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

A contemporary analysis of disease upstaging of Gleason 3 + 3 prostate cancer patients after robot-assisted laparoscopic prostatectomy

BACKGROUND

Risk of biochemical recurrence (BCR) in localised prostate cancer can be stratified using the 5-tier Cambridge Prognostic Group (CPG) or 3-tier European Association of Urology (EAU) model. Active surveillance is the current recommendation if CPG1 or EAU low-risk criteria are met. We aimed to determine the contemporary rates of upgrading, upstaging and BCR after radical prostatectomy for CPG1 or EAU low-risk disease.

METHODS

A database of all robotic-assisted laparoscopic prostatectomies (RALPs) performed in Glasgow between 12/2015 and 05/2022 was analysed. Rates of upgrading, upstaging and BCR post-RALP for CPG1 or EAU low-risk disease were defined. Univariate and multivariate analysis were performed to assess the relationship between patient factors and outcomes.

RESULTS

A total of 1223 RALP cases were identified. A total of 12.6% met CPG1 criteria with 70.1% and 25.3% upgraded and upstaged to extraprostatic disease post-operatively respectively. A total of 5.8% met EAU low-risk criteria with 60.6% upgraded and 25.4% upstaged to extraprostatic disease post-operatively respectively. CPG1 (p < 0.0001) and EAU low-risk (p = 0.02) patients were at a significantly higher risk of BCR if upstaged.

DISCUSSION

Many patients who met CPG1 or EAU low-risk criteria were upgraded post-RALP and approximately 25% were upstaged due to extraprostatic disease. Upstaging puts patients at a significantly higher risk of BCR.

Effect of different catheter pathways on wounds after minimally invasive radical prostatectomy: A meta-analysis

Prostate cancer is one of the most common malignancies worldwide and the fifth leading cause of cancer deaths in men. With the rapidly increasing surgical rate of minimally invasive radical prostatectomy, there is still controversy about how to use a urinary catheter post-operatively. Thus, we attempted to compare the post-operative wound-related outcomes through a meta-analysis of urethral catheterisation (UC) versus suprapubic catheterisation (SPC) after minimally invasive radical prostatectomy. As of August 2023, the authors conducted systematic searches in databases such as PubMed, Embase, Web of Science and the Cochrane Library. The authors reviewed the relevant literature separately to determine comparisons between SPC and UC treatment after radical prostatectomy. A total of 395 subjects were enrolled in the five trials, met the eligibility criteria and were included in the meta-analysis. Data collection and analysis revealed significant differences in catheter bother to patients for surgical trauma (MD, 0.98; 95% CI, 0.48, 1.48 p = 0.0001), with SPC causing less catheter bother to patients post-operatively; post-operative catheter-related problems (OR, 3.3; 95% CI, 0.03, 326.1 p = 0.61), the POD1 of the post-operative period (MD, - 0.09; 95% CI, -0.75, 0.94 p = 0.83) and the POD3 of the post-operative period (MD, -0.49; 95% CI, -0.99, 0.01 p = 0.06); there was no statistically significant difference in wound pain. Compared with UC, SPC patients had less post-operative catheter distress. Thus, SPC is more beneficial in reducing post-operative wound discomfort in patients. The validity of the results remains to be tested in more and better studies.

Complications of extraperitoneal robot-assisted radical prostatectomy in high-risk prostate cancer: A single high-volume center experience

Introduction

The role of robot-assisted radical prostatectomy (RARP) in high-risk prostate cancer (PCa) has been debated over the years, but it appears safe and effective in selected patients. While the outcomes of transperitoneal RARP for high-risk PCa have been already widely investigated, data on the extraperitoneal approach are scarcely available. The primary aim of this study is to evaluate intra- and postoperative complications in a series of patients with high-risk PCa treated by extraperitoneal RARP (eRARP) and pelvic lymph node dissection. The secondary aim is to report oncological and functional outcomes.

Methods

Data of patients who underwent eRARP for high-risk PCa were prospectively collected from January 2013 to September 2021. Intraoperative and postoperative complications were recorded, as also perioperative, functional, and oncological outcomes. Intraoperative and postoperative complications were classified by employing Intraoperative Adverse Incident Classification by the European Association of Urology and the Clavien–Dindo classification, respectively. Univariate and multivariate analyses were performed to evaluate a potential association between clinical and pathological features and the risk of complications.

Results

A total of 108 patients were included. The mean operative time and estimated blood loss were 183.5 ± 44 min and 115.2 ± 72.4 mL, respectively. Only two intraoperative complications were recorded, both grade 3. Early complications were recorded in 15 patients, of which 14 were of minor grade, and 1 was grade IIIa. Late complications were diagnosed in four patients, all of grade III. Body mass index (BMI) &gt; 30 kg/m2, Prostate-Specific Antigen (PSA) &gt; 20 ng/mL, PSA density &gt;0.15 ng/mL2, and pN1 significantly correlated with a higher rate of overall postoperative complications. Moreover, BMI &gt;30 kg/m2, PSA &gt;20 ng/mL, and pN1 significantly correlated with a higher rate of early complications, while PSA &gt;20 ng/mL, prostate volume &lt;30 mL, and pT3 were significantly associated with a higher risk of late complications. In multivariate regression analysis, PSA &gt;20 ng/mL significantly correlated with overall postoperative complications, while PSA &gt; 20 and pN1 correlated with early complications. Urinary continence and sexual potency were restored in 49.1%, 66.7%, and 79.6% of patients and in 19.1%, 29.9%, and 36.2% of patients at 3, 6, and 12 months, respectively.

Conclusions

eRARP with pelvic lymph node dissection in patients with high-risk PCa is a feasible and safe technique, resulting in only a few intra- and postoperative complications, mostly of low grade.

Retzius-sparing versus modified anatomical structures preserving and retzius repairing robotic-assisted radical prostatectomy: A prospective randomized comparison on functional outcomes with a 1-year follow-up

Objectives; To compare the short-term and 1-yr follow-up functional outcomes of modified anatomical structures preserving and retzius-repairing robot-assisted radical prostatectomy (APR-RARP) compared with retzius-sparing (RS) RARP. Methods; 80 consecutive patients aged 40-75 yr with low-intermediate risk prostat cancer (PCa) were prospectively randomized to APR-RARP or RS-RARP. Urinary continence (UC) recovery rates were evaluated from catheter removal up to 1 yr follow-up. Postoperative UC was defined as 0 pads/one security pad per day. UC recovery rates from catheter removal to 1 yr were calculated by Kaplan-Meier curve; log-rank test was used for the curve comparison. Postoperative potency was evaluated at 3 and 12 months after surgeries. Perioperative complications, positive surgical margin (PSM), and biochemical recurrence rates represent secondary outcomes reported in the study. Results; At the catheter removal, 1, 3, 6 and 12 months after surgery, 52.5% (CI% 95% 37.6-67), 82.5% (CI% 95% 70.8-94), 95% (CI% 95% 88.3-99.1), 97.5% (CI% 95% 92.5-99.9) and 97.5% (CI% 95% 92.5-99.9) of men undergoing the APR-RARP were continent (0 pads/one security pad per day), compared with 61.5% (CI% 95% 46.5-76.6), 89.7% (CI% 95% 80.3-98.1), 97.5% (CI% 95% 92.6-99.9), 97.5% (CI% 95% 92.6-99.9) and 97.5% (CI% 95% 92.6-99.9) undergoing the RS-RARP, respectively, and the Kaplan Meier curve showed no statistically significant difference for both technique at any time point (log-rank p = 0.556). The median (95% confidence interval [CI]) time to UC recovery was 9.8 (5.2-14.4) days for the APR-RARP versus 6.7 (3.2-10.2) days for the RS-RARP group. Potency rates were similar in both groups at 3 and 12 months after surgeries. The two compared approaches, in terms of rate of complications, PSM were similar. Conclusions; Surgeons can achieve functional results comparable to the retzius-sparing technique with the modified reconstructive anterior approach, without changing the surgical technique they are used to.

Robotic Radical Prostatectomy at the Egyptian National Cancer Institute: Overcoming the Challenges in the Initial Case Series

BACKGROUND: Robotic prostatectomy is showing progressive worldwide spread owing to potential clinical benefits, but at a higher cost. AIM: This article describes the challenges and clinical outcomes of the first group of patients undergoing robotic prostatectomy in Egypt. DESIGN, SETTING, PARTICIPANTS: From 2017 to 2019, the data of all (55) patients undergoing robotic radical prostatectomy at the National Cancer Institute of Egypt were retrospectively analyzed. OUTCOME EVALUATION: Short-term operative outcomes, complications, technical difficulties, pathologic data, and biochemical recurrence were reported. RESULTS: Average blood loss was 296 ml; one patient required blood transfusion. One case required open conversion, another required re-docking of the robot. Setup time was significantly improved from an average of 27.7 min in the first 27 cases to an average of 17.3 min in the final 28 cases (p < 0.0001). Complications developed in 27% of our patients. Continence recovery at catheter removal, 1st, 3rd, 6th, and 12th months were 32.7%, 50.9%, 65.5%, 74.5%, and 96%, respectively. CONCLUSIONS: Results from the first series of robotic radical prostatectomy were encouraging. Technical challenges can be overcome in a short period using a dedicated team supplemented by institutional support. Acceptable complication rate and satisfactory outcomes regarding continence and blood loss were observed.

Oncological and Postoperative Outcomes of Robot-Assisted Laparoscopic Radical Prostatectomy in Renal Transplant Recipients: A Multicenter and Comparative Study

BACKGROUND

Robot-assisted laparoscopic radical prostatectomy (RARP) has been poorly studied in men with renal graft.

OBJECTIVE

To determine the predictive factors for oncologic outcomes and complications after RARP in renal transplants recipients (RTRs).

DESIGN AND PARTICIPANTS

A retrospective multicenter controlled study identified all RTRs who had undergone RARP between 2008 and 2016 in 2 experts departments. All RTRs were matched 1:1 with patients who had also undergone RARP but with no history of renal transplant (control group).

INTERVENTION

Robot-assisted laparoscopic radical prostatectomy.

OUTCOME MEASUREMENTS

Incontinence, oncologic outcomes, and complications according to the Clavien-Dindo classification.

STATISTICAL ANALYSIS

Comparisons of the quantitative variables using Student's t tests, and comparisons of the qualitative variables using χ2 tests. Statistical analyses were performed using SAS (version 9.3). Independent risk factors of biochemical recurrence (BCR), postoperative complications, or incontinence were searched by using a multivariate linear regression.

RESULTS

Twenty-seven RTRs were included in the transplant group and compared with 27 men in the control group with similar preoperative characteristics. Univariate analysis showed a shorter BCR-free survival in RTRs, with 26.9 months vs 49.3 months in the control group (P = .018). BCR rate was similar in each group (7.4% vs 11.1%, P = .639). No difference between groups was showed for immediate postoperative complications (29.6% vs 22.2%, P = .279). Multivariate analysis showed that a renal graft history was an independent risk factor of shorter BCR-free survival (hazard ratio = 4.291; 95% confidence interval, 2.102-8.761 and P < .001). Even if it is the first comparative study on this topic, the low number of men included is the main limitation of our study.

CONCLUSIONS

These findings show the reliability of RARP in RTRs. The rate of BCR does not appear more frequently but BCR-free survival seems shorter in these patients. A prospective comparative study remains necessary with more patients to confirm our results.

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.