Technique of traction-free nerve-sparing robotic prostatectomy: delicate tissue handling by real-time penile oxygen monitoring

Detection of Apical Cancer with Novel Imaging Modalities to Predict Apical Margin Positivity in Robotic Assisted Radical Prostatectomy

OBJECTIVES

To evaluate margin positivity at apex utilizing preoperative magnetic resonance imaging [MRI], micro-ultrasound [MUS], prostate specific membrane antigen positron emission tomography PSMA PET] scan, biopsy location and intraoperative timing of deep venous complex [DVC] ligation during robot assisted radical prostatectomy [RARP].

METHODS

Institution review board approved retrospective study underwent RARP between November 2022 to March 2024. All patients underwent preoperative MRI, MUS and PSMA PET scan. Patients underwent RARP using either standard DVC [done prior apical dissection] ligation or delayed DVC [after prostate removal] technique. All patients underwent intra operative frozen section analysis by an experienced genitourinary pathologist. Descriptive statistics were performed. Data analyzed using R software version 4.3.3.

RESULTS

Total 619 prostate cancer patients underwent RARP. Of these, 365 men underwent RARP using delayed DVC ligation technique and 254 men using standard DVC ligation technique. There was no statically significant difference in 2 groups on demographic parameters, MRI, MUS and PSMA-PET scan features. Sensitivity of MRI, MUS, PSMA-PET and prostate biopsy for detection of apical positive margin were 66%, 81%, 81% and 73% respectively. Specificity of MRI, MUS, PSMA-PET and prostate biopsy for detection of apical positive margin were 45%, 14%, 16% and 30% respectively. When all modalities are used accumulatively, apical cancer was missed only in 1% of cases.

CONCLUSIONS

With proper preoperative understanding of apical lesion location, timing of DVC ligation [standard vs delayed] doesn't impact apical positive surgical margins. Combination of MRI, MUS, PSMA-PET and prostate biopsy reduce apical positive surgical margin rates significantly.

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.

Saline-assisted fascial exposure (SAFE) technique to improve nerve-sparing in robot-assisted laparoscopic radical prostatectomy

OBJECTIVE

To provide a summary of our initial experience and assess the impact of the Saline-Assisted Fascial Exposure (SAFE) technique on erectile function (EF), urinary continence, and oncological outcomes after Robot-Assisted Laparoscopic Radical Prostatectomy (RALP).

PATIENTS AND METHODS

From January 2021 to July 2022, we included patients with a baseline Sexual Health Inventory for Men (SHIM) score of ≥17 and a high probability of extracapsular extension (ECE), ranging from 21% to 73%, as per the Martini et al. nomogram. A propensity score matching was carried out at a ratio of 1:2 between patients who underwent RALP + SAFE (33) and RALP alone (66). The descriptive statistical analysis is presented. The SAFE technique was performed using two approaches, transrectal guided by micro-ultrasound or transperitoneal. Its principle entails a low-pressure injection of saline solution in the periprostatic fascia to achieve an atraumatic dissection of the neural hammock. Potency was defined as a SHIM score of ≥17 and continence as no pads per day.

RESULTS

At follow-up intervals of 6, 13, 26, and 52 weeks, the SHIM score differed significantly between the two groups, favouring the RALP + SAFE (P = 0.01, P < 0.001, P < 0.001, and P = 0.01, respectively). These results remained significant when the mean SHIM score was assessed. As shown by the cumulative incidence curve, EF rates were higher in the RALP + SAFE compared to the RALP alone group (log-rank P < 0.001). The baseline SHIM and use of the SAFE technique were independent predictors of EF recovery.

CONCLUSIONS

The use of the SAFE technique led to better SHIM scores at 6, 13, 26, and 52 weeks after RALP in patients at high risk of ECE who underwent a partial NS procedure.

Robotic-assisted Versus Laparoscopic Radical Prostatectomy: 12-month Outcomes of the Multicentre Randomised Controlled LAP-01 Trial

BACKGROUND

Recently, our LAP-01 trial demonstrated superiority of robotic-assisted laparoscopic radical prostatectomy (RARP) over conventional laparoscopic radical prostatectomy (LRP) with respect to continence at 3 mo.

OBJECTIVE

To compare the continence, potency, and oncological outcomes between RARP and LRP in the 12-mo follow-up.

DESIGN, SETTING, AND PARTICIPANTS

In this multicentre, randomised, patient-blinded controlled trial, patients referred for radical prostatectomy to four hospitals in Germany were randomly assigned (3:1) to undergo either RARP or LRP.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Continence was assessed as a patient-reported outcome through validated questionnaires. Secondary endpoints included potency and oncological outcomes. Data were statistically analysed by bivariate tests and multivariable models.

RESULTS AND LIMITATIONS

At 12 mo, follow-up data were available for 701 of 782 patients. Continence at 6 and 12 mo after surgery was better in RARP patients, however no longer statistically significant (p = 0.068 and 0.38, respectively). Patients who were potent at baseline and underwent nerve-sparing surgery reported significantly higher potency after RARP, as defined by the capability to maintain an erection sufficient for intercourse at 3 (p = 0.005), 6 (p = 0.018), and 12 mo (p = 0.013). There were no statistically significant differences in oncological outcomes at 12 mo. It is a limitation that the influence of different anastomotic techniques was not investigated in this study.

CONCLUSIONS

Both LRP and RARP offer a high standard of therapy for prostate cancer patients. However, robotic assistance offers better functional outcomes in specific areas such as potency and early continence in patients who are eligible for nerve-sparing RP.

PATIENT SUMMARY

We compared outcomes 12 mo after radical prostatectomy between robotic-assisted and conventional laparoscopy. Both methods were equivalent with respect to oncological outcomes. Better recovery of continence in patients with robotic-assisted surgery, which was observed at 3 mo, blurred up to 12 mo. A benefit of robotic-assisted surgery was also observed in potency.

Robot-assisted radical prostatectomy: Advancements in surgical technique and perioperative care

We reviewed the evolving strategies, practice patterns, and recent advancements aimed at improving the perioperative and surgical outcomes in patients undergoing robot-assisted radical prostatectomy for the management of localized prostate cancer.

Technical advances in nerve-sparing and continence preservation

PURPOSE OF REVIEW

Urinary incontinence and erectile dysfunction are common after radical prostatectomy. These side effects greatly impact patients' quality of life. Therefore, surgical techniques and technology tools are constantly being developed to optimize trifecta outcomes. Here we focus on advances in nerve-sparing (NS) and continence preservation.

RECENT FINDINGS

New surgical techniques dedicated to preservation rather than reconstruction have been developed to improve urinary continence (UC) and NS. On the other hand, intraoperative assessment of prostatic and periprostatic structures has shown promising outcomes toward NS whereas avoiding omission of extracapsular extension (ECE). Likewise, neural regeneration strategies are under research to improve return of erectile function and UC.

SUMMARY

Superb outcomes after Robot-Assisted Radical Prostatectomy require a proper balance between NS and risk of ECE. Detailed anatomic knowledge together with an accurate surgical planning are cornerstone for tailoring the approach in each case.

Nerve-sparing robot-assisted radical prostatectomy: Current perspectives

Robotic-assisted radical prostatectomy (RARP) is the current standard of care with long term cure in organ-confined disease. The introduction of nerve-sparing (NS) to standard RARP has shown positive results in terms of functional outcomes in addition to the oncological outcomes. This article reviews the current perspectives of NS-RARP in terms of applied anatomy of the prostatic fascial planes, the neurovascular bundle (NVB), various NS techniques and postoperative functional outcomes. A non-systematic review was done using PubMed, Embase and Medline databases to retrieve and analyse articles in English, with following keywords "prostate cancer", "robotic radical prostatectomy", "nerve-sparing". The Delphi method was used with an expert panel of robotic surgeons in urology to analyse the potency outcomes of various published comparative and non-comparative studies. The literature has shown that NS-RARP involves various techniques and approaches while there is a lack of randomized studies to suggest the superiority of one over the other. Variables such as preoperative risk assessments, baseline potency, surgical anatomy of individual patients and surgeons' expertise play a major role in the outcomes. A tailored approach for each patient is required for applying the NS approach during RARP.

Use of chitosan membranes after nerve-sparing radical prostatectomy improves early recovery of sexual potency: results of a comparative study

OBJECTIVES

To evaluate the 1-year efficacy of chitosan membrane (ChiMe) application on the neurovascular bundles (NVBs) after nerve-sparing (NS) robot-assisted radical prostatectomy (RARP) in potency recovery rate. To compare the results with those of a contemporary cohort of patients who did not benefit from chitosan use.

PATIENTS AND METHODS

Patients in the ChiMe group were enrolled at our institution from July 2015 to September 2016 in a preliminary phase II study. All of them underwent NS-RARP with ChiMe applied on the NVBs and were followed over time to complete a 1-year follow-up. The control group was composed of patients who underwent NS-RARP at our institution without the application of ChiMe from January 2015. The patients were further classified into two groups based on the amount of nerves spared: Group A, comprised patients who underwent a monolateral or bilateral full NS; Group B, comprised patients in which a full NS was not performed. The demographics, peri- and postoperative data, and complications were recorded and compared. Potency recovery was recorded for Group A vs Group B in both the ChiMe and the control groups.

RESULTS

In all, 136 patients were enrolled in the ChiMe group and 334 patients in the control group. There were no differences between groups in terms of baseline variables. Based on the amount of nerves preserved, 183 patients were included in Group A and 287 in Group B. Odds ratios at different time points showed that the only two factors influencing potency recovery were the amount of nerves preserved (Group A vs Group B) and the application or not of ChiMe on the NVBs spared. Comparing the ChiMe vs control groups at different time points, we found a statistically significant improvement in the potency recovery rate in the ChiMe group at 1 month (36.76% vs 25.88%; P = 0.02) and 2 months (52.2% vs 39.22%; P = 0.01) after surgery, showing a favourable trend at every time point of the entire follow-up period, even if not significant after the second postoperative month. In Group A, the log-rank test showed a statistically significant difference between the ChiMe vs control groups (P = 0.02), in particular at 1 and 2 months after surgery (P = 0.02 and P = 0.01, respectively).

CONCLUSION

The application of ChiMe on the NVBs resulted in a higher potency recovery rate at 1 and 2 months after a bilateral or monolateral full NS-RARP. A trend of a higher and shorter potency recovery rate showed it to be favourable to use ChiMe, even in the cohort of patients who did not undergo a full NS procedure.

A prediction model relating the extent of intraoperative fascia preservation to erectile dysfunction after nerve-sparing robot-assisted radical prostatectomy

Robot-assisted radical prostatectomy (RARP) is performed in patients with prostate cancer. Unfortunately, 10-46% of patients may still suffer from limited erectile function (EF) after RARP. This study aimed to develop a prediction model based on the extent of fascia preservation (FP) and postoperative EF after RARP. A previously developed FP score quantizing the extent and regions of nerve-preservation was determined in a cohort of 1241 patients who underwent RARP. The predictive value of the FP score for post-prostatectomy EF (following the international index erectile function (IIEF) score, EF domain) was analyzed. To increase the predictive value of the scoring system, the FP regions were related to postoperative EF, nerve distribution and co-morbidity factors. Finally, a prediction model for EF was developed based on the studied cohort. When corrected for the preoperative IIEF-EF, the FP score was shown to be a significant denominator for IIEF (p = 2.5 × 10^- 15) with an R² of 35%. Variable selection performed using the Akaike information criterion led to a final prediction model for postoperative IIEF after nerve-preservation based on the FP score. Furthermore, patient's age, preoperative IIEF score, CCIS and use of clips for nerve sparing were significantly associated with postoperative IIEF-EF. More anterior fascia preservation was correlated with better EF outcome and age was a strong independent predictor of EF outcome. In older men, the relative benefit of more extensive fascia preservation was at least similar to younger men, despite a lower baseline IIEF-EF score. Quantitative nerve-sparing FP scoring could be related to the postoperative IIEF-EF and integrated into a multivariate prediction model, which includes with age, use of surgical clips, the Charlson Comorbidity Index Score (CCIS), and preoperative IIEF-EF. When further validated the prediction model could provide patients and care-givers a qualitative estimation of EF outcome after RARP.

Outcomes of robotic-assisted radical prostatectomy for patients in two extreme age-groups (< 50 years vs > 65 years)

Background and aims

To assess the outcomes of robotic radical prostatectomy in two different age subgroups of pre-operatively potent patients: younger than 50 years and older than 65 years.

Methods

We included in the present study a number of 202 patients with prostate cancer divided into two groups: 99 patients older than 65 years (group 1) and 103 patients younger than 50 years (group 2).

Results

More than half of the younger patients were low-risk vs 57% of the older patients who were high-risk. Overall positive surgical margins rate was 21.2% in group 1 vs 12.1% in group 2. The early biochemical recurrence at 6 months after radical prostatectomy was 4% in group 1 vs 11.6% in group 2. The continence rate at 6 months was similar between the two groups and was not correlated with the patients’ age (p=0.72), nerve-sparing (p=0.3 for group 1, p=0.92 for group 2) or pathological staging (overall p=0.81, p=0.89 in group 1 and p=0.63 in group 2). We observed a significantly higher rate of potency for patients in group 2 (91.5% vs 47.2%, p<0.0001). The most important factor associated with the regain of potency at 6 months after the procedure was the age of the patient (p<0.0001), independently of the type of nerve-sparing performed.

Conclusions

Age seems to be the most important predictor of the regain of potency after robotic radical prostatectomy. Patients should be counseled accordingly in order to have realistic expectations about the functional results after robotic-assisted surgery.

Chitosan membranes applied on the prostatic neurovascular bundles after nerve-sparing robot-assisted radical prostatectomy: a phase II study

OBJECTIVE

To evaluate the feasibility and the safety of applying chitosan membrane (ChiMe) on the neurovascular bundles (NVBs) after nerve-sparing robot-assisted radical prostatectomy (NS-RARP). The secondary aim of the study was to report preliminary data and in particular potency recovery data.

PATIENTS AND METHODS

This was a single-centre, single-arm prospective study, enrolling all patients with localised prostate cancer scheduled for RARP with five-item version of the International Index of Erectile Function scores of >17, from July 2015 to September 2016. All patients underwent NS-RARP with ChiMe applied on the NVBs. The demographics, perioperative, postoperative and complications data were evaluated. Potency recovery data were evaluated in particular and any sign/symptom of local allergy/intolerance to the ChiMe was recorded and evaluated.

RESULTS

In all, 140 patients underwent NS-RARP with ChiMe applied on the NVBs. Applying the ChiMe was easy in almost all the cases, and did not compromise the safety of the procedure. None of the patients reported signs of intolerance/allergy attributable to the ChiMe and potency recovery data were encouraging.

CONCLUSION

In our experience, ChiMe applied on the NVBs after NS-RARP was feasible and safe, without compromising the duration, difficulty or complication rate of the 'standard' procedure. No patients had signs of intolerance/allergy attributable to the ChiMe and potency recovery data were encouraging. A comparative cohort would have added value to the study. The present paper was performed before Conformité Européene (CE)-mark achievement.

Erectile dysfunction in robotic radical prostatectomy: Outcomes and management

Robot-assisted laparoscopic prostatectomy (RALP) has emerged as the most common treatment for localized prostate cancer. With improved surgical precision, RALP has produced hope of improved potency rates, especially with the advent of nerve-sparing and other modified techniques. However, erectile dysfunction (ED) remains a significant problem for many men regardless of surgical technique. To identify the functional outcomes of robotic versus open and laparoscopic techniques, new robotic surgical techniques and current treatment options of ED following RALP. A Medline search was performed in March 2014 to identify studies comparing RALP with open retropubic radical prostatectomy (RRP) and laparoscopic radical prostatectomy, modified RALP techniques and treatment options and management for ED following radical prostatectomy. RALP demonstrates adequate potency rates without compromising oncologic benefit, with observed benefit for potency rates compared with RRP. Additionally, specific surgical technical modifications appear to provide benefit over traditional RALP. Phosphodiesterase-5 inhibitors (PDE5I) demonstrate benefit for ED treatment compared with placebo. However, long-term benefit is often lost after use. Other therapies have been less extensively studied. Additionally, correct patient identification is important for greatest clinical benefit. RALP appears to provide beneficial potency rates compared with RRP; however, these effects are most pronounced at high-volume centers with experienced surgeons. No optimal rehabilitation program with PDE5Is has been identified based on current data. Additionally, vacuum erection devices, intracavernosal injections and other techniques have not been well validated for post RALP ED treatment.

Newer concepts in neural anatomy and neurovascular preservation in robotic radical prostatectomy

With more than 60% of radical prostatectomies being performed robotically, robotic-assisted laparoscopic prostatectomy (RALP) has largely replaced the open and laparoscopic approaches and has become the standard of care surgical treatment option for localized prostate cancer in the United States. Accomplishing negative surgical margins while preserving functional outcomes of sexual function and continence play a significant role in determining the success of surgical intervention, particularly since the advent of nerve-sparing (NS) robotic prostatectomy. Recent evidence suggests that NS surgery improves continence in addition to sexual function. In this review, we describe the neuroanatomical concepts and recent developments in the NS technique of RALP with a view to improving the “trifecta” outcomes.

Robotic radical prostatectomy: The new gold standard

Objectives

Open radical prostatectomy (RP) has been the standard and primary treatment for focal prostate cancer. However, in recent years this view has changed, as robot-assisted laparoscopic RP has gained acceptance among urologists. In this review we evaluate the importance and place of robotics in laparoscopic urological surgery, discussing several techniques that are currently being used and potentially new techniques that might be used in the future.

Methods

We systematically reviewed papers published between 1998 and 2011 using the keywords ‘robotic prostatectomy’ ‘gold standard’ and the Medline database. In addition, after selecting relevant reports we searched ‘related citations’ of the documents to find further supporting published papers.

Results

In all, 50 original papers were identified using the search criteria; we also found 28 through ‘related citations’ browsing. Papers were selected according to their relevance to the current topic (i.e. RP, original articles) and incorporated into this review. These papers were used for their information on the advantages of using robotics, as well as innovative ideas being used in the field of robotic urological surgery.

Conclusion

Almost a decade after the first robotic RP many reports show the benefits and advantages of incorporating robotics into urological surgery. Robotic surgery decreases the learning curve necessary for surgeons when compared with laparoscopic techniques. In addition, patients prefer robotics, as the procedure is less invasive, diminishes the duration of hospitalisation and speeds the return to function.