A prospective comparative analysis of robot-assisted vs open simple prostatectomy for benign prostatic hyperplasia

Outcomes of robotic modified Freyer's prostatectomy in an Australian patient cohort

Introduction

The study aims to demonstrate the feasibility, safety and efficacy of robotic simple prostatectomy (RSP) using the modified Freyer's approach in an Australian patient cohort. Although RSP is performed in several Australian centres, there is a paucity of published Australian data.

Methods

We reviewed prospectively collected perioperative and outcomes data for patients who underwent a robotic modified Freyer's prostatectomy (RMFP) from June 2019 to March 2022. Statistics were completed using SPSS statistics v27.0 and reported as mean and range with a p value of <0.05 considered statistically significant.

Results

There were 27 patients who underwent RMFP over the study period with a mean age of 67 years and prostate volume of 159.74 cc (100-275). The mean console time was 168 min (122-211), blood loss of 233 ml (50-600) and average length of hospital stay of 3.8 days (3-8). The preoperative versus postoperative outcome means were as follows: serum prostate-specific antigen was 9.69 versus 1.2 ng/mL, IPPS score was 17.1 versus 1.25, quality of life (QOL) score 3.4 versus 0.4, postvoid residual volume: 223.6 versus 55.9 ml, Q-max 7.86 versus 29.6 ml/s. These were all statistically significant (p < 0.001). The mean weight of resected tissue was 74 g (43-206) with 25 patients having benign histopathology and two being diagnosed with prostate cancer (Gleason 3 + 3 = 6 and 3 + 4 = 7). No patients returned to theatre or required a blood transfusion.

Conclusions

Data from our patient cohort demonstrate the feasibility, safety and efficacy of RMFP for benign prostatic hyperplasia in an Australian patient cohort. Our outcomes compare favourably with published studies on RSP.

Perioperative, functional, and oncologic outcomes of minimally-invasive surgery for highly complex renal tumors (RENAL or PADUA score ≥ 10): an evidence-based analysis

The primary objective of the current study is to undertake a comparative analysis of the effectiveness and safety of minimally-invasive partial nephrectomy (MIPN; including laparoscopic and robotic approaches) and open partial nephrectomy (OPN) for the treatment of highly complex renal tumors (defined as PADUA or RENAL score ≥ 10). A comprehensive search was conducted in four electronic databases (PubMed, Web of Science, Embase, and Cochrane Library) to identify relevant studies published in the English language up to April 2023. The current study employed Review Manager 5.4 and encompassed controlled trials of both MIPN and OPN for the treatment of highly complex renal tumors. This study comprised a total of eight comparative trials involving 1161 patients. MIPN demonstrated a significant reduction in length of hospital stay (weighted mean difference [WMD] - 2.08 days, 95% confidence interval [CI] - 2.48, - 1.68; p < 0.00001), blood loss (WMD - 39.86 mL, 95% CI - 75.32, - 4.39; p = 0.03), transfusion rates (odds ratio [OR] 0.30, 95% CI 0.13, 0.71; p = 0.006), and overall complications (OR 0.46, 95% CI 0.31, 0.70; p = 0.0003). However, there were no significant differences between MIPN and OPN in terms of operative time, warm ischemia time, conversion to radical nephrectomy rates, renal functional and oncologic outcomes. This study reveals that MIPN presents several benefits in comparison to OPN, including decreased length of hospital stay, blood loss, transfusion rates, and complications, while still offering renal functional and oncological outcomes that are comparable to those of OPN in patients with highly complex renal tumors.

Single-port transvesical versus open simple prostatectomy: a perioperative comparative study

OBJECTIVE

To compare the initial perioperative outcomes of single-port transvesical simple prostatectomy (SP RASP) patients to those of open simple prostatectomy (OSP).

PATIENTS AND METHODS

Perioperative data from 42 consecutive patients with BPH who underwent SP RASP were prospectively reviewed. Similarly, data from forty-three consecutive patients who underwent the standard OSP, were retrospectively collected. Through direct suprapubic bladder access, prostatic enucleation was performed using the prostatic capsule as a landmark. Then a complete vesicourethral mucosal advancement flap was accomplished. OSP was performed according to the standard approach. Demographics, Intra- and perioperative data were analyzed and assessed with a descriptive analysis.

RESULTS AND LIMITATIONS

Baseline characteristics were comparable between the two groups, except for the preoperative median post-void residual volume, which was higher in the OSP group (p = 0.004). The SP RASP group had less intraoperative estimated blood loss (p < 0.001), no need for continuous bladder irrigation (p < 0.001), and less in-hospital opioid use (p < 0.001). Patients in the SP RASP group were discharged on postoperative day zero, compared to a median of 2 days for OSP (p < 0.001). The median Foley catheter duration was 7 days for SP RASP, compared to a median of 10 days for OSP (p < 0.001). SP RASP group had fewer postoperative complications, however, this did not reach statistical significance.

CONCLUSION

SP RASP is an alternative approach in treating surgical BPH. It may offer patients less morbidity in comparison to OSP.

Perioperative and oncologic outcomes of minimally-invasive surgery for renal cell carcinoma with venous tumor thrombus: a systematic review and meta-analysis of comparative trials

BACKGROUND

The present study aimed to conduct a pooled analysis to compare the perioperative and oncologic outcomes of minimally-invasive radical nephrectomy with tumor thrombus (MI-RNTT) with open radical nephrectomy with tumor thrombus (O-RNTT).

METHODS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Four electronic databases (PubMed, Embase, Web of Science, and the Cochrane Library database) were systematically searched to identify relevant studies published in English up to December 2022. The primary outcomes were perioperative results, complications, and oncologic outcomes. Review Manager 5.4 was used for this analysis.

RESULTS

In total, eight retrospective trials with a total of 563 patients were included. Compared to O-RNTT, MI-RNTT had shorter hospitalization time [weighted mean difference (WMD) -3.58 days, 95% CI: -4.56 to -2.59; P <0.00001), lower volumes of blood loss (WMD -663.32 ml, 95% CI: -822.22 to -504.42; P <0.00001), fewer transfusion rates (OR 0.18, 95% CI: 0.09-0.35; P <0.00001), fewer overall complications (OR 0.33, 95% CI: 0.22-0.49; P <0.00001), and fewer major complications s (OR 0.49, 95% CI: 0.24-1.00; P =0.05). However, operative time, intraoperative complications, mortality rate (intraoperative, within 30 days, and total mortality), overall survival, recurrence-free survival, and cancer-specific survival did not significantly differ between the two groups.

CONCLUSIONS

MI-RNTT possesses more benefits than O-RNTT in terms of length of hospital stay, blood loss, and complications and provides comparable mortality rates and oncologic outcomes. However, more comprehensive and rigorous research is warranted to further validate the outcomes, which should include a larger sample size and comprehensive data from high-volume medical centers.

Surgical treatment of benign prostatic hyperplasia: Thulium enucleation versus single-port transvesical robotic simple prostatectomy

Objective

The objective of this work is to compare our outcomes using thulium laser enucleation of prostate (ThuLEP) to the single-port robot-assisted simple prostatectomy (SP RASP) in the surgical management of benign prostatic hyperplasia (BPH).

Methods

A retrospective cohort study was conducted from January 2017 through December 2021 of men who underwent SP RASP and ThuLEP performed by a single surgeon with an enucleation experience of >300 cases and extensive robotic experience. The primary outcome was changed in International Prostate Symptom Score (IPSS) postoperatively. Secondary outcomes were operative time, length of stay (LOS), change in post-void residuals (PVR), de novo stress- or urge-urinary incontinence (SUI, UUI), and rate of complications.

Results

One hundred two patients underwent surgery during the study period: 33 RASP and 69 ThuLEP. There was no difference in preoperative characteristics, including age and body mass index, between both groups. Changes in IPSS scores postoperatively were not significant between SP RASP versus ThuLEP (-17 vs. -14, p = 0.2956). SP RASP had a longer operative time (180 vs. 90 min, p < 0.0001). There was no difference in LOS (0 vs. 0 days, p = 0.2904). There was no difference in change in PVR (-96 vs. -91 mL, p = 0.8504). SP RASP patients had significantly less postoperative SUI than ThuLEP (0 vs. 13 patients, p = 0.0083), while there was no difference in UUI between both groups (4 vs. 2 patients, p = 0.0843). There was no difference in 30-day complication rate (21.2% vs. 21.7%, p = 0.9517), although there were three ThuLEP patients with Clavien-Dindo Class III or higher complication.

Conclusions

There was no difference in change in IPSS scores between the two groups. ThuLEP is associated with shorter postoperative catheter days and decreased operative times. Hospital LOS was equivalent. SP RASP demonstrates significantly improved continence rates. Though SP RASP is within the initial learning curve at our institution, early results demonstrate the role for this modality alongside ThuLEP in the treatment of large gland BPH.

Robotic assisted simple prostatectomy versus other treatment modalities for large benign prostatic hyperplasia: a systematic review and meta-analysis of over 6500 cases

BACKGROUND

Current guidelines recommend simple prostatectomy or endoscopic enucleation of the prostate (EEP) as treatment of choice for bladder prostatic obstruction (BPO) caused by large prostate glands. We aimed to provide a wide-ranging analysis of the currently available evidence, comparing safety and effectiveness of robot-assisted simple prostatectomy (RASP) versus open simple prostatectomy (OSP), laparoscopic simple prostatectomy (LSP), and laser EEP.

METHODS

A systematic search was performed across MEDLINE, EMBASE, and Web of Science databases for retrospective and prospective studies comparing RASP to OSP or LSP or laser EEP (HoLEP/ThuLEP). Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) recommendations were followed to design the search strategies, selection criteria, and evidence report. A meta-analysis evaluated perioperative safety and effectiveness outcomes. The weighted mean difference and risk ratio were used to compare continuous and dichotomous variables, respectively. Quality was assessed using the Newcastle-Ottawa scale and the Cochrane Collaboration's tool for RCT article assessing risk of bias.

RESULTS

15 studies, including 6659 patients, were selected for meta-analysis: 13 observational studies, 1 non-randomized prospective study, and 1 randomized controlled trial. RASP was associated with statistically significant longer operative time (OT) and lower postoperative complication rate, length of stay (LOS), estimated blood loss (EBL), and transfusion rate (TR) compared to OSP. LSP showed longer LOS and lower postoperative SHIM score, with no difference in OT, EBL, and complications. Compared to laser EEP, RASP presented longer LOS and catheterization time and higher TR. ThuLEP presented shorter OT than RASP. No difference were found in functional outcomes between groups both subjectively (IPSS, QoL) and objectively (Qmax, PVR).

CONCLUSION

RASP has become a size-independent treatment for the management of BPO caused by a large prostate gland. It can duplicate the functional outcomes of OSP while offering a better safety profile. When compared to LSP, the latter still stands as a valid lower-cost option, but it requires solid laparoscopic skill sets and therefore it is unlikely to spread on larger scale. When compared to laser EEP, RASP offers a shorter learning curve, but it still suffers from longer catheterization time and LOS.

Urethra-Sparing Robot-Assisted Simple Prostatectomy for Postoperative Antegrade Ejaculation

BACKGROUND

We report a comparative analysis of extraperitoneal urethra-sparing robot-assisted simple prostatectomy (EUS-RASP) versus robot-assisted simple prostatectomy (RASP) using the Freyer approach for patients with a large prostate volume greater than 80 mL.

METHODS

A total of 32 patients underwent EUS-RASP, and 30 underwent RASP from April 2018 to November 2021. All the perioperative data and 6-month follow-up data were collected prospectively. We retrospectively evaluated baseline characteristics and functional outcomes, including International Prostate Symptom Scores (IPSSs) and quality of life (QOL), maximum flow rate, and post-void residual volume, between the two groups. Sexual function was analyzed in the EUS-RASP group.

RESULTS

The patients undergoing EUS-RASP and RASP had comparable baseline characteristics and functional outcomes. The EUS-RASP group showed a shorter operative time (123.4 ± 15.2 min vs. 133.7 ± 21.4 min, p = 0.034), length of hospital stay (2.9 ± 1.5 days vs. 4.6 ± 1.5 days, p = 0.001), and catheterization time (2.4 ± 1.7 days vs. 8.1 ± 2.4 days, p < 0.001). A total of 14/32 (43.8%) patients reported normal preoperative ejaculatory function in the EUS-RASP group, and 11/14 (78.6%) maintained antegrade ejaculation postoperatively.

CONCLUSIONS

Extraperitoneal urethra-sparing RASP is an effective and feasible procedure that can improve voiding function and allow for the maintenance of ejaculatory function in patients with large prostates.

Comparison between minimally invasive partial nephrectomy and open partial nephrectomy for complex renal tumors: a systematic review and meta-analysis

BACKGROUND

The present study aimed to conduct a pooled analysis to compare the efficacy and safety of minimally invasive partial nephrectomy (MIPN) with open partial nephrectomy (OPN) in patients with complex renal tumors (defined as PADUA or RENAL score ≥7).

METHODS

The present study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, Supplemental Digital Content 1, http://links.lww.com/JS9/A394 . We conducted a systematic search of the PubMed, Embase, Web of Science, and Cochrane Library databases until October 2022. MIPN and OPN-controlled trials for complex renal tumors were included. The primary outcomes were perioperative results, complications, renal function, and oncologic outcomes.

RESULTS

A total of 2405 patients were included in 13 studies. MIPN outperformed OPN in terms of hospital stay [weighted mean difference (WMD) -1.84 days, 95% CI -2.35 to -1.33; P <0.00001], blood loss (WMD -52.42 ml, 95% CI -71.43 to -33.41; P <0.00001), transfusion rates [odds ratio (OR) 0.34, 95% CI 0.17-0.67; P =0.002], major complications (OR 0.59, 95% CI 0.40-0.86; P =0.007) and overall complications (OR 0.43, 95% CI 0.31-0.59; P <0.0001), while operative time, warm ischemia time, conversion to radical nephrectomy rates, estimated glomerular decline, positive surgical margins, local recurrence, overall survival, recurrence-free survival, and cancer-specific survival were not significantly different.

CONCLUSIONS

The present study demonstrated that MIPN was associated with a shorter length of hospital stay, less blood loss, and fewer complications in treating complex renal tumors. MIPN may be considered a better treatment for patients with complex tumors when technically feasible.

Perioperative, functional, and oncologic outcomes of robot-assisted versus open partial nephrectomy for complex renal tumors (RENAL score ≥ 7): an evidence-based analysis

This study aims to assess the efficacy and safety of robot-assisted partial nephrectomy (RAPN) compared with open partial nephrectomy (OPN) in the management of complex renal tumors (defined as RENAL score ≥ 7). We conducted a comprehensive literature search in PubMed, Embase, Web of Science, and Cochrane Library to identify relevant comparative studies up to January 2023. This study was conducted with the Review Manager 5.4 software, and included RAPN and OPN-controlled trials for complex renal tumors. The prime outcomes were to assess the perioperative results, complications, renal function, and oncologic outcomes. A total of 1493 patients were included in seven studies. Compared to OPN, RAPN was associated with a significantly shorter hospital stay (weighted mean difference [WMD] - 1.53 days, 95% confidence interval [CI] - 2.44, - 0.62; p = 0.001), less blood loss (WMD - 95.88 mL, 95% CI - 144.19, - 47.56; p = 0.0001), lower transfusion rates (OR 0.33, 95% CI 0.15, 0.71; p = 0.005), fewer major complications (OR 0.63, 95% CI 0.39, 1.01; p = 0.05), and fewer overall complications (OR 0.49, 95% CI 0.36, 0.65; p < 0.00001). Nevertheless, no statistically significant differences were found between the two groups in operative time, warm ischemia time, estimated glomerular decline, intraoperative complications, positive surgical margins, local recurrence, overall survival, and recurrence-free survival. The study demonstrated that RAPN had superior perioperative parameters and fewer complications when compared to OPN for complex renal tumors. However, no significant differences were found in terms of renal function and oncologic outcomes.

Comparison between robot-assisted versus open nephroureterectomy for upper tract urothelial carcinoma: outcomes from a pooled analysis

The present study aimed to compare the efficacy and safety between robot-assisted nephroureterectomy (RANU) and open nephroureterectomy (ONU) for the treatment of upper tract urothelial carcinoma (UTUC). We systematically searched four electronic databases (PubMed, Embase, Web of Science, and Cochrane Library) to locate pertinent studies published in English up to January 2023. The primary outcomes evaluated included perioperative results, complications, and oncologic outcomes. Statistical analyses and calculations were performed using Review Manager 5.4. The study was registered with PROSPERO (ID: CRD42022383035). In total, eight comparative trials, including 37,984 patients were enrolled. Compared to ONU, RANU was associated with a significantly shorter length of stay (weighted mean difference [WMD] - 1.63 days, 95% confidence interval [CI] - 2.90, - 0.35; p = 0.01), less blood loss (WMD - 107.04 mL, 95% CI - 204.97, - 9.11; p = 0.03), less major complication(OR 0.78, 95% CI 0.70, 0.88; p < 0.0001), and lower positive surgical margin (PSM) (OR 0.33, 95% CI 0.12, 0.92; p = 0.03). However, no statistically significant differences were observed between the two groups in operative time, transfusion rates, rate of lymph node dissection, lymph node yield, overall complications, overall survival, cancer-specific survival, recurrence-free survival, and progression-free survival. RANU has superior advantages compared to ONU in terms of length of hospital stay, blood loss, postoperative complications, and PSM, while providing comparable oncologic outcomes in patients with UTUC.

Robotic versus open simple prostatectomy for benign prostatic hyperplasia in large glands: single-centre study

PURPOSE

Robot-assisted simple prostatectomy (RASP) for benign prostatic hyperplasia (BPH) is a recently described surgical approach, but comparison with open simple prostatectomy (OSP) lack in the literature. We compared perioperative outcomes of OSP versus RASP.

METHODS

Patients who underwent simple prostatectomy between 2017 and 2020 were included in this retrospective study. OSP was performed by the transvesical technique and RASP was performed with a DaVinci Xi robot, using the transvesical extraperitoneal approach. Perioperative and postoperative data were compared and complications risk factors for complications were identified.

RESULTS

and limitations. Overall, 103 patients were included (median age 72 years [IQR = 67-76]). Forty-seven underwent RASP and 56 OSP. The median volume of the prostate gland was 130 mL [IQR = 100-180] in the RASP group and 126 mL [IQR = 100-160] in the OSP group. RASP was associated with a significant reduction in blood loss (median 200 vs. 400 mL; p < 0.001), shorter hospital stay (5 vs. 10 days; p < 0.001) and median catheterisation time (4 vs. 9 days; p < 0.001). In the RASP group, there were fewer grade ≥ 2 complications (2 (4.3%) vs. 13 (23.2%); p = 0.005) and less need for transfusions (0 vs. 6 (11%), p = 0.005). Preoperative prostate volume was a risk factor for complications (OR = 1.2 [95% CI 1.1-1.5]; p = 0.01) while robot-assisted surgery was a protective factor (OR 0.3 [95% CI 0.05-0.9]; p = 0.05). Functional outcomes between the two groups were identical at 12 months follow up.

CONCLUSION

RASP is a safe and effective procedure. When compared with OSP, RASP was associated with decreased morbidity as well as reduced hospital stay and catheterisation time. Functional outcomes were comparable to the open approach.

Standard Multi-Port versus Single-Port Robot‑Assisted Simple Prostatectomy: A Single Center Initial Experience

BACKGROUND

Robot-assisted simple prostatectomy (RASP) has emerged as a safe surgical treatment for patients with benign prostatic hyperplasia with large glands (>80 ml). Several studies reported on perioperative outcomes of RASP by the standard multiport (MP) da Vinci robotic system approach. Studies conducted on RASP utilizing the novel single-port da Vinci® SP robotic platform (Intuitive Surgical, Sunnyvale, CA) are scarce. We aimed to compare intraoperative and short-term postoperative outcomes between the da Vinci MP and SP robots for patients undergoing RASP in a referral center.

METHODS

In this retrospective study, we reviewed all patients who underwent RASP using MP or SP robot from September, 2016 to March, 2021. Intraoperative data, overall 30-day complications, complications by Clavien-Dindo classification and 90-day readmission and reoperation rates were assessed and compared between the two groups using appropriate statistical methods.

RESULTS

Seventy-five patients who underwent RASP were identified. Of these, 47 were in the MP group and 28 were in the SP. Compared to SP, mean operative time in MP group was 216.6 vs. 232.4 minutes (p=0.39), EBL was 195.7 vs. 227.1 ml (p=0.43) and length of stay was 2 vs. 2.5 days (p=0.45). There was a trend toward higher overall complication rate in SP group vs. MP (42.86% vs. 21.28%, p=0.09). There were no significant differences in the readmission (17.02% vs. 10.71%, p=0.52) and reoperation (2.1% vs. 7.14%, p=0.34) rates between MP vs. SP group.

CONCLUSION

SP-RASP is safe and shows equivalent perioperative outcomes when compared to the MP robotic system. A marginal increase of complication rate was recorded in the SP group; however, this did not demonstrate statistical significance.

Mid-term functional outcomes of extraperitoneal robot-assisted simple prostatectomy: a single centre experience

For large prostate volume, open simple prostatectomy (OSP) or holmium laser enucleation are the gold standard surgical treatment medical therapy failure. Robot-assisted simple prostatectomy (RASP) has recently been proposed as an alternative to OSP and endoscopic techniques. Our objective was to describe our extraperitoneal RASP technique for patients with benign prostate obstruction (BPO), and to report on perioperative and mid-term functional outcomes. Data were collected prospectively for all consecutive patients who underwent RASP in our high-volume tertiary hospital over a 6-year period. International Prostate Symptom Score (IPSS), International Index of Erectile Function-5 (IIEF-5) and uroflow findings were compared before and after surgery. Intraoperative and postoperative outcomes were also assessed. Forty-seven patients were included in the study. There was no intraoperative incident and no blood transfusion was needed after surgery. Median time to bladder catheter removal was 4 days and patients were discharged the day after. Within 90 postoperative days, 6 patients (12%) experienced at least one complication, all low-grade except one (2.1%) which was Clavien IIIa grade. By univariate analysis, the only risk factor for postoperative complications was the Charlson comorbidity index (OR = 2.1, 95% CI = [1.1-4.7], p = 0.04). At 12 months, a significant improvement IPSS and uroflow rate was observed. No patient reported stress urinary incontinence. Extraperitoneal RASP appears to be a safe and effective technique for men with LUTS related to large BPO. RASP is less invasive than OSP and wide diffusion of the robot-system could lead to the rapid implementation of RASP as a treatment for large prostate.

Robotic-assisted versus open simple prostatectomy: Results from a systematic review and meta-analysis of comparative studies

PURPOSE

To review safety and efficacy of robotic-assisted simple prostatectomy (RASP) compared to open simple prostatectomy (OP).

MATERIALS AND METHODS

A comprehensive literature search was performed to assess the differences in perioperative course and functional outcomes in patients with benign prostatic hyperplasia and surgical indication. The incidences of complications were pooled using the Cochran-Mantel-Haenszel Method and expressed as odds ratio (OR), 95% confidence interval (CI), and p-values. Perioperative course and functional outcomes were pooled using the inverse variance of the mean difference (MD), 95% CI, and p-values. Analyses were two-tailed and the significance was set at p<0.05.

RESULTS

Eight studies were accepted. Meta-analysis showed significantly longer surgical time (MD, 43.72; 95% CI, 30.57-56.88; p<0.00001) with a significantly lower estimated blood loss (MD, -563.20; 95% CI, -739.95 to -386.46; p<0.00001) and shorter postoperative stay (MD, -2.85; 95% CI, -3.72 to -1.99; p<0.00001) in RASP. Catheterization time did not differ (MD, 0.65; 95% CI, -2.17 to 3.48; p=0.65). The risk of blood transfusion was significantly higher in OP (OR, 0.23; 95% CI, 0.17-0.33; p<0.00001). The risk of recatheterization (OR, 1.96; 95% CI, 0.32-11.93; p=0.47), postoperative urinary infections (OR, 0.89; 95% CI, 0.23-3.51; p=0.87) and 30-day readmission rate (OR, 0.96; 95% CI, 0.61-1.51; p=0.86) did not differ. At 3-month follow-up, functional outcomes were similar.

CONCLUSIONS

RASP demonstrated a better perioperative outcome and equal early functional outcomes as compared to OP. These findings should be balanced against the longer operative time and higher cost of robotic surgery.

Robotic Freyer's prostatectomy: Operative technique and single-center experience

Introduction:

Transurethral resection of prostate replaced open surgery and remained the gold standard in surgical management of benign prostatic hyperplasia (BPH). Holmium laser enucleation and bipolar resection of prostate managed even larger glands. Open simple prostatectomy remains an option for large glands and concurrent pathologies. Minimally invasive laparoscopic simple prostatectomy lacks general acceptance. Surgeons have now started exploring the robotic platform due to its advantages. Herein, we present the technique and initial outcomes of robotic Freyer's prostatectomy (RFP).

Materials and Methods:

Thirteen transperitoneal RFPs were performed using the DaVinci Xi platform. We evaluated perioperative characteristics and functional outcomes.

Results:

Median patient age was 67.8 years and the mean prostate volume was 105.8 ml. The median International Prostate Symptom Score (IPSS) and American Urological Association quality of life (AUA-QoL) score was 19.6 and 5.3. There were no intraoperative complications or conversion to open surgery. The mean console time and estimated blood loss were 107.30 min and 92.5 ml, respectively. One patient required redo-surgery by robotic technique due to urine leak (Clavien-Dindo Grade 3b complication). Mean hospital stay and catheter duration were 4.9 days and 5.2 days, respectively. Change (preoperative vs. postoperative) in IPSS (19.6 vs. 4.67 points), maximum flow rate (6.8 vs. 15.1 ml/s), AUA-QoL score (5.3 vs. 2.2 points) and PVR (179.4 vs 7.1 ml) were significant (P < 0001).

Conclusions:

RFP is a safe and effective option for managing BPH, especially for large glands. It confers minimally invasive surgery benefits with good functional outcomes.

The place of robotic-assisted laparoscopy for BPO surgical management in 2021

PURPOSE OF REVIEW

Robot-assisted laparoscopic simple prostatectomy (RASP) is being used increasingly for the surgical treatment of benign prostatic obstruction (BPO). Our purpose is to review the main outcomes of RASP for the management of BPO.

RECENT FINDINGS

A computerised bibliographic search of Medline was performed for articles that included detailed results of RASP, published over the past 2 years. Although RASP seems to be associated with better perioperative and functional outcomes, this procedure remains expensive when compared to open or endoscopic surgery. However, considering the enhanced safety of RASP compared to open simple prostatectomy and its favourable learning-curve when compared to endoscopic laser enucleation, RASP seems to be a good and effective option in centres with extended robotic expertise. Single-port robotic surgery appeared to be safe and effective in two preliminary studies. Other studies reported interesting and improved results for the preservation of ejaculatory function.

SUMMARY

Many RASP techniques have been developed, with the common goal of improving the quality of life of patients. Although the cost of RASP is higher than open surgery, the perioperative benefits of the robotic approach make RASP a favourable option in centres with extended robotic expertise.

Robotic-Assisted vs. Open Simple Prostatectomy for Large Prostates: A Meta-Analysis

Purpose: To compare the efficacy and safety of robotic-assisted simple prostatectomy and open simple prostatectomy for large benign prostatic hyperplasia. Methods: We systematically searched the Cochrane Library, PubMed, Embase, and Science databases for studies published through December 2020. Controlled trials on RASP and OSP for large prostates were included. The meta-analysis was conducted with the Review Manager 5.4 software. Results: A total of seven studies with 3,777 patients were included in the analysis. There were no significant differences in IPSS (WMD, 0.72; 95%CI: -0.31, 1.76; P = 0.17), QoL (WMD, 0.00; 95%CI: -0.39, 0.39; P > 0.99), Qmax (WMD, 1.88; 95% CI: -1.15, 4.91; P = 0.22), or PVR (WMD, -10.48; 95%CI: -25.13, 4.17; P = 0.16) among patients undergoing RASP and OSP. However, compared with patients who underwent OSP, patients who underwent RASP had a shorter LOS (WMD, -2.83; 95%CI: -3.68, -1.98; P < 0.001), less EBL (WMD, -304.68; 95% CI: -432.91, -176.44; P < 0.001), a shorter CT (WMD, -2.61; 95%CI: -3.94, -1.29; P < 0.001), and fewer overall complications (OR, 0.30; 95% CI: 0.16, 0.57; P < 0.001). Nevertheless, RASP was associated with a longer OT (WMD, 59.69, 95% CI: 49.40, 69.98; P < 0.001). Conclusion: The results of the current study demonstrated that RASP provided similar efficacy to those of OSP in the treatment of large prostate, while maintaining better security. Our findings indicate that RASP is a feasible and effective alternative to OSP.

Are all procedures for benign prostatic hyperplasia created equal? A systematic review on post-procedural PSA dynamics and its correlation with relief of bladder outlet obstruction

PURPOSE

To evaluate and provide a comprehensive literature review of Prostate specific antigen (PSA) dynamics after various surgical procedures for benign prostatic hyperplasia (BPH).

METHODS

A thorough PubMed database search was performed over last 30 years including terms "PSA" and various surgical procedures for BPH. PSA nadir after various procedure was evaluated. The post-operative improvement in International Prostate Symptom Score, maximum void rates and post-void residue after surgeries were recorded. An indirect correlation was made between PSA nadir and outcome of various BPH surgical procedures.

RESULTS

Enucleation procedures like simple prostatectomy and endoscopic enucleation of prostate (EEP) produced maximum drop in PSA level after surgery and were associated with the highest improvement in post-operative parameters. The PSA nadir following resection techniques like transurethral resection of prostate and Holmium laser resection of prostate and vaporization technique was variable and less robust when compared to EEP. Newer techniques like Aquablation, Rezum, Urolift, Prostate artery embolization and Temporary implantable nitinol devices (iTIND) produce relatively less reduction in PSA and lesser percentile improvement in post-operative parameters.

CONCLUSIONS

Various surgical procedures for BPH result in varying PSA nadirs level. Enucleation procedures and simple prostatectomy produce the most drastic and sustained decrease in PSA. There is a possible indirect evidence suggesting that the level of PSA nadir corresponds closely with the degree of post-operative improvement and durability of the procedure. Establishing the new PSA nadir at 3-6 months after the procedure is recommended as a part of routine surveillance for prostate cancer in eligible patients.

From open simple to robotic-assisted simple prostatectomy (RASP) for large benign prostate hyperplasia: the time has come

PURPOSE

Robotic-assisted simple prostatectomy (RASP) has recently been studied as an alternative to open simple prostatectomy or endoscopic treatment options. At present, there is no defined recommendation for a robotic procedure as a standard surgical technique to treat large benign prostate hyperplasia.

METHODS

Several robotic techniques have been described since 2007. Contemporaneously, multiple endoscopic enucleation techniques have been proposed. Nevertheless, open simple prostatectomy still remains a mainstay of therapy. We aimed to evaluate the development of robotic-assisted prostatectomy for large benign prostatic obstruction, thus comparing the technical aspects and clinical outcomes with open and endoscopic enucleation.

RESULTS

Robotic-assisted simple prostatectomy provides significantly less blood loss and shorter hospital stay but longer operative time compared to open simple prostatectomy. Compared to endoscopic treatments, robotic approaches have a similar perioperative outcome, but cause less urethral trauma or potential bladder neck strictures. Moreover, concomitant bladder pathologies can be treated within the same setting.

CONCLUSION

Robotic-assisted simple prostatectomy is an effective and safe technique, and can hence be considered to become the preferred first-line therapy to treat patients with obstructive large prostate glands.

Robotic-assisted simple prostatectomy versus open simple prostatectomy: a New York statewide analysis of early adoption and outcomes between 2009 and 2017

The factors driving early adoption of robotic-assisted simple prostatectomy (RASP) for large gland BPH have not yet been identified. This study aims to determine the patient, provider, and facility level differences and predictors in undergoing RASP versus OSP. This population-based cohort study used data from the all-payer New York State Statewide Planning and Research Cooperative System (SPARCS) database. Patient, provider, and facility characteristics for each cohort were analyzed, and a multivariate analysis was conducted to identify predictive factors associated with undergoing RASP versus OSP. From 2009 to 2017, 1881 OSP and 216 RASP cases were identified. RASP utilization increased from 2.6% of all cases in 2009 to 16.8% in 2017. Patient demographics were similar between both cohorts. Median length of stay was shorter for RASP patients (3 vs. 4 days, p < 0.001), and OSP was associated with a long length of stay (> 7 days) (p < 0.001). There were no significant differences in 30- and 90-day readmission rates or 1-year mortality. More OSP patients were discharged to continued care facilities than RASP patients (p = 0.049), and more RASP patients were discharged to home compared to OSP patients (p = 0.035). Positive predictors for undergoing RASP included teaching hospital status, medium and high hospital bed volume, high hospital operative volume, high surgeon volume, and surgeons that graduated within 15 years of surgery. As RASP shows favorable perioperative outcomes, the diffusion of robotic technology and newer graduates entering the workforce may augment the upward trend of RASP utilization.

The New American Urological Association Benign Prostatic Hyperplasia Clinical Guidelines: 2019 Update

PURPOSE OF REVIEW

The goal of this paper was to analyze the efficacy of the current modalities available to surgically treat lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH).

RECENT FINDINGS

There have been significant surgical advancements for the treatment of BPH, including an increasing development and utilization of minimally invasive surgical techniques (MISTs). These procedures have varying outcomes that are critical to understand. In addition, MISTs have important adverse effects, though have minimized effects on sexual function when compared to more invasive surgical techniques. It is important for all urologists to be familiar with the surgical techniques available to treat BPH and the updated American Urological Association (AUA) Guidelines. Further studies evaluating efficacy, safety, and sexual functioning will help guide care in the future and evolve practice.

Robotic-Assisted Simple Prostatectomy: A Systematic Review

Contemporary minimally invasive surgical (MIS) treatment options of patients with male Lower Urinary Tract Symptoms (LUTS) in men with prostate glands >80 mL include Holmium Laser Enucleation Prostate (HoLEP), Thulium laser VapoEnucleation Prostate (ThuVEP), and Laparoscopic (LSP) or Robotic-Assisted Simple Prostatectomy (RASP). Implementing new laser technologies is costly, and the steep learning curve of these laser techniques limit their wide range use. This promoted the use of LSP and RASP in centers with readily established laparoscopy or robotic surgery programs. The aim of this study is to review case and comparative series of RASP. We systematically reviewed published data from 2008 to 2020 on RASP and have identified 26 non-comparative and 9 comparative case series. RASP has longer operation time but less time spent in hospital and less blood loss. The outcomes of improvements in symptom score, post-voiding residual urine (PVR), postoperative PSA decline, complications, and cost are similar when compared to open and laser enucleation techniques. These outcomes position RASP as a viable MIS treatment option for patients with male LUTS needing surgical treatment for enlarged prostates. Nevertheless, prospective, randomized controlled trials (RCTs) with multicenter and large sample size are needed to confirm the findings of this systematic review.

Intermediate-term Urinary Function and Complication Outcomes After Robot-Assisted Simple Prostatectomy

OBJECTIVE

To assess the incidence of delayed complications after robot-assisted simple prostatectomy and evaluate postoperative lower urinary tract symptoms (LUTS) as a function of time with intermediate-term follow-up.

METHODS

We retrospectively reviewed 150 patients who underwent robot-assisted simple prostatectomy between May, 2013 and January, 2019. Indication for surgery was bothersome LUTS refractory to medical management and prostate volume ≥80 milliliters. The severity of LUTS was assessed using the International Prostate Symptom Score (IPSS) and quality of life (QOL) score. One-way analysis of variance test with post hoc Tukey's honest significant difference test was used to compare postoperative IPSS and QOL scores as a function of time; P <.05 was considered significant.

RESULTS

At a mean ± SD follow up of 31.3 ± 18.2 months, none of the patients developed a bladder neck contracture and none of the patients required reoperation for LUTS. Postoperatively, IPSS and QOL scores decreased with an increasing duration of follow up (P <.001). Mean IPSS and QOL scores improved between 2 weeks and 3 months postoperatively (P = .027 and P = .006, respectively). After 3 months postoperatively, mean IPPS and QOL scores stabilized and remained unchanged up to 36 months of follow-up (all P >.05).

CONCLUSION

Robotic simple prostatectomy is associated with a low incidence of delayed complications at a mean of 31.3 months postoperatively. After robotic simple prostatectomy, urinary function outcomes improve in the early postoperative period with maximal improvement occurring at 3 months. Excellent urinary function outcomes are durable up to at least 36 months postoperatively.

Robot-assisted simple prostatectomy versus open simple prostatectomy: a single-center comparison

Purpose

Open simple prostatectomy (OSP) is a standard surgical technique for patients with benign prostatic hyperplasia with prostate size larger than 80 ml. As a minimally invasive approach, robot-assisted simple prostatectomy (RASP) emerged as a feasible surgical alternative. Currently, there are no definite recommendations for the standard use of RASP. Therefore, we aimed at investigating various clinical outcomes comparing RASP with OSP.

Methods

In this retrospective single-center study, we evaluated clinical data from 103 RASP and 31 OSP patients. Both cohorts were compared regarding different clinical characteristics with and without propensity score matching. To detect independent predictive factors for clinical outcomes, multivariate logistic regression analysis was performed.

Results

Robot-assisted simple prostatectomy patients demonstrated a lower estimated blood loss and need for postoperative blood transfusions as well as less postoperative complications. OSP had a shorter operative time (125 min vs. 182 min) longer hospital stay (11 days vs. 9 days) and longer time to catheter removal (8 days vs. 6 days). In the multivariate analysis, RASP was identified as an independent predictor for longer operative time, lower estimated blood loss, shorter length of hospital stay, shorter time to catheter removal, less postoperative complications and blood transfusions.

Conclusion

Robot-assisted simple prostatectomy is a safe alternative to OSP with less perioperative and postoperative morbidity. Whether OSP (shorter operative time) or RASP (shorter length of hospital stay) has a more favorable economic impact depends on the particular conditions of different health care systems. Further prospective comparative research is warranted to define the value of RASP in the current surgical management of benign prostatic hyperplasia.