Open Conversion during Minimally Invasive Radical Prostatectomy: Impact on Perioperative Complications and Predictors from National Data

Changing trends in robot-assisted radical prostatectomy: Inverse stage migration-A retrospective analysis

Background

With increasing availability of data on outcomes of surgery for prostate cancer, the profile of patients undergoing robot-assisted radical prostatectomy (RARP) has changed over the past decade. This impacts the decision-making process for surgeons and patients, particularly in low-incidence regions of Asia. Our institution was among the first in Asia to acquire a da Vinci surgical robot in 2005. We evaluated the changes in the clinical and pathology profile of patients undergoing RARP at our institution over the past 15 years (2005-2019).

Methods

A retrospective analysis of patients undergoing RARP between April 2005 and December 2019 was conducted from the hospital database. The patients were divided into two groups; patients undergoing RARP from April 2005 to December 2012 (Group I, first 8 years) and January 2013 to December 2019 (Group II, next 7 years). The perioperative characteristics were compared between these two groups to assess changes in their profile and outcome.

Results

Four hundred forty-seven patients were included in this study; 244 (54.6%) in Group I and 203 (45.4%) in Group II. The median prostate specific antigen in Group II was significantly higher than that in Group I (14.5 vs. 11.7 ng/ml, P = 0.016). Unfavorable pathological characteristics, i.e., Gleason Grade ≥3, perineural invasion, and the margin positivity rate increased substantially from 18.5% to 37.5%, 20.5% to 36.9%, and 15.2% to 26.6%, respectively, in Group II compared with Group I. More patients in Group II received adjuvant therapy than in Group I (P < 0.001).

Conclusion

There has been a change in profile of patients undergoing RARP and patients with more unfavorable disease characteristics such as higher prostate specific antigen and tumor grade are undergoing surgery. In line with international trends, the number of patients with low-grade disease undergoing surgery has substantially decreased. Multimodal treatment with adjuvant therapy is increasingly used, particularly in high-risk disease.

A Systematic Review of the Impact of Surgeon and Hospital Caseload Volume on Oncological and Nononcological Outcomes After Radical Prostatectomy for Nonmetastatic Prostate Cancer

CONTEXT

The impact of surgeon and hospital volume on outcomes after radical prostatectomy (RP) for localised prostate cancer (PCa) remains unknown.

OBJECTIVE

To perform a systematic review on the association between surgeon or hospital volume and oncological and nononcological outcomes following RP for PCa.

EVIDENCE ACQUISITION

Medline, Medline In-Process, Embase, and the Cochrane Central Register of Controlled Trials were searched. All comparative studies for nonmetastatic PCa patients treated with RP published between January 1990 and May 2020 were included. For inclusion, studies had to compare hospital or surgeon volume, defined as caseload per unit time. Main outcomes included oncological (including prostate-specific antigen persistence, positive surgical margin [PSM], biochemical recurrence, local and distant recurrence, and cancer-specific and overall survival) and nononcological (perioperative complications including need for blood transfusion, conversion to open procedure and within 90-d death, and continence and erectile function) outcomes. Risk of bias (RoB) and confounding assessments were undertaken. Both a narrative and a quantitative synthesis were planned if the data allowed.

EVIDENCE SYNTHESIS

Sixty retrospective comparative studies were included. Generally, increasing surgeon and hospital volumes were associated with lower rates of mortality, PSM, adjuvant or salvage therapies, and perioperative complications. Combining group size cut-offs as used in the included studies, the median threshold for hospital volume at which outcomes start to diverge is 86 (interquartile range [IQR] 35-100) cases per year. In addition, above this threshold, the higher the caseload, the better the outcomes, especially for PSM. RoB and confounding were high for most domains.

CONCLUSIONS

Higher surgeon and hospital volumes for RP are associated with lower rates of PSMs, adjuvant or salvage therapies, and perioperative complications. This association becomes apparent from a caseload of >86 (IQR 35-100) per year and may further improve hereafter. Both high- and low-volume centres should measure their outcomes, make them publicly available, and improve their quality of care if needed.

PATIENT SUMMARY

We reviewed the literature to determine whether the number of prostate cancer operations (radical prostatectomy) performed in a hospital affects the outcomes of surgery. We found that, overall, hospitals with a higher number of operations per year have better outcomes in terms of cancer recurrence and complications during or after hospitalisation. However, it must be noted that surgeons working in hospitals with lower annual operations can still achieve similar or even better outcomes. Therefore, making hospital's outcome data publicly available should be promoted internationally, so that patients can make an informed decision where they want to be treated.

Prevalence of Postprostatectomy Incontinence Requiring Anti-incontinence Surgery After Radical Prostatectomy for Prostate Cancer: A Retrospective Population-Based Analysis

Purpose

The aim of this study was to examine the prevalence of surgery for post-prostatectomy incontinence (PI) following minimally invasive surgery compared to conventional open surgery for prostate cancer.

Methods

This retrospective cohort study used the Florida State Ambulatory Surgery and State Inpatient Databases, 2008 to 2010, RP patients were identified using ICD-9/10 procedure codes and among this cohort PI was identified also using ICD-9/10 codes. Surgical approaches included Minimally invasive (robotic or laparoscopic) vs. open (retropubic or perineal) RP. The primary outcome was the overall prevalence of surgery for PI. The secondary outcome was the association of PI requiring anti-incontinence surgery with the surgical approach for RP.

Results

Among the 13535 patients initially included in the study (mean age, 63.3 years), 6932 (51.2%) underwent open RP and 6603 (49.8%) underwent minimally invasive RP. The overall prevalence of surgical procedures for PI during the observation period among the all patients who had received RP was 3.3%. The rate of PI surgery for patients receiving minimally invasive surgery was higher than that for patients receiving open surgery (4.8% vs. 3.0%; risk difference, 1.8%; 95% CI, 0.3% to 3.4%). The adjusted prevalence of PI surgery for patients who had undergone laparoscopic RP was higher than that for those with retropubic RP (8.6% vs. 3.7%).

Conclusions

Among patients undergoing RP for prostate cancer, the prevalence of PI surgery is not negligible. Patients undergoing minimally invasive RP had higher adjusted rates for PI surgery compared to open approaches, which was attributed to high rate of PI surgery following laparoscopic approach and low rate of PI surgery following perineal approach. More studies are needed to establish strategies to reduce the rate of PI surgery after RP.

Robotic prostatectomy after abandoned open radical prostatectomy—Technical aspects and outcomes

Objective

To describe the technical aspects and outcomes of robotic‐assisted radical prostatectomy (RARP) following abandoned open radical prostatectomy (ORP).

Patients and Methods

A retrospective review was performed of patients who underwent RARP following abandonment of ORP between 2016 and 2020. RARP was undertaken by two highly experienced robotic surgeons. Analysis of patient and operative characteristics, outcomes, and reasons for abandonment of ORP were described.

Results

Six patients were included for analysis with a median age of 63.5 years [50.3‐67.5]. The median body mass index (BMI) was 34.7 [27.8‐36.2]. All patients had intermediate‐risk prostate cancer. Small prostate and deep pelvis were given as reasons for abandoning ORP in five cases (83.3%), with four of these also attributing increased BMI as a factor. Extensive mesh from previous bilateral inguinal hernia repair was cited as the reason for abandonment in the remaining patient. One patient had commenced androgen deprivation therapy following abandoned ORP. Extensive retropubic adhesions were noted at the time of RARP in five of six patients, with intraoperative complication of small bladder lacerations encountered in the patient with prior mesh hernia repair. The median time from abandoned ORP to RARP was 128 days [40‐216]. Median operating time was 160 minutes [139‐190] and estimated blood loss was 225 mL [138‐375]. Negative margins were obtained in four of six cases, with further salvage treatment being required in one case at a median follow‐up duration of 10.5 months [6.5‐25.3].

Conclusion

Abandonment of ORP is an uncommonly reported event, however, in this small case series, we demonstrate that, in the hands of experienced surgeons, RARP is a safe and technically feasible alternative in such cases. Increased BMI, small prostate size and pelvic anatomical constraints appear to be common catalysts for abandonment of open surgery in this cohort. Identifying these high‐risk patients early and considering referral to robotic centers may be preferred.

[Prostate cancer: surgical complications]

Radical prostatectomy (RP), performed as an open, laparoscopic or robotic procedure, remains the "gold standard" for patients with localised prostate cancer who can be cured with surgery and have a life expectancy of at least 10 years. Today, RP is also used as a first-line treatment for locally advanced prostate cancer, possibly in a multimodal setting with adjuvant radiation/hormonal therapy. The increasing experience of surgeons, better knowledge of anatomy and refinements of surgical techniques have greatly improved oncological and functional outcomes. In our article we would like to give an overview of the complications associated with this surgical procedure.

Treatment outcomes of bladder neck contractures from surgical clip erosion: a matched cohort comparison

Vesicourethral anastomotic stenosis (VUS) from surgical clip erosion after radical prostatectomy (RP) is a rare scenario with potentially significant quality of life implications. The literature is limited to case series, and the impact of clip erosion on VUS prognosis is not known. Years 2001 to 2012 of our institutional RP registry were queried for patients with symptomatic VUS without prior strictures or radiotherapy. Patients with clip-associated VUS (caVUS) were identified and compared to a 1:3 matched cohort (based on age, Gleason score, and year of surgery) of non-caVUS patients using descriptive statistics and time to event analyses. At a median follow-up of 54 months after RP, 243 men with symptomatic VUS were identified of which 21 (8.6%) were caVUS. Robotic RPs had a higher rate of caVUS (0.5%) vs. open RPs (0.06%), P<0.01. Patients with caVUS had longer time to diagnosis after RP compared to a matched cohort of 63 non-caVUS patients (median 9.2 vs. 3.7 months after RP, P<0.01). Although patients with caVUS had a higher VUS recurrence rate after endoscopic treatment compared to patients with non-caVUS, the difference was not statistically significant on log-rank comparison (3-year VUS recurrence rate 56.4% vs. 39.4%, P=0.23). Majority of VUS recurrences were within 18 months of initial treatment. Clip erosion is responsible for 8.6% of VUS after RP, takes longer to present than non-caVUS, and was seen more commonly after a robotic RP. VUS recurrence rates are similar for caVUS and non-caVUS.

Freehand diffuse optical spectroscopy imaging for intraoperative identification of major venous and arterial vessels underlying peritoneal fat: an in vivo demonstration in a pig model

Inadvertent injury to important anatomic structures is a significant risk in minimally invasive surgery (MIS) that potentially requires conversion to an open procedure, which results in increased morbidity and mortality. Surgeons operating minimal-invasively currently do not have an easy-to-use, real-time device to aid in intraoperative identification of important anatomic structures that underlie tissue planes. We demonstrate freehand diffuse optical spectroscopy (DOS) imaging for intraoperatively identifying major underlying veins and arteries. An applicator probe that can be affixed to and detached from an 8-mm laparoscopic instrument has been developed. The 10-mm DOS source-detector separation renders sampling of tissue heterogeneities a few millimeters deep. DOS spectra acquired consecutively during freehand movement of the applicator probe on the tissue surface are displayed as a temporal and spectral image to assist in spatially resolved identification of the underlying structures. Open surgery identifications of the vena cava and aorta underlying peritoneal fat of ∼4  mm in thickness using the applicator probe under room light were demonstrated repeatedly in multiple pigs in vivo.

The Value of Open Conversion Simulations During Robot-Assisted Radical Prostatectomy: Implications for Robotic Training Curricula

INTRODUCTION

There is a lack of protocols, formal guidance, and procedural training regarding open conversions from robot-assisted radical prostatectomy (RARP) to open radical prostatectomy (ORP). An open conversion places complex demands on the healthcare team and has recently been shown to be associated with adverse perioperative outcomes.

AIMS

To perform a root cause analysis of open conversion simulations from RARP to ORP to identify errors that may contribute to adverse events.

METHODS

From May 2013 to December 2013, with a team of two surgeons, an anesthesiologist, and three nurses, we simulated 20 emergencies during RARP that require open conversion. A human simulation model was intubated and prepared in the Trendelenburg position; a robot da Vinci SI was locked to it. All simulations were timed, transcribed, and filmed to identify errors and areas for improvement. An institutional conversion protocol was developed at the end of the conversion training.

RESULTS

The average conversion time was 130.9 (interquartile range [IQR] 90-201) seconds. Frequencies of the observed errors were as follows: lack of task sequence (70%), errors in robot movements (50%), loss of sterility (50%), space conflict (40%), communication errors (25%), lack of leadership (25%), and accidental fall of surgical devices (25%). Four main strategies were implemented to reduce errors: improving leadership, clearly defining roles, improving knowledge base, and surgical room reorganization. By the last simulation, conversions were performed without errors and using 55.2% less time compared with initial simulations.

CONCLUSIONS

In this preliminary study, repeated simulations, increased leadership, improved role delineation, and surgical room reorganization enabled faster and less flawed conversions. Further studies are needed to identify if such protocols may translate to actual safety improvement during open conversions.