The first 1000 cases of laparoscopic radical prostatectomy in the UK: evidence of multiple 'learning curves'

Simulating complex patient populations with hierarchical learning effects to support methods development for post-market surveillance

BACKGROUND

Validating new algorithms, such as methods to disentangle intrinsic treatment risk from risk associated with experiential learning of novel treatments, often requires knowing the ground truth for data characteristics under investigation. Since the ground truth is inaccessible in real world data, simulation studies using synthetic datasets that mimic complex clinical environments are essential. We describe and evaluate a generalizable framework for injecting hierarchical learning effects within a robust data generation process that incorporates the magnitude of intrinsic risk and accounts for known critical elements in clinical data relationships.

METHODS

We present a multi-step data generating process with customizable options and flexible modules to support a variety of simulation requirements. Synthetic patients with nonlinear and correlated features are assigned to provider and institution case series. The probability of treatment and outcome assignment are associated with patient features based on user definitions. Risk due to experiential learning by providers and/or institutions when novel treatments are introduced is injected at various speeds and magnitudes. To further reflect real-world complexity, users can request missing values and omitted variables. We illustrate an implementation of our method in a case study using MIMIC-III data for reference patient feature distributions.

RESULTS

Realized data characteristics in the simulated data reflected specified values. Apparent deviations in treatment effects and feature distributions, though not statistically significant, were most common in small datasets (n < 3000) and attributable to random noise and variability in estimating realized values in small samples. When learning effects were specified, synthetic datasets exhibited changes in the probability of an adverse outcomes as cases accrued for the treatment group impacted by learning and stable probabilities as cases accrued for the treatment group not affected by learning.

CONCLUSIONS

Our framework extends clinical data simulation techniques beyond generation of patient features to incorporate hierarchical learning effects. This enables the complex simulation studies required to develop and rigorously test algorithms developed to disentangle treatment safety signals from the effects of experiential learning. By supporting such efforts, this work can help identify training opportunities, avoid unwarranted restriction of access to medical advances, and hasten treatment improvements.

Learning curves in laparoscopic and robot-assisted prostate surgery: a systematic search and review

PURPOSE

To perform a systematic search and review of the available literature on the learning curves (LCs) in laparoscopic and robot-assisted prostate surgery.

METHODS

Medline was systematically searched from 1946 to January 2021 to detect all studies in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, reporting on the LC in laparoscopic radical prostatectomy (LRP), laparoscopic simple prostatectomy (LSP), robot-assisted radical prostatectomy (RARP) and robot-assisted simple prostatectomy (RSP).

RESULTS

In total, 47 studies were included for qualitative synthesis evaluating a single technique (LRP, RARP, LSP, RSP; 45 studies) or two techniques (LRP and RARP; 2 studies). All studies evaluated outcomes on real patients. RARP was the most widely investigated technique (30 studies), followed by LRP (17 studies), LSP (1 study), and RSP (1 study). In LRP, the reported LC based on operative time; estimated blood loss; length of hospital stay; positive surgical margin; biochemical recurrence; overall complication rate; and urinary continence rate ranged 40-250, 80-250, 58-200, 50-350, 110-350, 55-250, 70-350 cases, respectively. In RARP, the corresponding ranges were 16-300, 20-300, 25-200, 50-400, 40-100, 20-250, 30-200, while LC for potency rates was 80-90 cases.

CONCLUSIONS

The definition of LC for laparoscopic and robot-assisted prostate surgery is not well defined with various metrics used among studies. Nevertheless, LCs appear to be steep and continuous. Implementation of training programs/standardization of the techniques is necessary to improve outcomes.

Effect of training and individual operator's expertise on prostate cancer detection through prostate biopsy: Implications for the current quantitative training evaluation system

Purpose

This study was conducted to evaluate the relevance of training and experience to gaining expertise in prostate biopsy based on an assessment of outcomes from the performance of urology residents.

Materials and Methods

We retrospectively reviewed the medical records of 10,299 patients who underwent prostate biopsy by 50 operators under a unified urology residency program. The number of prostate biopsies performed by an operator for each patient was used as an indicator of operator experience. Residents were grouped into quartiles according to cancer detection rates in the first 50 and the last 50 procedures.

Results

Among 10,299 patients (median age, 67.5 years; median prostate-specific antigen [PSA], 7.04 ng/mL), the overall prostate cancer detection rate and that for patients with PSA <10.0 ng/mL were 37.0% and 25.9%, respectively. Operator experience was a significant predictor for cancer detection in patients with PSA <10.0 ng/mL. Cancer detection rates and the proportion of more advanced prostate cancers were higher in the last 50 cases than in the first 50 cases. Detection rates varied significantly among operator; residents with higher detection rates at training initiation showed even higher detection rates after additional training.

Conclusions

Training that adds to the cumulative experience of a trainee appears to play a meaningful role in improving cancer detection rates. The level of skill required to achieve mastery for independent practice may be assessed from the accuracy results of prostate biopsy procedures, and trainees with poor rates will require more technical training to improve precision.

Comparison of surgical outcomes between open and robot-assisted minimally invasive pancreaticoduodenectomy

BACKGROUND

Robot surgery is a new method that maintains advantages and overcomes disadvantages of conventional methods, even in pancreatic surgery. This study aimed to evaluate safety and benefits of robot-assisted minimally invasive pancreaticoduodenectomy (robot PD).

METHODS

This study included 237 patients who underwent PD between 2015 and 2017. Demographics and surgical outcomes were evaluated.

RESULTS

Fifty-one patients underwent robot PD and 186 underwent open PD. Robot PD group had younger age (60.7 vs. 65.4 years, P = 0.006) and lower body mass index (22.7 vs. 24.0, P = 0.007). Robot PD group had lower proportion of patients with firm or hard pancreatic texture (15.7% vs. 38.2%, P = 0.004) and smaller pancreatic duct size (2.3 vs. 3.3 mm, P = 0.002). Two groups had similar operation time (robot vs. open: 335.6 vs. 330.1 min) and complications (15.7% vs. 21.0%), including postoperative pancreatic fistula rate (6.0% vs. 12.0%). Robot PD group had lower postoperative pain score (3.7 vs. 4.1 points, P = 0.008), and shorter postoperative stay (10.6 vs. 15.3 days, P = 0.001).

CONCLUSION

Robot PD is comparable to open PD in early outcomes. Robot PD is safe and feasible and enables early recovery; indication for robot PD is expected to expand in the near future.

The influence of previous robotic experience in the initial learning curve of laparoscopic radical prostatectomy

Introduction:

This study analyzed the impact of the experience with Robotic-Assisted Laparoscopic Prostatectomy (RALP) on the initial experience with Laparoscopic Radical Prostatectomy (LRP) by examining perioperative results and early outcomes of 110 patients. LRPs were performed by two ro-botic fellowship trained surgeons with daily practice in RALP.

Patients and Methods:

110 LRP were performed to treat aleatory selected patients. The patients were divided into 4 groups for prospective analyses. A transperitoneal approach that simulates the RALP technique was used.

Results:

The median operative time was 163 minutes (110-240), and this time significantly decreased through case 40, when the time plateaued (p=0.0007). The median blood loss was 250mL. No patients required blood transfusion. There were no life-threatening complications or deaths. Minor complications were uniformly distributed along the series (P=0.6401). The overall positive surgical margins (PSM) rate was 28.2% (20% in pT2 and 43.6% in pT3). PSM was in the prostate apex in 61.3% of cases. At the 12-month follow-up, 88% of men were continent (0-1 pad).

Conclusions:

The present study shows that there are multiple learning curves for LRP. The shallowest learning curve was seen for the operative time. Surgeons transitioning between the RALP and LRP techniques were considered competent based on the low perioperative complication rate, absence of major complications, and lack of blood transfusions. This study shows that a learning curve still exists and that there are factors that must be considered by surgeons transitioning between the two techniques.

Establishing a teaching unit in laparoscopic radical prostatectomy: An Australian experience

Objective:

The aim of this project was to examine the role of surgical mentorship on the perioperative and oncological outcomes of patients undergoing laparoscopic radical prostatectomy (LRP) performed by two urologists inexperienced in the procedure.

Methods:

Forty-one (41) consecutive LRP cases were performed for clinically localised prostate cancer between December 2006 and June 2008 at a single centre. The surgical mentor approach was used with an experienced LRP surgeon being present for all cases that were performed by two urologists training in LRP. Data was retrospectively reviewed to assess morbidity and oncological outcomes of patients undergoing LRP by the team of trainees.

Results:

No LRP cases were converted to open and no major intraoperative complications were noted. Mean intraoperative blood loss was 493 ml (range 150–1000 ml) with the mean operative time being 220 minutes (range 100–315 minutes). The overall positive margin rate was only 12% (five out of 41 cases).

Conclusion:

LRP teaching units can be established with appropriate mentor supervision and can result in good oncological outcomes and minimal morbidity that compares favourably to robotic-assisted radical prostatectomy (RARP).

Laparoscopic versus Robotic-Assisted Radical Prostatectomy for the Treatment of Localised Prostate Cancer: A Systematic Review

Background: Prostate cancer is a prominent form of cancer diagnosed in men living in developed countries, for which radical prostatectomy is a common frontline treatment. The aim of this systematic review was to determine whether robot-assisted laparoscopic radical prostatectomy (RALP) is more effective in the treatment of localised prostate cancer, compared to laparoscopic radical prostatectomy (LRP). Methods: An electronic search of Medline, Scopus, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials (Central) was performed up until December 2014. Randomised controlled trials (RCTs) that offered a direct comparison of laparoscopic and robotic techniques were eligible for inclusion in this review. Results: A total of 93 articles were identified through the literature search, of which 2 were included in this review. Meta-analysis of 2 studies identified a significantly higher rate of return of erectile function in the RALP group (relative risk (RR) 1.51; 95% confidence interval (CI) 1.19, 1.92). A similar effect was observed with return to continence function (RR 1.14; 95% CI 1.04, 1.24). Conclusions: This systematic review offers the first evaluation of evidence from RCTs with respect to the effectiveness of RALP and LRP in the treatment of localised prostate cancer. Preliminary results suggest that RALP was more efficient at preserving the erectile function and continence in comparison to LRP.

Minimum 5-year follow-up of 1138 consecutive laparoscopic radical prostatectomies

OBJECTIVES

To investigate the long-term outcomes of laparoscopic radical prostatectomy (LRP).

PATIENTS AND METHODS

In all, 1138 patients underwent LRP during a 163-month period from 2000 to 2008, of which 51.5%, 30.3% and 18.2% were categorised into D'Amico risk groups of low-, intermediate- and high-risk, respectively. All intermediate- and high-risk patients were staged by preoperative magnetic resonance imaging or computed tomography and isotope bone scanning, and had a pelvic lymph node dissection (PLND), which was extended after April 2008. The median (range) patient age was 62 (40-78) years; body mass index was 26 (19-44) kg/m(2) ; prostate-specific antigen level was 7.0 (1-50) ng/mL and Gleason score was 6 (6-10). Neurovascular bundle was preservation carried out in 55.3% (bilateral 45.5%; unilateral 9.8%) of patients.

RESULTS

The median (range) gland weight was 52 (14-214) g. The median (range) operating time was 177 (78-600) min and PLND was performed in 299 patients (26.3%), of which 54 (18.0%) were extended. The median (range) blood loss was 200 (10-1300) mL, postoperative hospital stay was 3 (2-14) nights and catheterisation time was 14 (1-35) days. The complication rate was 5.2%. The median (range) LN count was 12 (4-26), LN positivity was 0.8% and the median (range) LN involvement was 2 (1-2). There was margin positivity in 13.9% of patients and up-grading in 29.3% and down-grading in 5.3%. While 11.4% of patients had up-staging from T1/2 to T3 and 37.1% had down-staging from T3 to T2. One case (0.09%) was converted to open surgery and six patients were transfused (0.5%). At a mean (range) follow-up of 88.6 (60-120) months, 85.4% of patients were free of biochemical recurrence, 93.8% were continent and 76.6% of previously potent non-diabetic men aged <70 years were potent after bilateral nerve preservation.

CONCLUSIONS

The long-term results obtainable from LRP match or exceed those previously published in large contemporary open and robot-assisted surgical series.

Robotic surgery of the pancreas

Pancreatic surgery is one of the most challenging and complex fields in general surgery. While minimally invasive surgery has become the standard of care for many intra-abdominal pathologies the overwhelming majority of pancreatic surgery is performed in an open fashion. This is attributed to the retroperitoneal location of the pancreas, its intimate relationship to major vasculature and the complexity of reconstruction in the case of pancreatoduodenectomy. Herein, we describe the application of robotic technology to minimally invasive pancreatic surgery. The unique capabilities of the robotic platform have made the minimally invasive approach feasible and safe with equivalent if not better outcomes (e.g., decreased length of stay, less surgical site infections) to conventional open surgery. However, it is unclear whether the robotic approach is truly superior to traditional laparoscopy; this is a key point given the substantial costs associated with procuring and maintaining robotic capabilities.

Surgical complications in kidney transplantation: no evidence for a learning curve

OBJECTIVE

To evaluate whether surgical complications after kidney transplantation correlate with surgeon's experience and whether individual surgeons' complication rates improve during their learning process.

STUDY DESIGN

Retrospective analysis: A generalized linear mixed-effects model was used to identify risk factors for surgical complications. Plots of cumulative sums of complications were used to evaluate the individual surgeons' performance.

SETTING

Single-center experience of a teaching hospital in Switzerland.

PARTICIPANTS

Consecutive kidney transplant recipients operated from 1962 until 2003.

RESULTS

A total of 1496 kidney transplants were analyzed; 73% were from deceased donors and 27% from living donors. At least 1 surgical complication occurred in 352 patients (24%). Male gender (odds ratio [OR] = 1.35, 95% CI: 1.04-1.74), donor's age (OR = 1.14, 95% CI: 1.06-1.24 per decade increment), and third or fourth vs. first or second transplant in a recipient (OR = 2.90, 95% CI: 1.02-8.24) were significantly associated with surgical complications. The surgeon's transplant experience was not found to be associated with surgical complications. Even surgeons with an experience of less than 10 kidney transplants did not have higher complication rates, 30-day mortality, or 1-year graft survival. Individual surgeons' complication rates analyzed by cumulative sum plots did not improve with increasing experience.

CONCLUSIONS

We present the largest single-center study on surgical complications after kidney transplantation, with unique data on the surgeon's experience for every single procedure. We found no evidence for a learning curve during training for kidney transplantation. We conclude that carefully selected experienced general and vascular surgeons can achieve good results in kidney transplantation after a relatively short training period.

Analysis of the pentafecta learning curve for laparoscopic radical prostatectomy

PURPOSE

Laparoscopic radical prostatectomy (LRP) has a long learning curve; however, little is known about the pentafecta learning curve for LRP. We analysed the learning curve for a fellowship trained surgeon with regard to the pentafecta with up to 6-year follow-up.

METHODS

A retrospective review was performed in 550 cases, by dividing these cases into 11 groups of 50 patients. Outcomes analysed were the following: (1) the pentafecta (complication rate, positive surgical margin (PSM) rate, continence, potency and biochemical recurrence); (2) operative time and blood loss; and (3) overall pentafecta attainment.

RESULTS

The mean complication rate for the entire series was 9 %; this plateaued after 150 cases. The overall PSM rate for the series was 23.5 %, 16.3 % for pT2 and 40.5 % for pT3. PSM plateaued after 200 cases. Excluding the first 100 cases, the overall PSM rate for pT2 was 10.9 % and 37.8 % for pT3. The continence rate stabilised after approximately 250 cases. The rate of male sling/artificial urinary sphincter plateaued after 200 cases. The potency learning curve continues to improve after 250 cases of nerve-sparing (ns) endoscopic extraperitoneal radical prostatectomy (EERPE) as does the pentafecta learning curve which closely follows the pattern of the potency learning curve. The last group of nsEERPE achieved pentafecta in 63 %.

CONCLUSION

This study shows multiple learning curves: an initial for peri-operative outcomes, then stabilisation of oncologic outcomes and the final for stabilisation of functional outcomes. In this series over 250 cases were required to achieve the learning curve.

Impact of a low-volume laparoscopic radical prostatectomy learning curve on perioperative outcomes: is it acceptable?

OBJECTIVE

The reproducibility of high-volume published series of laparoscopic radical prostatectomy (LRP) is still debatable. Many questions about its implementation, safety, and number of procedures required to achieve competence and improvement of outcomes with the technique remain unclear, and a learning curve study is crucial to investigate the acceptable performance of this advanced, minimally invasive procedure.

SUBJECTS AND METHODS

Between 2004 and 2011, 240 consecutive patients underwent an LRP performed by a single surgeon and were divided into the first, second, and third groups of 80 patients each. Perioperative and oncologic outcomes were compared across the groups to assess the impact of the learning curve for LRP. All surgical complications were classified using the Clavien-Dindo system (CDS).

RESULTS

Mean (range) patient age was 61 (43-78) years. The mean (range) level of prostate-specific antigen was 6.47 (3-18) ng/mL. The mean (range) Gleason sum was 6 (5-9). There was a significant reduction in the mean operative time (P<.001), mean anastomosis time (P<.001), mean blood loss (P<.001), mean hospital stay (P<.001), and mean minor CDS complications (P<.01) among the three groups as the series progressed. The D'Amico tumor stage was an independent factor for positive surgical margin across the learning curve (P<.001).

CONCLUSIONS

Our study demonstrated safety and low morbidity of the LRP technique since the beginning of a learning curve development, in which up to 80 cases were necessary to create a plateau to improve faster perioperative parameters, although, from the plateau created, it requires a very large number of surgeries for slightly better, additional overall benefits. In spite of its complexity and steep learning curve, new surgeons can be encouraged in the LRP technique with mentorship training without compromising overall outcomes, permitting the wide spread of an alternative minimally invasive procedure in low-volume centers.

Five-year oncological outcomes of endoscopic extraperitoneal radical prostatectomy (EERPE) for prostate cancer: results from a medium-volume UK centre

OBJECTIVE

To determine the 5-year oncological outcomes of endoscopic extraperitoneal radical prostatectomy (EERPE) from a medium-volume centre, thereby providing much needed data on outcomes from the UK.

PATIENTS AND METHODS

From January 2006 to January 2012, 575 patients underwent EERPE for localized prostate cancer, performed by a single surgeon who had completed a modular training programme. Follow-up was as per local hospital policy and data were collected in our prospective database. A retrospective review of patient demographics, prostate-specific antigen (PSA) levels, pathological T stages, Gleason scores, surgical margin status and biochemical recurrence (BCR) data was performed. BCR was defined as PSA >0.2 μg/L.

RESULTS

The mean (range) patient age was 62 (40.3-76.5) years and the mean (range) follow-up was 30 (12-72) months. The median (interquartile range [IQR]) operating time was 135 (120-170) min and the median (IQR) blood loss was 200 (100-250) mL. Of the 575 patients, 135 (23.5%) had positive surgical margins (PSMs). The PSM rate for pT2 disease was 66/406 patients (16.3%) and for pT3 disease it was 68/168 patients (40.5%). Overall BCR-free survival at 5-years was 81.5%. Multivariate Cox analysis showed that PSMs, Gleason score, D'Amico risk category and pT stage were independent predictors of BCR-free survival.

CONCLUSIONS

This assessment of the oncological results of EERPE, which included the surgical learning curve, shows that the adoption of EERPE after mentored fellowship training translates into mid-term oncological outcomes in line with those of retropubic/transperitoneal laparoscopic approaches and with large-volume centres worldwide which have pioneered laparoscopic radical prostatectomy. The study shows that EERPE in a medium-volume second generation laparoscopic centre (that introduced EERPE after adequate training in pioneering centres) produces results with good 5-year oncological outcomes, similar to those of other major series, for patients in the UK.

Urinary function and health-related quality of life of patients after laparoscopic radical prostatectomy: two methods of assessment for 112 patients with up to six years of follow-up

Background:

Wide variation exists between methods of assessment of urinary function following laparoscopic radical prostatectomy (LRP).

Objective:

To assess post-operative urinary function and quality of life (QOL) after LRP using validated questionnaires and compare these results with subjective assessments obtained during outpatient consultations.

Design, setting and participants:

Between January 2004 and December 2009, 200 men with organ-confined prostate cancer underwent LRP at our centre. Post-operative urinary function and QOL were evaluated using validated questionnaires (ICIQ-MLUTS and FACT-P). Data regarding urinary function, which were collected at the outpatient clinic (OPC), were also available for these 112 patients.

Outcome measurements and statistical analysis:

Objective post-operative urinary function obtained from validated questionnaires using univariate and multivariate logistic regression models to evaluate the impact of urinary symptoms on QOL.

Results and limitations:

Based on the validated questionnaires, 75% (75/112) of patients had low incontinence scores (0 to 8/24) at a mean follow-up of 37 months. On subjective assessment at the OPC, 82% (92/112) of patients were considered dry (pad free). The majority of patients had a high QOL score (109–156), indicating good quality of life. Urinary symptoms’ severity was significantly correlated with QOL, where severe symptoms were associated with lower QOL. A literature search revealed wide discrepancies in the assessment of functional outcomes following LRP rendering comparison between studies extremely difficult.

Conclusions:

The functional outcomes of LRP vary depending on the assessment used. There continues to be a lack of congruity between the methodologies used in the literature and few studies published have used validated questionnaires.

Oncological and functional results of extraperitoneal laparoscopic radical prostatectomy

The oncological and functional results of 329 cases in a population treated with extraperitoneal laparoscopic radical prostatectomy (ELRP) were evaluated retrospectively. A total of 329 inconsecutive patients with prostate cancer (PCa) who underwent ELRP were retrospectively analyzed. The median initial prostate-specific antigen (PSA) level was 17.35 ng/ml. The median biopsy Gleason score was 7.77. Patients with a T2 or T3a clinical stage had received preoperative neoadjuvant hormonal therapy (NHT) for 3 to 9 months prior to ELRP. No conversion or re-intervention were observed. The median time for anastomosis, surgery time and postoperative catheterization time were 13.0 min, 90.0 min and 6 days, respectively. The median estimated blood loss was 75 ml. There were 12 temporary urinary leakages requiring prolonged catheterization to 14 days. There was 1 case of deep vein thrombosis, 1 case of alimentary tract hemorrhage and 7 cases of anterior urethral stricture. The median follow-up time was 27 months. A total of 17 patients were lost during the follow-up period. No rectal injury, lymphocele, incision hernia, postoperative persistent urinary leak or anastomotic stricture occurred. Younger patients (≤67 years of age) had a more rapid recovery of continence and a better postoperative potency. The overall positive surgical margin rate was 16.7%, which correlated with the pathological stage and Gleason score, respectively (both P<0.001). A total of 89 (28.6%) patients were diagnosed with biochemical recurrence. The initial PSA value, PSM, pathological stage and Gleason score were identified as independent prognostic factors for biochemical recurrence-free survival using multivariate analysis. Our results demonstrated that preoperative NHT had significant effects on the pathological Gleason score (P<0.001) and surgical margin (P=0.027), but no significant impact on biochemical recurrence (P=0.202). The reproducibility of ELRP has been proven as a reliable curative treatment in Western countries during the last 15 years. Due to the increase in PCa patients, the results of our study may aid surgeons who use ELRP for the first time.

Cancer control, continence, and potency after laparoscopic radical prostatectomy beyond the learning and discovery curves

PURPOSE

To investigate the results of laparoscopic radical prostatectomy (LRP) beyond the learning and discovery curves of 700 patients previously reported by the authors for potency.

PATIENTS AND METHODS

Five hundred consecutive patients underwent LRP during a 28-month period with a minimum follow-up of 12 months. Median age (with range) = 61.0 (33-76) years; prostate-specific antigen level = 7.0 (1-37); biopsy Gleason sum = 7 (4-10). Clinical stage was T1 in 41.0%, T2 in 54.2%, and T3 in 4.8%. Nerve preservation (NP) was performed bilaterally in 57.9%, unilaterally in 15.3%, and on neither side in 26.8%.

RESULTS

Median operative time was 157 (91-331) minutes, with no conversions or intraoperative blood transfusions; 0.4% of patients received a transfusion postoperatively, and 4.2% had complications. There were no rectal injuries. The overall positive margin rate was 13.0% and correlated with pathologic parameters. At a minimum of 1 year follow-up (mean=13.5 (12-36) mos), overall survival was 100%, and biochemical disease-free survival was 98.8%. The pad-free rate was 97.4%. Potency (International Index of Erectile Function-5 score ≥17) at a mean follow-up of 13.5 months in previously potent men in their 4th, 5th, 6th, and 7th decades after bilateral NP was 100.0%, 91.8%, 82.9%, and 60.0% and after unilateral NP was 100%, 66.7%, 50.1%, and 0.0%. Overall potency after bilateral neurovascular bundle NVB preservation was 86.9%.

CONCLUSION

LRP is capable of matching or exceeding the best results for open radical prostatectomy and robot-assisted radical prostatectomy when performed by an experienced surgeon in a high-volume setting. These results suggest that the method used to perform radical prostatectomy is a less important determinant of success than surgical experience.

Laparoscopic radical prostatectomy: 10 years experience

PURPOSE

The authors assess the morbidity, functional results and oncologic follow-up of a series of laparoscopic radical prostatectomies performed in over a 10-year period.

MATERIALS AND METHODS

The data on 780 laparoscopic radical prostatectomies performed between September 1997 and December 2007 were stored in a personal database. The following parameters are described and critically analyzed: operative time, blood transfusions, conversions, length of hospital stay, complications, functional results of sexual potency and urinary continence, surgical margins and oncologic follow-up.

RESULTS

Operative time averaged 125 minutes, with a mean bleeding volume of 335 mL and mean hospital stay of 4.3 days. The rate of conversion to open surgery was 1.36% and the overall complication rate was 14.24%. The pathology analysis showed pT2 tumors in 82.60% and pT3 tumors in 17.39% of cases. The overall positive margin rate was 19.58%, with a biochemical recurrence of 10.27% at a mean follow-up of 62.5 months. Urinary continence and sexual potency yielded rates of 88% and 61%, respectively, 12 months after surgery.

CONCLUSIONS

Laparoscopic radical prostatectomy is a technically well-defined procedure that provides good oncologic and functional results after proper training.

Incidence of surgical site infection associated with robotic surgery

OBJECTIVE

Robot-assisted surgery is minimally invasive and associated with less blood loss and shorter recovery time than open surgery. We aimed to determine the duration of robot-assisted surgical procedures and the incidence of postoperative surgical site infection (SSI) and to compare our data with the SSI incidence for open procedures according to national data.

DESIGN

Retrospective cohort study.

SETTING

A 689-bed academic medical center.

PATIENTS

All patients who underwent a surgical procedure with use of a robotic surgical system during the period from 2000-2007.

METHODS

SSIs were defined and procedure types were classified according to National Healthcare Safety Network criteria. National data for comparison were from 1992-2004. Because of small sample size, procedures were grouped according to surgical site or wound classification.

RESULTS

Sixteen SSIs developed after 273 robot-assisted procedures (5.9%). The mean surgical duration was 333.6 minutes. Patients who developed SSI had longer mean surgical duration than did patients who did not (558 vs 318 minutes; P<.001). The prostate and genitourinary group had 5.74 SSIs per 100 robot-assisted procedures (95% confidence interval [CI], 2.81-11.37), compared with 0.85 SSIs per 100 open procedures from national data. The gynecologic group had 10.00 SSIs per 100 procedures (95% CI, 2.79-30.10), compared with 1.72 SSIs per 100 open procedures. The colon and herniorrhaphy groups had 33.33 SSIs per 100 procedures (95% CI, 9.68-70.00) and 37.50 SSIs per 100 procedures (95% CI, 13.68-69.43), respectively, compared with 5.88 and 1.62 SSIs per 100 open procedures from national data. Patients with a clean-contaminated wound developed 6.1 SSIs per 100 procedures (95% CI, 3.5-10.3), compared with 2.59 SSIs per 100 open procedures. No significant differences in SSI rates were found for other groups.

CONCLUSIONS

Increased incidence of SSI after some types of robot-assisted surgery compared with traditional open surgery may be related to the learning curve associated with use of the robot.

The learning curve for laparoscopic radical prostatectomy: an international multicenter study

PURPOSE

It is not yet possible to estimate the number of cases required for a beginner to become expert in laparoscopic radical prostatectomy. We estimated the learning curve of laparoscopic radical prostatectomy for positive surgical margins compared to a published learning curve for open radical prostatectomy.

MATERIALS AND METHODS

We reviewed records from 8,544 consecutive patients with prostate cancer treated laparoscopically by 51 surgeons at 14 academic institutions in Europe and the United States. The probability of a positive surgical margin was calculated as a function of surgeon experience with adjustment for pathological stage, Gleason score and prostate specific antigen. A second model incorporated prior experience with open radical prostatectomy and surgeon generation.

RESULTS

Positive surgical margins occurred in 1,862 patients (22%). There was an apparent improvement in surgical margin rates up to a plateau at 200 to 250 surgeries. Changes in margin rates once this plateau was reached were relatively minimal relative to the CIs. The absolute risk difference for 10 vs 250 prior surgeries was 4.8% (95% CI 1.5, 8.5). Neither surgeon generation nor prior open radical prostatectomy experience was statistically significant when added to the model. The rate of decrease in positive surgical margins was more rapid in the open vs laparoscopic learning curve.

CONCLUSIONS

The learning curve for surgical margins after laparoscopic radical prostatectomy plateaus at approximately 200 to 250 cases. Prior open experience and surgeon generation do not improve the margin rate, suggesting that the rate is primarily a function of specifically laparoscopic training and experience.

Operator is an independent predictor of detecting prostate cancer at transrectal ultrasound guided prostate biopsy

PURPOSE

We investigated whether interoperator differences exist in the setting of prostate cancer detection by transrectal ultrasound guided prostate biopsy. Our secondary aim was to investigate whether a learning curve exists for prostate cancer detection.

MATERIALS AND METHODS

A prospective database from 2000 to 2008 including 9,072 transrectal ultrasound guided prostate biopsies at our institution was limited to 4,724 done at initial presentation. Biopsies were performed by 4 uroradiologists. The OR for detecting cancer on transrectal ultrasound guided prostate biopsy was calculated for likely independent prognostic variables, including operator. We also examined the rate of biopsy positivity in increments, comparing the first and last cohorts. The senior radiologist (AT) with the most biopsies (75%) was considered the referent for prostate cancer detection. Univariate and multivariate logistic regression modeling was used to determine significant covariates with p <0.05 deemed relevant.

RESULTS

Prostate cancer was detected in 2,331 men (49.3%). Operators performed a median of 514 transrectal ultrasound guided prostate biopsies (range 187 to 3,509) with a prostate cancer detection rate of 43.8% to 52.4% (p = 0.001). Other significant covariates were prostate specific antigen, suspicious lesions on ultrasound, nodule on digital rectal examination, smaller prostate volume and increasing patient age. Operator was a significant multivariate predictor of cancer detection (OR 0.67 to 0.89, p = 0.003). No learning curve was detected and biopsy rates were consistent throughout the series.

CONCLUSIONS

Significant differences in prostate cancer detection exist among operators who perform transrectal ultrasound guided prostate biopsy even in the same setting. The volume of previously performed transrectal ultrasound guided prostate biopsies does not appear to influence the positive prostate cancer detection rate, nor could a learning curve be identified. Differences in prostate cancer detection among operators are likely related to unknown differences in expertise or technique. Further research is needed.

Robotic-assisted laparoscopic prostatectomy

Prostate cancer remains a significant health problem worldwide and is the second highest cause of cancer-related death in men. While there is uncertainty over which men will benefit from radical treatment, considerable efforts are being made to reduce treatment related side-effects and in optimising outcomes. This article reviews the development and introduction of robotic-assisted laparoscopic radical prostatectomy (RALP), the results to date, and the possible future directions of RALP.