by using augmented reality three-dimensional (AR-3D) models in patients scheduled for nerve-sparing RARP (NS-RARP).

DESIGN, SETTING, AND PARTICIPANTS

Between March 2019 and July 2019, 20 consecutive prostate cancer patients underwent NS-RARP with IFS directed to the index lesion with the help of AR-3D models (study group). Control group consists of 20 patients matched with 1:1 propensity score for age, clinical stage, Prostate Imaging Reporting and Data System score v2, International Society of Urological Pathology grade, prostate volume, NS approach, and prostate-specific antigen in which RARP was performed by cognitive assessment of mpMRI.

SURGICAL PROCEDURE

In the study group, an AR-3D model was superimposed to the surgical field to guide the surgical dissection. Tissue sampling for IFS was taken in the area in which the index lesion was projected by AR-3D guidance.

MEASUREMENTS

Chi-square test, Student t test, and Mann-Whitney U test were used to compare, respectively, proportions, means, and medians between the two groups.

RESULTS AND LIMITATIONS

Patients in the AR-3D group had comparable preoperative characteristics and those undergoing the NS approach were referred to as the control group (all p ≥ 0.06). Overall, positive surgical margin (PSM) rates were comparable between the two groups; PSMs at the level of the index lesion were significantly lower in patients referred to AR-3D guided IFS to the index lesion (5%) than those in the control group (20%; p = 0.01).

CONCLUSIONS

The novel technique of AR-3D guidance for IFS analysis may allow for reducing PSMs at the level of the index lesion.

PATIENT SUMMARY

Augmented reality three-dimensional guidance for intraoperative frozen section analysis during robot-assisted radical prostatectomy facilitates the real-time assessment of surgical margins and may reduce positive surgical margins at the index lesion.

Evaluation of Oncological Outcomes and Data Quality in Studies Assessing Nerve-sparing Versus Non-Nerve-sparing Radical Prostatectomy in Nonmetastatic Prostate Cancer: A Systematic Review

CONTEXT

Surgical techniques aimed at preserving the neurovascular bundles during radical prostatectomy (RP) have been proposed to improve functional outcomes. However, it remains unclear if nerve-sparing (NS) surgery adversely affects oncological metrics.

OBJECTIVE

To explore the oncological safety of NS versus non-NS (NNS) surgery and to identify factors affecting the oncological outcomes of NS surgery.

EVIDENCE ACQUISITION

Relevant databases were searched for English language articles published between January 1, 1990 and May 8, 2020. Comparative studies for patients with nonmetastatic prostate cancer (PCa) treated with primary RP were included. NS and NNS techniques were compared. The main outcomes were side-specific positive surgical margins (ssPSM) and biochemical recurrence (BCR). Risk of bias (RoB) and confounding assessments were performed.

EVIDENCE SYNTHESIS

Out of 1573 articles identified, 18 studies recruiting a total of 21 654 patients were included. The overall RoB and confounding were high across all domains. The most common selection criteria for NS RP identified were characteristic of low-risk disease, including low core-biopsy involvement. Seven studies evaluated the link with ssPSM and showed an increase in ssPSM after adjustment for side-specific confounders, with the relative risk for NS RP ranging from 1.50 to 1.53. Thirteen papers assessing BCR showed no difference in outcomes with at least 12 mo of follow-up. Lack of data prevented any subgroup analysis for potentially important variables. The definitions of NS were heterogeneous and poorly described in most studies.

CONCLUSIONS

Current data revealed an association between NS surgery and an increase in the risk of ssPSM. This did not translate into a negative impact on BCR, although follow-up was short and many men harbored low-risk PCa. There are significant knowledge gaps in terms of how various patient, disease, and surgical factors affect outcomes. Adequately powered and well-designed prospective trials and cohort studies accounting for these issues with long-term follow-up are recommended.

PATIENT SUMMARY

Neurovascular bundles (NVBs) are structures containing nerves and blood vessels. The NVBs close to the prostate are responsible for erections. We reviewed the literature to determine if a technique to preserve the NVBs during removal of the prostate causes worse cancer outcomes. We found that NVB preservation was poorly defined but, if applied, was associated with a higher risk of cancer at the margins of the tissue removed, even in patients with low-risk prostate cancer. The long-term importance of this finding for patients is unclear. More data are needed to provide recommendations.

A Randomised Controlled Trial to Assess the Benefit of Posterior Rhabdosphincter Reconstruction in Early Urinary Continence Recovery after Robot-assisted Radical Prostatectomy

Posterior rhabdosphincter reconstruction (PRR) has been proposed to improve early urinary continence (UC) recovery after radical prostatectomy (RP). In order to generate level 1b evidence, we designed a double-blind randomised controlled trial powered to detect a 20% increase in early UC recovery after robot-assisted RP (RARP). A group of 153 patients with cT1c-3a N0M0 prostate cancer were randomised (73 to control arm and 80 to PRR arm) and 152 completed 12-mo follow-up. For UC defined as no pad use, the recovery hazard ratio at 1-mo follow-up was 2.312 (95% confidence interval [CI] 1.081-4.937; p =  0.030). UC recovery was observed in 33.8% of patients in the PRR arm and 18.1% of patients in the control arm (p =  0.022). At 3-mo follow-up the corresponding rates were 58.8% and 43.1% (p =  0.038). The median time to UC recovery was 106 d (95% CI 73-139) in the control arm and 64 d (95% CI 39-89) in PRR arm (p =  0.897). No differences in pathological outcomes or early and late surgical complications were observed between the arms. We conclude that PRR is safe and increases early UC recovery after RARP. PATIENT SUMMARY: We investigated reconstruction of a muscular ring that controls the flow of urine, called the rhabdosphincter, after removal of the prostate in robot-assisted surgery. The procedure is safe and increases early recovery of urinary continence. This trial is registered at ClinicalTrials.gov as NCT03302169.

A systematic review of nerve-sparing surgery for high-risk prostate cancer

INTRODUCTION

We provide a systematic analysis of nerve-sparing surgery (NSS) to assess and summarize the risks and benefits of NSS in high-risk prostate cancer (PCa).

EVIDENCE ACQUISITION

We have undertaken a systematic search of original articles using 3 databases: Medline/PubMed, Scopus, and Web of Science. Original articles in English containing outcomes of nerve-sparing radical prostatectomy (RP) for high-risk PCa were included. The primary outcomes were oncological results: the rate of positive surgical margins and biochemical relapse. The secondary outcomes were functional results: erectile function (EF) and urinary continence.

EVIDENCE SYNTHESIS

The rate of positive surgical margins differed considerably, from zero to 47%. The majority of authors found no correlation between NSS and a positive surgical margin rate. The rate of biochemical relapse ranged from 9.3% to 61%. Most of the articles lacked data on odds ratio (OR) for positive margin and biochemical relapse. The presented results showed no effect of nerve sparing (NS) on positive margin (OR=0.81, 0.6-1.09) or biochemical relapse (hazard ratio [HR]=0.93, 0.52-1.64). A strong association between NSS and potency rate was observed. Without NSS, between 0% and 42% of patients were potent, with unilateral 79-80%, with bilateral - up to 90-100%. Urinary continence was not strongly associated with NSS and was relatively good in both patients with and without NSS.

CONCLUSIONS

NSS may provide benefits for patients with urinary continence and significantly improves EF in high-risk patients. Moreover, it is not associated with an increased risk of relapse in short- and middle-term follow-up. However, the advantages of using such a surgical technique are unclear.

Real-time Augmented Reality Three-dimensional Guided Robotic Radical Prostatectomy: Preliminary Experience and Evaluation of the Impact on Surgical Planning

BACKGROUND

Augmented reality (AR) is a novel technology adopted in prostatic surgery.

OBJECTIVE

To evaluate the impact of a 3D model with AR (AR-3D model), to guide nerve sparing (NS) during robot-assisted radical prostatectomy (RARP), on surgical planning.

DESIGN, SETTING, AND PARTICIPANTS

Twenty-six consecutive patients with diagnosis of prostate cancer (PCa) and multiparametric magnetic resonance imaging (mpMRI) results available were scheduled for AR-3D NS RARP.

INTERVENTION

Segmentation of mpMRI and creation of 3D virtual models were achieved. To develop AR guidance, the surgical DaVinci video stream was sent to an AR-dedicated personal computer, and the 3D virtual model was superimposed and manipulated in real time on the robotic console.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The concordance of localisation of the index lesion between the 3D model and the pathological specimen was evaluated using a prostate map of 32 specific areas. A preliminary surgical plan to determinate the extent of the NS approach was recorded based on mpMRI. The final surgical plan was reassessed during surgery by implementation of the AR-3D model guidance.

RESULTS AND LIMITATIONS

The positive surgical margin (PSM) rate was 15.4% in the overall patient population; three patients (11.5%) had PSMs at the level of the index lesion. AR-3D technology changed the NS surgical plan in 38.5% of men on patient-based and in 34.6% of sides on side-based analysis, resulting in overall appropriateness of 94.4%. The 3D model revealed 70%, 100%, and 92% of sensitivity, specificity, and accuracy, respectively, at the 32-area map analysis.

CONCLUSIONS

AR-3D guided surgery is useful for improving the real-time identification of the index lesion and allows changing of the NS approach in approximately one out of three cases, with overall appropriateness of 94.4%.

PATIENT SUMMARY

Augmented reality three-dimensional guided robot-assisted radical prostatectomy allows identification of the index prostate cancer during surgery, to tailor the surgical dissection to the index lesion and to change the extent of nerve-sparing dissection.

Sildenafil orodispersible film in the treatment of erectile dysfunction after radical prostatectomy: A single-centre open-label uncontrolled trial

Phosphodiesterase-5 inhibitors are the first-line therapy for erectile dysfunction (ED) after radical prostatectomy (RP). This single-centre open-label uncontrolled study evaluated the efficacy and safety of the new sildenafil orodispersible film (ODF) in ED treatment after RP. Sildenafil 100 mg ODF was administered twice a week for 3 months to patients under 75 years of age, with a Framingham cardiovascular risk score < 20% and a pre-operative International Index of Erectile Function (IIEF)-5 score ≥ 17, who had undergone open RP between 2016 and 2018. Erectile function was assessed pre-operatively, post-operatively and after treatment through the IIEF-5 score, the Sexual Encounter Profile Question (SEP-Q) 2 and SEP-Q3; adverse events (AE) were also investigated after 3 months. A total of 65 patients with a median (25th-75th percentile) post-operative IIEF-5 score of 8 (7-9) were treated. Nine (13.8%) patients reported AE of mild/moderate grade and discontinued treatment. A significant IIEF-5 score median (25th-75th percentile) increase of 10 (0-12) was found after treatment in the other 56 patients (p < .001). Sildenafil 100 mg ODF was effective in ED after RP in terms of improved IIEF-5 score and improved SEP-Q2 and SEP-Q3 in 67.9% of patients. It could represent a valid alternative for those patients with low compliance to tablet intake.

[Robot-assisted radical prostatectomy - functional result. Part II]

Robot-assisted surgery is one of the most important achievements of modern medicine. Robot-assisted operations widely used in urology, gynecology, general and cardiovascular surgery are considered by many experts as a new 'gold standard' of surgical treatment of various diseases in developed countries. Well-known advantages of robot-assisted surgery are low invasiveness, 3D-visualization of surgical field, high accuracy of instrument movements resulting minimal intraoperative blood loss, short hospital-stay, rapid recovery and short social maladjustment of operated patients. Robot-assisted radical prostatectomy in patients with prostate cancer is the most common robotic procedure worldwide. Better functional outcomes are due to another (new) understanding of pelvic surgical anatomy, changed approach to dissection and preservation of external urethral sphincter and neurovascular bundles. Prostate neuroanatomy, various variants of preservation of neurovascular bundles are reviewed in the article. Moreover, own experience of robot-assisted radical prostatectomy followed by favorable functional results is presented.

MRI Displays the Prostatic Cancer Anatomy and Improves the Bundles Management Before Robot-Assisted Radical Prostatectomy

OBJECTIVES

To evaluate the impact of multiparametric magnetic0 resonance imaging (mpMRI) to guide the nerve-sparing (NS) surgical plan in prostate cancer (PCa) patients referred to robot-assisted radical prostatectomy (RARP).

METHODS

One hundred thirty-seven consecutive PCa patients were submitted to RARP between September 2016 and February 2017 at two high-volume European centers. Before RARP, each patient was referred to 1.5T or 3T mpMRI. NS was recorded as Grade 1, Grade 2, Grade 3, and Grade 4 according to Tewari and colleagues classification. A preliminary surgical plan to determinate the extent of NS approach was recorded based on clinical data. The final surgical plan was reassessed after mpMRI revision. The appropriateness of surgical plan change was considered based on the presence of extracapsular extension or positive surgical margins (PSMs) at level of neurovascular bundles area at final pathology. Furthermore, we analyzed a control group during the same period of 166 PCa patients referred to RARP in both institutions without preoperative mpMRI to assess the impact of the use of mpMRI on the surgical margins.

RESULTS

Considering 137 patients with preoperative mpMRI, the mpMRI revision induced the main surgeon to change the NS surgical plan in 46.7% of cases on patient-based and 56.2% on side-based analysis. The surgical plan change results equally assigned between the direction of more radical and less radical approach both on patient-based (54.7% vs 54.3%) and on side-based levels (50% vs 50%), resulting an overall appropriateness of 75%. Moreover, patients staged with mpMRI revealed significant lower overall PSMs compared with control group with no mpMRI (12.4% vs 24.1%; p ≤ 0.01).

CONCLUSIONS

mpMRI induces robotic surgeons to change the surgical plan in almost half of individuals, thus tailoring the NS approach, without compromising the oncologic outcomes. Compared to patients treated without mpMRI, the use of preoperative mpMRI can significantly reduce the overall PSMs.

Transperitoneal versus extraperitoneal approach in laparoscopic radical prostatectomy: A meta-analysis

BACKGROUND

To compare the transperitoneal approach with extraperitoneal approach in laparoscopic radical prostatectomy (LRP) (including pure and robotic-assisted LRP) using meta-analytic techniques.

METHODS

Medline (PubMed), Embase, Ovid, CMB, and Cochrane databases were searched for studies that compared the transperitoneal and extraperitoneal approaches in LRP from January 2000 to January 2017. Outcomes included were operative time, operative bloods joss (milliliters), rate of transfusion, rate of open conversion, rate of intraoperative complications, rate of postoperative complications, and time of postoperative catheterization.

RESULTS

Thirteen studies including 1674 patients were selected for the meta-analysis. 850 (50.8%) cases had undergone transperitoneal LRP (TLRP) and 824 (49.2%) cases had undergone the extraperitoneal LRP (ELRP). Comparison of operative time between the TLRP group and the ELRP group showed no significant differences (weighted mean difference [WMD] = 21.21,95%CI = -1.16-43.57, P = .06). No significant differences were observed in blood loss (WMD = -6.04, 95%CI = -43.38-31.29, P = .75) and the rate of transfusion (odds ratio [OR] = 1.03, 95%CI = 0.55-1.96, P = .92) between the 2 groups. No significant differences were observed for the rate of intraoperative complications (OR = 1.25, 95%CI = 0.57-2.21, P = .75) and the rate of open conversion (OR = 1.12, 95%CI = 0.32-4.97, P = .75). Significant differences were observed in the TLRP group compared with the ELRP group (OR = 1.69, 95%CI: 1.23-2.32, P = .001) regarding the rate of postoperative complications.

CONCLUSIONS

Our meta-analysis findings revealed that the TLRP group showed no significant differences in most important indicators compared with ELRP. Moreover, TLRP showed higher rate of postoperative complications compared with ELRP.

Prostate MRI prior to radical prostatectomy: effects on nerve sparing and pathological margin status

OBJECTIVES

The aim of this study was to assess the positive surgical margin (PSM) and nerve sparing (NS) rates in patients who underwent prostate MRI (pMRI) prior to radical prostatectomy (RP) and compare them with matched, nonimaged control RP patients.

METHODS

We identified 204 men who underwent preoperative pelvic MRI (pelMRI), of whom 176 (86.3%) underwent pMRIs, within 60 days of RP, and compared them (1:1) with a nonim-aged control group matched by surgeon, age, race, body mass index (BMI), prostate-specific antigen (PSA), pathological Gleason score, prostate specimen weight, and RP year.

RESULTS

The rates of nonfocal extracapsular extension (nfECE) on RP pathology in the MRI and control groups were similar. PSM rates were lower in the MRI group (13.7% vs 19.3%; P=0.14), but the difference did not meet statistical significance; this was also the case in patients with nfECE on RP pathology (27.7% vs 39.5%; P=0.3). NS rates were similar between groups. In the MRI group, 54 (26.5%) patients had an MRI suspicious for nfECE; their PSM rate (20.4%) was higher than that of patients with an MRI not suspicious for nfECE (11.3%; P=0.11), but the difference lacked statistical significance; the former group had significantly lower rates of NS. Limitations of the study include sample power and nonuniform heeding of MRI results by each surgeon.

CONCLUSION

MRI did not significantly decrease the rates of PSM, including in the subset of patients with nfECE on final pathology. Even wider resection may be necessary in patients with MRIs suggesting locally-advanced disease. Studies with greater power are needed.

Postprostatectomy Erectile Dysfunction: A Review

In the current era of the early diagnosis of prostate cancer (PCa) and the development of minimally invasive surgical techniques, erectile dysfunction (ED) represents an important issue, with up to 68% of patients who undergo radical prostatectomy (RP) complaining of postoperative erectile function (EF) impairment. In this context, it is crucial to comprehensively consider all factors possibly associated with the prevention of post-RP ED throughout the entire clinical management of PCa patients. A careful assessment of both oncological and functional baseline characteristics should be carried out for each patient preoperatively. Baseline EF, together with age and the overall burden of comorbidities, has been strongly associated with the chance of post-RP EF recovery. With this goal in mind, internationally validated psychometric instruments are preferable for ensuring proper baseline EF evaluations, and questionnaires should be administered at the proper time before surgery. Careful preoperative counselling is also required, both to respect the patient's wishes and to avoid false expectations regarding eventual recovery of baseline EF. The advent of robotic surgery has led to improvements in the knowledge of prostate surgical anatomy, as reflected by the formal redefinition of nerve-sparing techniques. Overall, comparative studies have shown significantly better EF outcomes for robotic RP than for open techniques, although data from prospective trials have not always been consistent. Preclinical data and several prospective randomized trials have demonstrated the value of treating patients with oral phosphodiesterase 5 inhibitors (PDE5is) after surgery, with the concomitant potential benefit of early re-oxygenation of the erectile tissue, which appears to be crucial for avoiding the eventual penile structural changes that are associated with postoperative neuropraxia and ultimately result in severe ED. For patients who do not properly respond to PDE5is, proper counselling regarding intracavernous treatment should be considered, along with the further possibility of surgical treatment for ED involving the implantation of a penile prosthesis.

Current status of various neurovascular bundle-sparing techniques in robot-assisted radical prostatectomy

Nerve-sparing procedures during robot-assisted radical prostatectomy (RARP) have demonstrated improved postoperative functional outcomes. This article provides an overview of clinically applied prostatic neuro-anatomy, various techniques of nerve sparing (NS), and recent innovations in NS and potency outcomes of NS RARP. We retrieved and reviewed all listed publications within PubMed using keywords: nerve sparing, robotic radical prostatectomy, prostate cancer, outcomes, pelvic neuroanatomy and potency. Studies reporting potency outcomes of NS RARP (comparative and non-comparative) were analysed using the Delphi method with an expert panel of urological robotic surgeons. Herein, we outline the published techniques of NS during RARP. Potency and continence outcomes of individual series are discussed in light of the evidence provided by case series and published trials. The potency outcomes of various comparative and non-comparative series of NS RARP have also been mentioned. There are numerous NS techniques reported for RARP. Each method is complimented with benefits and constrained by idiosyncratic caveats, and thus, careful patient selection, a wise intraoperative clinical judgment and tailored approach for each patient is required, when decision for nerve sparing is made. Further large prospective multi-institutional randomized controlled trials are required to evaluate potency and continence outcomes of these techniques, using a rigid standard patient selection criteria and definition of potency are warranted in the new era of functional outcome-driven research.

Significant reduction in positive surgical margin rate after laparoscopic radical prostatectomy by application of the modified surgical margin recommendations of the 2009 International Society of Urological Pathology consensus

OBJECTIVES

To verify retrospectively the margin status and analyse the location and characteristics of positive surgical margins (PSMs) in patients undergoing radical prostatectomy (RP), by a central pathology review, based on the consensus conference 2009 updated margin criteria from the International Society of Urological Pathology (ISUP).

PATIENTS AND METHODS

The detailed PSM characteristics of 441 patients who underwent laparoscopic RP (LRP) between 1999 and 2007 were centrally reviewed with regard to location, number, Gleason score at the PSM and tumour width. Predictors of PSMs and the impact of several PSM characteristics on clinical outcomes were examined. Patient characteristics were compared using the chi-squared test. Differences in recurrence-free survival (RFS) rates were analysed using the log-rank test and presented as Kaplan-Meier survival curves. Univariable and multivariable Cox regression analysis for the prediction of RFS was performed.

RESULTS

Central pathology review using the updated PSM definition according to ISUP 2009, resulted in reclassification of a substantial number of patients with PSMs (n = 113, 26.6%) as R0. Several PSM characteristics with a higher risk of biochemical recurrence (BCR) were identified as the strongest independent predictors of RFS: pathological stage; Gleason score; and the presence of multiple PSMs (hazard ratio [HR] 1.78; 95% confidence interval [CI] 1.08-2.96; P = 0.025). Further analysis replacing the location of PSM by the width categories of PSM showed that a PSM >3 mm was an independent predictor of RFS (HR 1.72; 95% CI 1.08-2.72; P = 0.022).

CONCLUSIONS

The impact of PSMs after LRP for prostate cancer remains unclear. PSMs in the present cohort of patients undergoing LRP had different characteristics and conferred different risks of BCR. A better understanding of PSM characteristics and a careful standardized pathological evaluation is needed to adequately counsel patients with respect to prognosis and adjuvant therapy after LRP.

Preservation of the neurovascular bundles is associated with improved time to continence after radical prostatectomy but not long-term continence rates: results of a systematic review and meta-analysis

CONTEXT

The aetiology of urinary incontinence following radical prostatectomy (RP) is incompletely understood. In particular, it is unclear whether there is a relationship between neurovascular bundle (NVB) sparing and post-RP urinary continence.

OBJECTIVE

To review systematically the association of NVB sparing in RP with postoperative urinary continence outcomes and synthesise the results in a meta-analysis.

EVIDENCE ACQUISITION

This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. PubMed, Medline, and Cochrane Central Register of Controlled Trials were searched (December 2013), yielding 3413 unique records. A total of 27 longitudinal cohort studies were selected for inclusion. Studies were evaluated using a predefined criteria adapted from the Cochrane Tool to Assess Risk of Bias in Cohort Studies.

EVIDENCE SYNTHESIS

Data from 13 749 participants in 27 studies were synthesised in a meta-analysis. An assessment of the study methodology revealed a high risk of bias due to differences in baseline characteristics, outcome assessment, and the likely presence of unreported confounding factors such as meticulous apical dissection. Meta-analysis demonstrated that nerve sparing (NS) compared with non-nerve sparing (NNS) resulted in improved early urinary continence rates up to 6 mo postoperatively. Beyond this time, no significant difference was observed. This effect was seen most clearly for bilateral NS compared with NNS. A sensitivity analysis of prospective cohort studies revealed consistent results.

CONCLUSIONS

This analysis demonstrates an association between NS and improved urinary continence outcomes up to 6 mo postoperatively. NS in men with poor preoperative erectile function should be considered in the context of oncologic risk stratification because it may improve time to continence recovery. The underlying cause of the relationship between NS and continence is unknown. It may represent preservation of the intrapelvic somatic nerves supplying the rhabdosphincter or the influence of other confounding factors. Future research should be directed towards improving understanding of the anatomy of urinary continence and the pathophysiology of post-RP incontinence.

PATIENT SUMMARY

We found that avoiding damage to the nerves around the prostate improves urinary continence in the first 6 mo after surgery. After this time, there is no difference in continence between men who had these nerves removed and those who had them saved. This finding could be due to a true effect of saving these nerves or to a number of other factors affecting the research.

RARP in high-risk prostate cancer: use of multi-parametric MRI and nerve sparing techniques

To examine the outcomes of patients with high-risk prostate cancer (PCa) treated by robot-assisted radical prostatectomy (RARP) and evaluate the value of multi-parametric magnetic resonance imaging (MRI) in estimating tumor stage, extracapsular extension, and grade, and the application of nerve sparing (NS) techniques. Patient demographics, preoperative imaging, surgical parameters, pathological features, functional and recurrence outcomes were collected retrospectively in patients with high-risk PCa who underwent RARP between December 2009 and October 2013. Pathological whole mount slides to assess NS were compared with potency, recovery of continence, and surgical margins (SM). Forty-four cases of high-risk PCa were identified with a median followup of 24 months and positive surgical margins (PSM) rate of 14%. Continence returned in 86%, with potency rate of 58%. Of the 25 cases with a preoperative multi-parametric MRI, MRI improved clinical staging from 28% to 88%, respectively. Following risk stratification of NS by microscopic analysis of whole mount pathology, patients with Group A (bilateral NS), Group B (unilateral NS), Group C (partial NS), and Group D (non-NS) had 100%, 92%, 91%, and 50% continence rates, and 100%, 80%, 45%, and 0% potency rates, respectively, with an inverse correlation to PSM. RARP in men with high-risk PCa can achieve favorable oncologic and functional outcomes. Preoperative MRI may localize high-grade tumors and improve clinical staging. Extent of NS is influenced by clinical staging and may balance potency and continence with PSMs.

Erectile dysfunction in robotic radical prostatectomy: Outcomes and management

Robot-assisted laparoscopic prostatectomy (RALP) has emerged as the most common treatment for localized prostate cancer. With improved surgical precision, RALP has produced hope of improved potency rates, especially with the advent of nerve-sparing and other modified techniques. However, erectile dysfunction (ED) remains a significant problem for many men regardless of surgical technique. To identify the functional outcomes of robotic versus open and laparoscopic techniques, new robotic surgical techniques and current treatment options of ED following RALP. A Medline search was performed in March 2014 to identify studies comparing RALP with open retropubic radical prostatectomy (RRP) and laparoscopic radical prostatectomy, modified RALP techniques and treatment options and management for ED following radical prostatectomy. RALP demonstrates adequate potency rates without compromising oncologic benefit, with observed benefit for potency rates compared with RRP. Additionally, specific surgical technical modifications appear to provide benefit over traditional RALP. Phosphodiesterase-5 inhibitors (PDE5I) demonstrate benefit for ED treatment compared with placebo. However, long-term benefit is often lost after use. Other therapies have been less extensively studied. Additionally, correct patient identification is important for greatest clinical benefit. RALP appears to provide beneficial potency rates compared with RRP; however, these effects are most pronounced at high-volume centers with experienced surgeons. No optimal rehabilitation program with PDE5Is has been identified based on current data. Additionally, vacuum erection devices, intracavernosal injections and other techniques have not been well validated for post RALP ED treatment.

A comprehensive review of neuroanatomy of the prostate

Although oncologic efficacy is the primary goal of radical prostatectomy, preserving potency and continence is also important, given the indolent clinical course of most prostate cancers. In order to preserve and recover postoperative potency and continence after radical prostatectomy, a detailed understanding of the pelvic anatomy is necessary to recognize the optimal nerve-sparing plane and to minimize injury to the neurovascular bundles. Therefore, we reviewed the most recent findings from neuroanatomic studies of the prostate and adjacent tissues, some of which are contrary to the established consensus on pelvic anatomy. We also described the functional outcomes of radical prostatectomies following improved anatomical understanding and development of surgical techniques for preserving the neurovascular bundles.

Analysis of the pentafecta learning curve for laparoscopic radical prostatectomy

PURPOSE

Laparoscopic radical prostatectomy (LRP) has a long learning curve; however, little is known about the pentafecta learning curve for LRP. We analysed the learning curve for a fellowship trained surgeon with regard to the pentafecta with up to 6-year follow-up.

METHODS

A retrospective review was performed in 550 cases, by dividing these cases into 11 groups of 50 patients. Outcomes analysed were the following: (1) the pentafecta (complication rate, positive surgical margin (PSM) rate, continence, potency and biochemical recurrence); (2) operative time and blood loss; and (3) overall pentafecta attainment.

RESULTS

The mean complication rate for the entire series was 9 %; this plateaued after 150 cases. The overall PSM rate for the series was 23.5 %, 16.3 % for pT2 and 40.5 % for pT3. PSM plateaued after 200 cases. Excluding the first 100 cases, the overall PSM rate for pT2 was 10.9 % and 37.8 % for pT3. The continence rate stabilised after approximately 250 cases. The rate of male sling/artificial urinary sphincter plateaued after 200 cases. The potency learning curve continues to improve after 250 cases of nerve-sparing (ns) endoscopic extraperitoneal radical prostatectomy (EERPE) as does the pentafecta learning curve which closely follows the pattern of the potency learning curve. The last group of nsEERPE achieved pentafecta in 63 %.

CONCLUSION

This study shows multiple learning curves: an initial for peri-operative outcomes, then stabilisation of oncologic outcomes and the final for stabilisation of functional outcomes. In this series over 250 cases were required to achieve the learning curve.