Comparative investigation on clinical outcomes of robot-assisted radical prostatectomy between experienced open prostatic surgeons and novice open surgeons in a laparoscopically naïve center with a limited caseload

Robotic radical prostatectomy: difficult to start, fast to improve? Influence of surgical experience in robotic and open radical prostatectomy

Purpose

The assistance of robotic systems raises the concern of whether there is an improved learning in robotic-assisted radical prostatectomy (RARP) compared to open retropubic radical prostatectomy (ORP).

Methods

We retrospectively analyzed data from 1438 patients who underwent ORP (n = 735) or RARP (n = 703). For each procedure, the level of experience of three different surgeons was summarized. Perioperative and pathological parameters reflecting surgical performance were compared between both learning curves. RARP data were influenced by new introduction of the robotic system.

Results

The median patient age at surgery was 66 years (IQR 42–80). Patients in the RARP group were younger (p < 0.001) and had a lower oncological risk (p < 0.001). Inexperienced RARP surgeons had a higher pT2-PSM rate and lower lymph node yield (13.8 ± 4.7 vs. 14.7 ± 4.8; p = 0.03) than inexperienced ORP surgeons. After 100 procedures, RARP and ORP surgeons had the same pT2-PSM rate (8% vs. 8%; p = 0.8) and lymph node yield (15.4 ± 5.4 vs. 15.4 ± 5.1; p = 1.0). In multivariate analysis for ORP, surgical inexperience (≤ 100 cases) was an independent predictor of a longer operating time (OR 9.0; p < 0.001) and higher amount of blood loss (OR 2.9; p < 0.001). For RARP, surgical inexperience (≤ 100 cases) was a predictor of a longer operating time (OR 3.9; p < 0.001), higher amount of blood loss (OR 1.9; p = 0.004), higher pT2-PSM rate (OR 1.6; p = 0.03), and lower lymph node yield (OR 0.6; p = 0.001).

Conclusions

Surgical experience has a relevant impact on perioperative and pathological parameters RARP has a higher initial pT2-PSM rate and lower lymph node yield than ORP. This is relevant for patient selection for novice teaching in RARP.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03763-w.

Surgeon case volume and continence recovery following radical prostatectomy: a systematic review

BACKGROUND

Urinary incontinence (UI) is a common complication following radical prostatectomy (RP). Prolonged UI has a substantial impact on quality of life and psychosocial well-being. As the RP technique is complex, it is reasonable to propose that surgeon experience could affect post-operative continence recovery outcomes. This study aimed to systematically evaluate evidence regarding a surgeon's experience and continence recovery after RP.

METHODS

A comprehensive search of the literature was performed in April 2020 using the Medline, Embase, CINAHL and psychINFO electronic databases according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. All English language studies investigating UI following RP, stratified by surgeon experience, were included. Surgeon experience was defined as average annual case load or volume.

RESULTS

Thirteen studies published between 2003 and 2020 met the inclusion criteria and were included in our systematic review. Three prospective and 10 retrospective cohort studies included a total of 47 316 patients undergoing RP via open, laparoscopic or robotic-assisted procedures. Heterogeneity in the definition of surgeon experience and UI did not allow a meta-analysis. The majority of studies reported that surgeons with higher surgical volumes achieved better continence recovery rates at the early (6-week), 3-month, 6-month and later (≥12-month) time points. Most studies where a high surgical volume was defined as >50 cases/year demonstrated a significant difference in continence outcomes.

CONCLUSION

Better urinary continence recovery results can be expected by patients who undergo RP performed by a surgeon with greater experience. An annual surgical case load of >50 cases/year results in improved continence recovery outcomes following RP.

Characteristics of urodynamic study parameters associated with intermediate-term continence after robot-assisted radical prostatectomy in elderly patients

PURPOSE

To investigate the relationship between urodynamic study (UDS) data and recovery of urinary incontinence (UI) in elderly patients who underwent robot-assisted radical prostatectomy (RARP).

MATERIALS AND METHODS

Seventy-five prostate cancer (PCa) patients received UDS before and at 3 months after RARP. They were divided into two groups; a younger group (<70 years old, n = 47) and older group (≥70 years, n = 28), and each was classified according to urinary continence (UC) or UI at 3 months post-RARP. Continence was defined as being pad-free or 1-safety pad usage per day.

RESULTS

In the older group, preoperative maximum urethral closure pressure (MUCP) in the UI group was significantly lower than that in the UC group. Detrusor overactivity (DO) rate was significantly higher in the older UI group than in the older UC group at both pre- and 3 months post-RARP. Persistent DO rate pre- and post-RARP was significantly higher in the older group than in the younger group. Regardless of age, postoperative DO was an independent predictor of UI 6 months post-RARP.

CONCLUSIONS

In elderly patients, low preoperative MUCP and both pre- and postoperative DO are associated with postoperative UI.

Perioperative outcomes and cost of robotic-assisted versus laparoscopic inguinal hernia repair

BACKGROUND

Utilization of robotic-assisted inguinal hernia repair (IHR) has increased in recent years, but randomized or prospective studies comparing outcomes and cost of laparoscopic and Robotic-IHR are still lacking. With conflicting results from only five retrospective series available in the literature comparing the two approaches, the question remains whether current robotic technology provides any added benefits to treat inguinal hernias. We aimed to compare perioperative outcomes and costs of Robotic-IHR versus laparoscopic totally extraperitoneal IHR (Laparoscopic-IHR).

METHODS

Retrospective analysis of consecutive patients who underwent Robotic-IHR or Laparoscopic-IHR at a dedicated MIS unit in the USA from February 2015 to June 2017. Demographics, anthropometrics, the proportion of bilateral and recurrent hernias, operative details, cost, length of stay, 30-day readmissions and reoperations, and rates and severity of complications were compared.

RESULTS

183 patients had surgery: 45 (24.6%) Robotic-IHR and 138 (75.4%) Laparoscopic-IHR. There were no differences between groups in age, gender, BMI, ASA class, the proportion of bilateral hernias and recurrent hernias, and length of stay. Operative time (Robotic-IHR: 116 ± 36 min, vs. Laparoscopic-IHR: 95±44 min, p < 0.01), reoperations (Robotic-IHR: 6.7%, vs. Laparoscopic-IHR: 0%, p = 0.01), and readmissions rates were greater for Robotic-IHR. While the overall perioperative complication rate was similar in between groups (Robotic-IHR: 28.9% vs. Laparoscopic-IHR: 18.1%, p = 0.14), Robotic-IHR was associated with a significantly greater proportion of grades III and IV complications (Robotic-IHR: 6.7% vs. Laparoscopic-IHR: 0%, p = 0.01). Total hospital cost was significantly higher for the Robotic-IHRs ($9993 vs. $5994, p < 0.01). The added cost associated with the robotic device itself was $3106 per case and the total cost of disposable supplies was comparable between the 2 groups.

CONCLUSIONS

In the setting in which it was studied, the outcomes of Laparoscopic-IHR were significantly superior to the Robotic-IHR, at lower hospital costs. Laparoscopic-IHR remains the preferred minimally invasive surgical approach to treat inguinal hernias.

Comprehensive approach for post-prostatectomy incontinence in the era of robot-assisted radical prostatectomy

Robot-assisted radical prostatectomy (RARP) has enabled steady and stable surgical procedures due to both meticulous maneuvers and magnified, clear, 3-dimensional vision. Therefore, better surgical outcomes have been expected with RARP than with other surgical modalities. However, even in the RARP era, post-prostatectomy incontinence has a relatively high incidence as a bothersome complication. To overcome post-prostatectomy incontinence, it goes without saying that meticulous surgical procedures and creative surgical procedures, i.e., "Preservation", "Reconstruction", and "Reinforcement" of the anatomical structures of the pelvis, are most important. In addition, medication and appropriate pad usage might sometimes be helpful for patients with post-prostatectomy incontinence. However, patients who have 1) BMI > 26 kg/m², 2) prostate volume > 70 mL, 3) eGFR < 60 mL/min, or a 4) Charlson comorbidity index > 2 have a tendency to develop post-prostatectomy incontinence despite undergoing the same surgical procedures. It is important for patients who have a high risk for post-prostatectomy incontinence to be given information about delayed recovery of post-prostatectomy incontinence. Thus, not only the surgical procedures, but also a comprehensive approach, as mentioned above, are important for post-prostatectomy incontinence.

A Clinician's Guide to Avoiding and Managing Common Complications During and After Robot-assisted Laparoscopic Radical Prostatectomy

CONTEXT

Robot-assisted radical prostatectomy (RARP) is on the advance globally, and it is essential for surgeons and patients to know the rates of perioperative complications.

OBJECTIVE

To provide evidence-based clinical guidance on avoiding and managing common complications during and after RARP in the context of a comprehensive literature review.

EVIDENCE ACQUISITION

In concordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis 2015 statement guidelines, a literature search of the PubMed database from August 1, 2011, to August 31, 2015, using the predefined search terms robot* AND radical prostatectomy, was conducted. The search resulted in 653 unique results that were subsequently uploaded to DistillerSR (Evidence Partners, Ottawa, Canada) for team-based screening and processing of references.

EVIDENCE SYNTHESIS

Overall, 37 studies met the inclusion criteria and were included. Median rate of overall complication was 12.6% (range: 3.1-42%). Most of the complications were minor (Clavien-Dindo grades 1 and 2). Grade 3 complications comprised the bulk of the major complications with a median rate of 2.7%; grade IV and V complications were exceedingly rare in all reports.

CONCLUSIONS

Despite continued adoption of the RARP technique globally, rates of overall complication remain low. Many of the complications experienced during and after RARP can be mitigated and prevented by experience and the implementation of safe techniques.

PATIENT SUMMARY

Despite continued adoption of the robot-assisted radical prostatectomy (RARP) technique globally, rates of overall and major complications remain low at 12.6% and 2.7%, respectively. Complications can be minimized and successfully managed using established techniques. RARP is a safe and reproducible technique.