Robotic-assisted Radical Prostatectomy Decreases the Incidence and Morbidity of Surgical Site Infections

The impact of minimally invasive surgical approaches on surgical-site infections

We performed a literature review to describe the risk of surgical-site infection (SSI) in minimally invasive surgery (MIS) compared to standard open surgery. Most studies reported decreased SSI rates among patients undergoing MIS compared to open procedures. However, many were observational studies and may have been affected by selection bias. MIS is associated with reduced risk of surgical-site infection compared to standard open surgery and should be considered when feasible.

Lower bleeding volume contributes to decreasing surgical site infection in radical cystectomy: A propensity score-matched comparison of open versus robot-assisted radical cystectomy

OBJECTIVES

To compare the incidence of surgical site infections (SSI) between robot-assisted and open radical cystectomies and investigate the risk factors for SSI after radical cystectomies.

METHODS

Consecutive patients who underwent radical cystectomy between July 2008 and December 2022 were retrospectively reviewed. The prevalence and characteristics of SSI after open and robot-assisted radical cystectomies were compared, and the risk factors for SSI were investigated using propensity score matching.

RESULTS

This study enrolled 231 patients (open: 145, robot-assisted: 86). In the robot-assisted group, urinary diversion was performed using an intracorporeal approach. SSI occurred in 34 (open: 28, robot-assisted: 6) patients, and the incidence was significantly lower in the robot-assisted group (19.3% vs. 7.0%, p = 0.007). After propensity score matching cohort (open: 34, robot-assisted: 34), increased bleeding volume, blood transfusion, and delayed postoperative oral feeding were significantly associated with SSI. Only increased bleeding volume remained a significant risk factor in the multivariate regression analysis (odds ratio, 1.13 [per 100 mL increase]; 95% confidence interval: 1.02-1.25; p = 0.001). The cutoff bleeding volume for predicting SSI was 1630 mL with an area under the receiver operating characteristic curve, sensitivity, and specificity of 0.773, 0.73, and 0.75, respectively.

CONCLUSIONS

The incidence of SSI after robot-assisted radical cystectomy was significantly lower than that after the open procedure. However, decreased bleeding volume, which was significantly associated with robot-assisted procedures, was an independent and more significant factor for reducing SSI after radical cystectomy than the differences of the surgical procedure even after propensity score matching.

Antimicrobial Prophylaxis in Robot-Assisted Laparoscopic Radical Prostatectomy: A Systematic Review

It remains unclear whether antibiotic prophylaxis (AP) should be recommended or discouraged in robot-assisted laparoscopic radical prostatectomy (RALP) for prostate cancer (PCa). The development of microbial resistance and side effects are risks of antibiotic use. This systematic review (SR) investigates the evidence base for AP in RALP. A systematic literature search was conducted until 12 January 2023, using Embase, MEDLINE, Cochrane CENTRAL, Cochrane CDSR (via Ovid) and CINAHL for studies reporting the effect of AP on postoperative infectious complications in RALP. Of 436 screened publications, 8 studies comprising 6378 RALP procedures met the inclusion criteria. There was no evidence of a difference in the rate and severity of infective complications within 30 days after RALP surgery between different AP protocols. No studies omitted AP. For patients who received AP, the overall occurrence of postoperative infectious complications varied between 0.6% and 6.6%. The reported urinary tract infection (UTI) rates varied from 0.16% (4/2500) to 8.9% (15/169). Wound infections were reported in 0.46% (4/865) to 1.12% (1/89). Sepsis/bacteraemia and hyperpyrexia were registered in 0.1% (1/1084) and 1.6% (5/317), respectively. Infected lymphoceles (iLC) rates were 0.9% (3 of 317) in a RALP cohort that included 88.6% pelvic lymph node dissections (PLND), and 3% (26 of 865) in a RALP cohort where all patients underwent PLND. Our findings underscore that AP is being administered in RALP procedures without scientifically proven evidence. Prospective studies that apply consistent and uniform criteria for measuring infectious complications and antibiotic-related side effects are needed to ensure the comparability of results and guidance on AP in RALP.

Evaluation of Surgical Site Infection in Mini-invasive Urological Surgery

Surgical Site Infection (SSI) is the most frequent source of infection in surgical patients and the second most frequent cause of hospital-acquired infection. The primary aim of this prospective study was to compare SSI occurrences between minimally invasive surgery (MIS) and open urological surgery. Secondly, perioperative outcomes were evaluated in two different approaches. A consecutive group of 60 patients undergoing urological surgery were prospectively enrolled in a single high-volume center between May and October 2018. We included procedures that were performed by minimally invasive or traditional techniques. We evaluated and compared the incidence of SSI and perioperative outcomes in terms of intraoperative bleeding, post-operative complications, postoperative pain, patient satisfaction with the analgesic treatment, time to flatus, time of oral intake and mobilization, and length of hospital stay. The two groups were homogeneous with regard to demographic data. Superficial incisional SSIs were diagnosed in 10% of cases (3/30) in the second group and 0% in the first (p<0.05); space/organ SSIs developed in 4 patients, which were diagnosed by ultrasound scan and confirmed by abdominal CT: 1 patient (3.3%) in group 1 showed an infected lymphocele, whereas 1 case of infected lymphocele and 2 cases of pelvic abscess were detected in group 2 (10%, p<0.05). All the perioperative outcomes as well as were overall complication rate favored MIS (p<0.05). The use of minimally invasive techniques in urological surgery reduced the risk of SSI by comparison with a traditional approach. In addition, MIS was associated with better perioperative outcomes and a lower overall complication rate.

Surgical site infections after radical prostatectomy: A comparative study between robot-assisted laparoscopic radical prostatectomy and retropubic radical prostatectomy

OBJECTIVE

Surgical site infection (SSI) is defined as infection at or near surgical incisions within 30 days of an operative procedure and classified either incisional superficial and deep or organ/space. The aim of the study is to report and compare the incidence and management of SSIs after robot-assisted laparoscopic radical prostatectomy (RALP) and retropubic radical prostatectomy (RRP).

MATERIAL AND METHODS

Within the last 4 years, we identified 285 patients that underwent RRP, n=187 (66%) or RALP, n=98 (34%). We reviewed the frequency, types and way of management of SSI complications.

RESULTS

A significant difference was found between RALP and RRP (2/98, 2% vs. 27/187, 14.4%; p<0.0001) as for SSIs. The time interval between the time of surgery and diagnosis of SSIs was longer in RALP relative to RRP (median 13.5 vs. 12.9 days, p=0.761).

CONCLUSION

All types of SSIs could be developed after RP, however RALP patients only experienced organ or space SSIs and have a lower rate of SSIs and shorter treatment time.

Long-term adverse effects after retropubic and robot-assisted radical prostatectomy. Nationwide, population-based study

BACKGROUND AND OBJECTIVES

Surgery for prostate cancer is associated with adverse effects. We studied long-term risk of adverse effects after retropubic (RRP) and robot-assisted radical prostatectomy (RARP).

METHODS

In the National Prostate Cancer Register of Sweden, men who had undergone radical prostatectomy (RP) between 2004 and 2014 were identified. Diagnoses and procedures indicating adverse postoperative effects were retrieved from the National Patient Register. Relative risk (RR) of adverse effects after RARP versus RRP was calculated in multivariable analyses adjusting for year of surgery, hospital surgical volume, T stage, Gleason grade, PSA level at diagnosis, patient age, comorbidity, and educational level.

RESULTS

A total of 11 212 men underwent RRP and 8500 RARP. Risk of anastomotic stricture was lower after RARP than RRP, RR for diagnoses 0.51 (95%CI = 0.42-0.63) and RR for procedures 0.46 (95%CI = 0.38-0.55). Risk of inguinal hernia was similar after RARP and RRP but risk of incisional hernia was higher after RARP, RR for diagnoses 1.48 (95%CI = 1.01-2.16), and RR for procedures 1.52 (95%CI = 1.02-2.26).

CONCLUSIONS

The postoperative risk profile for RARP and RRP was quite similar. However, risk of anastomotic stricture was lower and risk of incisional hernia higher after RARP.

Utilization of a novel valveless trocar system during robotic-assisted laparoscopic prostatectomy

PURPOSE

To evaluate the effect of a novel valveless trocar system (VTS) on perioperative outcomes in patients undergoing robotic-assisted laparoscopic prostatectomy (RALP).

METHODS

A single-institution retrospective review was performed of 792 patients undergoing RALP. Preoperative patient variables, tumor characteristics, and perioperative variables were collected and analyzed. The first 150 patients were excluded from analysis to account for the learning curve of robotic surgery. Univariate and multivariate linear regression models were used to assess factors affecting operative time (ORT).

RESULTS

A total of 257 and 385 patients underwent RALP utilizing the VTS and conventional insufflation, respectively. There were no significant differences in American Society of Anesthesiologist score, body mass index (BMI), prostate volume, final Gleason score, estimated blood loss, and complications between the cohorts. The only difference noted was a significantly shorter mean ORT in the VTS cohort (149.5 vs. 170.1 min, p < 0.0001). In light of this finding, further analysis was performed to identify associations with ORT. Multivariable analysis demonstrated that VTS, BMI, final Gleason score, prostate volume, surgeon, and node dissection were significantly associated with ORT. The use of the VTS decreased mean ORT by 23.2 min when controlling for confounding factors (p < 0.001). The performance of a nerve sparing operation was found to decrease ORT by 15.9 min (p < 0.001), though more often performed for lower-risk disease.

CONCLUSION

The use of a novel VTS demonstrated decreased ORT in patients undergoing RALP when controlling for confounding factors. Prospective randomized trials are needed to evaluate its ultimate benefit in various surgical cohorts.

Multidetector CT imaging of post-robot-assisted laparoscopic radical prostatectomy complications

Background

Robot-assisted laparoscopic radical prostatectomy (RALRP) is currently accepted as the preferred minimally invasive surgical treatment for localised prostate cancer, with optimal oncologic and functional results. Despite growing surgical experience, reduced postoperative morbidity and hospital stays, RALRP-related complications may occur, which are severe in 5–7 % of patients and sometimes require reoperation. Therefore, in hospitals with an active urologic surgery, urgent diagnostic imaging is increasingly requested to assess suspected early complications following RALRP surgery.

Methods

Based upon our experience, this pictorial review discusses basic principles of the surgical technique, the optimal multidetector CT (MDCT) techniques to be used in the postoperative urologic setting, the normal postoperative anatomy and imaging appearances.

Results

Afterwards, we review and illustrate the varied spectrum of RALRP-related complications including haemorrhage, urinary leaks, anorectal injuries, peritoneal changes, surgical site infections, abscess collections and lymphoceles, venous thrombosis and port site hernias.

Conclusion

Knowledge of surgical procedure details, appropriate MDCT acquisition techniques, and familiarity with normal postoperative imaging appearances and possible complications are needed to correctly perform and interpret early post-surgical imaging studies, particularly to identify those occurrences that require prolonged in-hospital treatment or surgical reintervention.

Teaching points

• Robot-assisted laparoscopic radical prostatectomy allows minimally invasive surgery of localised cancer

• Urologic surgeons may request urgent imaging to assess suspected postoperative complications

• Main complications include haemorrhage, urine leaks, anorectal injuries, infections and lymphoceles

• Correct multidetector CT techniques allow identifying haematomas, active bleeding and extravasated urine

• Imaging postoperative complications is crucial to assess the need for surgical reoperation

Comparison of postoperative infection between robotic-assisted laparoscopic prostatectomy and open radical prostatectomy

BACKGROUND

Robotic-assisted laparoscopic prostatectomy (RALP) has been rapidly adapted worldwide. The purpose of this study was to investigate postoperative infection (POI) after RALP and compare it with that after open radical prostatectomy (ORP).

METHODS

89 consecutive RALP cases and 105 recent ORP cases were enrolled. POIs were categorized according to CDC guideline criteria. Laboratory data relating to infection such as serum white blood cells (WBC) and C-reactive protein (CRP) were comparatively investigated before and after the surgeries. Data were collected and analyzed retrospectively.

RESULTS

There was one surgical site infection patient in the RALP cases (1/89, 1.12%). ORP cases had a comparatively higher ratio of POI (6/105, 4.77%), but the difference did not reach statistical significance (p = 0.0876). The postoperative rise of serum WBC (postoperative days 1 and 4) and CRP (postoperative days 1, 4 and 7) was significantly suppressed from pre-surgery data in RALP when compared to ORP.

CONCLUSIONS

RALP tended to have a lower rate of POI than ORP even though this change was not statistically significant and the postoperative rise of serum WBC and CRP was significantly suppressed in RALP compared to ORP. A prospective study with a standardized prophylactic antibiotic administration may be necessary for further evaluation of potential guidelines for RALP.

Predictors and costs of surgical site infections in patients with endometrial cancer

OBJECTIVE

Technological advances in surgical management of endometrial cancer (EC) may allow for novel risk modification in surgical site infection (SSI).

METHODS

Perioperative variables were abstracted from EC cases surgically staged between January 1, 1999, and December 31, 2008. Primary outcome was SSI, as defined by American College of Surgeons National Surgical Quality Improvement Program. Counseling and global models were built to assess perioperative predictors of superficial incisional SSI and organ/space SSI. Thirty-day cost of SSI was calculated.

RESULTS

Among 1369 EC patients, 136 (9.9%) had SSI. In the counseling model, significant predictors of superficial incisional SSI were obesity, American Society of Anesthesiologists (ASA) score >2, preoperative anemia (hematocrit <36%), and laparotomy. In the global model, significant predictors of superficial incisional SSI were obesity, ASA score >2, smoking, laparotomy, and intraoperative transfusion. Counseling model predictors of organ/space SSI were older age, smoking, preoperative glucose >110 mg/dL, and prior methicillin-resistant Staphylococcus aureus (MRSA) infection. Global predictors of organ/space SSI were older age, smoking, vascular disease, prior MRSA infection, greater estimated blood loss, and lymphadenectomy or bowel resection. SSI resulted in a $5447 median increase in 30-day cost.

CONCLUSIONS

Our findings are useful to individualize preoperative risk counseling. Hyperglycemia and smoking are modifiable, and minimally invasive surgical approaches should be the preferred surgical route because they decrease SSI events. Judicious use of lymphadenectomy may decrease SSI. Thirty-day postoperative costs are considerably increased when SSI occurs.