Laparoscopic radical prostatectomy: initial short-term experience

The impact of surgical technique on very early functional outcomes after radical prostatectomy

INTRODUCTION

To determine the very early functional as well as oncological outcomes after robot-assisted radical prostatectomy (RARP) and open radical prostatectomy (ORP) at a single institution.

METHODS

We identified patients who underwent RARP or ORP at our institution between August 2021 and July 2023. The main criterion for surgical technique selection was patient preference. Primary endpoints included anastomosis leakage rate, very early continence rate reported by standardized pad-test, and positive surgical margin rate. Furthermore, we analyzed operation time, hospital stay, postoperative analgesia, and complication rates.

RESULTS

In this prospective study, we analyzed data from 222 radical prostatectomies (111 RARP and 111 ORP). There were no significant differences in preoperative age, prostate size, and risk stratification among the groups. Patients who underwent RARP had lower anastomosis leakage rates (8.1% vs. 18.9%) and slightly lower early continence rates (76.6% vs. 78.4%) when compared to patients who underwent ORP. Positive surgical margin rates were similar, and complication rates were also comparable. Operation time was similar for both techniques, but the hospital stay was significantly shorter in the RARP group (6.3 vs. 9.1 days, p=0.03). The ORP group experienced significantly higher opioid administration postoperatively (p<0.001).

CONCLUSIONS

From a functional and oncological point of view, both techniques are safe and provide excellent outcomes when performed by experienced surgeons. Nevertheless, patients are likely to benefit from a shortened hospital stay and reduced postoperative pain after RARP.

Checking vesicourethral anastomosis for urinary extravasation during radical prostatectomy: is it still necessary in the robotic era? A prospective, randomized case-control study

PURPOSE

This study aims to evaluate the role of intraoperative control of the watertightness of vesicourethral anastomosis extravasation control (VUAEC) in predicting vesicourethral anastomosis (VUA) healing and early postoperative outcomes in patients undergoing robot-assisted radical prostatectomy (RARP).

METHODS

100 patients who underwent RARP between October 2020 and May 2023 were consecutively included in the study. Preoperatively, the patients were randomized to undergo VUAEC (Group-A) or not (Group-B). Patients in Group-A were evaluated in 2 subgroups: those with no extravasation observed during VUAEC (Group-A1; n = 31 (62%)) and those with extravasation (Group-A2; n = 19 (38%)). On the 8th post-operative day, a gravity cystogram (GC) was performed on all patients to assess VUA healing.

RESULTS

There was no statistically significant difference between the groups in terms of clinical features, drain removal time, length of hospital stay, extravasation on GC, catheter removal time and postoperative complications (p > 0.05, for each). There was also no statistically significant difference between the subgroups in terms of drain removal time, length of hospital stays, catheter removal time (p > 0.05, for each). In Group-A2, urinary extravasation on GC was found in a greater percentage, but the difference remained statistically insignificant (p = 0.082).

CONCLUSIONS

Performing intraoperative VUAEC did not have a significant role in the prediction of VUA healing and early postoperative outcomes in patients undergoing RARP. The current study did not identify a substantial clinical benefit of routine intraoperative VUAEC.

Intraoperative workload of the surgeon in robot-assisted radical prostatectomy: a systematic review

In the present study, we aimed to systematically evaluate the current evidence regarding the intraoperative workload of surgeons performing robot-assisted radical prostatectomy (RARP) for prostate cancer. A systematic search was carried out in the PubMed-MEDLINE and Web of Science databases through April 2024 using the following search terms: "workload AND robot assisted radical prostatectomy", "workload AND robotic radical prostatectomy", "task load AND robotic radical prostatectomy", "task load AND robot assisted radical prostatectomy" and "NASA-TLX AND robot assisted radical prostatectomy" by combining population, intervention, comparison, and outcome (PICO) terms, following preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. We therefore selected studies that included patients with prostate cancer (P) who underwent robotic radical prostatectomy (I) and reported a workload/task load questionnaire (C) to assess the intraoperative workload/task load of the surgeon performing robot-assisted radical prostatectomy (O). A total of 11 studies were identified. The surgeon's workload during RARP was assessed using the National Aeronautics and Space Administration task load index (NASA-TLX) and/or the surgery task load index (SURG-TLX) in the studies. Total NASA-TLX scores of the studies ranged from 22.7 ± 3.2 to 62.0 ± 6.4. Mental and physical demands, flow interruptions, surgeon experience, the use of single or multiple ports, and the relationship between the surgeon and other staff in the operating theater may play a role in the intraoperative workload of the console surgeon. The studies we reviewed suggest that RARP offers an acceptable workload for the console surgeon despite its mental demands.

Comparison of incidence of acute kidney injury after robot-assisted radical prostatectomy with that after open retropubic and extraperitoneal laparoscopic radical prostatectomies in patients with prostate cancer

Background

We retrospectively evaluated the postoperative renal function in patients who had undergone radical prostatectomy to compare the incidences of postoperative acute kidney injury (AKI) among the patients who had undergone robot-assisted radical prostatectomy (RARP), retropubic radical prostatectomy (RRP), and extraperitoneal laparoscopic radical prostatectomy (exLRP).

Materials and methods

Patients with prostate cancer who had undergone radical prostatectomy at our institution between 2008 and 2014 were included. Robot-assisted radical prostatectomy was performed using an intraperitoneal approach in a 25-degree Trendelenburg position, whereas other procedures were performed with the patient in the supine position. We evaluated the serum creatinine levels and estimated glomerular filtration rates immediately after surgery and on postoperative day 1. We evaluated the incidence of AKI after prostatectomy using the Acute Kidney Injury Network criteria of the Kidney Disease: Improving Global Outcomes guidelines.

Results

A total of 150 consecutive patients were included, with each of the 3 groups (RARP, RRP, and exLRP) comprising 50 patients. Postoperative AKI was observed in 15 (30.0%), 1 (2.0%), and 3 (6.0%) patients in the RARP, RRP, and exLRP groups, respectively. Stage 1 AKI was observed in all the patients except one. The incidence of AKI in RARP group was significantly higher than that in the other groups (p < 0.001). In the RARP group, the serum creatinine level was significantly elevated immediately after the surgery; however, it returned to baseline on postoperative day 1. Surgical procedures were the only independent factor associated with AKI incidence.

Conclusions

This study suggest that compared with RRP and exLRP, RARP is associated with a higher incidence of postoperative AKI, although most patients recover rapidly. Intra-abdominal pneumoperitoneum may contribute to AKI onset.

Comparison of perioperative and functional outcomes of single-incision versus standard multi-incision robot-assisted laparoscopic radical prostatectomy: a prospective, controlled, nonrandomized trial

To compare perioperative and functional outcomes between improved (port-free) single-site robot-assisted laparoscopic radical prostatectomy (pf-ssRARP) and standard multi-port robot-assisted radical prostatectomy (MPRARP). A total of 372 consecutive patients underwent RARAP using the da Vinci Si® robotic surgical system. Group I (n = 210) included patients undergoing pf-ssRARP and Group II (n = 162) included patients undergoing MPRARP. Demographics and perioperative data including postoperative recovery outcomes were recorded and compared between the two groups. Overall mean operative time was significantly shorter with the pf-ssRARP compared to the MPRARP (p < 0.05). The length of hospitalization after the pf-ssRARP was shorter (p < 0.05). In Group I, the positive surgical margin rate was 15.2%; while in Group II, the positive margin rate was 33.3% (p < 0.05). The rate of instant urinary continence was significantly higher in Group I than in Group II (p < 0.05). The percentage of urinary continence was higher in the pf-ssRARP than in the MPRARP, at 6 months post-surgery (p < 0.05) and 9 months post-surgery (p < 0.05). There was no significant difference in the proportion of erectile function in the pf-ssRARP and MPRARP groups at the time of reaching the endpoint of this study (p > 0.05). The two groups were comparable in terms of total hospitalization costs (p < 0.05). The improved (port-free) single-site robot-assisted laparoscopic radical prostatectomy is a practical and easy technique to implement in clinical practice. Extraperitoneal implementation of the modified technique requires only a small incision, no special PORT, no additional auxiliary foramen creation, increased postoperative aesthetics and reduced hospitalization costs, and a high percentage of early postoperative urinary control recovery.

Effects of laparoscopic radical prostatectomy on wound infection of surgery in patients with prostate cancer: A meta-analysis

This meta-analysis aims to comprehensively assess the impact of laparoscopic radical prostatectomy (LRP) on wound infection in patients with prostate cancer (PCa). A systematic search was conducted, from database inception to November 2023, in EMBASE, Google Scholar, Cochrane Library, PubMed, Wanfang and China National Knowledge Infrastructure databases for randomized controlled trials (RCTs) comparing LRP with open radical prostatectomy (ORP) in the treatment of PCa. Two researchers independently screened the literature, extracted data and conducted quality assessments based on pre-defined inclusion and exclusion criteria. Stata 17.0 software was employed for data analysis. Overall, 15 RCTs involving 1458 PCa patients were included. The analysis revealed the incidence of wound infection (odds ratio [OR] = 0.28, 95% confidence interval [CI] = 0.16-0.51, p < 0.001) and complications (OR = 0.27, 95% CI = 0.20-0.37, p < 0.001) was significantly lower in the LRP group compared to the ORP group. This study demonstrates that LRP in PCa patients can effectively reduce the incidence of wound infections and complications, indicating significant therapeutic efficacy and justifying its broader clinical application.

Evaluating the Oncological and Functional Outcomes in 167 Patients Undergoing Laparoscopic Radical Prostatectomy: Could Laparoscopy Still be a Viable Option in Suitable Patients?

Aim: To evaluate the oncological and functional outcomes of 167 patients who underwent laparoscopic radical prostatectomy (LRP). Materials and Methods: The retrospective study included 167 patients who were treated with LRP due to clinically localized prostate cancer between January 2007 and April 2012. Most of the patients were treated with the extraperitoneal approach. Preoperative evaluations included age, serum prostate-specific antigen (PSA) level, and biopsy Gleason score. Perioperative evaluations included duration of operative time and anastomosis time, blood loss (milliliter), and complications. Postoperative evaluations included length of hospital stay and catheterization time. Continence and erectile function were evaluated both pre- and postoperatively. The patients who used no pads or no more than one pad daily and the ones who had only a few urine leakages on effort or exertion were accepted as continent. Postoperative potency was defined as the ability to achieve sexual intercourse with or without the use of PDE-5 inhibitors. Results: Mean age and mean operative time were 62.4 ± 6.0 years and 220.5 ± 45.6 minutes, respectively. Mean anastomosis time was 35.6 ± 9.8 minutes. Mean serum PSA level and mean Gleason score were 17.5 ± 9.97 ng/mL and 6.16 ± 0.42, respectively. Pelvic lymphadenectomy was performed in 94 patients and nerve-sparing procedures in 61 patients. The pathological analysis revealed positive surgical margin in 35 patients (20.9%). Bilateral and unilateral nerve-sparing LRP procedures were performed in 51 (30.5%) and 10 (6%) patients, respectively. At 12 months after surgery, 3 (1.8%) patients were using 2 or more pads per day, 19 (26.4%) patients were satisfied with erection, hardness, and duration of intercourse, and 9 (12.5%) patients had an erection with insufficient hardness and duration. Conclusion: LRP is an acceptable method in localized prostate cancer due to its perioperative and early postoperative results.

Comparison of perioperative, oncologic, and functional outcomes between 3D and 2D laparoscopic radical prostatectomy: a systemic review and meta-analysis

Objectives

Literature regarding experience with 3D laparoscopy about prostatectomy has remained scanty, and this could be related to the rise of robotic assisted laparoscopic surgery. This study aimed to perform a systemic review and meta-analysis to evaluate the perioperative, functional, and oncologic outcomes between 3D and 2D laparoscopic radical prostatectomy (LRP).

Methods

We systematically searched the PubMed, Embase, and Cochrane Library databases for studies that compared perioperative, functional, or oncologic outcomes of both 3D and 2D LRP. The Newcastle-Ottawa Scale (NOS) tool and Jadad scale were used to assess the risk of bias in the included studies. Review Manager 5.3 was used for the meta-analysis.

Results

Seven studies with a total of 542 patients were included in the analysis. Among them, two were RCTs. There was no difference between groups in terms of preoperative characteristics. Anastomosis time, hospital day, and overall complication rates were similar in 3D than 2D group. However, operative time [mean difference (MD) -36.96; 95% confidence interval [CI] -59.25 to -14.67; p = 0.001], blood loss (MD -83.5; 95% CI -123.05 to -43.94; p <0.0001), and days of drainage (MD -1.48; 95% CI -2.29 to -0.67; p = 0.0003) were lower in 3D LRP. 2D and 3D LRP showed similarity in the positive surgical margin (PSM) rate and biochemical recurrence (BCR) rate at 3, 6, and 12months postoperatively. Additionally, there was no significant differences in continence and potency recovery rate between two group except higher continence rate of 3D LRP at 3 months.

Conclusion

Current evidence shows that 3D LRP offers favorable outcomes compared with 2D LRP, including operative time, blood loss, days of drainage, and early continence. However, there was no conclusive evidence that 3D LRP was advantaged in terms of oncologic and functional outcomes (except for continence rate at 3 months).

Systematic review registration

The study has been registered on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023426403).

Cumulative sum analysis of the learning curve of laparoendoscopic single-site robot-assisted radical prostatectomy

BACKGROUND

Radical prostatectomy has become the gold standard for treating localized prostate cancer. Improvement in the single-site technique and surgeon's skill reduces not only the hospital duration but also the number of wounds. Realizing the learning curve for a new procedure can prevent unnecessary mistakes.

OBJECTIVE

To analyze the learning curve of extraperitoneal laparoendoscopic single-site robot-assisted radical prostatectomy (LESS-RaRP).

METHODS

We retrospectively evaluated 160 patients diagnosed with prostate cancer during June 2016 to December 2020 who underwent extraperitoneal LESS-RaRP. Calculated cumulative sum analysis (CUSUM) was used to evaluate the learning curves for the extraperitoneal setting time, robotic console time, total operation time, and blood loss. The operative and functional outcomes were also assessed.

RESULTS

The learning curve of the total operation time was observed in 79 cases. For the extraperitoneal setting and robotic console times, the learning curve was observed in 87 and 76 cases, respectively. The learning curve for blood loss was observed in 36 cases. No in-hospital mortality or respiratory failure was observed.

CONCLUSION

Extraperitoneal LESS-RaRP using the da Vinci Si system is safe and feasible. Approximately 80 patients are required to achieve a stable and consistent operative time. A learning curve for blood loss was observed after 36 cases.

The RECOURSE Study: Long-term Oncologic Outcomes Associated With Robotically Assisted Minimally Invasive Procedures for Endometrial, Cervical, Colorectal, Lung, or Prostate Cancer: A Systematic Review and Meta-analysis

OBJECTIVE

To assess long-term outcomes with robotic versus laparoscopic/thoracoscopic and open surgery for colorectal, urologic, endometrial, cervical, and thoracic cancers.

BACKGROUND

Minimally invasive surgery provides perioperative benefits and similar oncological outcomes compared with open surgery. Recent robotic surgery data have questioned long-term benefits.

METHODS

A systematic review and meta-analysis of cancer outcomes based on surgical approach was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines using Pubmed, Scopus, and Embase. Hazard ratios for recurrence, disease-free survival (DFS), and overall survival (OS) were extracted/estimated using a hierarchical decision tree and pooled in RevMan 5.4 using inverse-variance fixed-effect (heterogeneity nonsignificant) or random effect models.

RESULTS

Of 31,204 references, 199 were included (7 randomized, 23 database, 15 prospective, 154 retrospective studies)-157,876 robotic, 68,007 laparoscopic/thoracoscopic, and 234,649 open cases. Cervical cancer: OS and DFS were similar between robotic and laparoscopic [1.01 (0.56, 1.80), P =0.98] or open [1.18 (0.99, 1.41), P =0.06] surgery; 2 papers reported less recurrence with open surgery [2.30 (1.32, 4.01), P =0.003]. Endometrial cancer: the only significant result favored robotic over open surgery [OS; 0.77 (0.71, 0.83), P <0.001]. Lobectomy: DFS favored robotic over thoracoscopic surgery [0.74 (0.59, 0.93), P =0.009]; OS favored robotic over open surgery [0.93 (0.87, 1.00), P =0.04]. Prostatectomy: recurrence was less with robotic versus laparoscopic surgery [0.77 (0.68, 0.87), P <0.0001]; OS favored robotic over open surgery [0.78 (0.72, 0.85), P <0.0001]. Low-anterior resection: OS significantly favored robotic over laparoscopic [0.76 (0.63, 0.91), P =0.004] and open surgery [0.83 (0.74, 0.93), P =0.001].

CONCLUSIONS

Long-term outcomes were similar for robotic versus laparoscopic/thoracoscopic and open surgery, with no safety signal or indication requiring further research (PROSPERO Reg#CRD42021240519).

A role for laparoscopy in the age of robotics: a retrospective cohort study of perioperative outcomes between 2D laparoscopic radical prostatectomy vs 3DHD laparoscopic radical prostatectomy

PURPOSE

Our study compares perioperative outcomes between two-dimensional (2D) laparoscopic radical prostatectomy (LRP) and the 4th generation three-dimensional/high definition (3DHD) LRP.

METHODS

Retrospectively acquired data from patients that underwent 2D LRP (n = 75) and 3DHD LRP (n = 75) from March 2013 to October 2015 were evaluated. Procedures were performed by a single surgeon. The extra-peritoneal approach with 5 trocars was utilized. Perioperative outcomes, potency, and continence were compared between groups.

RESULTS

Patient characteristics were similar between the two groups in terms of age (p = 0.44), prostate-specific antigen (PSA) levels (p = 0.34), and Gleason scores (p = 0.14). Body mass index (BMI) was significantly higher in the 3DHD group (p = 0.0036). Postoperatively, no significant differences were observed in Hgb loss (p = 0.50), positive surgical margins (p = 1.00), and post-op Gleason scores (p = 0.30). Significant differences were observed for length of hospital stay (p < 0.001) and Jackson-Pratt (JP) drainage (p < 0.001). Regarding potency, 73.7% and 51.6% of the patients in the 3DHD and 2D groups regained potency at 6 months, respectively (p = 0.0025). Almost 43% of the patients in the 3DHD group regained continence at 1 month while for the 2D groups it was only 17.3% (p = 0.0008).

CONCLUSION

3DHD and 2D LRP have resulted in good outcomes in the perioperative periods. Our results show decreased JP drainage, shorter length of hospital stay, earlier return of urinary control, and earlier return of sexual function in the 3DHD LRP group. In lower volume centers where robotics equipment is not feasible due to economic barriers 3DHD can be safely performed as a minimally invasive alternative.

Long-term comparative outcome analysis of a robot-assisted laparoscopic prostatectomy with retropubic radical prostatectomy by a single surgeon

We aimed to report a comprehensive outcome analysis of robot-assisted laparoscopic prostatectomies (RALP) performed by a single surgeon and compared it to retropubic radical prostatectomies (RRP) done by the same surgeon in a high-volume center. Preoperative, perioperative, and postoperative data were collected prospectively and compared with retrospective retropubic radical prostatectomy data. Perioperative, oncological data, and functional results in the first year were compared between the two groups. There were 547 RARPs between 4th August 2011 and 31st December 2018, and 428 RRPs between 1st January 1996 and 31st December 2009 which were included in this review. While the operation time was in favour of the open group (196 vs 160 min, p < 0.01), the estimated blood loss (188 vs 316 ml, p < 0.01), blood transfusion rate (3% vs 7%, p = 0.021), hospital stay (4 days vs 7 days), and mean catheter duration (12 vs 15 days) were in favour of the robotic group. Majority of the complications belonged to Clavien-Dindo group II in both groups and the rates were not significantly different (p = 0.33). The 12-month continence rate was in favour of the RALP group (98.3% vs 99.2%, p < 0.01). Overall survival of the RALP cohort at 24 months was 99.8%, 60 months 96.1%, 84 months 87.3%, 96 months 81.3%), and 108 months was 79.5%. Overall survival at 24 months was 99.8%, 60 months 96.1%, 84 months 87.3%, 96 months 81.3%, and 108 months 79.5%. RALP is a safe, minimally invasive, technically feasible procedure with comparable functional and oncological outcomes. Our study showed superior perioperative and continence outcomes in RALP. However, despite its growing popularity, RRP still remains the gold standard in India due to its affordability and accessibility.

Clinicopathological Significances of Positive Surgical Resection Margin after Radical Prostatectomy for Prostatic Cancers: A Meta-Analysis

Background and Objectives: This study aims to elucidate the positive rate and the clinicopathological significance of surgical margin after radical prostatectomy (RP) through a meta-analysis. Materials and Methods: This meta-analysis finally used 59 studies, including the information about the positive surgical margin (PSM) and those clinicopathological significances after RP. The subgroup analysis for the estimated rates of PSM was evaluated based on types of surgery, grade groups, and pathological tumor (pT) stages. We compared the clinicopathological correlations between positive and negative surgical margins (NSM). Results: The estimated PSM rate was 25.3% after RP (95% confidence interval [CI] 21.9-29.0%). The PSM rates were 26.0% (95% CI 21.5-31.1%) 28.0% (95% CI 20.2-37.5%) in robot-assisted RP and nerve-sparing RP, respectively. The PSM rate was significantly higher in high-grade groups than in low-grade groups. In addition, the higher pT stage subgroup had a high PSM rate compared to the lower pT stage subgroups. Patients with PSM showed significantly high PSA levels, frequent lymphovascular invasion, lymph node metastasis, and extraprostatic extension. Biochemical recurrences (BCRs) were 28.5% (95% CI 21.4-36.9%) and 11.8% (95% CI 8.1-16.9%) in PSM and NSM subgroups, respectively. Patients with PSM showed worse BCR-free survival than those with NSM (hazard ratio 2.368, 95% CI 2.043-2.744%). Conclusions: Our results showed that PSM was significantly correlated with worse clinicopathological characteristics and biochemical recurrence-free survival. Among the results in preoperative evaluations, grade group and tumor stage are useful for the prediction of PSM.

A Historical Perspective of The Evolution of Laparoscopic Surgeries in Urology

Recent decades have seen the rapid progression of minimally invasive surgery in urology with continuing developments in robotic technology paving ways into a new era. In addition to these technological innovations, interests from urologists in developing and embracing new techniques have become a forefront in the ongoing evolution of the field allowing for improvement intraoperative experience as well as morbidity and mortality outcomes. This article aims to provide an overview of the historical development of laparoscopic surgery in urology whilst also providing a brief look into its future.

Propensity-Score Matched Analysis Between Extraperitoneal Single Port and Intraperitoneal Multiport Radical Prostatectomy: A Single-Institutional Experience

OBJECTIVES

To compare the perioperative results and intermediate-term functional outcomes of single port and multiport robotic-assisted laparoscopic prostatectomy by using a propensity-score analysis.

MATERIALS AND METHODS

We evaluated all patients who underwent robotic prostatectomy by three urologic surgeons at our institution between January 2019 and October 2020. Demographic, intraoperative, and postoperative data were collected and assessed. Patients were matched based on body mass index, Gleason group, and prostate volume using the optimal matching method.

RESULTS

Overall, 98 and 165 patients underwent single port and multiport robotic prostatectomy, respectively. Following propensity-score matching, 98 multiport cases were matched 1:1 to single port cases. The median operative time was lower for multiport (111.5 vs 147.0 minutes, p=0.0000). Single port had a lower median estimated blood loss (50.0 vs 75.0 mL, p=0.0006), pain score on postoperative day 0 (1.0 vs 2.0, p=0.0004), opioid use at postoperative day 1 (0.0 [IQR 0.0-5.0] vs 0.0 MME [IQR 0.0-7.5], p=0.0058), cumulative opioid use (2.0 vs 7.0 MME, p=0.0008), and lymph node yield (4.0 vs 7.0 nodes, p=0.0051). Single port had a greater percentage of men regain full erectile function by 6 months (23.8% vs 4.8%, p=0.002).

CONCLUSIONS

The single port robotic system is a safe option for localized prostate cancer treatment, offering superior pain control and comparable perioperative results and intermediate-term functional outcomes compared to the multiport robotic approach.

Transperineal single-port robot-assisted radical prostatectomy with Si da Vinci surgical system: initial experience and description of technique

Background

Single-port robotic-assisted radical laparoscopic prostatectomy has emerged as a novel robotic-assisted radical laparoscopic prostatectomy in recent years, arousing wide attention. However, single-port robotic-assisted radical laparoscopic prostatectomy using Si da Vinci surgical system has been rarely reported, especially via the transperineal approach.

Methods

We retrospectively collected 9 cases of prostate cancer patients who underwent transperineal single-port robot-assisted radical prostatectomy (t-spPARP) using Si da Vinci surgical system in our center from May 2020 to June 2020. The operation time, estimated blood loss (EBL), complications, changes in prostate-specific antigen (PSA) 3 months after surgery, and urinary continence recovery 6 months after surgery were analyzed.

Results

No perioperative complications were recorded. The median [interquartile range (IQR)] operation time was 350 [150] min and the median [IQR] EBL was 300 [100] mL. PSA levels were less than 0.01 ng/mL at 3 months postoperatively in all cases (undetectable in 8 cases). All the 9 patients recovered their urinary continence 6 months after surgery and merely two patients required pads during the day.

Conclusions

t-spRARP was verified as a safe and feasible surgical alternative to treat patients with localized prostate cancer, especially for those whose prostate is small-volume or who had abdominal surgery history.

Single-Port versus Multiple-Port Robot-Assisted Radical Prostatectomy: A Systematic Review and Meta-Analysis

Background: Single-port robotic-assisted radical prostatectomy has been reported as a safe and feasible technique. However, recent studies comparing single-port versus multiple-port robotic radical prostatectomy have displayed conflicting results. Objectives: To investigate the benefit of single-port robotic radical prostatectomy and the impact on outcome compared to multiple-port robotic radical prostatectomy. Methods: Based on PRISMA and AMSTAR criteria, a systematic review and meta-analysis were carried out. Finally, we considered the controlled studies with two cohorts (one cohort for single-port RARP and the other cohort for multiple-port RARP). For statistical analysis, Review Manager (RevMan) software version 5.4 was used. The Newcastle-Ottawa Scale was employed to assess the risk of bias. Results: Five non-randomized controlled studies with 666 patients were included. Single-port robotic radical prostatectomy was associated with shorter hospital stays. Only 60.6% of single-port patients (109/180) required analgesia compared to 90% (224/249) of multiple-port patients (Z = 3.50; p = 0.0005; 95% CI 0.07:0.47). Opioid administration was also significantly lower in single-port patients, 26.2% (34/130) vs. 56.6% (77/136) (Z = 4.90; p < 0.00001; 95% CI 0.15:–0.44) There was no significant difference in operative time, blood loss, complication rate, positive surgical margin rate, or continence at day 90. Conclusion: The available data on single-port robotic radical prostatectomy is very limited. However, it seems comparable to the multiple-port platform in terms of short-term outcomes when performed with expert surgeons. Single-port prostatectomies might provide a shorter hospital stay and a lower requirement for opioids; however, randomized trials with long-term follow-up are mandatory for valid comparisons.

Impact of Prostate Size on the Outcomes of Radical Prostatectomy: A Systematic Review and Meta-Analysis

Simple Summary

Prostate size can vary widely among men regardless of whether they have prostate cancer or not. Many studies reported very conflicting results regarding the impact of prostate size on the outcome of radical prostatectomy. This is the first systematic review and meta-analysis on this topic to investigate the impact of prostate size on the operative, functional and oncological outcomes of radical prostatectomy. In general, a smaller prostate can be associated with fewer surgical complications, but with a higher chance of positive surgical margins. This can be useful when counseling patients before surgery.

Abstract

Background: The impact of prostate size on the radical prostatectomy outcome is not clear. Several published reports have shown conflicting results. Objectives: To investigate the effect of prostate size on the surgical, functional and oncological results of radical prostatectomy. Methods: A systematic review and meta-analysis were carried out in accordance with the PRISMA criteria. Finally, we investigated the research that reported on the impact of prostate size on radical prostatectomy outcome. The Review Manager (RevMan) software version 5.4 was utilized for statistical analysis. Results: Eighteen studies including 12,242 patients were included. Estimated blood loss was significantly less with smaller prostates (Z = 3.01; p = 0.003). The complications rate was 17% with larger prostates, compared to 10% for smaller prostates (Z = 5.73; p < 0.00001). Seventy-three percent of patients with a smaller prostate were continent within one month, compared to 64% with a larger prostate (Z = 1.59; p = 0.11). The rate of positive surgical margins was significantly higher with smaller prostates (20.2% vs. 17.8%). (Z = 2.52; p = 0.01). The incidence of biochemical recurrence was higher with smaller prostates (7.8% vs. 4.9%) (Z = 1.87; p = 0.06). Conclusion: Larger prostate size is associated with more blood loss and a higher rate of complications. However, the oncological outcome is better, compared to that in patients with smaller prostates. The impact of the size on the functional outcome is not clear.

Oncological and functional outcomes of extraperitoneal laparoscopic radical prostatectomy: An 18-years, single-center experience

OBJECTIVE

To present a retrospective analysis on the oncological and functional outcomes of a single-center experience on a large series of extraperitoneal laparoscopic radical prostatectomies (eLRP) with an extended follow-up.

MATERIALS AND METHODS

Herein we present a retrospective review of patients who underwent eLRP. Oncological and functional follow-up data were collected by means of outpatient visits and telephone interviews, assessing overall mortality and biochemical recurrence-free survival. Patients with clinical T4 stage prostate cancer (PCa), previous surgery for benign prostatic hyperplasia (BPH), previous androgen deprivation, radiotherapy, concomitant chemotherapy and/or experimental therapies, and with insufficient follow-up data were excluded. Preoperative data recorded were age, body mass index, ultrasound prostate volume, preoperative PSA and clinical stage of PCa. Operative data (operative time, nerve sparing technique and any perioperative complication) and pathological findings were obtained by consulting the surgical and pathological reports. Oncological and functional follow-up were collected during follow-up visits and telephone interview.

RESULTS

Between January 2001 and December 2019, overall 938 eLRP were performed at our Institution. The median follow-up was 132 months. 69.7% of the patients had complete dataset. The estimated overall biochemical recurrence (BCR)-free survival was 71.4% at 5 years and 58.9% at 10 years. Cancer specific survival was 84,5%. Erectile function was preserved in the most of patients as postoperative IIEF-5 score within 12 months after surgery was > 12 in the 82.1%. About the urinary incontinence, 0.76% of the patients presented severe incontinence (continued and persistent loss of urine) and 7.0% were mildly incontinent (using up to one pad per day). Conclusions; eLRP has shown oncological and functional results comparable to other minimally invasive techniques and to open radical prostatectomy (ORP), with favorable perioperative outcomes than the open technique and a reduced complication rate.

Prospective evaluation of urinary continence after laparoscopic radical prostatectomy using a validated questionnaire and daily pad use assessment: which definition is more relevant to the patient's perception of recovery?

Introduction

No standard definition for urinary continence after radical prostatectomy exists, and there are discrepancies in continence rates reported in the literature, as well as rates reported by physicians and patients. Therefore, we used two tools, a validated questionnaire and daily pad use, to identify the criteria that best reflects patients’ perceptions of continence recovery.

Material and methods

This is a prospective study of 74 patients who underwent nerve-sparing laparoscopic radical prostatectomy. Continence was assessed monthly for 3 months following catheter removal using the International Consultation on Incontinence Questionnaire Short Form (ICIQ-UI SF) and by recording the number of pads the patients used on a daily basis. According to daily pad use, patients were categorized as either dry (no-pads), socially continent (0–1 pad) or incontinent (≥2 pads).

Results

Seventy-four patients were enrolled with a mean age of 64.3 (±5.6) years. There were no significant differences in continence rates using scores from the International Consultation on Incontinence Questionnaire- Short Form (ICIQ-UI SF) or no-pad use (29.7% vs 32.4%, 45.9% vs 48.6% and 54.1% vs. 54.1%, at the 1-, 2- and 3-month follow-ups, respectively). However, the number of socially continent patients was significantly higher (59.5%, 70.3% and 81.1%, at the 1-, 2- and 3-month follow-ups, respectively [p <0.001]).

Conclusions

The totally dry definition better reflected patients’ perceptions rather than the socially continent definition for the evaluation of continence recovery following laparoscopic radical prostatectomy. To avoid discrepancies, we recommend the use of a validated questionnaire as well as the no-pad definition to standardize the reporting of post radical prostatectomy continence rates.

[Interactions between radical prostatovesiculectomy and diagnosis of prostate cancer : A medical-historical inventory on the occasion of 20 years of robot-assisted treatment]

Die Frage, was zuerst war – in diesem Falle die Diagnostik des Prostatakarzinoms oder seine Therapie – erscheint auf den ersten Blick widersinnig und erinnert an die klassische metapherartige Problemstellung, die schon den griechischen Schriftsteller Plutarch (45–125) beschäftigte. Ist es heute selbstverständlich, dass vor der Behandlung einer Erkrankung die sichere Diagnosestellung steht, so muss dies medizinhistorisch jedoch als nicht konsistent erachtet werden. Die Anfänge der radikalen Prostatektomie zur Behandlung des Prostatakarzinoms lassen sich, ähnlich wie die ersten operativen Therapien von Nieren- und Harnblasentumoren, in der Pionierzeit der Organchirurgie im Deutschen Kaiserreich (1871–1918) verorten. Die Etablierung dieses Eingriffs in seiner heutigen Form mit größeren Fallzahlen ist wiederum dem Nestor der US-amerikanischen Urologie, Hugh Hampton Young (1870–1945), zu verdanken, der 1904 die erste aus heutiger Sicht als vollumfänglich zu bezeichnende perineale Prostatovesikulektomie durchführte. Wenngleich die Indikation seither weitgehend unverändert geblieben ist, war dieser Eingriff in den letzten Jahrzehnten doch umfangreichen Veränderungen unterworfen. Wie aber hat sich die Diagnostik des Prostatakarzinoms in dieser Zeitspanne entwickelt? Naturgemäß sehr viel dynamischer! Denn als der Leiteingriff Prostatovesikulektomie bereits etabliert war, begann im Laufe des 20. Jahrhunderts erst langsam, dann dynamischer deren Entwicklung. Wir stellen anhand medizin(histor)ischer Originalquellen daher nicht nur die Grundlagen und Weiterentwicklungen des etablierten und zugleich immer wieder Innovationen unterworfenen Leiteingriffs der Urologie vor, sondern gehen vielmehr auch auf wesentliche Umfeldentwicklungen benachbarter medizinischer Disziplinen ein. Erst diese Entwicklungen schafften übrigens auch die Grundlage für die korrekte Indikationsstellung und das Aufzeigen von Alternativen zur radikalen Prostatovesikulektomie.

Radical Prostatectomy: Sequelae in the Course of Time

Objective: Radical prostatectomy (RP) is a frequent treatment for men suffering from localized prostate cancer (PCa). Whilst offering a high chance for cure, it does not come without a significant impact on health-related quality of life. Herein we review the common adverse effects RP may have over the course of time. Methods: A collaborative narrative review was performed with the identification of the principal studies on the topic. The search was executed by a relevant term search on PubMed from 2010 to February 2021. Results: Rates of major complications in patients undergoing RP are generally low. The main adverse effects are erectile dysfunction varying from 11 to 87% and urinary incontinence varying from 0 to 87% with a peak in functional decline shortly after surgery, and dependent on definitions. Different less frequent side effects also need to be taken into account. The highest rate of recovery is seen within the first year after RP, but even long-term improvements are possible. Nevertheless, for some men these adverse effects are long lasting and different, less frequent side effects also need to be taken into account. Despite many technical advances over the last two decades no surgical approach can be clearly favored when looking at long-term outcome, as surgical volume and experience as well as individual patient characteristics are still the most influential variables. Conclusions: The frequency of erectile function and urinary continence side effects after RP, and the trajectory of recovery, need to be taken into account when counseling patients about their treatment options for prostate cancer.

Bladder neck sparing during robot-assisted laparoscopic radical prostatectomy: Six-year experience

OBJECTIVE:

Prostate cancer is the most frequently diagnosed cancer among men in developed countries. Radical prostatectomy (RP) is the standard surgical treatment for patients with organ-confined disease and robot-assisted laparoscopic radical prostatectomy (RALP) procedures get more popular in the past 20 years. The most important factor of continence after RP is the preservation of the functional sphincter mechanisms. Tunc et al. described the novel bladder neck preserving technique in RALRP in 2015. The purpose of this study is to present our long-term results of our novel technique during RALP performed by single surgeon (LT).

METHODS:

In this study, 331 patients who went under procedure RALP between January 2012 and December 2017 analyzed retrospectively. Bladder neck sparing technique was performed for all patients used by a four-armed da Vinci robotic surgical system (Intuitive Surgical, Inc., Sunnyvale, CA). Quality of life (QoL) scores were assessed before RALP, after urethral catheter removal, and at the 1^st month after RALP used by SF-12 QoL questionnaire. Patients without urine leakage during coughing or sneezing, as well as those who stayed totally dry, were considered as continent. Those who used more than 1 protective pad per day and/or had urine leakage during coughing, sneezing, or during the night were considered incontinent.

RESULTS:

The mean operation time, docking time, and anastomosis time were 76.9±28.9, 7.2±2.2, and 18±3.1 min, respectively. Estimated blood loss was 51.6±22.9 ml. The mean hospital stay was 2.2±0.8 days. The mean duration of the catheter was 7.1±1.3 days. After catheter removal, 310 (93.6%) of patients were continent immediately. During follow-up, 318 (96%) were continent after 1 month and 329 (99.3%) were totally continent after 1 year. No patient received surgical treatment for stress incontinence.

CONCLUSION:

Since we have defined bladder neck sparing technique, we have realized that our technique is very effective with our long-term results. Our novel technique provided very early continence at the time of catheter removal after RALP within short-term follow-up in addition to favorable oncologic results.

Incidental finding of prostate cancer in Transurethral Resection of Prostate (TURP) specimens: a retrospective analysis from a Tertiary Care Hospital in Pakistan

Introduction

incidental prostate cancer findings reflect the great burden of prostatic cancer across the globe. Our 10 year retrospective analysis aimed to identify the incidence and clinic-pathologic features of prostate cancer incidentally detected in patients undergoing transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH), and to estimate the clinical value of pathologic review of all TURP specimens.

Methods

after excluding patients with a known diagnosis of prostate cancer prior to TURP a total of 2,386 men (ages 25-98) were identified by pathology (TURP) specimens. Yearly incidences, Gleason score, grade, pathologic stage were recorded for all incidental prostate cancer patients.

Results

a total of 256 (10.7%) patients were found to have prostate cancer. Mean Age was 68.51±9.22 years. T1a and T1b stage prostatic carcinoma was found in 9.9% and 90.1% of these patients respectively. Forty-nine percent (49%) patients had higher Gleason scores (>7). After subtracting average incidences between 5-year intervals, a statistical rise of almost 4% was found.

Conclusion

our analysis concludes that a large proportion (10.7%) of patients had incidental prostate cancer and the incidence was increasing in recent years in Pakistan and in comparison, to Asian countries. In Pakistan there is a scarcity of updated national cancer registries. The growing incidence of high Gleason scores requires keen and prompt attention. The diverse ethnic and socioeconomic background of patients propels their propensity towards loss of follow up with already limited tertiary healthcare institutes in Pakistan. This pathologic review of TURP specimens is valuable for Asiatic and non-Asiatic populations.

Preoperative exercise interventions to optimize continence outcomes following radical prostatectomy

Urinary incontinence is a common and predictable consequence among men with localized prostate cancer who have undergone radical prostatectomy. Despite advances in the surgical technique, urinary continence recovery time remains variable. A range of surgical and patient-related risk factors contributing to urinary incontinence after radical prostatectomy have been described, including age, BMI, membranous urethral length and urethral sphincter insufficiency. Physical activity interventions incorporating aerobic exercise, resistance training and pelvic floor muscle training programmes can positively influence the return to continence in men after radical prostatectomy. Traditional approaches to improving urinary continence after radical prostatectomy have typically focused on interventions delivered during the postoperative period (rehabilitation). However, the limited efficacy of these postoperative approaches has led to a shift from the traditional reactive model of care to more comprehensive interventions incorporating exercise-based programmes that begin in the preoperative period (prehabilitation) and continue after surgery. Comprehensive prehabilitation interventions include appropriately prescribed aerobic exercise, resistance training and specific pelvic floor muscle instruction and exercise training programmes. Transperineal ultrasonography is a non-invasive and validated method for the visualization of the action of the pelvic floor musculature, providing real-time visual biofeedback to the patient during specific pelvic floor muscle instruction and training. Importantly, the waiting time before surgery can be used for the delivery of comprehensive prehabilitation exercise-based interventions to increase patient preparedness in the lead-up to surgery and optimize continence and health-related quality-of-life outcomes following radical prostatectomy.

Diffusion and adoption of the surgical robot in urology

Over the last two decades, robotic surgery has become a mainstay in hospital systems around the world. Leading this charge has been Intuitive Surgical Inc.’s da Vinci robotic system (Sunnyvale, CA, USA). Through its innovative technology and unique revenue model, Intuitive has installed 4,986 robotic surgical systems worldwide in the last two decades. The rapid rate of adoption and diffusion of the surgical robot has been propelled by many important industry-specific factors. In this review, we propose a model that explains the successful adoption of robotic surgery due to its three core groups: the surgeon, the hospital administrator, and the patient.

Comparison of Perioperative, Oncological, and Functional Outcomes of Three-Dimensional Versus Robot-Assisted Laparoscopic Radical Prostatectomy: A Preliminary Study

Background: Radical prostatectomy (RP) is the first-line treatment modality for prostate cancer and can be performed using retropubic or minimally invasive techniques. New technologies such as the da Vinci robotic system and three-dimensional (3D) laparoscopic imaging system have been developed to overcome the challenges of conventional laparoscopy. This study aimed to compare the perioperative, oncological, and functional outcomes of robot-assisted laparoscopic RP (RALP) and 3D laparoscopic RP (3D LRP). Materials and Methods: The study was approved by the local ethics committee and included 65 patients (38 RALP, 27 3D LRP) who underwent RP with the diagnosis of localized prostate cancer between May 2019 and January 2020. All demographic, clinical, perioperative, pathological, and postoperative variables were recorded. Results: There was no statistically significant difference between the two groups in terms of preoperative patient characteristics. The mean operative times of the RALP and 3D LRP groups were 135.74 ± 11.51 and 165.37 ± 15.86 minutes, respectively, with a statistically significant difference between the two groups (P = .001). The mean estimated blood loss was 237 ± 71 mL in the RALP group and 257 ± 54 mL in the 3D LRP group, with no statistically significant difference between the two groups (P = .236). In the 6 months of follow-up, there was no statistically significant difference between the two groups in terms of biochemical recurrence, continence, and potency. Conclusion: RALP and 3D LRP have similar perioperative, short-term oncological and functional outcomes other than the operative time. There is a need for prospective, randomized studies with larger populations evaluating long-term oncological and functional outcomes.

Extraperitoneal Robotic Laparo-Endoscopic Single-Site Plus1-Port Radical Prostatectomy Using the da Vinci Single-Site Platform

Currently, over 80% of radical prostatectomies have been performed with the da Vinci Surgical System. In order to improve the aesthetic outlook and decrease the morbidity of the operation, the new da Vinci Single Port (SP) system was developed in 2018. However, one major problem is the SP system is still not available in most countries. We aim to present our initial experience and show the safety and feasibility of the single-site robotic-assisted radical prostatectomy (LESS-RP) using the da Vinci Single-Site platform. From June 2017 to January 2020, 120 patients with localized prostate cancer (stage T1–T3b) at Kaohsiung Medical University Hospital were included in this study. We describe our technique and report our initial results of LESS-RP using the da Vinci Si robotic system. Preoperative, intraoperative and postoperative patient variables were recorded. Prostate-specific antigen (PSA)-free survival was also analyzed. A total of 120 patients were enrolled in the study. The median age of patients was 68 years (IQR 63–71), with a median body mass index of 25 kg/m² (IQR 23–27). The median PSA value before operation was 10.7 ng/mL (IQR 7.9–21.1). The median setup time for creat-ing the extraperitoneal space and ports document was 25 min (IQR 18–34). The median robotic console time and operation time were 135 min (IQR 110–161) and 225 min (IQR 197–274), respectively. Median blood loss was 365 mL (IQR 200–600). There were 11 (9.2%) patients who experienced complications (Clavien–Dindo classification Gr II). The me-dian catheter duration was 8 days (IQR 7–9), with a median of 10 days (IQR 7–11) of hospital stay. The PSA free-survival rate was 86% at a median 19 months (IQR 6–28) of follow up. Robotic radical prostatectomy using the da Vinci Single-Site platform system is safe and feasible, with acceptable outcomes.

Laparoscopic radical prostatectomy: a single surgeon’s experience in 80 cases after 2 years of formal training

Background

To assess the learning curve in laparoscopic radical prostatectomy (LRP) performed by a single surgeon who had a healthcare career as a surgical first assistant for 2 years in high-volume centers treating > 150 cases per year.

Methods

The records of 80 LRP cases performed between October 2017 and August 2018 by a single surgeon were consecutively divided into four groups (groups A = first 20 cases, B = second 20 cases, C = third 20 cases, and D = last 20 cases). The groups were compared in terms of surgical and functional outcomes with a minimum follow-up of 6 months.

Results

Clinical and surgical stages of the four groups were similar between groups. The operative time (126.8 ± 5.48 min; P = 0.001) and time of removal of the drain (1.65 ± 0.93 days; P = 0.029) were significantly lower in group D; however, hospitalization, catheterization time, and blood loss were similar between groups. The complication rate was low. No patient had a visceral injury, and there were no procedures needed to open conversion. The positive surgical margin (PSM) rates were similar between groups. In terms of continence and potency, all groups were similar at the 6th-month follow-up after surgery.

Conclusions

Our results showed that prior experience in laparoscopic surgery as a surgical first assistant in a high-volume center improves the learning curve and oncological and functional outcomes, and helps to minimize the complication rate

3D laparoscopic prostatectomy: A prospective single-surgeon learning curve in the first 200 cases with oncologic and functional results

BACKGROUND

Studies for 3D-laparoscopic prostatectomy (3D-LRP) learning curve and surgical results are lacking. Combining 3D vision to LRP attenuates differences compared to Robotic assisted laparoscopic prostatectomy (RALP) with similar mini-invasiveness but lower costs.

MATERIALS AND METHODS

Two hundred consecutive men with localized prostate cancer underwent 3D-LRP at Seinäjoki central hospital between 2013 and 2018. Oncological and functional results were documented. Long-term functional evaluation was done using EPIC-26 survey. Clavien-Dindo classification was used to assess complications during first 3 months. All operations were performed by a single surgeon (M.R.) with no experience of LRP or 3D-LRP. The learning curve was assessed by evaluating urethral anastomosis- and total operative time. Perioperative and postoperative data was collected prospectively during surgery and at subsequent control visits up to minimum of 1 year.

RESULTS

A plateau in anastomosis time was reached after 30 cases and in operative time after 60 cases. Median operative time was 114 min (78-258 min) and median time for anastomosis was 25 min (11-90 min). Median blood loss was 150 ml (10-800 ml); 93.5% of the patients were discharged within the first 3 days. Clavien-Dindo ≥3a complications occurred in 6.5%. Positive surgical margins occurred in 23%. One-year after the operation, 93.3% had PSA ≤ 0.1; 91.9% of the patients were dry or used one daytime pad. EPIC-26 scores were as follows: Urinary incontinence 79.25 (14.5-100), urinary irritative/obstructive 93.75 (31.25-100), bowel 100 (33.33-100), sexual 36.17 (0-100) and hormonal 95 (37.5-100).

CONCLUSION

The learning curve for 3D laparoscopic prostatectomy is comparable to RALP, which makes it a cost-effective alternative with comparable oncological and functional results.

New Evolution of Robotic Radical Prostatectomy: A Single Center Experience with PERUSIA Technique

Radical prostatectomy (RP) is the standard surgical treatment of organ-confined prostate cancer in patients with a life expectancy of at least 10 years. In a recent prospective study, we described the PERUSIA (Posterior, Extraperitoneal, Robotic, Under Santorini, Intrafascial, Anterograde) technique, which is an extraperitoneal full nerve sparing robotic RP, showing its feasibility and safety. The aim of this retrospective study was to evaluate the peri-operative, oncologic, and functional outcomes of the PERUSIA technique. We retrospectively analyzed the data of 454 robotic-assisted radical prostatectomies (RARP) performed using the PERUSIA technique from January 2012 to October 2019. We evaluated perioperative outcomes (operative time, estimated blood loss, catheterization time, complication rate, length of stay), oncological (positive surgical margins and biochemical recurrence), and functional outcomes in terms of urinary continence and sexual potency. The overall complication rate was 16%, positive surgical margins were 8.1%, and biochemical recurrence occurred in 8.6% at median follow-up of 47 months. Urinary continence was achieved in 69% of cases the day after the removal of the catheter, in 92% at 3 months, and in 97% at 12 months after surgery. The average rate of sexual potency was 72% and 82% respectively 3 and 12 months after surgery. Our findings show that the PERUSIA technique is a safe extraperitoneal approach to perform a full nerve sparing technique providing exciting functional outcomes.

Comparison of functional and oncological outcomes of innovative "three-port" and traditional "four-port" laparoscopic radical prostatectomy in patients with prostate cancer

Background

To compare the functional and oncological outcomes between innovative “three-port” and traditional “four-port” laparoscopic radical prostatectomy (LRP) in patients with prostate cancer (PCa).

Methods

We retrospectively collected the data of PCa patients treated at our institutions from June 2012 to May 2016. According to the inclusion criteria, a total of 234 patients were included in the study, including 112 in group A (four-port) and 122 in group B (three-port). The perioperatively surgical characteristics, functional and oncological outcomes were compared between groups.

Results

There were no statistical differences in the baseline parameters between these two groups. Compared with group A, the operative time (OT) and estimated blood loss (EBL) were significantly less in group B. On follow-up, the rate of positive surgical margin (PSM), prostate specific antigen (PSA) biochemical recurrence and continence after LRP did not show any statistically significant difference between the groups. An identical conclusion was also received in comparison of overall survival (OS) and biochemical recurrence-free survival (BRFS) between both groups.

Conclusions

Innovative “three-port” LRP can significantly shorten the OT and reduce the EBL compared with the traditional “four-port” LRP. Meanwhile, it does not increase the rate of PSM and PSA biochemical recurrence. “Three-port” LRP could be popularized in the future in view of its superior surgical technique, considerably better functional outcomes and remarkable oncological control.

Pelvic lymph node dissection in prostate cancer: Laparoscopy is not dead

CONTEXT

Pelvic lymph node dissection (PLND) in localized prostate cancer is feasible through an open, laparoscopic or robot-assisted approach. Data comparing the three approaches is sparse.

OBJECTIVE

To perform a review in order to compare the effectiveness of the different PLND approaches.

ACQUISITION OF EVIDENCE

A search was performed including the following words: ("pelvic lymph node dissection") OR ("pelvic lymphadenectomy") AND ("French"[Language] OR "English"[Language]) AND ("1990"[Date-Publication]: "3000"[Date-Publication]) AND prostatectomy[Title]). Twenty-nine articles were finally included in the qualitative synthesis.

EVIDENCE SYNTHESIS

Laparoscopic pelvic lymph node dissection in prostate cancer is a minimally invasive procedure with a relatively short operative time, minimal blood loss, lower level of pain, shorter hospital stay, and fewer perioperative complications when compared to an open approach. This technique is more cost-effective than a robot-assisted approach.

CONCLUSION

Concerning the treatment of localized prostate cancer, laparoscopic pelvic lymph node dissection should be learned and applied by urologists.

Outcomes of Minimally Invasive Radical Prostatectomy-a Contemporary Review

Prostatectomy has been widely accepted as a treatment option for prostate cancer and can be performed via an open, laparoscopic, and robotic approach. The outcomes following prostatectomy are primarily sub-grouped into oncological and functional outcomes. Oncological outcomes have been comparable in the above three surgical modalities. However, the robotic platform seems to have a better functional outcome compared to open prostatectomy. The data on the outcome of the laparoscopic approach is scarce and is not widely performed due to technical difficulty. With experience continence outcomes have reached a plateau in many robotic series, however, the potency outcome is the real Achilles tendon of this procedure. Many factors influence potency outcomes but the amount and quality of nerve-sparing is one factor that is under a surgeon's control and it improves with experience.

Role of sparing of puboprostatic ligaments on continence recovery after radical prostatectomy: a randomized controlled trial

OBJECTIVE

Sparing of puboprostatic ligaments (PPLs) during radical prostatectomy was introduced as a technique to improve urinary continence. This study aims to study the effect of sparing of PPLs during laparoscopic radical prostatectomy in terms of continence during the first 3 months.

METHODS

A total of 74 patients, diagnosed with clinically localized prostate cancer, were randomly assigned to two equal groups; PPLs division and sparing during LRP. Based on the number of daily used pads, both groups completed 3 months follow-up to assess continence recovery. The effects of age, preoperative total prostate-specific antigen (PSA) and clinical tumor stage on continence recovery were also studied. The study was registered and approved by the Ethics Committee of Alexandria University-Faculty of Medicine (Protocol No. 0201074).

RESULTS

Seventy-four patients were enrolled, with a mean age of 63.8 years. Baseline characteristics were comparable, except significantly higher mean PSA in the division group. Sixty patients were continent (0-1 pad/day) at 3 months follow-up. Continence was significantly better in the sparing than division group at 1 week after catheter removal (67.6% vs 40.5%, p = 0.01), at 1 month (73% vs 45.9%, p = 0.009) and 2 months (89.2% vs 51.4%, p = 0.0001). At 3 months follow-up, there was no significant difference between both groups (83.3% vs 78.4% for sparing and division groups, respectively; p = 0.28). Moreover, continence was significantly improved at 3 months compared to 1 week in both groups.

CONCLUSION

Sparing of puboprostatic ligaments during radical prostatectomy significantly improves postoperative early recovery of urinary continence.

Historical Considerations and Surgical Quality Improvement in Robotic Prostatectomy

Laparoscopic prostatectomy was technically challenging and not widely adopted. Robotics led to the widespread adoption of minimally invasive prostatectomy, which has been used heavily, supplanting the open and traditional laparoscopic approach. The benefits of robotic prostatectomy are disputed. Data suggest that robotic prostatectomy outcomes have improved over time.

Predictors of Prolonged Laparoscopic Radical Prostatectomy and the Creation of a Scoring System for the Duration

Purpose

To identify the relevant factors, and create and validate a predictive scoring system for the duration of laparoscopic radical prostatectomy (LRP).

Patients and Methods

We retrospectively analyzed clinicopathological data from 436 patients who underwent LRP between January 2014 and January 2019, of whom 304 cases were used as a model creation group and 132 were used as a validation group. Uni/multivariate linear regression analysis was performed to determine the predictors of the duration of the procedure and a novel scoring system was created using these predictors. External validation of the scoring system was performed. The Hosmer–Lemeshow test was used to determine the goodness-of-fit of the model and calibration plots were created for visual assessment.

Results

“Prolonged duration” was defined as a duration of the procedure that was longer than the mean (>150 min) duration. Multivariate analysis showed that body mass index (BMI), prostate volume, intravesicular protrusion of the prostate (IPP), the ratio of the cross-sectional areas of the prostate and the Retzius space (P/R), pelvic lymph node dissection, and neurovascular bundle (NVB) preservation were significant predictors of prolonged duration. A scoring system that included these six parameters was created and the area under the curve achieved during receiver operating characteristic analysis using this scoring system was 0.874 (95% confidence interval [CI]: 0.836–0.913). The Hosmer–Lemeshow test showed that the scoring system was well calibrated (X²=5.339, P=0.376). The external validation showed that the model had high predictive accuracy (AUC=0.835, 95% CI: 0.764–0.906) and goodness-of-fit (X²=4.401, P=0.493).

Conclusion

The following factors were significantly associated with prolonged duration of laparoscopic radical prostatectomy: BMI, prostate volume, IPP, P/R, pelvic lymph node dissection, and NVB preservation. The novel scoring system created can be used to accurately predict the duration of the procedure, assess the difficulty of surgery, and improve perioperative efficiency.

Relationship between robotic-assisted radical prostatectomy and retropubic radical prostatectomy in the learning curve of a single surgeon as a novice in radical prostatectomy: A retrospective cohort study

OBJECTIVE

We compared the learning curve and pathologic and functional outcomes of retropubic radical prostatectomy (RRP) and robotic-assisted radical prostatectomy (RARP) performed during the same time period by a novice to identify how the two surgical types affect each other.

METHODS

We retrospectively reviewed 480 men who underwent RRP or RARP for prostate cancer between January 2008 and December 2012. Operation time, estimated blood loss (EBL), positive surgical margin (PSM) rate, urinary continence and potency recovery, and complications were compared. Scatter-graphs were drawn using locally weighted scatterplot smoothing (LOWESS).

RESULTS

Operation time reached the lowest point in the 90th case in RRP and the 200th case in RARP. EBL showed a similar pattern, reaching the lowest point in the 95th case in RRP and the 230th case in RARP. The lowest points for both operation time and EBL took about 3 years to reach for both surgical types. PSM rate was not significantly different (P = 0.807). No pads were required at 6 and 12 months in 55.6% and 66.9% of patients in RRP, respectively, but in 79.6% and 88.4% of patients in RARP. The potency recovery rates were 59.1% in RRP and 70.9% in RARP at 12 months.

CONCLUSIONS

When RRP and RARP were begun contemporaneously by a novice, they showed similar learning curve patterns. The direct tactile feedback in RRP and the magnified field of view and detailed techniques in RARP help improve surgical skills complementarily to attain proficiency in both surgical types.

The 100 most-cited articles in urological surgery: A bibliometric analysis

BACKGROUND

The purpose of this bibliometric analysis was to identify and assess the 100 most-cited articles (T100 articles) on urological surgery.

METHODS

The Web of Science (WoS) Core Collection database was used to investigate the T100 articles in the field of urological surgery. Different aspects of the T100 articles, including the countries, journals, authors, and topics, were analyzed.

RESULTS

The number of citations of T100 articles published between 1989 and 2016 ranged from 334 to 2189. The T100 articles originated from 28 countries, with more than half originating from the USA (n = 80). Professor Bill-Axelson A from Uppsala University Hospital published the largest number of T100 articles as the first author (4) and as a coauthor (1). The Memorial Sloan Kettering Cancer Center from the USA is the top institution with the most T100 articles in the field of urological surgery. The special journal Journal of Urology published 41 of the T100 articles, which had a total of 19780 citations.

CONCLUSIONS

Our study analyzed the 100 most-cited articles in the field of urological surgery. The USA is the dominant country in terms of the number of T100 articles, scientists and institutions. Surgery related to urological cancer has garnered the most academic attention, especially prostate cancer and renal cancer.

Effects of Retzius sparing on robot-assisted laparoscopic prostatectomy: a systematic review with meta-analysis

BACKGROUND

To comprehensively evaluate the efficacy and safety of Retzius sparing (RS) for men undergoing robot-assisted laparoscopic prostatectomy (RARP).

METHODS

We searched four electronic databases and reference lists of relevant studies for eligible research published before March 11, 2019. After quality assessment, eligible studies were synthesized for relevant outcomes, including positive surgical margin (PSM), continence, incontinence, complication, console time, and hospital stay.

RESULTS

Two randomized clinical trials and four observational studies were included in this study. Quantitative syntheses revealed significantly higher PSM rates in RS-RARP compared with conventional RARP (c-RARP) (odds ratio [OR] 1.68, p = 0.02). Furthermore, we found significantly higher PSM rates at the anterior site in RS-RARP compared with c-RARP (OR 4.34, p = 0.03) and significantly lower incontinence rates in RS-RARP in the first month (OR 0.30, p < 0.001) and 12th month (OR 0.25, p < 0.001).

CONCLUSIONS

Our syntheses revealed higher PSM rates in the RS-RARP group, especially in the anterior aspect. However, RS-RARP had superior functional outcome of urinary continence and lower console time than did c-RARP with equivalent complication rates. Thus, we suggest that operators pay more attention to making clear surgical margins if the lesion is in anterior prostate when performing RS-RARP.

Does The Learning Curve Affect the Surgical, Functional, and Oncologic Outcomes in Bilateral Nerve-Sparing Robot Assisted Laparoscopic Prostatectomy?

Introduction

Nowadays, the expectations for functional prostatectomy outcomes are quite high. Robot-assisted laparoscopic radical prostatectomy (RALRP) has become an increasingly common treatment option for men with localized prostate cancer. In this study, we aimed to present the results of our bilateral nerve-sparing RALRP procedure and to evaluate the effects of the learning curve (LC) on perioperative data, early oncologic, and functional outcomes.

Methods

The records of 132 RALRP cases performed between January 2016 and March 2019 by a single surgeon experienced in open and laparoscopic radical prostatectomy were evaluated retrospectively. Results of 91 cases with the bilateral nerve-sparing technique were analyzed. The learning curve was determined using the moving average method. LC analysis using the moving average method showed that the LC stabilized between cases 40 and 50. So, patients were divided into two groups: group 1 consisted of the first 45 cases, while group 2 consisted of 46-91^st cases. The groups were compared in terms of surgical, functional, and oncologic outcomes.

Results

The mean duration of surgery was significantly reduced in the second group (250 vs 235 min, p <0.002). However, there was no statistically significant difference between the groups in terms of hemoglobin decrease, hospitalization and catheterization time, and intraoperative and postoperative complication rates. The rates of pT2 cancers’ positive surgical margins (PSMs) were 32.4% and 19.4%, respectively. The recovery rate of continence in all the patients was 90.1% at 12 months. The potency ratios were calculated as 33.8% at 12 months. There was no statistically significant difference between the groups in terms of potency and continence rates at 3 months and 12 months, postoperatively.

Conclusion

For surgeons experienced in retropubic radical prostatectomy (RRP) and laparoscopic radical prostatectomy (LRP) surgeries, RALRP is a safe and feasible surgical procedure for both oncological and functional outcomes even during the learning curve.