Robotic Prostatectomy: A Review of Outcomes Compared with Laparoscopic and Open Approaches

Comparative Safety of Robotic-Assisted vs Laparoscopic Cholecystectomy

Importance

Robotic-assisted cholecystectomy is rapidly being adopted into practice, partly based on the belief that it offers specific technical and safety advantages over traditional laparoscopic surgery. Whether robotic-assisted cholecystectomy is safer than laparoscopic cholecystectomy remains unclear.

Objective

To determine the uptake of robotic-assisted cholecystectomy and to analyze its comparative safety vs laparoscopic cholecystectomy.

Design, Setting, and Participants

This retrospective cohort study used Medicare administrative claims data for nonfederal acute care hospitals from January 1, 2010, to December 31, 2019. Participants included 1 026 088 fee-for-service Medicare beneficiaries 66 to 99 years of age who underwent cholecystectomy with continuous Medicare coverage for 3 months before and 12 months after surgery. Data were analyzed August 17, 2022, to June 1, 2023.

Exposure

Surgical technique used to perform cholecystectomy: robotic-assisted vs laparoscopic approaches.

Main Outcomes and Measures

The primary outcome was rate of bile duct injury requiring definitive surgical reconstruction within 1 year after cholecystectomy. Secondary outcomes were composite outcome of bile duct injury requiring less-invasive postoperative surgical or endoscopic biliary interventions, and overall incidence of 30-day complications. Multivariable logistic analysis was performed adjusting for patient factors and clustered within hospital referral regions. An instrumental variable analysis was performed, leveraging regional variation in the adoption of robotic-assisted cholecystectomy within hospital referral regions over time, to account for potential confounding from unmeasured differences between treatment groups.

Results

A total of 1 026 088 patients (mean [SD] age, 72 [12.0] years; 53.3% women) were included in the study. The use of robotic-assisted cholecystectomy increased 37-fold from 211 of 147 341 patients (0.1%) in 2010 to 6507 of 125 211 patients (5.2%) in 2019. Compared with laparoscopic cholecystectomy, robotic-assisted cholecystectomy was associated with a higher rate of bile duct injury necessitating a definitive operative repair within 1 year (0.7% vs 0.2%; relative risk [RR], 3.16 [95% CI, 2.57-3.75]). Robotic-assisted cholecystectomy was also associated with a higher rate of postoperative biliary interventions, such as endoscopic stenting (7.4% vs 6.0%; RR, 1.25 [95% CI, 1.16-1.33]). There was no significant difference in overall 30-day complication rates between the 2 procedures. The instrumental variable analysis, which was designed to account for potential unmeasured differences in treatment groups, also showed that robotic-assisted cholecystectomy was associated with a higher rate of bile duct injury (0.4% vs 0.2%; RR, 1.88 [95% CI, 1.14-2.63]).

Conclusions and Relevance

This cohort study's finding of significantly higher rates of bile duct injury with robotic-assisted cholecystectomy compared with laparoscopic cholecystectomy suggests that the utility of robotic-assisted cholecystectomy should be reconsidered, given the existence of an already minimally invasive, predictably safe laparoscopic approach.

Quadrifecta outcomes and their predictors following robotic radical prostatectomy: a study of newly established robotic center in India

Active surveillance (AS), radical prostatectomy (RP), and radical radiotherapy (RT) are the three options for localized prostate cancer. Only a few studies have been conducted in developing countries or in centers in their initial learning curve that predict the outcomes of RARP. Therefore, this study aimed to present data from a novice center; how we started and progressed, and to compare our results with the rest of the world. This is a retrospective analysis to study the outcomes following robot-assisted radical prostatectomy and to identify the predictors of quadrifecta outcomes, i.e., the patients who were continent, did not have complications, were biochemical recurrence free with at least 1 year of follow-up and had negative surgical margins. In our data, we excluded the erectile function as one of the parameters as the majority of our patients were not sexually active or did not want to discuss this parameter. Seventy-two patients were included in this study, and 50 (69.4%) of these achieved the quadrifecta outcomes. Of all the factors, studied, seven factors were statistically significantly different between Group I (quadrifecta achieved) and Group II (quadrifecta not achieved), namely, BMI, co-morbidities like CAD, COPD, ASA grade, pre-op D'Amico risk stratification groups, clinical staging, positive lymph-node status, and hospital stay. With this study, we reported outcomes of RARP in a newly established robotic center and the results were fairly comparable with the well-developed center in India and abroad, emphasizing the short learning curve, and so, the requirement of establishing more robotic surgery centers in developing as well as developed countries.

Disparities in access to robotic technology and perioperative outcomes among patients treated with radical prostatectomy

BACKGROUND

Most radical prostatectomies are completed with robotic assistance. While studies have previously evaluated perioperative outcomes of robot-assisted radical prostatectomy (RARP), this study investigates disparities in access and clinical outcomes of RARP.

STUDY DESIGN

The National Cancer Database (NCDB) was used to identify patients who received radical prostatectomy for cancer between 2010 and 2017 with outcomes through 2018. RARP was compared to open radical prostatectomy (ORP). Odds of receiving RARP were evaluated while adjusting for covariates. Overall survival was evaluated using a propensity-score matched cohort.

RESULTS

Overall, 354 752 patients were included with 297 676 (83.9%) receiving RARP. Patients who were non-Hispanic Black (82.8%) or Hispanic (81.3%) had lower rates of RARP than non-Hispanic White (84.0%) or Asian patients (87.7%, p < 0.001). Medicaid or uninsured patients were less likely to receive RARP (75.5%) compared to patients with Medicare or private insurance (84.4%, p < 0.001). Medicaid or uninsured status was associated with decreased odds of RARP in adjusted multivariable analysis (OR 0.61, 95% CI 0.49-0.76). RARP was associated with decreased perioperative mortality and improved overall survival compared to ORP.

CONCLUSION

Patients who were underinsured were less likely to receive RARP. Improved access to RARP may lead to decreased disparities in perioperative outcomes for prostate cancer.

Nerve spare robot assisted laparoscopic prostatectomy with amniotic membranes: medium term outcomes

INTRODUCTION

dHACM is a source of factors including cytokines that allow anti-inflammatory and proliferative elements to be utilized for wound and ulcer management. We present our experience of using dHACM in a cohort of patients undergoing nerve-sparing (NS) robot-assisted laparoscopic prostatectomy (RALP). Our objective is to investigate the functional and oncological outcomes of NS after placing amniotic or dehydrated human amnion/chorion membrane (dHACM) on preserved neurovascular bundles (NVBs). From 2013 to 2019, our institution performed transperitoneal multi-port da Vinci robotic prostatectomy. The NVBs are spared by releasing their fascial planes posteriorly, followed by an anterior release of the plane at a similar level. Once the retrograde release of the NVB is performed then 599 patients underwent placement of dHACM graft (AmnioFix by MiMedx, Marietta, GA, USA). The graft was cut into two 4 × 1 cm pieces and laid over the NVB as a wrap. In order to inform the urological community of oncological and functional outcomes, we excluded patients with less than 12 months follow up (n = 64), benign prostatic hyperplasia (n = 5), and unilateral NS (n = 1). 529 (88%) patients were included in this study who underwent a partial or full bilateral NS with dHACM. 529 patients were followed-up for a median (IQR) of 42 months (25-89). Demographics include median (IQR) age 57 years (52-62), median preoperative SHIM score of 24 (21-15), and AUASS of 5 (2-11). Full NS was performed in 74% (391/529). Pathological staging was pT2 = 399 (75%), pT3a = 107 (20%), pT3b = 19 (4%) and pT4 = 4 (1%) with N1 = 3 (0.6%). The number of patients with PSM was 86 (16%), and the overall BCR in the entire cohort was 10%. Postoperatively, 434 (82%) were sexually active. Median time to potency was 119 (37-420) days and time to continence was 42 (23-91) days. Regarding full vs partial NS: median post op SHIM score 18 (13-20) vs 15 (6-20), median time to potency 92 (35-365) days vs 184 (42-560) days, and median time to continence 42 (23-91) days vs 44 (30-92) days. Age > 55 vs ≤ 55 years: median post op SHIM score 18 (12-20) vs 15 (10-20), median time to potency 167 days (42-549) vs 80 (35-288) days, and median time to continence 42 (25-116) days vs 42 (29-76) days. In our series the application of amniotic membrane/dHACM has led to acceptable post RALP outcomes. The BCR rate of 10% in addition to the recovery of potency at a median time of 3 months and continence at 6 weeks is an encouraging result of dHACM. Our findings indicate that dHACM allowed for an even faster period for continence recovery which was independent of grade of NS. Future comparative studies may further assess the impact of new amniotic membrane types on the functional and oncological outcomes after RALP.

Evaluation of Biochemical Recurrence and Correlation with Various Parameters After Robotic-Assisted Radical Prostatectomy: a Single Center Experience

Introduction

Biochemical recurrence (BCR) is widely used as an early end point to assess treatment success and frequently prompts the initiation of secondary therapy after radical prostatectomy. We conducted an observational, ambispective study to evaluate BCR after robotic-assisted radical prostatectomy (RARP) for clinically localized prostate cancer. We also analyzed correlation of BCR with pre-operative PSA level, D'Amico classification, pathological stage, post-operative GS, and positive surgical margins after RARP.

Material and Methods

A total of 90 patients with clinically localized carcinoma prostate (≤ T 2), who underwent RARP between April 2012 and April 2017 at our institute with 3 year of minimum follow-up were included in our study. Patients having locally advanced disease on clinical staging or died of unrelated cause in follow up or lost to follow up were excluded from study. Patients who had persistent detectable PSA (> 0.20 ng/ml) at 6 week with a second confirmatory level of PSA greater than 0.2 ng/ml at 3rd month were excluded from study.

Results

The age of the patient ranges from 46 to 79 years with the mean age of 65.36 ± 6.55 years. The mean PSA was 24.36 ± 26.68 ng/ml with range between 1.8 and 126.6 ng/ml. Nine patients (10%) developed BCR at 1-year follow-up and 81 patients were BCR-free. Thus, 1-year BCRFS and BCR rate were 90% and 10%, respectively in our study. Total 17 patients (18.9%) developed BCR during a 2-year period and 73 patients were free of BCR. Thus, 2-year BCRFS and BCR rate were 81.1% and 18.9%, respectively. A total of 29 patients (32.2%) had BCR and 61 patients were free of BCR at 3 years of follow-up. Thus, overall 3-year BCR rate and 3-year BCRFS rate were 32.2% and 67.8%, respectively. There was significant correlation of BCR with pre-operative PSA level, D'Amico classification, pathological stage, post-operative GS, and positive surgical margins.

Conclusions

There is relative paucity of data regarding the BCR rate after RARP in the Indian scenario. The BCR rate in our study was similar to previously published Western and limited Indian data on RARP series in localized prostate cancer. There was significant correlation of BCR with PSA, post-operative GS, pathological stage, PSM, and D'Amico classification.

The Use of Digital Pathology and Artificial Intelligence in Histopathological Diagnostic Assessment of Prostate Cancer: A Survey of Prostate Cancer UK Supporters

There has been particular interest in the deployment of digital pathology (DP) and artificial intelligence (AI) in the diagnosis of prostate cancer, but little is known about the views of the public on their use. Prostate Cancer UK supporters were invited to an online survey which included quantitative and qualitative questions exploring views on the use of DP and AI in histopathological assessment. A total of 1276 responses to the survey were analysed (response rate 12.5%). Most respondents were supportive of DP (87%, 1113/1276) and of testing AI in clinical practice as a diagnostic adjunct (83%, 1058/1276). Respondents saw DP as potentially increasing workflow efficiency, facilitating research, education/training and fostering clinical discussions between clinician and patient. Some respondents raised concerns regarding data security, reliability and the need for human oversight. Among those who were unsure about AI, information was requested regarding its performance and others wanted to defer the decision to use it to an expert. Although most are in favour of its use, some are unsure, and their concerns could be addressed with more information or better communication. A small minority (<1%) are not in favour of the testing of the use of AI in histopathology for reasons which are not easily addressed.

Extraperitoneal Laparoscopic Versus Transperitoneal Robot-Assisted Laparoscopic Approaches for Extended Pelvic Lymph Node Dissection During Radical Prostatectomy

Background: We aim to directly compare the feasibility and safety of extended pelvic lymph node dissection (PLND) during transperitoneal robotic-assisted radical prostatectomy (Tp-RARP) and extraperitoneal laparoscopic radical prostatectomy (Ep-LRP). Materials and Methods: We retrospectively identified the prospectively maintained database records of 162 patients diagnosed with prostate cancer (PC) who underwent Ep-LRP or Tp-RARP with extended PLND. Patients with risk of nodal metastases over 5% according to Briganti nomogram received extended PLND. All data analyzed in this study were based on the documentation in our PC database including age, body mass index, Charlson comorbidity index score, preoperative prostate-specific antigen, history of abdominal surgery, biopsy Gleason score, total operation time, postoperative pelvic drainage time, pathological results, lymph node yield (LNY), percentage lymph node involvement (%LNI), and perioperative complications. Patients were followed up for biochemical recurrence in the postoperative period. Results: Eighty-two of the 162 enrolled patients were in group 1 (Ep-LRP+PLND) and 80 were in group 2 (Tp-RARP+PLND). There were no statistically significant differences between the groups regarding preoperative demographics and clinical characteristics. The median LNY was 17 (range 8-27) and 17.5 (range 10-29) in groups 1 and 2, respectively, and no statistically significant difference was found. There was no significant difference between the groups in terms of biochemical recurrence-free survival with mean follow-up of 44.8 months after radical surgery. Conclusion: Our results support the view that extended PLND through the Ep-LRP approach is a feasible and safe procedure without compromising oncological efficacy compared with a similar template attempted during Tp-RARP. Clinical Trial Registration number is 01/21-2.

Open retropubic radical prostatectomy

Radical prostatectomy (RP) is a common treatment choice for localized prostate cancer. While there is increasing utilisation of robotic assisted RP in some centres, open RP (ORP) remains well established and commonly performed in many parts of the world. The goals of modern ORP are to remove the prostate en-bloc with negative surgical margins, while minimising blood loss and preserving urinary continence and erectile function. We present a technical review of ORP incorporating contemporary techniques for control of the deep venous complex, additional haemostatic measures, nerve-sparing and vesicourethral reconstruction.

Assessment of the lower urinary tract symptoms after robotic-assisted radical prostatectomy: the behavior of voiding, storage and post micturition symptoms

INTRODUCTION

despite being infrequent, urinary incontinence has a huge impact on the quality of life of patients undergoing radical prostatectomy, even with the robotic-assisted technique.

OBJECTIVE

to assess the evolution of urinary symptoms from preoperative to 12 months after robotic-assisted radical prostatectomy.

METHODS

data was collected from 998 patients who underwent robotic-assisted radical prostatectomy. Demographic data, preoperative and postoperative information on patients were documented. The ICIQ and IPSS questionnaires were also applied preoperatively and after 1, 3, 6 and 12 months after the operation. Results: Out of 998 patients, 257 correctly completed all questionnaires. The mean age of the patients was 60 ± 0.74 years. We found that the total IPSS increased initially and at 6 months after the operation, it was already lower than the initial preoperative value (7.76 at 6 months vs. 9.90 preoperative, p <0.001), being that questions regarding voiding symptoms were the first to improve followed by the questions regarding post micturition and storage symptoms. As for the ICIQ variables, there was an increase with radical prostatectomy and none of them returned to the preoperative level (p<0.001).

CONCLUSIONS

robotic assisted radical prostatectomy causes, at first, a worsening of urinary symptoms in the lower tract with subsequent recovery. Recovery begins with voiding symptoms, followed by post micturition and storage symptoms. The symptoms assessed by the IPSS evolve to better parameters even than those of the preoperative period, while the symptoms of incontinence assessed by the ICIQ do not reach the preoperative levels in the studied interval.

Review of the use of prophylactic drain tubes post‐robotic radical prostatectomy: Dogma or decent practice?

Objective

To assess the necessity of routine prophylactic drain tube use following robot‐assisted radical prostatectomy (RARP).

Method

We performed a literature review using the Medline, Scopus, and Web of Science databases with no restriction of language from January 1900 to January 2020. The following terms we used in the literature search: prostatectomy, radical prostatectomy, robot assisted, drainage, and drain tube.

Results

We identified six studies that examined the use of routine prophylactic drain tubes following RARP. One of these studies was a randomized study that included 189 patients, with 97 in the pelvic drain (PD) arm and 92 in the no pelvic drain (ND) arm. This non‐inferiority showed an early (90‐day) complication rate of 17.4% in the ND arm versus 26.8% in the PD arm (P < .001). Another non‐inferiority randomized control trial (RCT) showed a complication rate of 28.9% in the PD group versus 20.4% in the ND group (P = .254). Similarly, the other studies found no benefit of routine use of prophylactic drain tube after RARP.

Conclusion

Drain tubes play a role during robotic‐assisted radical prostatectomy, however, following a review of the current available literature, they can be safely omitted and we suggest that clinicians may be selective in their use.

Variation in the utilization of robotic surgical operations

The appropriate use of the robot in surgery continues to evolve. Robotic operations (RO) are particularly advantageous for deep pelvic and retroperitoneal procedures, but the implementation of RO is unknown. We aimed to examine regional variation for the most commonly performed RO in general, gynecologic, and urologic surgery. A three-state inpatient database from 2008 to 2011 was used. Nine common robotic inpatient general, gynecologic and urologic surgery procedures were analyzed. States were divided into hospital service areas (HSAs). The percentage of RO was calculated for each operation. Hospital service areas that had < 50% or > 150% of the RO average were outliers. Hospital service areas were compared based on demographics, patterns of adoption, variation in usage, and association with population, physician and hospital density. Hysterectomies were the procedure that was performed most often robotically. Over 50% of radical prostatectomies were performed robotically. Procedures with the highest rate of RO performance were performed with the least variation. Characteristics that were significantly correlated with RO included provider and hospital density. Variation in the utilization of RO is common and differs by operation. Physician density impacts access to care and is associated with the variation in use of RO depending on procedure type. Further research is needed to understand the causes of variation and adoption of RO.

A comparison of perioperative outcome between robot-assisted and laparoscopic radical prostatectomy: experience of a single institution

PURPOSE

To compare perioperative and pathological results in different approaches of robotic or laparoscopic radical prostatectomy.

MATERIALS AND METHODS

We retrospectively reviewed 206 patients diagnosed with pros¬tate cancer (PC) from June 2016 to October 2017 in the First Affiliated Hospital of Nan¬jing Medical University. A total of 132 cases underwent robot-assisted laparoscopic radical prostatectomy (RLRP) including 54 patients on transperitoneal robot-assisted laparoscopic radical prostatectomy (Tp-RLRP) and 78 on extraperitoneal robot-assisted laparoscopic radical prostatectomy (Ep-RLRP). Meanwhile, 74 patients performed with extraperitoneal laparoscopic radical prostatectomy (Ep-LPR) were also included. Peri¬operative and pathological data were compared among these groups.

RESULTS

All operations were completed without conversion. There was no signifi¬cant difference in basic and pathological characteristics of patients between each two groups. In Tp-RLRP vs. Ep-RLRP: Significant differences were found in the comparison in to¬tal operation time [235.98 ± 59.16 vs. 180.45 ± 50.27 min, P = 0.00], estimated blood loss (EBL) [399.07 ± 519.57 vs. 254.49 ± 308.05 mL, P = 0.0473], postoperative pelvic drainage time [5.37 ± 2.33 vs. 4.24 ± 3.08 d, P = 0.0237] and postoperative length of stay [8.15 ± 3.30 vs. 6.49 ± 3.49 d, P = 0.0068] while no significant differences were detected in other variables. In Ep-RLRP vs. Ep-LPR: Longer total operation time was observed in Ep-RLRP when compared to Ep-LPR [180.45 ± 50.27 vs. 143.80 ± 33.13 min, P = 0.000]. No significant differences were observed in other variables.

CONCLUSION

In RLRP, Ep-RLRP was proved a safe and effective approach based on the perioperative results compared to Tp-RLRP. Ep-RLRP and Ep-LPR provides equivalent perioperative and pathological outcomes.

Changes of Cerebral Blood Volume During Robot-Assisted Laparoscopic Radical Prostatectomy: Observational Prospective Study Using Near-Infrared Time-Resolved Spectroscopy

Purpose: Robot-assisted laparoscopic radical prostatectomy (RARP) requires a steep head-down tilt and pneumoperitoneum, which may cause an increase in cerebral blood volume (CBV). With a new near-infrared time-resolved spectroscopy device, the tNIRS-1, we can measure the absolute value of the cerebral hemoglobin concentration and hence calculate CBV and cerebral oxygen saturation (rSO₂). Using this device, we evaluated the time course of CBV during surgery and also evaluated the changes in rSO₂ simultaneously. Materials and Methods: We performed a prospective observational study of 21 patients scheduled for RARP. We evaluated CBV and rSO₂ by using the tNIRS-1 at 10 time points during surgery. Results: The CBV was 2.92 ± 0.38 mL ·100 g^-1 after the end of anesthetic preparation. It significantly increased to 3.05 ± 0.44 mL ·100 g^-1 after the head-down tilt and was around 3.1 mL ·100 g^-1 until 120 minutes after the head-down tilt. However, just before the return to the horizontal position, it decreased to 2.93 ± 0.46 mL ·100 g^-1 and then decreased more after the return to the horizontal position. Changes in rSO₂ over time were within only 3%, and no significant differences from the control value were observed. Conclusions: The increase in CBV was <10% despite the steep head-down tilt and pneumoperitoneum, and it was compensated for at around the end of surgery. Clinically significant changes in rSO₂ were not observed during the surgery.

Robotic radical prostatectomy in 93 cases: Outcomes of the first ERUS robotic urology curriculum trained surgeon in Turkey

OBJECTIVE

This study presents the surgical, oncological, and functional outcomes of the first 93 robotic radical prostatectomy (RARP) procedures performed in Erzurum, Turkey. These procedures were performed by a single surgeon who had completed the European Association of Urology Robotic Urology Section (ERUS) RARP curriculum in an ERUS-certified training center in Ankara.

MATERIAL AND METHODS

The study present the results of 93 RARP procedures performed by a single surgeon. The surgeon performing the operations completed an ERUS training program structured for RARP by two robotic surgeons holding ERUS training certificates in an ERUS-approved academic robotic surgery training center in Ankara. The RARP cases performed by the surgeon after completion of the training between April 2016 and August 2018 were retrospectively evaluated.

RESULTS

The mean patient age was 63.62±7.04 years, and the mean preoperative serum prostate-specific antigen level was 8.34±4.96 ng/mL. Preoperatively, 82 and 4 patients had prostate biopsy Gleason scores of 3+3 and 4+3, respectively. Bilateral neurovascular bundle (NVB) sparing, unilateral NVB-sparing, and non-NVB-sparing surgery were performed in 21, 13, and 59 cases, respectively. The mean prostate weight was 85.34±47.57 g. Posterior rhabdosphincter reconstruction was performed in 60 (64.5%) cases. Mean console time, intraoperative blood loss, duration of hospital stay, and urethral catheter removal time were 170.49±36.50 min, 100.70±34.08 cc, 6.84±2.28 days, and 7.40±3.11 days, respectively. During the perioperative period (0-30 days), five minor (prolonged drain output, n=3; rectocele, n=1; gout arthritis, n=1) and six major (inguinal hernia, n=1; incisional hernia, n=2; anastomotic urinary leakage, n=2; myocardial infarction, n=1) complications were identified. No complication was detected during postoperative days 31-90. Postoperative pathological stages included pT2a, pT2b, and pT2c disease in 77 (82.8%), 9 (9.7%), and 7 (7.5%) patients, respectively. The positive surgical margin (SM) rate was 10.7% (n=10), including patients with pT2a (n=6) and pT2c (n=2) diseases. Eleven (11.8%) patients underwent pelvic lymph node (LN) dissection. The mean LN yield was 16.45±4.29. The mean length of follow-up was 11.17±8.01 months. Biochemical recurrence was observed in two patients, one of whom received maximal androgen blockage (MAB), and the other one received pelvic radiotherapy+MAB. All the patients with at least one-year follow-up (n=48, 51.6%) were fully continent (0 pads/day). Of the 40 (43%) patients with no preoperative erectile dysfunction (ED) and with at least three-month follow-up, 18 (45%) had no ED, with or without any additional medication including phosphodiesterase-5 (PDE5) inhibitors.

CONCLUSION

RARP is a safe minimally invasive procedure with acceptable morbidity, excellent operative, pathological and oncological outcomes, and satisfactory functional results. The ERUS RARP curriculum provides effective and sufficient training.

Propofol attenuates the increase of sonographic optic nerve sheath diameter during robot-assisted laparoscopic prostatectomy: a randomized clinical trial

Background

Robot-assisted laparoscopic prostatectomy (RALP) requires pneumoperitoneum and the Trendelenburg position to optimize surgical exposure, which can increase intracranial pressure (ICP). Anesthetic agents also influence ICP. We compared the effects of propofol and sevoflurane on sonographic optic nerve sheath diameter (ONSD) as a surrogate for ICP in prostate cancer patients who underwent RALP.

Methods

Thirty-six patients were randomly allocated to groups receiving propofol (propofol group, n = 18) or sevoflurane (sevoflurane group, n = 18) anesthesia. The ONSD was measured 10 min after induction of anesthesia in the supine position (T1); 5 min (T2), 30 min (T3), and 60 min (T4) after establishing pneumoperitoneum and the Trendelenburg position; and at the end of surgery after desufflation in the supine position (T5). Respiratory and hemodynamic variables were also evaluated.

Results

The ONSD was significantly different between the propofol group and the sevoflurane group at T4 (5.27 ± 0.35 mm vs. 5.57 ± 0.28 mm, P = 0.007), but not at other time points. The ONSDs at T2, T3, T4, and T5 were significantly greater than at T1 in both groups (all P < 0.001). Arterial carbon dioxide partial pressure, arterial oxygen partial pressure, peak airway pressure, plateau airway pressure, systolic blood pressure, pulse pressure variation, body temperature and regional cerebral oxygen saturation, except heart rate, were not significantly different between the two groups.

Conclusions

The ONSD was significantly lower during propofol anesthesia than during sevoflurane anesthesia 60 min after pneumoperitoneum and the Trendelenburg position, suggesting that propofol anesthesia may help minimize ICP changes in robotic prostatectomy patients.

Trial registration

Clinicaltrials.gov identifier: NCT03271502. Registered August 31, 2017.

Effect of Mannitol on Ultrasonographically Measured Optic Nerve Sheath Diameter as a Surrogate for Intracranial Pressure During Robot-Assisted Laparoscopic Prostatectomy with Pneumoperitoneum and the Trendelenburg Position

INTRODUCTION

CO₂ pneumoperitoneum and the steep Trendelenburg position during robot-assisted laparoscopic prostatectomy (RALP) can increase intracranial pressure (ICP). Mannitol is widely used to treat increased ICP. However, no studies to date have specifically evaluated the effect of mannitol on ICP in patients undergoing RALP. Ultrasonographic measurement of the optic nerve sheath diameter (ONSD) is considered a reliable technique to noninvasively evaluate the ICP. Therefore, this study compared ONSDs as a surrogate for ICP before and after mannitol administration in prostate cancer patients undergoing RALP.

METHODS

Mannitol (0.5 g/kg) was administered after pneumoperitoneum establishment and shifting to the Trendelenburg position. ONSDs were measured at six predetermined time points: 10 minutes after anesthesia induction (T0); 5 minutes after pneumoperitoneum and the Trendelenburg position before mannitol administration (T1); 30 minutes (T2), 60 minutes (T3), and 90 minutes (T4) after completion of mannitol administration during pneumoperitoneum and the Trendelenburg position; and at skin closure in the supine position (T5). Moreover, intraoperative hemodynamic and respiratory variables were evaluated simultaneously.

RESULTS

Thirty-six patients were analyzed. ONSDs were significantly lower at T2, T3, and T4 than at T1 (all p < 0.001), with the greatest decrease observed at T4 compared with T1 (4.46 ± 0.2 mm vs 4.81 ± 0.3 mm, p < 0.001). Regional cerebral oxygen saturation, cardiac output, corrected flow time, peak velocity, body temperature, arterial CO₂ partial pressure, peak airway pressure, plateau airway pressure, dynamic compliance, and static compliance were not significantly different during pneumoperitoneum and the Trendelenburg position; however, mean arterial blood pressure and heart rate were significantly different.

CONCLUSIONS

Mannitol decreases the ONSD in patients undergoing RALP with CO₂ pneumoperitoneum and the steep Trendelenburg position. This result provides useful information on the beneficial effects of mannitol administration on prostate cancer patients who may develop increased ICP during RALP.

Anaesthetic issues in robotic-assisted minimally invasive surgery

Over the past decade there has been an exponential increase in the number of robotic-assisted surgical procedures performed in Australia and internationally. Despite this growth, there are no level I or II studies examining the anaesthetic implications of these procedures. Available observational studies provide insight into the significant challenges for the anaesthetist. Most anaesthetic considerations overlap with those of non-robotic surgery. However, issues with limited patient access and extremes of positioning resulting in physiological disturbances and risk of injury are consistently demonstrated concerns specific to robotic-assisted procedures.

Treatment Availability Influences Physicians' Portrayal of Robotic Surgery During Clinical Appointments

In order to empower patients as decision makers, physicians must educate them about their treatment options in a factual, nonbiased manner. We propose that site-specific availability of treatment options may be a novel source of bias, whereby physicians describe treatments more positively when they are available. We performed a content analysis of physicians' descriptions of robotic prostatectomy within 252 appointments at four Veterans Affairs medical centers where robotic surgery was either available or unavailable. We coded how physicians portrayed robotic versus open prostatectomy across specific clinical categories and in the appointment overall. We found that physicians were more likely to describe robotic prostatectomy as superior when it was available [F(1, 42) = 8.65, p = .005]. We also provide initial qualitative evidence that physicians may be shaping their descriptions of robotic prostatectomy in an effort to manage patients' emotions and demand for the robotic technology. To our knowledge, this is the first study to provide empirical evidence that treatment availability influences how physicians describe the advantages and disadvantages of treatment alternatives to patients during clinical encounters, which has important practical implications for patient empowerment and patient satisfaction.

Standardized 4-step technique of bladder neck dissection during robot-assisted radical prostatectomy

Bladder neck (BN) dissection is considered one of the most challenging steps during robot-assisted radical prostatectomy. Better understanding of the BN anatomy, coupled with a standardized approach may facilitate dissection while minimizing complications. We describe in this article the 4 anatomic spaces during standardized BN dissection, as well other technical maneuvers of managing difficult scenarios including treatment of a large median lobe or patients with previous transurethral resection of the prostate. The first step involves the proper identification of the BN followed by slow horizontal dissection of the first layer (the dorsal venous complex and perivesicle fat). The second step proceeds with reconfirming the location of the BN followed by midline dissection of the second anatomical layer (the anterior bladder muscle and mucosa) using the tip of the monopolar scissor until the catheter is identified. The deflated catheter is then grasped by the assistant to apply upward traction on the prostate from 2 directions along with downward traction on the posterior bladder wall by the tip of the suction instrument. This triangulation allows easier, and safer visual, layer by layer, dissection of the third BN layer (the posterior bladder mucosa and muscle wall). The forth step is next performed by blunt puncture of the fourth layer (the retrotrigonal fascia) aiming to enter into the previously dissected seminal vesical space. Finally, both vas deferens and seminal vesicles are pulled through the open BN and handed to the assistant for upper traction to initiate Denovillier's dissection and prostate pedicle/neurovascular bundle control.

Open versus robotic cystectomy: Comparison of outcomes

Open radical cystectomy (ORC) is the current gold standard treatment for muscle invasive bladder cancer. As surgeons become more proficient in minimally invasive and robotic surgical techniques, the number of patients undergoing robotic-assisted radical cystectomy (RARC) is increasing. Although minimally invasive methods are on the rise, research that critically compares open surgery with robotic methods is limited. In this review, we surveyed and appraised the current literature comparing ORC and RARC with regards to perioperative, functional, and oncologic outcomes in order to distinguish the benefits and disadvantages of each method. Here we report that RARC is associated with several perioperative advantages over ORC such as lower estimated blood loss and transfusion rate, and possibly faster gastrointestinal recovery, lower narcotic requirement, and shorter length of stay. ORC is less costly and permits less time in the operating room. Recent data suggests that there is no difference between ORC and RARC when comparing urinary continence and postoperative quality of life. Moreover, ORC and RARC are both associated with similar rates of obtaining positive surgical margins, lymph node yield, and recurrence. However, RARC patients had an increased likelihood of having distant metastases to extrapelvic lymph nodes and the peritoneum. At this point, it is unclear if ORC or RARC has superior patient outcomes, and more research is needed to ascertain management-altering conclusions.

Feasibility of planned mini-laparotomy and adhesiolysis at the time of robotic-assisted radical prostatectomy in patients with prior major abdominal surgery

INTRODUCTION

Our aim was to report our experience on the feasibility of completing radical prostatectomy robotically after planned open adhesiolysis for prior major abdominal surgery with previous midline laparotomy scar.

METHODS

We searched our prospectively collected database of robotic assisted-radical prostatectomy (RARP) performed between October 2006 and October 2012 by a single fellowship-trained surgeon to identify all patients who underwent planned initial mini-laparotomy for release of abdominal adhesions at time of RARP. Among 250 RARP patients, five patients fulfilled these criteria.

RESULTS

All patients had prostatectomy completed robotically. The mean values of patients' demographics were as follows: Age 61.8 years (range 54-69), body mass index 30.7 (range 24.3-45.3), and prostate volume 41.5 ml (range 30.8-54). Mean operative time was 245 min (range 190-280) and estimated blood loss 410 ml (range 300-650). Median hospital stay was one day (range 1-7). Postoperatively, there was one prolonged ileus, which resolved spontaneously, and one myocardial infarction.

CONCLUSIONS

Robotic completion of radical prostatectomy after open adhesiolysis is feasible. This approach maintains most minimally invasive advantages of RARP, despite a slightly longer hospital stay. In the best interest of patients, robotic surgeons are encouraged to finish the case robotically rather than attempting an open approach.

Most common robotic bariatric procedures: review and technical aspects

Since its appear in the year 1997, when Drs. Cadiere and Himpens did the first robotic cholecystectomy in Brussels, not long after the first cholecystectomy, they performed the first robotic bariatric procedure. It is believed that robotically-assisted surgery’s most notable contributions are reflected in its ability to extend the benefits of minimally invasive surgery to procedures not routinely performed using minimal access techniques. We describe the 3 most common bariatric procedures done by robot. The main advantages of the robotic system applied to the gastric bypass appear to be better control of stoma size, avoidance of stapler costs, elimination of the potential for oropharyngeal and esophageal trauma, and a potential decrease in wound infection. While in the sleeve gastrectomy and adjustable gastric banding its utility is more debatable, giving a bigger advantage during surgery on patients with a very large BMI or revisional cases.

Health-related quality of life in robotic versus open radical prostatectomy

INTRODUCTION

It is unclear whether health-related quality of life (HRQoL) outcomes are superior in robot-assisted radical prostatectomy (RARP) compared to open prostatectomy (ORP).

METHODS

We retrospectively analyzed records from men who received ORP or RARP at our institution between January 2009 and December 2012. Patients completed a demographics questionnaire and the Patient-Oriented Prostate Utility Scale (PORPUS), a validated disease-specific HRQoL instrument prior to surgery and every 3 months up to 15 months after surgery.

RESULTS

In total, 974 men met the inclusion criteria (643 ORP and 331 RARP patients). At baseline, RARP patients were significantly younger (p < 0.001), had lower body mass index (BMI) (p < 0.001), lower preoperative prostate-specific antigen (PSA) (p < 0.001), fewer comorbidities (p < 0.004), and higher baseline PORPUS scores (p = 0.024). On follow-up, unadjusted PORPUS scores were significantly higher in the RARP group at each point. On multivariable analysis adjusting for age, ORP versus RARP procedure, Gleason score, BMI, first PSA, comorbidity, ethnicity, and baseline PORPUS scores, PORPUS score was higher for the RARP group at 3 months (p = 0.038) and 9 months (p = 0.037), but not at 6, 12, and 15 months (p = 0.014). No difference met pre-defined thresholds of clinical significant.

CONCLUSIONS

Though unadjusted HRQoL outcomes appeared improved with RARP compared to ORP differences, adjusted differences were seen at only 2 of 5 postoperative time points, and did not meet pre-defined thresholds of clinical significance. Further randomized trials are needed to assess whether one treatment option provides consistently better HRQoL outcomes.

Disparities in the receipt of robot-assisted radical prostatectomy: between-hospital and within-hospital analysis using 2009-2011 California inpatient data

OBJECTIVES

Despite the rapid proliferation of robot-assisted radical prostatectomy (RARP), little attention has been paid to patient utilisation of this newest surgical innovation and barriers that may result in disparities in access to RARP. The goal of this study is to identify demographic and economic factors that decrease the likelihood of patients with prostate cancer (PC) receiving RARP.

DESIGN, SETTING AND PARTICIPANTS

A retrospective, pooled, cross-sectional study was conducted using 2009-2011 California State Inpatient Data and American Hospital Association data. Patients who were diagnosed with PC and underwent radical prostatectomy (RP) from 225 hospitals in California were identified, using ICD-9-CM diagnosis and procedure codes.

PRIMARY OUTCOME MEASURES

Patients' likelihood of receiving RARP was associated with patient and hospital characteristics using the two models: (1) between-hospital and (2) within-hospital models. Multivariate binomial logistic regression was used for both models. The first model predicted patient access to RARP-performing hospitals versus non-RARP-performing hospitals, after adjusting for patient and hospital-level covariates (between-hospital variation). The second model examined the likelihood of patients receiving RARP within RARP-performing hospitals (within-hospital variation).

RESULTS

Among 20,411 patients who received RP, 13,750 (67.4%) received RARP, while 6661 (32.6%) received non-RARP. This study found significant differences in access to RARP-performing hospitals when race/ethnicity, income and insurance status were compared, after controlling for selected confounding factors (all p<0.001). For example, Hispanic, Medicare and Medicaid patients were more likely to be treated at non-RARP-performing hospitals versus RARP-performing hospitals. Within RARP-performing hospitals, Medicaid patients had 58% lower odds of receiving RARP versus non-RARP (adjusted OR 0.42, p<0.001). However, there were no significant differences by race/ethnicity or income within RARP-performing hospitals.

CONCLUSIONS

Significant differences exist by race/ethnicity and payer status in accessing RARP-performing hospitals. Furthermore, payer status continues to be an important predictor of receiving RARP within RARP-performing hospitals.

Pentafecta outcomes after robot-assisted laparoscopic radical prostatectomy: first 100 cases in Latinoamerican Hospital

OBJECTIVE

Radical prostatectomy (RP) is the standard treatment for cancer control in the long term. The rise of minimally invasive surgery and new technologies have yielded better results and enabled us to pursue more ambitious objectives. The main works still use the trifecta as classic presentation, but this does not cover all aspects of surgery. Pentafecta is a new and more comprehensive methodology to report outcomes after RP, including complications and surgical margin status with the three major outcomes classically reported. The purpose of this study is to report our experience with robot-assisted laparoscopic radical prostatectomy (RALRP) by applying the concept of pentafecta.

MATERIAL AND METHOD

Describe the experience in this institution from March 2009 to December 2012 of RALRP by pentafecta.

RESULTS

We performed 101 interventions and obtained the following results: Average age 60.89 ± 7.32 years (40-77), total PSA 8.5 ± 5.57 ng/dl (0.2-29); D'Amico classification: Low 29 (28.71%), Medium 65 (64.36%), High 7 (6.93%); Operative time 253.44 ± 51.51 min (90-540), Complications 12.9% (Clavien I-II 10.89% and Clavien IIIa 1.98%); Positive surgical margins 20.83%; Biochemistry recurrence 12.5% follow-up (6-44 months); and Continence 87.5% per year and Potency 59.52%.

CONCLUSIONS

RALRP is a safe and reproducible procedure with excellent results in terms of pentafecta, inclusive during the initial experience at a low volumen center for prostate cancer. A longer follow-up study and experience with higher volume of patients are required to obtain better results and data to be compared with excellence centers.

Robotic surgery in urological oncology: patient care or market share?

Surgical robotic use has grown exponentially in spite of limited or uncertain benefits and large costs. In certain situations, adoption of robotic technology provides value to patients and society. In other cases, however, the robot provides little or no increase in surgical quality, with increased expense, and, therefore, does not add value to health care. The surgical robot is expensive to purchase, maintain and operate, and can contribute to increased consumerism in relation to surgical procedures, and increased reliance on the technology, thus driving future increases in health-care expenditure. Given the current need for budget constraints, the cost-effectiveness of specific procedures must be evaluated. The surgical robot should be used when cost-effective, but traditional open and laparoscopic techniques also need to be continually fostered.

A multicomponent theory-based intervention improves uptake of pelvic floor muscle training before radical prostatectomy: a 'before and after' cohort study

OBJECTIVE

To assess the effect of a multicomponent theory-based intervention, incorporating patient information guides, an evidence summary, audit and feedback processes and a provider directory, in the provision/receipt of preoperative pelvic floor muscle training (PFMT) among patients undergoing radical prostatectomy.

SUBJECTS AND METHODS

Over an 18-month period (9 months before and 9 months after the intervention), we measured the provision/receipt of preoperative PFMT using surveys of patients undergoing radical prostatectomy at one public hospital (n = 32) and two private hospitals (n = 107) in Western Sydney, Australia, as well as practice audits of associated public sector (n = 4) and private sector (n = 2) providers of PFMT. Self-report urinary incontinence was assessed 3 months after radical prostatectomy using the International Consultation on Incontinence Questionnaire - Urinary Incontinence Form (ICIQ-UI Short Form).

RESULTS

There was a significant increase in the proportion of survey respondents receiving preoperative PFMT post-intervention (post-intervention: 42/58 respondents, 72% vs pre-intervention: 37/81 respondents, 46%, P = 0.002). There was a corresponding significant increase in provision of preoperative PFMT by private sector providers (mean [sd] post-intervention: 16.7 [3.7] patients/month vs pre-intervention: 12.1 [3.6] patients/month, P = 0.018). Respondents receiving preoperative PFMT had significantly better self-report urinary incontinence at 3 months after radical prostatectomy than those who did not receive preoperative PFMT (mean [sd] ICIQ-UI Short Form sum-scores: 6.2 [5.0] vs 9.2 [5.8], P = 0.002).

CONCLUSIONS

The intervention increased the provision/receipt of preoperative PFMT among patients undergoing radical prostatectomy. Additional component strategies aimed at increasing the use of public sector providers may be necessary to further improve PFMT receipt among patients undergoing radical prostatectomy in the public hospital system.

Oncological and functional outcomes of 722 robot-assisted radical prostatectomy (RARP) cases: The largest Canadian 5-year experience

INTRODUCTION

While RARP (robotic-assisted radical prostatectomy) has become the predominant surgical approach to treat localized prostate cancer, there is little Canadian data on its oncological and functional outcomes. We describe the largest RARP experience in Canada.

METHODS

Data from 722 patients who underwent RARP performed by 7 surgeons (AEH performed 288, TH 69, JBL 23, SB 17, HW 15, QT 7, and KCZ 303 patients) were collected prospectively from October 2006 to December 2013. Preoperative characteristics, as well as postoperative surgical and pathological outcomes, were collected. Functional and oncological outcomes were also assessed up to 72 months postoperative.

RESULTS

The median follow-up (Q1-Q3) was 18 months (9-36). The D'Amico risk stratification distribution was 31% low, 58% intermediate and 11% high-risk. The median operative time was 178 minutes (142-205), blood loss was 200 mL (150-300) and the postoperative hospital stay was 1 day (1-23). The transfusion rate was only 1.0%. There were 0.7% major (Clavien III-IV) and 10.1% minor (Clavien I-II) postoperative complications, with no mortality. Pathologically, 445 men (70%) were stage pT2, of which 81 (18%) had a positive surgical margin (PSM). In addition, 189 patients (30%) were stage pT3 and 87 (46%) with PSM. Urinary continence (0-pads/day) returned at 3, 6, and 12 months for 68%, 80%, and 90% of patients, respectively. Overall, the potency rates (successful penetration) for all men at 6, 12, and 24 months were 37%, 52%, and 59%, respectively. Biochemical recurrence was observed in 28 patients (4.9%), and 14 patients (2.4%) were referred for early salvage radiotherapy. In total, 49 patients (8.4%) underwent radio-therapy and/or hormonal therapy.

CONCLUSIONS

This study shows similar results compared to other high-volume RARP programs. Being the largest RARP experience in Canada, we report that RARP is safe with acceptable oncologic outcomes in a Canadian setting.

Retrograde robotic radical prostatectomy: description of a new technique and early perioperative outcomes

Objectives. This research was conducted to describe a novel technique for performing robotic-assisted laparoscopic prostatectomy (RALP) using a retrograde approach that mimics the classic open surgical technique. Methods. From June 2009 to March 2011, we performed 18 nonconsecutive RALPs using a novel retrograde approach. Patients were initially selected with D'Amico low to intermediate risk disease. Pre-, intra-, and postoperative data were analyzed in all patients. Results. All 18 patients had successful surgery without any intraoperative complications. Mean preoperative PSA was 6.0 ng/mL. Nine patients had biopsy Gleason score (GS) 6, seven patients had GS 7, and two patients had GS 8. Fourteen patients had clinical stage T1c and four patients had stage T2a. Mean operative time was 198 minutes, with a mean robotic console time of 168 minutes. Fifteen patients had T2 disease on the final pathology and three had T3 disease. With a median follow-up of 11 months, 10 patients had an undetectable PSA. Conclusions. Our early experience with retrograde robotic-assisted laparoscopic prostatectomy demonstrates the feasibility of this approach with early outcomes comparable to the contemporary antegrade approach. Long-term study with a greater number of patients will be necessary to fully evaluate the oncologic and functional outcomes using this technique.

Matched comparison of outcomes following open and minimally invasive radical prostatectomy for high-risk patients

PURPOSE

Comparative data related to the use of open and minimally invasive surgical approaches for the treatment of high-risk prostate cancer (PCa) remain limited. We determined outcomes of open radical prostatectomy (RRP), laparoscopic RP (LRP), and robot-assisted RP (RARP) in matched cohorts of patients with high-risk prostate cancer.

MATERIALS AND METHODS

A total of 805 patients with high-risk PCa [prostate-specific antigen (PSA) >20 ng/mL, Gleason score ≥8, or clinical stage ≥cT2c] were identified. A total of 407 RRP cases were propensity score (PS) matched 1:1 to 398 LRP or RARP cases to yield 3 cohorts (RARP, LRP, and RRP) of 110 patients each for analysis. PS matching variables included the following: age, clinical stage, preoperative PSA, biopsy Gleason score, surgeon experience, and nerve-sparing technique. Overall survival (OS) and recurrence-free survival (RFS) were compared with log-rank test. RFS predictor analysis was calculated within Cox regression models.

RESULTS

Pathological Gleason scores <7, =7, and >7 were found in 3.3, 50.9, and 45.8 % of patients. There were no statistically significant differences for pathological stage and positive surgical margins between surgical techniques. Mean 3-year RFS was 41.4, 77.9, and 54.1 %, for RARP, LRP, and RRP, respectively (p < 0.0001 for RARP vs. LRP). There were no significant differences for mean estimated 3-year OS for patients treated with RARP, LRP, or RRP (95.4, 98.1, and 100 %).

CONCLUSIONS

RARP demonstrated similar oncologic outcomes compared to RRP and LRP in a PS-matched cohort of patients with high-risk prostate cancer.

First report: Robotic pelvic exenteration for locally advanced rectal cancer

AIM

The aim of this study was to present the feasibility and surgical outcome of robotic en bloc resection of the rectum and with prostate and seminal vesicle invaded by rectal cancer.

METHOD

The details of three consecutive cases involving male patients in their forties, with locally invasive low rectal cancers are presented. The da Vinci robotic system was used by experienced colorectal and urological surgeons to perform en bloc resection of the rectum, prostate and seminal vesicles.

RESULTS

In the first case, coloanal and vesico-urethral anastomoses were performed, and the second included an end colostomy and vesico-urethral anastomosis. The bladder and bulbar urethra were also removed en bloc in the third case, with robotic intracorporeal ileal conduit formation and end colostomy. There was no major complication postoperatively. In the second patient there was a minor leakage at the vesico-urethral anastomosis. The third was readmitted the following week with a urinary infection which settled with intravenous antibiotics. In the first case, the circumferential resection margin was microscopically positive but the patient is currently free of recurrence after 14 months. In the second and third cases, all margins were clear.

CONCLUSION

This the first report of the use of the da Vinci robotic system for pelvic exenteration in patients with locally advanced rectal cancer invading the prostate and seminal vesicles. The robot may have a potential role in selected patients requiring exenterative pelvic surgery particularly in men.

Ureteral injuries sustained during robot-assisted radical prostatectomy

BACKGROUND AND PURPOSE

During the last decade, the annual volume of robot-assisted prostatectomies performed in the United States has risen steadily. Refinements in surgical technique, understanding of anatomy, and experience have led to more complex patients being offered surgery for management of organ-confined prostate cancer. Complication rates of robot-assisted prostatectomy have been reported in several articles; however, a paucity of data exists when evaluating ureteral injuries sustained during robot-assisted prostatectomy. No standardized universal criteria for reporting and grading of complications exists; therefore, the Martin-Donat criteria with Clavien-Dindo classification system were used to evaluate ureteral injuries in our series.

PATIENTS AND METHODS

From January 2001 to June 2013, 6442 consecutive patients were treated with robot-assisted prostatectomy at the same institution by one of five surgeons. All complications were documented through a prospectively maintained prostate cancer database with supplementation from electronic medical records, operative and nursing notes, claims data, discharge summaries, outpatient and emergency visits, institutional morbidity and mortality data, as well as National Surgical Quality Improvement Program data. The Martin-Donat criteria were used to facilitate the accurate and comprehensive reporting of surgical complications while complication severity was assigned following the Clavien-Dindo classification system.

RESULTS

Three patients sustained ureteral injuries (ureteral transection) in our series. Both surgeons were beyond their learning curve (greater than 1000 cases) when the injuries occurred; one patient needed readmission, and all patients had risk factors predisposing them to ureteral injury. Each patient was managed with robot-assisted ureteroneocystostomy (1), open transureteroureterostomy (1) and robot-assisted ureteroureterostomy (1) respectively.

CONCLUSIONS

Ureteral injuries are uncommon; however, thorough preoperative evaluation and surgical planning could identify patients at high risk for sustaining ureteral injury during prostatectomy. Measures can be taken preoperatively or intraoperatively to reduce the probability of ureteral injury, eliminating the necessity for additional procedures postoperatively.

Preoperative factors predictive of posterolateral extracapsular extension after radical prostatectomy

Purpose

In radical prostatectomy (RP) procedures, sparing the neurovascular bundles adjacent to the posterolateral aspect of the prostatic fascia has often been suggested as a possible risk factor for positive surgical margins. Here we aimed to quantify the probability of extracapsular extension (ECE) at the posterolateral side of the prostate to aid in nerve-sparing decision making.

Materials and Methods

We evaluated 472 patients who underwent RP between July 2007 and January 2012. All patients underwent preoperative magnetic resonance imaging (MRI) with diffusion-weighted imaging and apparent diffusion coefficient mapping. We analyzed 944 side-specific prostate lobes with preoperative variables. To quantify the risk of side-specific posterolateral ECE after RP, we developed a risk-stratification scoring system through logistic regression analysis.

Results

Overall, 20.6% of 944 prostate lobes had ECE. In the multivariate analysis, prostate-specific antigen (PSA), biopsy Gleason score ≥7, percentage of side-specific cores with tumor, and posterolateral ECE on MRI were independent predictive factors of posterolateral ECE. On internal and external validation to calculate the predicted risk, the Hosmer-Lemeshow goodness-of-fit test showed good calibration (p=0.396).

Conclusions

PSA, biopsy Gleason score, percentage of side-specific cores with tumor, and posterolateral ECE on MRI are independent predictors of posterolateral ECE. The scoring system derived from this study will provide objective parameters for use when deciding if the neurovascular bundle can be safely spared.

Perioperative, oncological and functional outcomes of the first robotic prostatectomy program in Quebec: Single fellowship-trained surgeon's experience of 250 cases

BACKGROUND

Robotic-assisted radical prostatectomy (RARP) is being increasingly done in Canada. Despite this, the Canadian literature lacks publications on the oncologic and functional outcomes of RARP. The objective of this study is to report the longest single surgeon experience in the province of Quebec.

METHODS

We collected prospective data from 250 consecutive patients who underwent RARP by a single fellowship trained surgeon (AEH) from October 2006 to October 2012. Mean follow-up was 28 months (range: 1-72). The D'Amico risk stratification distribution was 34% in low-risk, 48% in intermediate-risk and 18% in high-risk groups.

RESULTS

The mean operation time (±SD) was 194 ± 60.6 minutes, and estimated blood loss 318 ± 179 mL. The transfusion rate was only 0.4%. All procedures were completed robotically. The mean hospital stay was 1.2 days, and 88% of patients were discharged on postoperative day 1. The mean catheterization time was 7 days (range: 6-13). There were 2% major (Clavien III-IV) and 7.2% minor (Clavien I-II) postoperative complications, and no mortalities. On final pathology, 76% of patients were organ-confined and 70% specimen-confined. Pathological Gleason sum ≥7 accounted for 86%. Return of urinary continence (0-pads) at 3, 6, 12, and 24 months was 73.3%, 83.5%, 92.3%, 96.5%, respectively. Potency rate (successful penetration with or without medication) at 6, 12, and 24 months was 49.3%, 85%, and 95.3%, respectively. Operative time and positive surgical margin (PSM) in organ-con-fined disease (pT2) decreased significantly after 50 cases. Seventeen patients (6.8%) had no undetectable prostate-specific antigen (PSA) at first visit (PSA <0.1 ng/mL). Of remaining 233 patients, biochemical recurrence (PSA >0.2 ng/mL) was 4.7% (11 patients), and another 3.4% (8 patients) received early salvage radiotherapy (rising PSA, but <0.2 ng/mL). No patients with undetectable PSA required salvage treatments within 6 months postoperatively.

CONCLUSIONS

Our results compare favourably with high-volume RARP programs, despite mainly intermediate- to high-risk disease. Initial learning curve was estimated to be 50 cases. Fellowship training was instrumental in achieving adequate functional and oncological outcomes, while maintaining low complications rate.

Ultrasound elastography as a tool for imaging guidance during prostatectomy: initial experience

BACKGROUND

During laparoscopic or robotic assisted laparoscopic prostatectomy, the surgeon lacks tactile feedback which can help him tailor the size of the excision. Ultrasound elastography (USE) is an emerging imaging technology which maps the stiffness of tissue. In the paper we are evaluating USE as a palpation equivalent tool for intraoperative image guided robotic assisted laparoscopic prostatectomy.

MATERIAL/METHODS

Two studies were performed: 1) A laparoscopic ultrasound probe was used in a comparative study of manual palpation versus USE in detecting tumor surrogates in synthetic and ex-vivo tissue phantoms; N=25 participants (students) were asked to provide the presence, size and depth of these simulated lesions, and 2) A standard ultrasound probe was used for the evaluation of USE on ex-vivo human prostate specimens (N=10 lesions in N=6 specimens) to differentiate hard versus soft lesions with pathology correlation. Results were validated by pathology findings, and also by in-vivo and ex-vivo MR imaging correlation.

RESULTS

In the comparative study, USE displayed higher accuracy and specificity in tumor detection (sensitivity=84%, specificity=74%). Tumor diameters and depths were better estimated using USE versus with manual palpation. USE also proved consistent in identification of lesions in ex-vivo prostate specimens; hard and soft, malignant and benign, central and peripheral.

CONCLUSIONS

USE is a strong candidate for assisting surgeons by providing palpation equivalent evaluation of the tumor location, boundaries and extra-capsular extension. The results encourage us to pursue further testing in the robotic laparoscopic environment.

Robotic surgical skills: acquisition, maintenance, and degradation

In newly trained surgeons, this study found that robotic surgical skills degraded significantly within 4 weeks of inactivity. Animate training may provide different skills than those acquired in dry lab.

Background and Objectives:

The degradation in robotic skills that occurs during periods of robotic surgical inactivity in newly trained surgeons was measured. The role of animate training in robotic skill was also assessed.

Methods:

Robotically naïve resident and attending surgeons underwent training with the da Vinci® robot on needle passage (DN), rocking ring transfer peg board (RPB), and running suture pod tasks (SP). Errors were established to convert actual time to adjusted time. Participants were deemed “proficient” once their adjusted times were within 80% of those set by experienced surgeons through repeated trials. Participants did not use the robot except for repeating the tasks once at 4, 8, and 12 weeks (tests). Participants then underwent animate training and completed a final test within 7 days.

Results:

Twenty-five attending and 29 resident surgeons enrolled; 3 withdrew. There were significant increases in time to complete each of the tasks, and in errors, by 4 weeks (Adjusted times: DN: 122.9 ± 2.2 to 204.2 ± 11.7, t=6.9, P<.001; RPB: 262.4 ± 2.5 to 364.7 ± 8.0, t=12.4, P<.001; SP: 91.4 ± 1.4 to 169.9 ± 6.8, t=11.3, P<.001). Times decreased following animate training, but not to levels observed after proficiency training for the RPB and SP modules.

Conclusions:

Robotic surgical skills degrade significantly within 4 weeks of inactivity in newly trained surgeons. Animate training may provide different skills than those acquired in the dry lab.

Lymphocele after extraperitoneal robot-assisted radical prostatectomy: a propensity score-matching study

OBJECTIVES

To investigate the incidence of lymphocele and determine the risk factors for postoperative lymphocele after extraperitoneal robot-assisted radical prostatectomy by using propensity score-matching.

METHODS

A total of 483 patients underwent extraperitoneal robot-assisted radical prostatectomy for prostate cancer between January 2009 and August 2011. Of these, 200 patients underwent pelvic lymph node dissection during robot-assisted radical prostatectomy. All patients underwent magnetic resonance imaging or computed tomography postoperatively to detect lymphocele after robot-assisted radical prostatectomy. Propensity scores for an established control group were calculated for each patient using multivariate logistic regression based on the following covariates: age, body mass index, preoperative prostate-specific antigen level, prostate volume calculated by transrectal ultrasound, biopsy Gleason sum and clinical tumor stage.

RESULTS

Lymphocele was identified in 41 patients (20.5%). There were no statistical differences in variables used in propensity score-matching. Operation time, estimated blood loss, catheterization and surgical margin positivity did not show differences between the two groups. Seminal vesicle invasion (P = 0.015) and tumor volume (P = 0.042) between the two groups were significantly different. In the multivariate logistic regression model, extracapsular extension (P = 0.017, odds ratio 4.231), seminal vesicle invasion (P = 0.028, odds ratio 2.643) and the number of positive lymph nodes (P = 0.041, odds ratio 3.532) were independent risk factors for lymphocele development after extraperitoneal robot-assisted radical prostatectomy with pelvic lymph node dissection.

CONCLUSIONS

Lymphocele might preferentially develop in cases with seminal vesicle invasion and large tumor volume. Additionally, extracapsular extension, seminal vesicle invasion, and the number of positive lymph nodes are independent risk factors for postoperative lymphocele after extraperitoneal robot-assisted radical prostatectomy.

Robotic and open radical prostatectomy in the public health sector: cost comparison

BACKGROUND

During 2008, the Royal Brisbane and Women's Hospital became the first public hospital in Australia to have a da Vinci Surgical Robot purchased by government funding. The cost of performing robotic surgery in the public sector is a contentious issue. This study is a single centre, cost analysis comparing open radical prostatectomy (RRP) and robotic-assisted radical prostatectomy (RALP) based on the newly introduced pure case-mix funding model.

METHODS

A retrospective chart review was performed for the first 100 RALPs and the previous 100 RRPs. Estimates of tangible costing and funding were generated for each admission and readmission, using the Royal Brisbane Hospital Transition II database, based on pure case-mix funding.

RESULTS

The average cost for admission for RRP was A$13 605, compared to A$17 582 for the RALP. The average funding received for a RRP was A$11 781 compared to A$5496 for a RALP based on the newly introduced case-mix model. The average length of stay for RRP was 4.4 days (2-14) and for RALP, 1.2 days (1-4). The total cost of readmissions for RRP patients was A$70 487, compared to that of the RALP patients, A$7160. These were funded at A$55 639 and A$7624, respectively.

CONCLUSIONS

RALP has shown a significant advantage with respect to length of stay and readmission rate. Based on the case-mix funding model RALP is poorly funded compared to its open equivalent. Queensland Health needs to plan on how robotic surgery is implemented and assess whether this technology is truly affordable in the public sector.