Apical Margins after Robot-Assisted Radical Prostatectomy: Does Technique Matter?

Value of three-dimensional visualization of preoperative prostatic magnetic resonance imaging based on measurements of anatomical structures in predicting positive surgical margin after radical prostatectomy

Background

Positive surgical margin (PSM) or apical positive surgical margin (APSM) is an established predictive factor of biochemical recurrence or disease progression in prostate cancer (PCa) patients after radical prostatectomy. Since there are limited usable magnetic resonance imaging (MRI)-based models, we sought to explore the role of three-dimensional (3D) visualization for preoperative MRI in the prediction of PSM or APSM.

Methods

From December 2016 to April 2022, 149 consecutive PCa patients who underwent radical prostatectomy were retrospectively selected from the Second Affiliated Hospital of Dalian Medical University. According to the presence of PSM or APSM, patients were divided into a PSM group (n=41) and a without PSM group (n=108) and into an APSM group (n=33) and a without APSM group (n=116). Twenty-one parameters, including prostate apical shape, PCa distance to the membranous urethra, and pubic angle, were measured on 3D visualization of MRI. The development of the nomogram models was built by the findings of multivariate logistic regression analysis for significant factors.

Results

To predict the probability of PSM, a longer PCa distance to the membranous urethra (OR=0.136, p=0.019) and the distance from the anterior peritoneum to the anterior border of the coccyx (work space AP, OR=0.240, p=0.030) were independent protective factors, while a type 3 prostate apical shape (OR=8.262, p=0.025) and larger pubic angle 2 (OR=5.303, p=0.029) were identified as independent risk factors. The nomogram model presented an area under the curve (AUC) of the receiver operating characteristic curve (ROC) of PSM of 0.777. In evaluating the incidence of APSM, we found that the distance to the membranous urethra (OR=0.135, p=0.014) was associated with a low risk of APSM, while larger pubic angle 1 (OR=4.666, p=0.043) was connected to a higher risk of APSM. The nomogram model showed that the AUC of APSM was 0.755.

Conclusion

As 3D visualization for preoperative MRI showed good performance in predicting PSM or APSM, the tool might be potentially valuable, which also needs to be validated by multicenter, large-scale, prospective studies.

Identifying prognostic parameters related to surgical technique in patients treated by robotic radical prostatectomy

INTRODUCTION AND OBJECTIVE

The most frequently studied factors in patients treated by robotic radical prostatectomy are PSA and pathological features of the biopsy and prostatectomy specimen. Studies on the factors associated with the surgical technique are scarce and with controversial results. The objective is to identify all possible surgical factors and their relationship with disease-free and metastasis-free survival.

PATIENTS AND METHOD

Prospective study approved by the Ethics Committee, including patients who underwent robotic radical prostatectomy since January 2009 with a minimum follow-up of 5 years. Surgeon, surgical time, blood loss, fascial access, continence techniques, preservation of the fascia, neurovascular bundles, bladder neck, urethra, learning curve and surgical complications, were analyzed as possible prognostic factors. We performed univariate and matched comparisons of survival using Kaplan-Meier estimation and long-rank tests. The significance level for multiple comparisons was established with False Discovery Rate-adjustment (adjusted p).

RESULTS

Cohort of 667 patients with a median follow-up of 69 months. In univariate analysis, surgeon (adjp=0.018), preservation of puboprostatic ligaments (adjp=0.02), preservation of endopelvic fascia (adjp=0.001) and performing periurethral suspension (adjp<0.001) are poor prognostic factors for disease-free survival. Fascia preservation also negatively affects metastasis-free survival (adjp=0.04). Previous abdominal surgeries, prostate, surgical time, blood loss, type of residual urethra, middle lobe, fascial access, fascia or bladder neck preservation, have no statistical significance.

CONCLUSIONS

The surgeon and specific aspects of the surgical technique are determining factors in disease-free survival. Preservation of the fascia is the only factor that negatively affects metastasis-free survival.

Management with Santorini’s Plexus Should Be Personalized during Prostatectomy

The aim of this study is to compare the results of laparoscopic prostatectomy in terms of management with Dorsal Venosus Complex (DVC)/Santorini’s plexus as it is still an open question in the field of urology. For this purpose, 457 patients after prostatectomy derived from two high volume centers were compared. In one center, patients underwent DVC ligation in all cases, whereas in the second center, this step was omitted. Subsequently, the histological and functional results were compared. Results showed that DVC management has an impact on blood loss and the duration of the surgery. In addition, omitting DVC ligation is demonstrated to reduce positive margin rate within the apex if the cancer was localized in this region. The continence and erectile function were similar in the 12-month follow up.

Comparison of extraperitoneal laparoscopic and extraperitoneal Senhance radical prostatectomy

BACKGROUND

Senhance is novel robotic platform which can be used to perform radical prostatectomy (RP). We compare our results of robotic RP to similar patients operated with laparoscopic technique.

PATIENTS AND METHODS

A prospective study of 61 patients operated laparoscopically and 107 patients operated using the Senhance robotic system. We have analysed operative and postoperative results in both groups.

RESULTS

There was no difference in the operative time, estimated blood loss, positive surgical margins, length of hospitalisation and catheterisation. There were 4 (6.5%) Clavien-Dindo grade I complications, and 5 (8.1%) late complications in laparoscopy. There were 6 (5.6%) Clavien-Dindo grade I, 3 (2.8%) grade II, 1 (0.9%) grade IV complications and 2 (1.9%) late complications in robotic group.

CONCLUSION

Senhance robot-assisted RP is safe, feasible and offers good and comparable functional and oncological outcomes to laparoscopy. The transition to robotic surgery with a relatively fast learning curve can be done effectively for surgeons with previous laparoscopic experience.

Prediction of a positive surgical margin and biochemical recurrence after robot-assisted radical prostatectomy

The positive surgical margin (PSM) and biochemical recurrence (BCR) are two main factors associated with poor oncotherapeutic outcomes after prostatectomy. This is an Asian population study based on a single-surgeon experience to deeply investigate the predictors for PSM and BCR. We retrospectively included 419 robot-assisted radical prostatectomy cases. The number of PSM cases was 126 (30.1%), stratified as 22 (12.2%) in stage T2 and 103 (43.6%) in stage T3. Preoperative prostate-specific antigen (PSA) > 10 ng/mL (p = 0.047; odds ratio [OR] 1.712), intraoperative blood loss > 200 mL (p = 0.006; OR 4.01), and postoperative pT3 stage (p < 0.001; OR 6.901) were three independent predictors for PSM while PSA > 10 ng/mL (p < 0.015; hazard ratio [HR] 1.8), pT3 stage (p = 0.012; HR 2.264), International Society of Urological Pathology (ISUP) grade > 3 (p = 0.02; HR 1.964), and PSM (p = 0.027; HR 1.725) were four significant predictors for BCR in multivariable analysis. PSMs occurred mostly in the posterolateral regions (73.8%) which were associated with nerve-sparing procedures (p = 0.012) while apical PSMs were correlated intraoperative bleeding (p < 0.001). A high ratio of pT3 stage after RARP in our Asian population-based might surpass the influence of PSM on BCR. PSM was less significant than PSA and ISUP grade for predicting PSA recurrence in pT3 disease. Among PSM cases, unifocal and multifocal positive margins had a similar ratio of the BCR rate (p = 0.172) but ISUP grade > 3 (p = 0.002; HR 2.689) was a significant BCR predictor. These results indicate that PSA and pathological status are key factors influencing PSM and BCR.

Techniques of robotic radical prostatectomy for the management of prostate cancer: which one, when and why

The advent of robotic assistance in surgery has completely revolutionized the surgical management of prostate cancer. It enables precise dissection and reconstruction in order to maximize oncological and functional outcomes. In many parts of the world, robot-assisted laparoscopic radical prostatectomy has evolved to become the surgical standard of care for localized disease, including in appropriately selected patients with high risk prostate cancer. Its role has also been expanded to encompass cytoreductive prostatectomy and salvage radical prostatectomy. As surgical expertise grows with robotic assistance, several novel and non-radical approaches have been developed to further mitigate treatment side effects. Patient characteristics, disease factors and surgeon expertise are important metrics for consideration when selecting the most appropriate technique for any given patient.

Delayed versus standard ligature of the dorsal venous complex during laparoscopic radical prostatectomy: A systematic review and meta-analysis of comparative studies

PURPOSE

To evaluate current views on comparing delayed ligature of the dorsal venous complex (D-DVC) with standard ligature of the dorsal venous complex (S-DVC) for safety, urinary control and oncological outcomes during laparoscopic radical prostatectomy.

METHODS

A comprehensive searching of PubMed, Web of science, Embase and the Cochrane Library was made and then we performed a meta-analysis, including all randomized controlled trials (RCTs) and retrospective studies, to evaluate the two different techniques.

RESULTS

Two RCTs and six retrospective studies containing 1822 cases (222 cases from RCTs and 1600 cases from retrospective studies) were identified. Although D-DVC was related to more blood loss (WMD: 7.30 mL; 95% CI, 2.43 to 12.16; p = 0.003), the blood transfusion rate between the two groups showed no significant difference (OR = 1.93; 95% CI, 0.55 to 6.73; p = 0.31), and patients in the D-DVC group could benefit from a shorter operative time (WMD: -30.83 min; 95% CI, -53.32 to -8.35; p = 0.007). Positive apical margin events were significantly less in the D-DVC group (OR = 0.39; 95% CI, 0.22 to 0.71; p = 0.002). As for urinary control, there were no differences in continence rates after 3 months (OR = 1.64; 95% CI, 0.98 to 2.73; p = 0.06) and 12 months (OR = 1.00; 95% CI, 0.63 to 1.57; p = 0.99) of follow-up. However, there was a significantly higher continence rate after 6 months of follow-up in the D-DVC group (OR = 1.46; 95% CI, 1.02 to 2.11; p = 0.04).

CONCLUSIONS

Standard and delayed approaches to DVC are equally safe and result in similar urinary control. The delayed approach could decrease the positive apical margin rate. However, further large-scale prospective studies are needed to investigate and compare the prognosis and long-term functional outcomes between the two approaches.

A technique of pretightening dorsal vein complex can facilitate laparoscopic radical prostatectomy

The ligation of dorsal venous complex (DVC) is a very important procedure during laparoscopic radical prostatectomy (LRP). Inaccurate DVC ligation may lead to severe bleeding or postoperative incontinence. We, therefore, designed the DVC pretightening technique to facilitate this procedure. The 32 involved patients with localized prostate cancer underwent LRP between July 2017 and October 2018. All of the patients received DVC pretightening technique. A laparoscopic intestinal clamp was used to narrow and strain DVC. The needle passage was limited between the bone and clamp. The ligation time, DVC-related blood loss, and continence data were recorded. The ligation of DVC in 32 patients was performed with DVC pretightening technique. Every suture was completed with one attempt. The mean ligation time was 2.7 ± 1.0 min. The DVC-related blood loss was 2.0 ± 1.3 ml. The 3-month continence rate was 81.3% (26/32). Positive margin rate was 9.4% (3/32). In conclusion, the DVC pretightening technique simplified the ligation of DVC during LRP. It is a safe and reliable technique. However, large-sample randomized controlled trials are still required to confirm the advantage of the new method in improving mean ligation time, DVC-related blood loss, continence rate, and positive margin rate.

A Novel Approach for Apical Dissection During Robot-assisted Radical Prostatectomy: The "Collar" Technique

BACKGROUND

Apical dissection in robot-assisted radical prostatectomy (RARP) affects not only cancer control, but also continence recovery.

OBJECTIVE

To describe a novel approach for apical dissection, the collar technique, to reduce apical positive surgical margins (PSMs).

DESIGN, SETTING, AND PARTICIPANTS

A total of 189 consecutive patients (81 in the control group, 108 in the collar technique group) underwent RARP at a single center.

PRIMARY OUTCOME

rates of apical PSMs; secondary outcome: urinary continence.

INTERVENTION

The urethral sphincter complex is incised 2-3mm distally to the apex, to stay farther from it and reduce PSMs; the underlying smooth muscle is exposed and incised closer to the apex to preserve the maximal length of the lissosphincter.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Mann-Whitney U and chi-square tests compared median and proportions between the two groups, respectively. Univariate logistic regression tested the association between technique employed and risk of apical PSMs.

RESULTS AND LIMITATIONS

Fourteen patients (7.4%) revealed apical PSMs (9.9% in the control group, 5.6% in the collar group; p=0.7). When the collar technique was used, significantly lower rates of apical PSMs occurred in pT2 disease (0% vs 7.1%; p=0.03). In case of apical tumor at preoperative magnetic resonance imaging (MRI; n=43), the collar technique determined significantly lower overall (9.7% vs 42%) and apical (3.2% vs 42%) PSMs (all p≤0.02). Continence recovery in the collar and control groups was similar. When preoperative MRI showed an apical tumor, the collar technique had a significantly lower risk of apical PSMs (odds ratio: 0.05, p=0.009).

CONCLUSIONS

The collar technique reduces the rates of apical PSMs in case of apical tumor, preserving the length of the lissosphincter.

PATIENT SUMMARY

We describe a novel approach for apical dissection during robot-assisted radical prostatectomy. Our technique reduces the rates of apical surgical margins in case of apical tumor at preoperative magnetic resonance imaging and leads to optimal continence recovery.

Review of optimal techniques for robotic-assisted radical prostatectomy

PURPOSE OF REVIEW

Robotic-assisted radical prostatectomy has been rapidly adopted and is now the standard of care in the surgical management of prostate cancer. Since the initial description in 2001, the technique has evolved to optimize oncological functional outcomes. Herein, we review key techniques for the robotic-assisted radical prostatectomy.

RECENT FINDINGS

With the current influx of new technology such as focal therapy, stereotactic body radiation therapy and prostate-sparing treatments, there is greater emphasis on maximizing outcomes of robotic-assisted radical prostatectomy. The evidence-based techniques of optimizing oncological outcomes including the lymph node dissection and improving cancer control through minimizing positive surgical margins are reviewed. Improvements in functional recovery has also been seen with technical modifications such as nerve sparing, preservation of the urethral support structures and the bladder neck and the urethra-vesical reconstruction.

SUMMARY

Robotic prostatectomy has demonstrated adequate long-term oncologic success and satisfactory functional recovery. As technology and techniques in robotic-assisted surgery evolve, surgeons will continue to optimize techniques to maximize functional outcome recovery and cancer control. Further studies are actively being conducted to provide level one evidence in multiple aspects of the robotic-assisted radical prostatectomy.

Wrong to be Right: Margin Laterality is an Independent Predictor of Biochemical Failure After Radical Prostatectomy

OBJECTIVES

To examine the impact of positive surgical margin (PSM) laterality on failure after radical prostatectomy (RP). A PSM can influence local recurrence and outcomes after salvage radiation. Unlike intrinsic risk factors, a PSM is caused by intervention and thus iatrogenic failures may be elucidated by analyzing margin laterality as surgical approach is itself lateralized.

PATIENTS AND METHODS

We reviewed 226 RP patients between 1991 and 2013 with PSM. Data includes operation type, pre/postoperative PSA, surgical pathology, and margin type (location, focality, laterality). The median follow-up was 47 months. Biochemical recurrence after RP was defined as PSA≥0.1 ng/mL or 2 consecutive rises above nadir. Ninety-two patients received salvage radiation therapy (SRT). Failure after SRT was defined as any PSA≥0.2 ng/mL or greater than presalvage. Kaplan-Meier and Cox multivariate analyses compared relapse rates.

RESULTS

The majority of PSM were iatrogenic (58%). Laterality was associated with differences in median relapse: right 20 versus left 51 versus bilateral 14 months (P<0.01). Preoperative PSA, T-stage, Gleason grade, and laterality were associated with biochemical progression on univariate and multivariate analyses. Right-sided margins were more likely to progress than left (hazard ratio, 1.67; P=0.04). More right-sided margins were referred for SRT (55% right vs. 23% left vs. 22% bilateral), but were equally salvaged. Only T-stage and pre-SRT PSA independently influenced SRT success.

CONCLUSIONS

Most PSM are iatrogenic, with right-sided more likely to progress (and sooner) than left sided. Margin laterality is a heretofore unrecognized independent predictor of biochemical relapse and hints at the need to modify the traditional unilateral surgical technique.

The application of a blunt-tip needle to suture the dorsal venous complex in robot-assisted laparoscopic radical prostatectomy

OBJECTIVES

Complete haemostasis of the dorsal venous complex (DVC) is of great importance in robot-assisted radical prostatectomy. In this study, we investigated the efficacy of blunt-tip needles in the surgery.

METHODS

Cases of robot-assisted laparoscopic radical prostatectomy were reviewed. If a blunt-tip needle had been used to suture the DVC, the patient was recruited to the blunt-tip group. If a regular needle was used, the patient was recruited to the control group. Patient characteristics and perioperative outcomes were recorded.

RESULTS

One hundred and nine cases were reviewed. A blunt-tip needle was used to suture the DVC in 67 cases, and a regular needle in 42 cases. All characteristics of the two groups are comparable (p > 0.05). In 66 cases in the blunt-tip group, no sutures or coagulations were needed when suturing the DVC, Five cases of DVC-related bleeding were observed in the control group, which is higher than in the blunt-tip group (p = 0.031). At the same time, no catheter was sutured in the blunt-tip group. All patients were followed for at least six months. The continence rate in the blunt-tip group is 89.6%, significantly higher than in the control group (73.8%, p = 0.031).

CONCLUSIONS

Using a blunt-tip needle to suture the DVC may reduce DVC-related bleeding and provide a better surgical field. It may be helpful in improving postoperative continence. However, its effect on positive margin at the apex still needs further investigation.

[MODIFICATIONS FOR CONTROLLING THE DORSAL VEIN COMPLEX IN ROBOTIC-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY]

OBJECTIVE

To investigate a superior method for controlling the dorsal vein complex (DVC) in robotic-assisted laparoscopic radical prostatectomy at Nagakubo hospital.

PATIENTS AND METHODS

DVC control was altered from suture ligation followed by DVC division (SL group, n = 115) to preceding division followed by suture (PD group, n = 62). Surgical margin status and functional outcomes were investigated.

RESULTS

No notable surgical complications were found in the PD group. Operation time and estimated blood loss were significantly less in the PD group; however, changes to serum hemoglobin before and after surgery showed no significant difference. The rates of positive surgical margin were 26.1% and 11.3% in the SL and PD groups, respectively (p = 0.021). Apical margin positivity was 9.6% and 3.2% in the SL and PD groups, respectively (p = 0.12). Urinary continence outcomes of within one pad/day and pad free in the SL and PD groups until 6 mo after surgery were 93.6% and 89.1% (P = 0.21), and 67.3% and 67.5% (p = 0.96), respectively. Erection recovery within 6 mo was 43.6% and 41.7% in the SL and PD groups (p = 0.91).

CONCLUSION

Preceding division followed by suture method decreased apical margin positivity and provided superior cancer control in comparison with suture ligation followed by DVC division, although, it was probably influenced by the learning curve. Functional outcomes were not significantly different with either method.

Robot-assisted radical prostatectomy: inching toward gold standard

Robot-assisted radical prostatectomy (RARP) offers excellent and lasting oncologic control. Technical refinements in apical dissection, such as the retroapical approach of synchronous urethral transection, and adoption of real-time frozen section analysis of the excised prostate during RARP have substantially reduced positive surgical margin rates, particularly in high-risk disease patients. Furthermore, precision offered by the robotic platform and technical evolution of radical prostatectomy, including enhanced nerve sparing (veil), have led to improved potency and continence outcomes as well as better safety profile in patients undergoing surgical therapy for prostate cancer.

Positive surgical margins after radical prostatectomy: a systematic review and contemporary update

CONTEXT

The clinical significance of positive surgical margins (PSMs) in radical prostatectomy (RP) specimens and the management of affected patients remain unclear.

OBJECTIVE

To address pitfalls in the pathologic interpretation of margin status; provide an update on the incidence, predictors, and long-term oncologic implications of PSMs in the era of robot-assisted laparoscopic RP (RALRP); and suggest a practical evidence-based approach to patient management.

EVIDENCE ACQUISITION

A systematic review of the literature was performed in April 2013 using Medline/PubMed, Web of Science, and Scopus databases and the Cochrane Database of Systematic Reviews. Studies focusing on PSMs in RP pertinent to the objectives of this review were included. Particular attention was paid to publications within the last 5 yr and those concerning RALRP.

EVIDENCE SYNTHESIS

A total of 74 publications were retrieved. Standardized measures to overcome variability in the pathologic interpretation of surgical margins have recently been established by the International Society of Urological Pathology. The average rate of PSMs in contemporary RALRP series is 15% (range: 6.5-32%), which is higher in men with a more advanced pathologic stage and equivalent to the rate reported in prior open and laparoscopic prostatectomy series. The likelihood of PSMs is strongly influenced by the surgeon's experience irrespective of the surgical approach. Technical modifications using the robotic platform and the role of frozen-section analysis to reduce the margin positivity rate continue to evolve. Positive margins are associated with a twofold increased hazard of biochemical relapse, but their association with more robust clinical end points is controversial. Level 1 evidence suggests that adjuvant radiation therapy (RT) may favorably affect prostate-specific antigen recurrence rates, but whether the therapy also affects systemic progression, prostate cancer-specific mortality, and overall survival remains debatable.

CONCLUSIONS

Although positive margins in prostate cancer are considered an adverse oncologic outcome, their long-term impact on survival is highly variable and largely influenced by other risk modifiers. Adjuvant RT appears to be effective, but further study is required to determine whether early salvage RT is an equivalent alternative.

Systematic review and meta-analysis of studies reporting oncologic outcome after robot-assisted radical prostatectomy

CONTEXT

Despite the large diffusion of robot-assisted radical prostatectomy (RARP), literature and data on the oncologic outcome of RARP are limited.

OBJECTIVE

Evaluate lymph node yield, positive surgical margins (PSMs), use of adjuvant therapy, and biochemical recurrence (BCR)-free survival following RARP and perform a cumulative analysis of all studies comparing the oncologic outcomes of RARP and retropubic radical prostatectomy (RRP) or laparoscopic radical prostatectomy (LRP).

EVIDENCE ACQUISITION

A systematic review of the literature was performed in August 2011, searching Medline, Embase, and Web of Science databases. A free-text protocol using the term radical prostatectomy was applied. The following limits were used: humans; gender (male); and publications dating from January 1, 2008. A cumulative analysis was conducted using Review Manager software v.4.2 (Cochrane Collaboration, Oxford, UK) and Stata 11.0 SE software (StataCorp, College Station, TX, USA).

EVIDENCE SYNTHESIS

We retrieved 79 papers evaluating oncologic outcomes following RARP. The mean PSM rate was 15% in all comers and 9% in pathologically localized cancers, with some tumor characteristics being the most relevant predictors of PSMs. Several surgeon-related characteristics or procedure-related issues may play a major role in PSM rates. With regard to BCR, the very few papers with a follow-up duration >5 yr demonstrated 7-yr BCR-free survival estimates of approximately 80%. Finally, all the cumulative analyses comparing RARP with RRP and comparing RARP with LRP demonstrated similar overall PSM rates (RARP vs RRP: odds ratio [OR]: 1.21; p=0.19; RARP vs LRP: OR: 1.12; p=0.47), pT2 PSM rates (RARP vs RRP: OR: 1.25; p=0.31; RARP vs LRP: OR: 0.99; p=0.97), and BCR-free survival estimates (RARP vs RRP: hazard ratio [HR]: 0.9; p=0.526; RARP vs LRP: HR: 0.5; p=0.141), regardless of the surgical approach.

CONCLUSIONS

PSM rates are similar following RARP, RRP, and LRP. The few data available on BCR from high-volume centers are promising, but definitive comparisons with RRP or LRP are not currently possible. Finally, significant data on cancer-specific mortality are not currently available.

Frequency of positive surgical margin at prostatectomy and its effect on patient outcome

A positive surgical margin at prostatectomy is defined as tumor cells touching the inked edge of the specimen. This finding is reported in 8.8% to 42% of cases (median about 20%) in various studies. It is one of the main determinants of eventual biochemical (PSA) failure, generally associated with a doubled or tripled risk of failure. The effect of a positive margin on outcome can be modified by stage or grade and the length, number and location of positive margins, as well as by technical operative approach and duration of operator experience. This paper tabulates data from the past decade of studies on margin status.

Impact of Partin nomogram on presurgical planning: intrafascial versus interfascial nerve sparing during robot-assisted radical prostatectomy

We studied the impact of using the Partin nomogram in tailoring the nerve sparing approach during robot-assisted radical prostatectomy. From July 2008 to July 2009, 168 patients underwent robot-assisted radical prostatectomy with bilateral nerves spared. All of the first 70 patients (cohort I) had intrafascial nerve sparing, while the Partin nomogram was used to determine the nerve sparing approach in the next 98 patients (cohort II). In patients with a probability greater than 53% of having pathologically non-organ-confined disease, conventional interfascial nerve sparing was performed; otherwise, intrafascial nerve sparing was carried out. Preoperative patient demographics were similar between the two cohorts. In cohort II, 68 and 30 patients had the bilateral nerves spared intrafascially and interfascially, respectively. Overall, the prevalence of pT3 disease in cohort I was 24.3% and in cohort II was 21.4%. The positive surgical margin rate in cohort I was 15.7% while that in cohort II was 6.1%. There was no significant difference in positive surgical margin rate in organ-confined (pT2) disease between the two groups (7.5 and 5.2%). On the other hand, pT3 positive surgical margin rate was significantly reduced in cohort II (41.2 and 4.8%, P = 0.013). Using the Partin nomogram in deciding interfascial versus intrafascial nerve sparing during robot-assisted radical prostatectomy gave a significant reduction of positive surgical margin rate in pT3 prostate cancers.

Ethnic variation in pelvimetric measures and its impact on positive surgical margins at radical prostatectomy

OBJECTIVES

We sought to evaluate the ethnic variation in pelvimetry and its impact as a predictor of positive surgical margins (PSM) at radical prostatectomy (RP).

METHODS

Preoperative MRI was performed in 482 Caucasian and 103 African American (AA) men undergoing RP without previous treatment from July 2003 to January 2005 and November 2001 to June 2007, respectively. We measured bony and soft tissue dimensions on magnetic resonance imaging (MRI) to evaluate the pelvic inlet, midplane, prostate size, and apical depth. Analysis of covariance was performed to determine the effect of ethnicity on the midpelvic area (MPA). We performed multivariate logistic regression analysis for prediction of overall and site-specific PSM.

RESULTS

AA men had a significantly steeper symphysis pubis angle (median, 43.1 vs. 41.3°, respectively, P = .001) and smaller MPA (median, 78.5 vs. 83.9 cm(2), respectively, P = .004). Ethnicity and BMI were found to have a significant effect on MPA. Apical depth of the prostate was identified as a significant independent predictor of apical PSM, with a more pronounced effect in AA men. Pelvimetric measures were not a significant predictor of other sites of PSM.

CONCLUSIONS

AA men have a significantly smaller MPA and steeper symphysis angle. The adverse impact of a deep pelvis, as measured by the apical prostatic depth on apical PSM was found to be greater in AA men. Evaluation of pelvic dimensions and prostate parameters in preoperative MRI may add to our understanding of their impact on surgical outcomes.

The depth of the prostatic apex is an independent predictor of positive apical margins at radical prostatectomy

OBJECTIVE

To determine the effect of a deep and narrow pelvis on apical positive surgical margins (PSM) at radical prostatectomy (RP), controlling for other clinical and pathological variables and surgical approach, i.e. open retropubic (RRP) vs laparoscopic (LRP), as apical dissection is expected to be more challenging at RP with a prostate situated deep in a narrow pelvis.

PATIENTS AND METHODS

From July 2003 to January 2005, 512 consecutive patients with preoperative prostate magnetic resonance imaging (MRI) underwent RRP or LRP with no previous radio- or hormonal therapy. An additional 74 patients with preoperative MRI undergoing RP from December 2001 to June 2007 who had an apical PSM were also included, with 586 patients comprising the study population. Bony and soft-tissue pelvic dimensions, including interspinous distance (ISD), bony (BFW) and soft tissue (SW) pelvic width, apical prostate depth (AD) and symphysis pubis angle, were measured on preoperative MRI. The pelvic dimension index (PDI), bony width index (BWI) and soft-tissue width index (SWI) were defined as ISD/AD, BFW/AD and SW/AD, respectively. Multivariate logistic regression was used to assess the effect of pelvic dimensions on apical PSM, controlling for surgical approach and clinical and pathological variables.

RESULTS

There was no significant difference in ISD, BFW, SW or symphysis angle between patients with and without apical PSM. The AD was significantly greater in men with an apical PSM and consequently PDI, BWI and SWI were significantly lower in men with an apical PSM. Each of PDI, AD, BWI and SWI was a significant independent predictor of apical PSM, independent of surgical approach, and other clinicopathological variables. The main limitations of the study were that it was retrospective, and the relatively few patients with apical PSM.

CONCLUSIONS

Apical prostate depth is an independent risk factor for apical PSM at RP. MRI pelvimetry might allow for preoperative planning of the approach to RP.

Anatomical retro-apical technique of synchronous (posterior and anterior) urethral transection: a novel approach for ameliorating apical margin positivity during robotic radical prostatectomy

OBJECTIVE

To describe a novel synchronous approach to apical dissection during robotic-assisted radical prostatectomy (RARP) which augments circumferential visual appreciation of the prostatic apex and membranous urethra anatomy, and assess its effect on apical margin positivity.

PATIENTS AND METHODS

Positive surgical margins (PSM) during RP predispose to earlier biochemical recurrence, and occur most frequently at the prostatic apex. Conventional apical transection after early ligation of the dorsal venous complex (DVC) remains suboptimal, as this approach obscures visualization of the intersection between prostatic apex and membranous urethra, leading to inadvertent apical capsulotomy and eventual margin positivity. A synchronous urethral transection commenced via a retro-apical approach was adopted in 209 consecutive patients undergoing RARP by one surgeon (A.T.) between April to September 2009. The apical margin rates for this group were compared with those of 1665 previous patients who received conventional urethral transection via an anterior approach after DVC ligation. Outcomes were adjusted for differences in clinicopathological variables. All RP specimens were processed according to institutional protocols, and examined by dedicated genitourinary pathologists. The location of PSMs was identified as apex, posterior, posterolateral, bladder neck, anterior, base, or multifocal.

RESULTS

Patients receiving synchronous urethral transection had significantly lower apical PSM rates than the control group (1.4% vs 4.4%, P = 0.04). This marked improvement in the retro-apical group occurred despite a significantly higher incidence of aggressive cancer (≥ pT3a) documented on final specimen pathology (16% vs 10%, P = 0.027).Technical difficulty was encountered in three of 209 study patients, in whom urethral transection had to be completed using the classic anterior approach.

CONCLUSION

Improved circumferential visualization of the prostatic apex, membranous urethra and their anatomical intersection facilitates precise dissection of the apex and its surrounding neural scaffold, and optimizes membranous urethral preservation. This has significantly ameliorated apical PSM rates in patients undergoing RARP, despite having to deal with more aggressive cancer on final specimen pathology.

Overcoming the learning curve for robotic-assisted laparoscopic radical prostatectomy

Robotic-assisted laparoscopic radical prostatectomy (RALP) has been rapidly adopted in the last few years despite having a prolonged learning curve. This article describes the RALP learning curve, reviews in detail the challenging steps of the operation, describes the authors' RALP technique, and concludes with tips to overcome the learning curve.

Impact of robotic training on surgical and pathologic outcomes during robot-assisted laparoscopic radical prostatectomy

OBJECTIVES

To prospectively compare outcomes during robotic prostatectomy between surgeons with formal training in either robotic prostatectomy (RALP) or laparoscopic prostatectomy (LRP).

METHODS

A total of 286 robotic prostatectomies were performed by 12 urologists between August 2008 and March 2009 as part of a new robotic surgery program at one of the largest health maintenance organizations in the United States. Four surgeons had formal training in RALP and 8 had formal training in LRP. We prospectively compared surgical and pathologic outcomes between these 2 groups of surgeons.

RESULTS

The 4 RALP surgeons performed 121 RALPs and the 8 LRP surgeons performed 165 RALPs. Patient demographics were similar between groups. The robot-naive group had significantly more clinical stage T1c than the robot-trained group (87.9% vs 74.4%, P = .003). Prostatectomy parameters were similar between the 2 groups of surgeons in terms of prostate size, Gleason score, pathologic stage, and estimated blood loss. The robot-trained surgeons had significantly lower overall positive margin rates (24% vs 34.6%, P = .05) and lower margin rates in T3 tumors (38.5% vs 61.8%, P = .07), which were approximately statistically significant. There was no difference in margin rates in T2 tumors. The robot-trained surgeons had significantly lower apical margin rates (8.3% vs 21.2%, P = .003) and lateral margin rates (1.7% vs 7.3%, P = .05). The robot-trained surgeons had 10%-15% shorter procedure times. There was no difference in complication rates.

CONCLUSIONS

Formal RALP training may be beneficial for surgical and pathologic outcomes of RALP compared with formal LRP training during the initial implementation of a new robotics program.

Evolution of Robot-Assisted Radical Prostatectomy

Introduction and Objective:

Open radical prostatectomy (RRP) is the gold standard and most widespread treatment for clinically localized prostate cancer. However, in recent years robot-assisted laparoscopic prostatectomy (RARP) is rapidly gaining acceptance among urologists worldwide. We sought to outline our surgical technique of robotic radical prostatectomy and provide practical recommendations based on available reports and personal experience. We also critically review the current experience on RARP world-wide and compare the available data with the gold standard open RRP series.

Material and Methods:

A systematic review of the literature was performed for all published manuscripts between 1997 and 2008 using the keywords — ‘robotic radical prostatectomy, ‘robot-assisted radical prostatectomy’, ‘laparoscopic radical prostatectomy’ and ‘robotic” using the Medline database.

Results:

A total of 226 original manuscripts on RARP were identified. Manuscripts were selected according to their relevance to the current topic (i.e. original articles, number of patients in the series, prospective data collection) and incorporated into this review.

Conclusions:

Eight years after the first RARP, multiple series are mature enough to demonstrate safety, efficiency and reproducibility of the procedure, as well as oncologic and functional outcomes comparable to its open counterpart. Further prospective, randomized studies comparing both surgical techniques are necessary in order to draw more definitive conclusions.