Transvesical robot-assisted radical prostatectomy: initial experience and surgical outcomes

Knowledge mapping of application of image-guided surgery in prostate cancer: a bibliometric analysis (2013-2023)

BACKGROUND

Image-guided surgery (IGS) refers to surgery navigated by medical imaging technology, helping doctors better clarify tumor boundaries, identify metastatic lymph nodes and preserve surrounding healthy tissue function. Recent studies have provided expectable momentum of the application of IGS in prostate cancer (PCa). The authors aim to comprehensively construct a bibliometric analysis of the application of IGS in PCa.

METHOD

The authors searched publications related to application of IGS in PCa from 2013 to 2023 on the web of science core collection (WoSCC) databases. VOSviewer, CiteSpace, and R package 'bibliometrix' were used for bibliometric analysis.

RESULTS

Two thousand three eighty-nine articles from 75 countries and 2883 institutions led by the United States were included. The number of publications related to the application of IGS in PCa kept high in the last decade. Johns Hopkins University is the top research institutions. Journal of Nuclear Medicine has the highest popularity as the selection of journal and co-cited journal. Pomper Martin G. had published the most paper. Ali Afshar-Oromieh was co-cited most frequently. The clinical efficacy of PSMA-PET/CT in PCa diagnosis and treatment are main topics in this research field, with emerging focuses on the use of fluorescence imaging guidance technology in PCa. 'PSMA' and 'PET/CT' are the main keywords as long-term research hotspots.

CONCLUSION

This study is the first bibliometric analysis of researches on application of IGS in PCa with three recognized bibliometric software, providing an objective description and comprehensive guidance for the future relevant investigations.

Design and navigation method of a soft robot for single-port transvesical radical prostatectomy

PURPOSE

Currently, the rigid instruments used for laparoscopic radical resection of prostate cancer not only have the risk of damage to tissues, blood vessels, and nerves, but their limited freedom will also cause surgical blind areas. Soft robots are expected to solve these issues due to inherent flexibility, compliance, and safe interaction with tissues and organs. In addition, to achieve high surgical accuracy and provide precise guidance for surgeons, the navigation method should be studied for the soft robot.

METHODS

A soft robot system for single-port transvesical radical prostatectomy (STRP) is developed, and a navigation method combining fiber Bragg gratings and electromagnetic tracking is proposed for the soft robot. To validate the soft robot design and the effectiveness of the navigation method, different groups of experiments are conducted.

RESULTS

The proposed navigation method can achieve accurate location and shape sensing of the soft manipulator. The experiments show that the maximum tip sensing error is 2.691 mm, which is 5.38 % of the robot length for static configurations, and that the average tip sensing error is 1.966 mm, which corresponds to 3.93 % of the robot length for dynamic scenarios. Additionally, phantom tests demonstrate that the designed soft robot can enter the prostate through navigation guidance in a master-slave control mode and cover the entire prostate space.

CONCLUSIONS

The designed soft robot system, due to its soft structure, good flexibility, and accurate navigation, is expected to improve surgical safety and precision, thereby exhibiting significant potential for STRP.

The effects of robot-assisted laparoscopic surgery with Trendelenburg position on short-term postoperative respiratory diaphragmatic function

OBJECTIVE

To study how Pneumoperitoneum under Trendelenburg position for robot-assisted laparoscopic surgery impact the perioperative respiratory parameters, diagrammatic function, etc. METHODS: Patients undergoing robot-assisted laparoscopic surgery in the Trendelenburg position and patients undergoing general surgery in the supine position were selected. The subjects were divided into two groups according to the type of surgery: robot-assisted surgery group and general surgery group. ① Respiratory parameters such as lung compliance, oxygenation index, and airway pressure were recorded at 5 min after intubation, 1 and 2 h after pneumoperitoneum. ② Diaphragm excursion (DE) and diaphragm thickening fraction (DTF) were recorded before entering the operating room (T1), immediately after extubation (T2), 10 min after extubation (T3), and upon leaving the postanesthesia care unit (T4). ③ Peripheral venous blood (5 ml) was collected before surgery and 30 min after extubation and was analyzed by enzyme-linked immunosorbent assay to determine the serum concentration of Clara cell secretory protein 16 (CC16) and surfactant protein D (SP-D).

RESULT

① Compared with the general surgery group (N = 42), the robot-assisted surgery group (N = 46) presented a significantly higher airway pressure and lower lung compliance during the surgery(P < 0.001). ② In the robot-assisted surgery group, the DE significantly decreased after surgery (P < 0.001), which persisted until patients were discharged from the PACU (P < 0.001), whereas the DTF only showed a transient decrease postoperatively (P < 0.001) and returned to its preoperative levels at discharge (P = 0.115). In the general surgery group, the DE showed a transient decrease after surgery(P = 0.011) which recovered to the preoperative levels at discharge (P = 1). No significant difference in the DTF was observed among T1, T2, T3, and T4. ③ Both the general and robot-assisted surgery reduced the postoperative serum levels of SP-D (P < 0.05), while the robot-assisted surgery increased the postoperative levels of CC16 (P < 0.001).

CONCLUSION

Robot-assisted laparoscopic surgery significantly impairs postoperative diaphragm function, which does not recover to preoperative levels at PACU discharge. Elevated levels of serum CC16 after surgery suggest potential lung injury. The adverse effects may be attributed to the prolonged Trendelenburg position and pneumoperitoneum during laparoscopic surgery.

Robot-assisted Surgery in the Field of Urology: The Most Pioneering Approaches 2015-2023

Robot-assisted surgery has emerged as a transformative technology, revolutionizing surgical approaches and techniques that decades ago could barely be imagined. The field of urology has taken charge in pioneering a new era of minimally invasive surgery with the ascent of robotic systems which offer enhanced visualization, precision, dexterity, and enabling surgeons to perform intricate maneuvers with improved accuracy. This has led to improved surgical outcomes, including reduced blood loss, lower complication rates, and faster patient recovery. The aim of our review is to present an evidence-based critical analysis on the most pioneering robotic urologic approaches described over the last eight years (2015-2023).

Vesicoprostatic muscle reconstruction: a step further for immediate and early urinary continence

OBJECTIVES

The vesicoprostatic muscle (VPM) is a longitudinal smooth muscle that originates from the trigone of the bladder or the opening of the ureter and is involved in urination as part of the detrusor apron. We explored the effect of VPM reconstruction on immediate and early recovery of urinary continence in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALP).

PATIENTS AND METHODS

A total of 523 patients with localized prostate cancer were enrolled from June 2018 to June 2020. All patients were diagnosed in our department based on magnetic resonance imaging and pathological findings on prostate biopsy. After 1:1 propensity score matching, 105 patient pairs were matched. The study was approved by our institutional review board and all surgeries were performed by three experienced high-volume surgeons. Demographic data, total operation time, pathological outcomes, the urinary continence rates of the two groups at different times after RALP, and factors influencing postoperative urinary continence after RALP were recorded. Student's t test was used to compare continuous variables and the Pearson χ² test to compare categorical variables. Logistic regression analysis was used to identify factors affecting immediate and early postoperative urinary control.

RESULTS

VPM reconstruction promoted immediate and early recovery of urinary continence (immediate continence, 66.67 vs. 40.00%, P = 0.000; 3-month continence, 80.95 vs. 64.76%, P = 0.008).

CONCLUSIONS

VPM reconstruction improved immediate and early urinary continence in patients who underwent RALP.

Evaluating post radical prostatectomy mechanisms of early continence

BACKGROUND

To identify the periprostatic structures associated with early return of urinary continence after radical prostatectomy (RP).

METHODS

We compared total continence results between four different techniques of robot-assisted radical prostatectomy (RARP). Specifically, we studied 1-week and 1-month zero-pad continence rates of anterior (n = 60), posterior (n = 59), a novel hybrid posterior-anterior (n = 12), and transvesical (n = 12) approaches of RARP. Each technique preserved a unique set of periprostatic anatomic structures, thereby, allowing evaluation of the individual impact of preservation of nerves, bladder neck, and space of Retzius with associated anterior support structures on early continence. Urethral length was preserved in all approaches. The space of Retzius was preserved in posterior and transvesical approaches, while the bladder neck was preserved in posterior and hybrid approaches. Nerve sparing was done per preoperative oncological risk. For all patients, 24-h pad usage rates and 24-h pad weights were noted at 1 week and 1 month after catheter removal. Multivariable logistic regression analysis was performed to identify predictors of early continence. Data were obtained from prospective studies conducted between 2015 and 2021.

RESULTS

At 1 week, 15%, 42%, 45%, and 8% of patients undergoing anterior, posterior, hybrid, and transvesical RARP approaches, respectively, were totally continent (p = 0.003). These rates at 1 month were 35%, 66%, 64%, and 25% (p = 0.002), respectively. The transvesical approach, which preserved the space of Retzius but not the bladder neck, was associated with the poorest continence rates, while the posterior and hybrid approaches in which the bladder neck was preserved with or without space of Retzius preservation were associated with quickest urinary continence recovery. Bladder neck preservation was the only significant predictor of 1-week and 1-month total continence recovery in adjusted analysis, Odds ratios 9.06 (p = 0.001) and 5.18 (p = 0.004), respectively.

CONCLUSIONS

The beneficial effect of the Retzius-sparing approach on early continence recovery maybe associated with bladder neck preservation rather than space of Retzius preservation.

Transvesical versus extraperitoneal single-port robotic radical prostatectomy: a matched-pair analysis

OBJECTIVE

To compare our initial perioperative and postoperative outcomes of the single-port (SP) transvesical radical prostatectomy (TVRP) approach with the single-port extraperitoneal radical prostatectomy (ERP) approach.

MATERIALS AND METHODS

Initial consecutive seventy-eight patients underwent SP TVRP between December 2020 and October 2021. Patients with extensive previous abdominal surgeries, or low- to intermediate-risk prostate cancer were selected. Data of consecutive 169 patients treated with SP ERP between February 2019 and November 2020, were used for comparison. Optimal matched-paired analysis of PSA value, biopsy Gleason score, and prostate volume was performed. Preoperative, perioperative, and early functional outcomes were included in the analysis. The median follow-up was 7 months and 9 months for TVRP and ERP groups respectively.

RESULTS

The median total operative time was longer in the TVRP compared to the ERP group (p = .002). There were no differences in intraoperative complications or surgical margin status. TVRP group had less rate of grade 3a Clavien-Dindo complications (p = .026). The Foley catheter duration was 3 (3, 4) days in the TVRP group compared to 7 (7, 8) days in the ERP group (p < .001). There was a consistently improved continence rate in the TVRP group at 6 weeks (72% TVRP, 48% ERP, p = .004), 3 months (97% TVRP, 81% ERP, p = .008), and 6 months postoperatively (100% TVRP, 93% ERP, p = .047). There was no difference in biochemical recurrence at 6 months of follow-up.

CONCLUSION

In our initial series, TVRP allows for a faster continence recovery, without other functional or oncological compromises.

De Novo Detrusor Underactivity and Other Urodynamic Findings after Radical Prostatectomy: A Systematic Review

Background and objectives: The aim of this systematic review is to evaluate the impact of radical prostatectomy (RP) on bladder function, with special attention towards detrusor underactivity investigated with the means of urodynamic evaluation. Materials and Methods: The review was performed in accordance with the PRISMA statement and was registered in the PROSPERO (ID#: CRD42020223480). The studied population was limited to men with prostate cancer who underwent urodynamic study prior to and after radical prostatectomy. Eight hundred twenty-seven studies were screened, with twenty-five finally included. A qualitative analysis was performed. Rates of detrusor underactivity (DU) before surgery were reported in eight studies and ranged from 1.6% to 75% (median of 40.8%). DU occurred de novo after RP in 9.1% to 37% of patients (median of 29.1%). On the other hand, preexisting DU resolved in 7% to 35.5% of affected men. Detrusor overactivity (DO) was the most frequently reported outcome, being assessed in 23 studies. The rate of DO preoperatively was from 5% to 76% (median of 25%). De novo was reported in 2.3–54.4% of patients (median of 15%) and resolved after RP in 19.6% to 87.5% (median of 33%) of affected patients. Baseline rates of bladder outlet obstruction (BOO) varied between studies from 19% to 59.3%, with a median of 27.8%. The most pronounced change after surgery was the resolution of BOO in 88% to 93.8% (median of 92%) of affected patients. Results: Rates of de novo impaired bladder compliance (IBC) varied from 3.2% to 41.3% (median of 13.3%), whereas the resolution of IBC was reported with rates ranging from 0% to 47% (median of 4.8%). Conclusions: BOO, DO, and DU are frequently diagnosed in men scheduled for RP. BOO is improved after RP in most patients; however, there is still a substantial rate of patients with de novo DU as well as DO which may impair functional outcomes and quality of life.

Clinical study on the minimally invasive percutaneous nephrolithotomy treatment of upper urinary calculi

BACKGROUND

Upper urinary tract stones are very common in my country, with an incidence of 1% to 5% in the North and an even higher incidence of 5% to 10% in the south. The incidence rate in the south is higher than that in the north, mainly due to the water quality, climate and eating habits of the region. From the perspective of sex, incidence is more likely in males than females. In the high-incidence population, young adults are most prone to stones. Men in the age range of 25 to 40 years are more likely to have stones.

AIM

To observe the therapeutic effect of minimally invasive percutaneous nephrolithotomy (mPCNL) on upper urinary tract stones and its influence on the renal function of patients.

METHODS

Patients with upper urinary tract stones who were treated in our hospital from February 2017 to March 2018 were selected as research subjects and were divided into the PCNL group and the mPCNL group according to the random number table method. The general conditions of the two groups of patients were observed during the perioperative period, and the differences in stone clearance, pain, renal function indicators and complication rates were compared between the two groups to determine which were statistically significant (P < 0.05).

RESULTS

The operation time of the mPCNL group was longer than that of the PCNL group (t = -34.392, P < 0.001), and the intraoperative blood loss of the mPCNL group was more than that of the PCNL group (t = 34.090, P < 0.001). There was no difference in renal function indices between the two groups of patients before treatment, and there was no difference in the levels of serum creatinine, β2 microglobulin or retinol binding protein in the mPCNL group after treatment. The visual analog scale score of patients in the mPCNL group was lower than that of the PCNL group (t = 12.191, P < 0.001), and there was no significant difference in the stone clearance rate between the two groups (χ² value = 1.013, P = 0.314). There was no significant difference in the incidence of urine extravasation, dyspnea and peripheral organ damage between the two groups (χ² value = 1.053, P = 0.305). At 1 mo after treatment and 3 mo after treatment, the quality of life of the mPCNL group was lower than that of the PCNL group, and the Qmax level of the mPCNL group was higher than that of the PCNL group.

CONCLUSION

mPCNL has a good therapeutic effect on upper urinary tract stones, with a high stone clearance rate without causing kidney damage or increasing the incidence of complications, and thus has good application value.

Independent Factors Affecting Postoperative Short-Term Urinary Continence Recovery after Robot-Assisted Radical Prostatectomy

Background

Our team had firstly applied the transvesical approach to robot-assisted radical prostatectomy (RARP) in patients afflicted with localized prostate cancer (PCa). The present study aims to present the postoperative recovery of urinary continence (UC) following the anterior, transvesical, and posterior approaches to RARP for localized PCa and evaluate the independent predictors to early UC recovery after RARP.

Methods

Patients harboring localized PCa and receiving anterior, transvesical, and posterior approaches to RARP between January 2017 and June 2020 were enrolled in this analysis. Results on UC recovery were compared between these three approaches with the Kaplan–Meier method. All clinical and pathological variables were further analyzed via univariable and multivariable regression analysis to determine the independent factors contributing to short-term UC recovery after RARP.

Results

A total of 135, 73, and 66 instances were included in the anterior, transvesical, and posterior groups, respectively. Over the postoperative follow-up period, both the transvesical and posterior approaches showed an advantage over the anterior approach in promoting postoperative UC recovery (both p values <0.001). Three months after surgery, 55 (40.7%), 4 (5.5%), and 5 (7.6%) patients failed to UC in the anterior, transvesical, and posterior groups, respectively. Patient age, preoperative PSA, prostate volume, biopsy Gleason score, surgical approach, extended lymph node dissection technique, nerve-sparing technique, and positive lymph node were related to UC status based on univariable analyses (p < 0.05). Multivariable analysis results point patient age, prostate volume, surgical approach, and nerve-sparing technique as independent factors that affect postoperative UC recovery after RARP.

Conclusions

The application of transvesical approach to RARP for localized PCa could obtain promising outcomes in terms of postoperative UC recovery. In addition, surgical strategies encompassing the nerve-sparing technique and the Retzius-sparing procedures, namely, the transvesical or posterior approach, during RARP could independently enable early achievement of postoperative continence.

Post-Radical Prostatectomy Erectile Dysfunction Assessed Using the IIEF-5 Questionnaire - A Systematic Literature Review

Erectile dysfunction is common postoperative complication after radical prostatectomy. The aim of this study is to evaluate erectile dysfunction among the population of men who have undergone radical prostatectomy. Finally, 21 articles are included in the current qualitative analysis. The results suggest that recovery in potency occurs after 12 months after surgery, and that different adjuvant treatment can be used to accelerate recovery and increase effectiveness. However, conclusions are not derived from all the selected articles, but are rather based on those which present clear numerical scores according to the IIEF-5 questionnaire.

Transvesical versus extravesical approach to laparoscopic posthysterectomy vesicovaginal fistula repair: A retrospective study from two medical centers

BACKGROUND

The controversy on the best surgical approach for vesicovaginal fistula (VVF) repair remains due to the scarcity of high-level evidences. We aim to analyze the efficacy and safety of the laparoscopic transvesical (LT) and laparoscopic extravesical (LE) approaches to posthysterectomy VVF (PH-VVF).

METHODS

Data of 64 patients with PH-VVFs who were laparoscopicly treated in the First Affiliated Hospital of Nanchang University and the Hangzhou Third Hospital from January 2011 to November 2019 were retrospectively collected. The operative time (OT), estimated bleeding volume (EBV), postoperative bladder function and complications, hospital stay length (HSL), surgery success rate, and recurrence were compared between the two groups.

RESULTS

In all, there were no significant differences in baseline characteristics between those two arms. Both approaches were successfully performed without open conversion in either group. The LT group was significantly corrected with a shorter mean OT than the LE group (p < 0.001), regardless of the fistula's position. No significant differences existed in the mean EBV and HSL between the two interventions (p = 0.136 and p = 0.210, respectively). The tendency of postoperative complications and success rates of surgery were also comparable in both groups. The patients in the LT group had similar bladder functions to those in LE group. The recurrence occurred in one patient in each arm during the follow-up periods of 12-36 months.

CONCLUSIONS

The LT approach is significantly related to a shorter OT than the LE approach without compromising the safety and success rates in repairing PH-VVF.

Transvesical Retzius-Sparing Versus Standard Robot-Assisted Radical Prostatectomy: A Retrospective Propensity Score-Adjusted Analysis

Objectives

To estimate the safety and efficiency of transvesical Retzius-sparing robot-assisted radical prostatectomy (T-RARP) compared with standard robot-assisted radical prostatectomy (S-RARP) for localized prostate cancer (PCa).

Materials and Methods

174 patients bearing localized PCa and undergoing T-RARP or S-RARP between October 2017 and January 2020 were retrospectively enrolled in our analysis. All potential baseline confounders were strictly restrained with propensity-score matching (PM) method (1: 1). Within the matched setting, the perioperative and functional outcomes were compared between the T-RARP and S-RARP groups, while the oncological results and functional recovery of the two arms were presented with Kaplan-Meier curves.

Results

Finally, 114 and 60 eligible patients harbouring localized PCa were identified in the S-RARP and T-RARP group, respectively. No significant differences between the two groups were found in all baseline characteristics after PM. Within the matched cohort, no case was converted to open surgery in either group. The T-RARP group was significantly related to a higher mean operative time (p = 0.001) and shorter median hospital stay length (p < 0.001). There were not significant differences in the median estimated blood loss and specimen Gleason score between the two arms. The proportions of transfusion, pT3a disease, postoperative complication, and positive surgical margin in the T-RARP group were also comparable to that in the S-RARP group. The mean prostate-specific antigen and median erectile functional scores did not differ significantly between the two groups at postoperative 3 months and last follow-up. T-RARP vs. S-RARP had significantly improved urinary continence (UC) rates at the removal of catheter (p < 0.001) and postoperative 3 months (p < 0.001), but the significant difference between the two groups in UC recovery disappeared at last follow-up (p = 0.119). No significant difference in biochemical recurrence-free survival was observed following the two surgeries (p = 0.727).

Conclusions

T-RARP by experienced hands was feasible for selected patients with clinically localized PCa, yielding significantly improved early return to UC and similar erectile functional preservation without compromising oncological control when compared with the standard approach.

Transvesical Versus Posterior Approach to Retzius-Sparing Robot-Assisted Radical Prostatectomy: A Retrospective Comparison With a 12-Month Follow-Up

Objectives

To assess the perioperative, functional, and oncological outcomes of transvesical robot-assisted radical prostatectomy (T-RARP) and posterior robot-assisted radical prostatectomy (P-RARP) for localized prostate cancer.

Materials and Methods

We analyzed the data of 96 patients who underwent T-RARP or P-RARP for localized prostate cancer between January 2017 and June 2019 in a retrospective fashion.

Results

No significant differences in the baseline characteristics existed between the T-RARP and P-RARP arms. Both interventions were successfully performed without open conversion in either group. T-RARP was associated with a slightly more operative time (135.3 vs. 127.3 min) and estimated blood loss (105.2 vs. 94.2 mL) than P-RARP, but the differences were not significant (both p > 0.05). The likelihood of transfusion, ≤Grade II, and >Grade II postoperative complications, pT3a disease and positive surgical margins in the T-RARP group was comparable with that in the P-RARP group. No significant differences were noted between these two arms in terms of UC at the removal of catheter and nocturia (p = 0.750 and p = 0.684, respectively), and all included patients recovered UC at 3 months postoperatively. The median International Index of Erectile Function-5 score in both groups remains comparable before and after RARP. The patients in the T-RARP and P-RARP groups had a similar biochemical recurrence-free survival (p = 0.387).

Conclusions

Both T-RARP and P-RARP by experienced hands are feasible for well-selected patients with prostate cancer, obtaining similar outcomes in terms of perioperative results, UC and erectile function, and oncological control within short-term follow-up.

Comprehensive approach for preserving cavernous nerves and erectile function after radical prostatectomy in the era of robotic surgery

A nerve-sparing procedure during robot-assisted radical prostatectomy has been considered one of the most important techniques for preserving postoperative genitourinary function. The reason is that adequate nerve-sparing procedures could preserve both erectile function and lower urinary tract function after surgery. When a nerve-sparing procedure is carried out, the cavernous nerves themselves cannot be visualized, despite the magnified viewing field during robot-assisted radical prostatectomy. Thus, nerve-sparing procedures have been considered challenging operations, even now. However, because not all surgeons have carried out a sufficient number of nerve-sparing procedures, the development of new nerve-sparing procedures or new methods for mapping the cavernous nerves is required. Recently, various new operative techniques, for example, Retzius-sparing robot-assisted radical prostatectomy, transvesical robot-assisted radical prostatectomy and retrograde release of neurovascular bundle technique during robot-assisted radical prostatectomy, have been developed. In addition, new surgical devices, for example, biological/bioengineering solutions for cavernous nerve protection and devices for identifying the cavernous nerves during radical prostatectomy, have developed to preserve the cavernous nerves. In contrast, limitations or problems in preserving cavernous nerves and postoperative erectile function have become apparent. In particular, the recovery rate of erectile function, the positive surgical margin rate at the site of nerve-sparing and the indications for nerve sparing have become obvious with the accumulation of much evidence. Furthermore, predictive factors for postoperative erectile function after nerve-sparing procedures have also been clarified. In this article, the importance of a comprehensive approach for early recovery of erectile function in the robot-assisted radical prostatectomy era is discussed.