Robot-assisted radical prostatectomy in the setting of previous abdominal surgery: Perioperative results, oncological and functional outcomes, and complications in a single surgeon's series

Single Port Radical Prostatectomy as a Viable Option for Highly Complex Patients: A Single Center Experience

OBJECTIVE

To explore the safety and feasibility of the Da Vinci single-port (SP) platform in robotic-assisted radical prostatectomy (SP-RARP), aiming to provide a viable option for patients with surgical and medical complexities that might otherwise limit their access to common minimally invasive technique.

METHODS

Data from 60 medically and surgically highly complex patients undergoing SP-RARP between December 2018 and December 2023 were analyzed. Variables included patient characteristics, surgical history, intraoperative and postoperative outcomes. Statistical analysis was conducted using Stata 17.0.

RESULTS

Fifty-three percent of cases had a hostile abdomen (HA) (≥1 major abdominal surgery), and 47% were medically highly complex (American Society of Anesthesiologists score ≥3, Charlson Comorbidity Index ≥5, and a body mass index ≥30). The extraperitoneal approach was used in 56% of HA cases and 68% of MHC cases. Intraoperative complications occurred in 12%, exclusively with the transperitoneal approach in HA cases. Postoperative complications (Clavien-Dindo ≥3) were 6% and 14%, respectively, with no significant difference between approaches. Same-day discharge was possible in 44% of HA cases and 54% of MHC cases, with significant statistical differences favoring the extraperitoneal approach in both groups.

CONCLUSION

SP-RARP, particularly the extraperitoneal approach, is a viable option for highly complex and challenging cases, providing acceptable oncological and functional outcomes. Prospective studies are crucial for further validating the safety and feasibility of SP-RARP in this patient population.

Robot-assisted low anterior resection in a patient with rectal cancer who had a urinary reservoir: A case report

Undergoing another surgery after a previous abdominal procedure can sometimes result in significant abdominal adhesions. We present a case of robot-assisted low anterior resection in a patient with rectal cancer who had a urinary reservoir. A 65-year-old male patient underwent robot-assisted total bladder resection and creation of a urinary reservoir for bladder cancer in 2013. He presented with melena. Thus, the findings revealed advanced low rectal cancer. The robot-assisted low anterior resection was performed in 2022. Extensive adhesions were observed in the pelvic space. The indocyanine green function was appropriately used, and the robotic surgery was completed without injury to the urinary reservoir or major complications. The surgical time was 510 min, and the blood loss volume was 15 mL. The patient had been recurrence free for 12 months following the surgery. Robot-assisted surgery can be beneficial for patients with rectal cancer with significant pelvic adhesions.

Incidental Prostate Cancer in Patients Treated for Benign Prostatic Hyperplasia: Analysis from a Contemporary National Dataset

(1) Background: Prostate Cancer (PCa) may be incidentally diagnosed during the microscopic evaluation of resected tissue from BPH surgeries, characterizing the clinical condition known as incidental PCa (iPCa). This study aims to assess the prevalence of iPCa following BPH surgery to evaluate the associated surgical procedures and to scrutinize preoperative and postoperative management. (2) Methods: A retrospective analysis was conducted using the PearlDiver™ Mariner database, containing patient records compiled between 2011 and 2021. International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes were employed to identify the population and outcomes. Our primary objective was to assess the prevalence of iPCa, categorized by the type of procedures, and to evaluate the subsequent treatment strategies. The secondary aim was to assess the impact of prostate biopsy (PB) and prostate MRI on iPCa detection. (3) Results: The overall cohort, accounting for 231,626 patients who underwent BPH surgery, exhibited a 2.2% prevalence rate of iPCa. The highest rate was observed for TURP (2.32%), while the lowest was recorded for RASP (1.18%). Preoperative MRI and PB demonstrated opposing trends over the years. Of the 5090 patients identified with iPCa, nearly 68% did not receive active treatment. The most common treatments were RT and ADT; 34.6% underwent RT, 31.75% received ADT, and 21.75% were treated with RT+ADT. RP was administered to approximately 9% of patients undergoing endoscopic procedures. Multivariate logistic regression analysis revealed age and openSP as additional risk factors for iPCa. Conversely, PB and MRI before surgery were linked to a decreased risk. (4) Conclusions: The contemporary prevalence of iPCa after BPH surgery is <3%. The increase in the use of prostate MRI mirrors a decline in the PB biopsy prior to BPH surgery but without resulting in an increased detection rate of iPCa. In contemporary routine clinical practice, iPCa is mostly managed in a different way when compared to biopsy-detected PCa.

Prospective cohort study investigating quality of life outcomes following multi-speciality robotic-assisted surgery

INTRODUCTION

Despite recent evidence on the surgical outcomes of robotic-assisted surgery (RAS), other patient centre outcomes, including quality of life (QOL), are lacking. This study aims to examine changes in QoL trajectories following RAS across different surgical specialities.

PATIENTS AND METHODS

A prospective cohort study was conducted for patients undergoing urologic, cardiothoracic, colorectal or benign gynaecological RAS, between June 2016 and January 2020 at a tertiary referral hospital in Australia. QoL was measured using the 36-item Short-Form Health Survey at pre-operative, 6 weeks and 6 months postoperatively. Physical and mental summary scores and utility index were primary outcomes, and sub-domains were secondary outcomes.

STATISTICAL ANALYSIS USED

Mixed-effects linear regressions were used to determine changes in QoL trajectories.

RESULTS

Of the 254 patients undergoing RAS, 154 underwent urologic, 36 cardiothoracic, 24 colorectal and 40 benign gynaecological surgery. Overall, the average age was 58.8 years and most patients were male (75.1%). Physical summary scores significantly decreased from pre-operative to 6 weeks' post-operative in urologic and colorectal RAS; with all surgical specialities at least returning to pre-operative levels within 6 months postoperatively. Mental summary scores consistently increased from pre-operative to 6 months postoperatively for colorectal and gynaecological RAS.

CONCLUSIONS

RAS contributed to positive changes in QoL, with physical health returning to the pre-operative level and mental health improvements across specialities, in the short term. While degrees of post-operative changes varied amongst specialities, significant improvements demonstrate benefits in RAS.

Safety and feasibility of robotic surgery for colon cancer patients with previous abdominal surgery: a propensity score-matching analysis

Robotic surgery is widely used in gastrointestinal surgery. While the application of robotic surgery for colon cancer patients with previous abdominal surgery (PAS) remains controversial for the fear of intra-abdominal adhesions. This study was aimed to evaluate the safety and feasibility of robotic colectomy for patients with PAS. The medical records of colon cancer patients who underwent robotic surgery at our hospital from June 2015 to August 2020 were extracted and analyzed. Propensity score-matching (PSM) analysis was implemented to minimize selection bias. We compared perioperative outcomes and postoperative complications between the patients with PAS or with no PAS (NPAS). A total of 79 patients (PAS group) and 348 patients (NPAS group) were included in our study. After PSM, 79 patients of PAS group and 79 patients of NPAS group were selected for further analysis. We did not find statistical difference in operative time, estimated blood loss, lymph nodes retrieved, length of hospital stay and hospital costs between the two groups. No difference was noted in the incidence of postoperative complications, conversion to open surgery and mortality between the two groups. According to the results of multivariate analysis, PAS was not identified as risk factor for postoperative complications. Left hemicolectomy and perioperative transfusion were associated with postoperative complications. PAS did not negatively affect the outcomes of robotic colectomy. After individually preoperative assessment, robotic surgery could be performed feasibly and safely for colon cancer patients with PAS.

Identifying prognostic parameters related to surgical technique in patients treated by robotic radical prostatectomy

INTRODUCTION AND OBJECTIVE

The most frequently studied factors in patients treated by robotic radical prostatectomy are PSA and pathological features of the biopsy and prostatectomy specimen. Studies on the factors associated with the surgical technique are scarce and with controversial results. The objective is to identify all possible surgical factors and their relationship with disease-free and metastasis-free survival.

PATIENTS AND METHOD

Prospective study approved by the Ethics Committee, including patients who underwent robotic radical prostatectomy since January 2009 with a minimum follow-up of 5 years. Surgeon, surgical time, blood loss, fascial access, continence techniques, preservation of the fascia, neurovascular bundles, bladder neck, urethra, learning curve and surgical complications, were analyzed as possible prognostic factors. We performed univariate and matched comparisons of survival using Kaplan-Meier estimation and long-rank tests. The significance level for multiple comparisons was established with False Discovery Rate-adjustment (adjusted p).

RESULTS

Cohort of 667 patients with a median follow-up of 69 months. In univariate analysis, surgeon (adjp=0.018), preservation of puboprostatic ligaments (adjp=0.02), preservation of endopelvic fascia (adjp=0.001) and performing periurethral suspension (adjp<0.001) are poor prognostic factors for disease-free survival. Fascia preservation also negatively affects metastasis-free survival (adjp=0.04). Previous abdominal surgeries, prostate, surgical time, blood loss, type of residual urethra, middle lobe, fascial access, fascia or bladder neck preservation, have no statistical significance.

CONCLUSIONS

The surgeon and specific aspects of the surgical technique are determining factors in disease-free survival. Preservation of the fascia is the only factor that negatively affects metastasis-free survival.

Predictive factors of postoperative complications and hospital readmission after implementation of the single-port robotic platform: A single-center and single-surgeon experience

OBJECTIVES

To measure the incidence, and identify potential risk factors of conversion, postoperative complication and readmission for patients treated with urological robotic single-port surgery.

METHODS

All consecutive urological surgery procedures carried out with the single-port robotic platform by the same surgeon in a single institution between September 2018 and March 2020 were included in this retrospective analysis. Demographic data, main perioperative outcomes and information related to the surgical technique were gathered and analyzed. A logistic regression model was used to assess predictive factors for any grade and high-grade (e.g. Clavien grade ≥3) postoperative complications, as well as predictive factors for readmission.

RESULTS

Analysis included 221 patients, of whom 194 (88%) underwent pelvic surgery and 27 (12.2%) underwent upper urinary tract surgery. Only one patient was converted to open surgery in the entire cohort. A total of 40 patients (18.1%) experienced postoperative complications, with grade ≥3 postoperative complications in 7.6% of the entire cohort. On multivariable analysis, the factors significantly associated with the risk of postoperative complication of any grade were diabetes (P < 0.001), perineal approach (P < 0.01) and postoperative pain management with opioids (P = 0.01). Only diabetes (P = 0.03) predicted a grade ≥3 complication. Overall, 17 patients (7.7%) were readmitted during the 3 months after surgery. A body mass index >30 kg/m² was the only identified predictor of readmission (P = 0.01).

CONCLUSION

A wide range of pelvic, extraperitoneal and upper-tract urological procedures can be carried out using the robotic single-port platform with a minimal conversion rate and low complication or readmission rate.

Robotic radical perineal prostatectomy: tradition and evolution in the robotic era

PURPOSE OF REVIEW

To provide an updated review of robotic radical perineal prostatectomy (r-RPP) with emphasis on the recent advances in terms of surgical technique, outcomes, and new robotic platforms.

RECENT FINDING

The technological innovations in the urological field have been applied to radical prostatectomy with the aim of preserving important anatomical structures and reduce patients' morbidity and mortality. In recent years, robotic surgery contributed to resurge radical perineal prostatectomy. In 2014, the Cleveland Clinic group was the first to demonstrate the utility of a robotic approach in RPP. To date, the majority of the reported studies showed that r-RPP has noninferior perioperative, short-term oncological, and functional outcomes compared with the traditional robot-assisted radical prostatectomy (RARP). Given these benefits, r-RPP is a promising approach in selected patients, such as obese ones. Moreover, robotic perineal pelvic lymph node dissection performed through the same incision of r-RPP and the new Single-Port (SP) Robotic System represent further steps towards the overcoming of some intrinsic limitation of this surgical approach making this technique suitable for a larger number of patients with prostatic cancer.

SUMMARY

Overall, r-RPP represents a reliable and effective novel surgical technique. However, more studies with long-term follow-up are needed to clarify the advantages over RARP.

Robot-assisted Radical Prostatectomy Using Single-port Perineal Approach: Technique and Single-surgeon Matched-paired Comparative Outcomes

BACKGROUND

Radical perineal prostatectomy (RPP) has been revived with the advent of single-port (SP) robotic surgery. However, its interest and precise role need to be evaluated and better defined.

OBJECTIVE

To describe in detail the technique of SP-RPP and compare initial perioperative outcomes with those of multiport robot-assisted transperitoneal radical prostatectomy (MP-RARP).

DESIGN, SETTING, AND PARTICIPANTS

From October 2018 to June 2020, perioperative data of 26 consecutive patients who underwent SP-RPP for localized prostate cancer (PCa) in a single institution were prospectively entered into an institutional review board-approved database. Data of 86 consecutive patients treated from September 2017 to September 2018 with MP-RARP by the same surgeon, before the beginning of the SP experience, were used as comparators.

SURGICAL PROCEDURE

SP-RPP was performed using the SP robotic platform (Intuitive Surgical, Sunnyvale, CA, USA) according to the technique described in the supplementary video.

MEASUREMENTS

Demographics, and intra- and postoperative data were analyzed in a matched-paired design with a 1:1 ratio on the following factors: age at surgery, prostate-specific antigen level, preoperative Gleason score, and history of abdominal surgery.

RESULTS AND LIMITATIONS

After matching, baseline characteristics were comparable except for the rate of prior laparotomy, which was higher in the SP-RPP group (52% vs 8%, p < 0.001). In the SP-RPP group, 84% of the patients had a high risk and an unfavorable intermediate risk of positive surgical margins (PSMs) versus 57% in the MP-RARP group (p = 0.03). While the rate of nonlimited PSMs (ie, >3 mm) was higher in the SP-RPP group (38.5% vs 7.7%, p < 0.01), the number of patients with biochemical recurrence at 1 yr was comparable between SP-RPP and MP-RARP (1 vs 3, p = 0.3).

CONCLUSIONS

SP-RPP is a complex procedure for patients with a complex surgical history and high-risk localized PCa with limited alternative therapeutic options.

PATIENT SUMMARY

Our study suggests that patients with high-risk localized prostate cancer and limited treatment options due to a complex abdominal surgical history (ie, frozen pelvis) may be suitable candidates for single-port radical perineal prostatectomy.

Robotic prostatectomy following previous major abdominal surgeries resulting from gunshot injury

Major previous abdominal surgery involving more than one abdominal quadrant may be considered a relative contraindication to robotic assisted radical prostatectomy (RARP) due to the potential increased risk of adhesions, bowel injuries, and is often associated with longer operating time and increased blood loss. We describe the use of a mini-laparotomy to allow safe port placement with extensive open and robotic adhesiolysis at the time of RARP with an excellent post-operative recovery, good oncologic and functional outcomes.

Robotic-assisted perineal versus transperitoneal radical prostatectomy: A matched-pair analysis

OBJECTIVE

We compared the outcomes of robotic-assisted radical perineal prostatectomy (r-PRP) versus robotic-assisted transperitoneal laparoscopic radical prostatectomy (RARP).

MATERIAL AND METHODS

Between November 2016 and September 2017 in our center, 40 patients underwent r-PRP, and 40 patients underwent RARP. All patients also underwent multiparametric magnetic resonance imaging (mpMRI) to exclude the cases with locally advanced disease. Patients with localized prostate cancer (C-T2N0M0) were included in the study. The exclusion criteria were contraindications for undergoing robotic radical prostatectomy; the Gleason score ≥4+3; extracapsular extension proven on biopsy or suspected on mpMRI; clinical stage ≥T2c; required pelvic lymph dissection according to Partin's normogram; previous radiation therapy; hormonal therapy; any previous prostatic, urethral, or bladder neck surgery; and preoperative urinary incontinence or erectile dysfunction. Patients were placed in the exaggerated lithotomy position with 15° Trendelenburg for r-PRP and 40° Trendelenburg for RARP.

RESULTS

The mean age for the r-PRP and RARP groups were 61.2 (46-73) and 62.2 (50-75) years, respectively. The mean body mass index was significantly higher in the r-PRP group (p=0.02). The mean procedure duration time was 169.4 (100-255) minutes for the r-PRP group and 173.1 (130-210) minutes for the RARP group. The mean console time and anastomosis time were significantly lower for the r-PRP group. The mean estimated blood loss was significantly lower for the r-PRP group (p=0.002). Immediate continence rates in the r-PRP and RARP groups following the urethral catheter removal were 42% and 35% (p=0.30), respectively. Continence rates increased to 94.2% in the r-PRP and 72% in RARP (p=0.001) group at the 6^th month, and to 95% in the r-PRP and 85.2% in RARP (p=0.02) group at the 9th month follow-up period. According to the International Index of Erectile Function-5 (IIEF-5), the erectile function rates at the 3-, 6-, and 9-month follow-up in the r-PRP group were 44%, 66%, and 75%, respectively. The rates in the RARP group at the 3-, 6-, and 9-month follow-up were 25%, 42%, and 66% (p=0.001), respectively.

CONCLUSION

In our experience, r-PRP has acceptable morbidity, excellent surgical and pathological outcomes, and satisfactory oncologic and functional results compared to RARP.

Peri- and post-operative results of initial robot-assisted radical prostatectomies of a surgeon graduating from a structured fellowship

Background: No validated training curriculum for robotic surgery exists so far. International scientific societies like ERUS (EAU Robotic Urology Section) seek to validate a structured training program for robotic surgeons. In 2014, ERUS launched Pilot Study II, a 6-month structured training program to allow a surgeon without prior robotic training to perform a complete RARP (robot-assisted radical prostatectomy) independently and effectively. Aim of the study: Here we report the detailed courses and training materials, specific surgical activities and perioperative efficacy and safety results of the first 52 RARP cases performed by a single surgeon after graduating from Pilot Study II. The aim is to compare these results with the literature and show if this sophisticated training helps patients undergoing this type of surgery achieve advantageous perioperative results. Material and methods: The fellowship was conducted from January to June 2014 and consisted of lectures on technical and non-technical skills, as well as e-learning, bedside assistance (at least 20), intensive training consisting of laboratory training (i.e., virtual reality simulation, dry lab (plastic model), wet lab on animal cadavers and living anaesthetized pigs) and dual-console live surgery followed by five months of modular training, where the trainee performed different steps of the surgery at the host center. After passing the final evaluation (a full recorded video of RARP evaluated blindly by robotic experts), the trainee was deemed capable of performing efficiently and safely a full case of RARP. Here we retrospectively report the content of training and perioperative results of the surgeon’s initial 52 RARPs performed from July 2014 to April 2015. Results: After graduating from the fellowship, the surgeon performed 52 cases of RARP. The mean patient age was 65.2 years, initial PSA 12.9 ng/ml, prostate volume 43.7 ml in TRUS, BMI 27.5, and 61% of patients had a prior abdominal or pelvic surgery. Because of internal regulations, every patient had a pelvic lymphadenectomy performed, three of whom had positive lymph nodes. The average estimated blood loss was 225.7 ml, and no patient needed intraoperative blood transfusion. The average console time was 174.2 minutes. Final full-mount pathology identified 23 patients (44.2%) with a locally advanced prostate cancer (T3 or T4). Positive surgical margins were present in three cases. A further 29 patients (55.8%) had locally confined disease (T2). Positive surgical margins were observed in 2 cases. Catheters were removed on the 5th postoperative day followed by a cystogram, with no urine leakage observed in 96.2% of cases. The safety of the procedure was good with one major (Clavien 4) and 13 minor (Clavien 1 and 2, i.e., uncomplicated urinary infection, urinary retention) complications. Conclusions: The study showed that graduating from an intensive and structured learning program in robotic surgery resulted in a faster learning curve, allowing the trainee to reach high safety parameters in performed surgeries. When compared with already published series, advantageous results could be observed. The study was limited by its retrospective design, the moderate number of patients and variables such as individual motivation, dexterity and attitude of the person in training. The advantages of such training should be further evaluated in controlled, multi-center trials.