Advances in Robotic-Assisted Radical Prostatectomy over Time

Develop prediction model to help forecast advanced prostate cancer patients' prognosis after surgery using neural network

Background

The effect of surgery on advanced prostate cancer (PC) is unclear and predictive model for postoperative survival is lacking yet.

Methods

We investigate the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database, to collect clinical features of advanced PC patients. According to clinical experience, age, race, grade, pathology, T, N, M, stage, size, regional nodes positive, regional nodes examined, surgery, radiotherapy, chemotherapy, history of malignancy, clinical Gleason score (composed of needle core biopsy or transurethral resection of the prostate specimens), pathological Gleason score (composed of prostatectomy specimens) and prostate-specific antigen (PSA) are the potential predictive variables. All samples are divided into train cohort (70% of total, for model training) and test cohort (30% of total, for model validation) by random sampling. We then develop neural network to predict advanced PC patients' overall. Area under receiver operating characteristic curve (AUC) is used to evaluate model's performance.

Results

6380 patients, diagnosed with advanced (stage III-IV) prostate cancer and receiving surgery, have been included. The model using all collected clinical features as predictors and based on neural network algorithm performs best, which scores 0.7058 AUC (95% CIs, 0.7021-0.7068) in train cohort and 0.6925 AUC (95% CIs, 0.6906-0.6956) in test cohort. We then package it into a Windows 64-bit software.

Conclusion

Patients with advanced prostate cancer may benefit from surgery. In order to forecast their overall survival, we first build a clinical features-based prognostic model. This model is accuracy and may offer some reference on clinical decision making.

The effect of the da Vinci® Vessel Sealer on robot-assisted laparoscopic prostatectomy complications

The da Vinci® Vessel Sealer is a major contributor to the total cost of robot-assisted laparoscopic prostatectomy (RALP). We aimed to assess whether the use of the Vessel Sealer is associated with better surgical outcomes in a population of patients that underwent RALP with lymphadenectomy. We tested whether the use of the Vessel Sealer is associated with the development of lymphocele and/or other surgical outcomes. Most surgeons used the Vessel Sealer in almost all or almost no patients. Thus, to avoid the potential confounding variable of surgeon skill, we performed the initial analyses using data from a single surgeon who changed practice over time, and then using the entire population. Overall, the Vessel Sealer was used in 500 (36%) RALPs. Surgeon 1 performed 492 surgeries, and used the Vessel Sealer in 191 (39%). The Vessel Sealer was not associated with better surgical outcomes in patients operated on by Surgeon 1. The odds ratio for development of lymphocele was 1.95 (95% confidence interval [CI] 0.57-6.75). In the entire population, use of the sealer was significantly associated with a very small reduction of blood loss (22 cc, CI 13-30) but with a 32-min increase in the operating room time (CI 26-37). Use of the Vessel Sealer will have, at best, a very small effect on RALP outcomes that is of highly questionable relevance given its cost. In light of these results, the Vessel Sealer will only be used at our institution in the context of clinical trials.

Comparison of Retzius-Sparing Robot-Assisted Radical Prostatectomy vs. Conventional Robot-Assisted Radical Prostatectomy: An Up-to-Date Meta-Analysis

Background: The Retzius space-sparing robot-assisted radical prostatectomy (RS-RARP) has shown better results in urinary continence, but its efficacy and safety compared to conventional robot-assisted radical prostatectomy (c-RARP) remain controversial.

Material and Methods: A research was conducted in Medline via PubMed, Cochrane Library, EMBASE, and Web of Science up to January 4, 2021, to identify studies comparing RS-RARP to c-RARP. We used RevMan 5.3 and STATA 14.0 for meta-analysis.

Results: A total of 14 studies involving 3,129 participants were included. Meta-analysis showed no significant difference in positive surgical margins (PSMs), but the RS-RARP group had significantly higher PSM rates in the anterior site [odds ratio (OR) = 2.25, 95% CI: 1.22–4.16, P = 0.01]. Postoperative continence in RS-RARP group at 1 month (OR = 5.72, 95% CI: 3.56–9.19, P < 0.01), 3 months (OR = 6.44, 95% CI: 4.50–9.22, P < 0.01), 6 months (OR = 8.68, 95% CI: 4.01–18.82, P < 0.01), and 12 months (OR = 2.37, 95% CI: 1.20–4.70, P = 0.01) was significantly better than that in the c-RARP group. In addition, the RS-RARP group had a shorter console time (mean difference = −16.28, 95% CI: −27.04 to −5.53, P = 0.003) and a lower incidence of hernia (OR = 0.35, 95% CI: 0.19–0.67, P = 0.001). However, there were no significant differences in estimated blood loss, pelvic lymph node dissection rate, postoperative complications, 1-year-biochemical recurrence rate, and postoperative sexual function.

Conclusions: Compared with c-RARP, RS-RARP showed better recovery of continence, shorter console time, and lower incidence of hernia. Although there was no significant difference in overall PSM, we suggest that the surgeon should be more careful if the lesion is in the anterior prostate.

Laparoendoscopic radical prostatectomy (LRP): stepwise transition from multi-site to single-site with the aid of the transurethral port

PURPOSE

To describe our initial experience with laparoendoscopic radical prostatectomy (LRP) and a stepwise transition towards transurethral assisted laparoendoscopic single-site RP (TU-LESS RP).

PATIENTS AND METHODS

From Jan. 2007 to Dec. 2016, 195 patients underwent RP, of which 89 patients were performed by LRP (Group A), 106 by TU-LESS RP (Group B). The peri-operative data were collected and analyzed. All data referring to patient demographics, surgery, pathology, and peri-operative outcomes were recorded. The cosmetic result was investigated by the Patient Scar Assessment Questionnaire (PSAQ). Analysis of variance or Chi squared test were adopted to analyze the data.

RESULTS

195 procedures were completed successfully. The operation time (109.6 ± 31.9 vs. 151.5 ± 87.3, P = 0.025) and anastomosis time (10.1 ± 4.8 vs. 21.8 ± 9.9, P < 0.001) of Group B was significantly reduced compared with Group A. Estimated blood loss in Group B was significantly lower than that in Group A (95.9 ± 11.1 vs. 180.2 ± 99.7, P = 0.006). About perioperative complications, Group B was also less compared with Group A (1.9% vs. 7.9%, P = 0.047). As to the usage of postoperative analgesics, Group B apparently used less than that in Group A (6.6% vs. 62.9%, P < 0.001), which is consistent with the visual analogue scale (VAS) of the two groups (1.7 ± 1.3 vs. 7.8 ± 1.1, P < 0.001). Patients in Group B were significantly more satisfied with incision healing than in group A (74.9 ± 9.3 vs. 49.7 ± 5.8, P < 0.001). There was no significant difference both in BCR rate and time between Group B and Group A. In urination control, more patients in Group B did not have urinary incontinence 3 month after RP compared with Group A (81.1% vs. 67.4%, P = 0.028).

CONCLUSIONS

LESS RP is proved to be feasible for the proper patients, but it is difficult to popularized due to inconvenient operation. While by means of TU-LESS, operating difficulty can be significantly decreased. TU-LESS RP will be wildly accepted by surgeons and patients because of cosmetic satisfaction and quicker recovery.

A review of the effects of tobacco smoking on the treatment of prostate cancer

Background:

Prostate cancer is the most commonly diagnosed malignancy and the third leading cause of death among Canadian men. The standard treatment modalities for prostate cancer include prostatectomy, radiation therapy, hormonal therapy and chemotherapy or any combination depending on the stage of the tumour. However, several studies have reported that tobacco smoking at the time of diagnosis and during treatment can potentially impact treatment efficacy, outcome and patients quality of life after treatment.

Materials and methods:

This narrative literature review elucidates the impacts of tobacco smoking on prostate cancer progression, treatment efficacy, including its effects on prostatectomy, radiation therapy and chemotherapy, risk of cancer recurrence and mortality and quality of life after treatment. Furthermore, we discuss the importance of integrating a smoking cessation programme into the treatment regimen for prostate cancer patients in order to yield more favourable treatment outcomes, reduce risk of recurrence and mortality and increase the quality of life after treatment for prostate cancer patients.

Conclusions:

Smoking cessation is one of the most important interventions to prevent cancer and it is also essential after the diagnosis of prostate cancer to improve clinical outcomes. All prostate cancer patients should be advised to quit tobacco use since it can potentially improve treatment response rates and survival, as well as reduce the risk of developing treatment complications and potentially improve the quality of life after treatment. There are several benefits to smoking cessation and it should become an important component of the cancer care continuum in all oncology programmes, starting from prevention of cancer through diagnosis, treatment, survivorship and palliative care. Evidence-based smoking cessation intervention should be sustainably integrated into any comprehensive cancer programme, and the information should be targeted to the specific benefits of cessation in cancer patients.

Development of a Patient-Based Model for Estimating Operative Times for Robot-Assisted Radical Prostatectomy

OBJECTIVES

To develop a methodology for predicting operative times for robot-assisted radical prostatectomy (RARP) using preoperative patient, disease, procedural, and surgeon variables to facilitate operating room (OR) scheduling.

METHODS

The model included preoperative metrics: body mass index (BMI), American Society of Anesthesiologists score, clinical stage, National Comprehensive Cancer Network risk, prostate weight, nerve-sparing status, extent and laterality of lymph node dissection, and operating surgeon (six surgeons were included in the study). A binary decision tree was fit using a conditional inference tree method to predict operative times. The variables most associated with operative time were determined using permutation tests. Data were split at the value of the variable that results in the largest difference in mean for surgical time across the split. This process was repeated recursively on the resultant data.

RESULTS

A total of 1709 RARPs were included. The variable most strongly associated with operative time was the surgeon (surgeons 2 and 4-102 minutes shorter than surgeons 1, 3, 5, and 6, p < 0.001). Among surgeons 2 and 4, BMI had the strongest association with surgical time (p < 0.001). Among patients operated by surgeons 1, 3, 5, and 6, RARP time was again most strongly associated with the surgeon performing RARP. Surgeons 1, 3, and 6 were on average 76 minutes faster than surgeon 5 (p < 0.001). The regression tree output in the form of box plots showed operative time median and ranges according to patient, disease, procedural, and surgeon metrics.

CONCLUSION

We developed a methodology that can predict operative times for RARP based on patient, disease and surgeon variables. This methodology can be utilized for quality control, facilitate OR scheduling, and maximize OR efficiency.

Effects of Retzius sparing on robot-assisted laparoscopic prostatectomy: a systematic review with meta-analysis

BACKGROUND

To comprehensively evaluate the efficacy and safety of Retzius sparing (RS) for men undergoing robot-assisted laparoscopic prostatectomy (RARP).

METHODS

We searched four electronic databases and reference lists of relevant studies for eligible research published before March 11, 2019. After quality assessment, eligible studies were synthesized for relevant outcomes, including positive surgical margin (PSM), continence, incontinence, complication, console time, and hospital stay.

RESULTS

Two randomized clinical trials and four observational studies were included in this study. Quantitative syntheses revealed significantly higher PSM rates in RS-RARP compared with conventional RARP (c-RARP) (odds ratio [OR] 1.68, p = 0.02). Furthermore, we found significantly higher PSM rates at the anterior site in RS-RARP compared with c-RARP (OR 4.34, p = 0.03) and significantly lower incontinence rates in RS-RARP in the first month (OR 0.30, p < 0.001) and 12th month (OR 0.25, p < 0.001).

CONCLUSIONS

Our syntheses revealed higher PSM rates in the RS-RARP group, especially in the anterior aspect. However, RS-RARP had superior functional outcome of urinary continence and lower console time than did c-RARP with equivalent complication rates. Thus, we suggest that operators pay more attention to making clear surgical margins if the lesion is in anterior prostate when performing RS-RARP.

Review of strategies and factors to maximize cost-effectiveness of robotic hysterectomies and myomectomies in benign gynecological disease

Common benign gynecologic procedures include hysterectomies and myomectomies, with hysterectomy being the most common gynecologic procedure in the United States [1]. While historically performed via laparotomy, the field of gynecologic surgery was revolutionized with the advent of laparoscopic techniques, with the most recent advancement being the introduction of robotic-assisted surgery in 2005. Robotic surgery has all the benefits of laparoscopic surgery such as decreased blood loss, quicker return to activities, and shorter length of hospital stay. Additional robotic-specific advantages include but are not limited to improved ergonomics, 3D visualization, and intuitive surgical movements. Despite these advantages, one of the most commonly cited drawbacks of robotic surgery is the associated cost. While the initial cost to purchase the robotic console and its associated maintenance costs are relatively high, robotic surgery can be cost-effective when utilized correctly.This article reviews application strategies and factors that can offset traditional costs and maximize the benefits of robotic surgery.

Variation in prostate surgery costs and outcomes in the USA: robot-assisted versus open radical prostatectomy

AIM

To compare perioperative complications, inpatient cost and length of stay between robot-assisted radical prostatectomy (RARP) and open radical prostatectomy (ORP) using National Inpatient Sample data from 2010 to 2015.

PATIENTS & METHODS

A total of 69,009 records with RARP or ORP were analyzed using multivariate logistic regression and generalized linear models.

RESULTS

The RARP had superior perioperative outcomes at a higher cost (adjusted mean difference = 2956; 95% CI: $2822-$3090) and shorter length of stay (mean difference = 0.85; 95% CI: 0.81-0.89) compared with ORP. Mean cost of RARP was lowest in urban teaching, private invest-own, high volume and northeast region hospitals and highest for black men.

CONCLUSION

Compared with ORP, RARP had significantly better perioperative outcomes at a higher cost.

Are We Improving Erectile Function Recovery After Radical Prostatectomy? Analysis of Patients Treated over the Last Decade

BACKGROUND

The last decade has seen several advances in radical prostatectomy (RP) technique and post-RP care that are relevant to erectile function (EF) recovery.

OBJECTIVE

We examined whether these practice changes have led to observed improvements in EF rates over time.

DESIGN, SETTING, AND PARTICIPANTS

We identified 2364 patients treated with either open or minimally-invasive RP at a single academic center in 2008-2015. To mitigate confounding by the surgical learning curve, only patients treated by surgeons who performed at least 100 procedures were considered.

INTERVENTION

EF before and after RP was assessed by the International Index of Erectile Function 6 (IIEF-6), with recovery defined as IIEF-6 ≥24.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We analyzed EF recovery rates of patients treated with bilateral nerve-sparing surgery and free from adjuvant/salvage treatment at the time of EF assessment. Local polynomial regression analyses explored changes in the outcomes over time. Linear and logistic regression analyses were used to estimate the influence of year of surgery on baseline variables and EF recovery.

RESULTS AND LIMITATIONS

We observed a significant decrease over time of the EF recovery rates at both 12 and 24mo post-RP (all p=0.01). However, patient's age at surgery increased over time (mean increase of 0.5 per year; p<0.01), with a resultant increase in risk of comorbidity (odds ratio [OR]=1.1, 95% confidence interval [CI]: 1.02-1.15; p=0.008) and thus decrease in baseline IIEF-6 score (0.35 points per year; p=0.0003). After accounting for baseline and pathological characteristics, urinary function, and type of surgery in a multivariable analysis, year of surgery was not associated with EF recovery (12mo: OR=0.97, 95% CI: 0.91-1.03, p=0.4; 24mo: OR=0.97, 95% CI: 0.91-1.03, p=0.3).

CONCLUSIONS

Findings from a high-volume center suggest that, despite the advancements in surgical and postoperative care, EF outcomes after RP have not improved over the last decade. Additional strategies are required to improve EF recovery after RP.

PATIENT SUMMARY

The probability of regaining potency after surgery for prostate cancer did not improve over the last decade; more efforts are needed to improve patient's care after radical prostatectomy.

Nerve Bundle Hydrodissection and Sexual Function after Robot Prostatectomy

Background and Objectives:

Loss of erectile function is common after prostatectomy, and surgeons have long sought techniques that reduce this adverse outcome. This study was conducted to assess erectile function after robot-assisted laparoscopic prostatectomy, with and without hydrodissection (HD) of the neurovascular bundles (NVBs).

Methods:

Using a database of 335 consecutive RALP procedures conducted by 2 surgeons, we identified all nerve-sparing surgeries performed by HD or standard dissection (SD). The primary and secondary endpoints were Sexual Health Inventory for Men (SHIM) scores and surgical margin positivity, respectively. Subset analyses were performed on men with preoperative SHIM scores ≥17. Determinants of the postoperative SHIM score were evaluated by multivariate linear regression.

Results:

Among men with preoperative SHIM scores ≥17 who underwent bilateral complete nerve sparing (n = 73), mean preoperative SHIM scores were similar in the HD and SD groups, but were significantly higher in the HD group at 6 months (16.1 ± 8.6 vs 8.3 ± 8.1; P = .024) and >1 year after surgery (16.9 ± 7.1 vs 9.1 ± 6.4; P = .004). According to multivariate linear regression analysis including all patients, HD at RALP (odds ratio [OR] 6.9; 95% confidence interval (CI) 2.8–11.0; P = .001) and preoperative SHIM score were independent predictors of erectile function at >1 year after surgery. There was no significant difference in surgical margin positivity between groups (P = .36).

Conclusion:

HD of the NVB appears to improve erectile function after RALP.

Radical prostatectomy for locally advanced and metastatic prostate cancer

The management of advanced prostate cancer remains challenging. Traditionally, radical prostatectomy was discouraged in patients with locally advanced or node positive disease owing to the increased complication rate and treatment related morbidity. However, technical advances and refinements in surgical techniques have enabled the outcomes for patients with high risk prostate cancer to be improved. More recently, the concept of cytoreductive prostatectomy has been described where surgery (often Combined with an extended lymph node dissection) is performed in the setting of metastatic disease. Indirect evidence suggests an advantage using the cytoreductive approach. Hypothetical explanations for this observed benefit include decreased tumour burden, immune modulation, improved response to secondary treatment and avoidance of secondary complications attributable to local tumour growth. Nevertheless, prospective trials are required to investigate this further.

Reducing Costs for Robotic Radical Prostatectomy: Three-instrument Technique

OBJECTIVE

To describe our technique for performing robotic-assisted laparoscopic prostatectomy (RALP) and pelvic lymph node dissection using only 3 robotic instruments to reduce disposable costs associated with the robotic surgical platform.

METHODS

The financial impact of robotic surgery is real. Whereas the initial capital investment of the robotic platform (including the cost of the device itself and the maintenance contract) is largely fixed, the cost of disposable instrumentation can vary depending on utilization. Herein we describe our technique for 3-instrument robotic radical prostatectomy that may decrease costs by limiting the use of disposable instruments.

RESULTS

Exclusion of the high-cost energy instruments may reduce operative costs by up to 40%. In addition, using 1 robotic needle driver vs 2 may decrease overall costs by another 12%. At our institution, we have adopted these techniques in cost-efficiency and have gone further by only using 3 instruments during robotic radical prostatectomy. The only 3 instruments necessary to perform a successful RALP are a robotic needle driver, Prograsp forceps, and monopolar scissors.

CONCLUSION

To improve the value of care while utilizing robotic technology, we must be cognizant of keeping operative costs to a minimum while maintaining positive patient outcomes. We demonstrate here a method to decrease disposable operating room costs while preserving the ability to successfully perform a RALP.

Efficacy and cost of robotic hepatectomy: is the robot cost-prohibitive?

Robotic technology is being utilized in multiple hepatobiliary procedures, including hepatic resections. The benefits of minimally invasive surgical approaches have been well documented; however, there is some concern that robotic liver surgery may be prohibitively costly and therefore should be limited on this basis. A single-institution, retrospective cohort study was performed of robotic and open liver resections performed for benign and malignant pathologies. Clinical and cost outcomes were analyzed using adjusted generalized linear regression models. Clinical and cost data for 71 robotic (RH) and 88 open (OH) hepatectomies were analyzed. Operative time was significantly longer in the RH group (303 vs. 253 min; p = 0.004). Length of stay was more than 2 days shorter in the RH group (4.2 vs. 6.5 days; p < 0.001). RH perioperative costs were higher ($6026 vs. $5479; p = 0.047); however, postoperative costs were significantly lower, resulting in lower total hospital direct costs compared with OH controls ($14,754 vs. $18,998; p = 0.001). Robotic assistance is safe and effective while performing major and minor liver resections. Despite increased perioperative costs, overall RH direct costs are not greater than OH, the current standard of care.

Robotic-assisted laparoscopic prostatectomy: An update on functional and oncologic outcomes, techniques, and advancements in technology

The robotic platform has revolutionized the management of prostate cancer over the last 15 years. Several techniques have been developed to improve functional and oncologic outcomes, including meticulous apical and posterior dissection, nerve sparing techniques, bladder neck and urethral length sparing, and anastomotic reconstruction. Future developments involving novel single-site, robotic technology will undoubtedly further the field of minimally invasive urology. These topics are reviewed within this article.

Reducing robotic prostatectomy costs by minimizing instrumentation

INTRODUCTION AND OBJECTIVE

Since the introduction of robotic surgery for radical prostatectomy, the cost-benefit of this technology has been under scrutiny. While robotic surgery professes to offer multiple advantages, including reduced blood loss, reduced length of stay, and expedient recovery, the associated costs tend to be significantly higher, secondary to the fixed cost of the robot as well as the variable costs associated with instrumentation. This study provides a simple framework for the careful consideration of costs during the selection of equipment and materials.

MATERIALS AND METHODS

Two experienced robotic surgeons at our institution as well as several at other institutions were queried about their preferred instrument usage for robot-assisted prostatectomy. Costs of instruments and materials were obtained and clustered by type and price. A minimal set of instruments was identified and compared against alternative instrumentation. A retrospective review of 125 patients who underwent robotically assisted laparoscopic prostatectomy for prostate cancer at our institution was performed to compare estimated blood loss (EBL), operative times, and intraoperative complications for both surgeons. Our surgeons now conceptualize instrument costs as proportional changes to the cost of the baseline minimal combination.

RESULTS

Robotic costs at our institution were reduced by eliminating an energy source like the Ligasure or vessel sealer, exploiting instrument versatility, and utilizing inexpensive tools such as Hem-o-lok clips. Such modifications reduced surgeon 1's cost of instrumentation to ∼40% less compared with surgeon 2 and up to 32% less than instrumentation used by surgeons at other institutions. Surgeon 1's combination may not be optimal for all robotic surgeons; however, it establishes a minimally viable toolbox for our institution through a rudimentary cost analysis. A similar analysis may aid others in better conceptualizing long-term costs not as nominal, often unwieldy prices, but as percent changes in spending. With regard to intraoperative outcomes, the use of a minimally viable toolbox did not result in increased EBL, operative time, or intraoperative complications.

CONCLUSION

Simple changes to surgeon preference and creative utilization of instruments can eliminate 40% of costs incurred on robotic instruments alone. Moreover, EBL, operative times, and intraoperative complications are not compromised as a result of cost reduction. Our process of identifying such improvements is straightforward and may be replicated by other robotic surgeons. Further prospective multicenter trials should be initiated to assess other methods of cost reduction.

Robot-assisted radical prostatectomy: inching toward gold standard

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

High-risk prostate cancer-classification and therapy

Approximately 15% of patients with prostate cancer are diagnosed with high-risk disease. However, the current definitions of high-risk prostate cancer include a heterogeneous group of patients with a range of prognoses. Some have the potential to progress to a lethal phenotype that can be fatal, while others can be cured with treatment of the primary tumour alone. The optimal management of this patient subgroup is evolving. A refined classification scheme is needed to enable the early and accurate identification of high-risk disease so that more-effective treatment paradigms can be developed. We discuss several principles established from clinical trials, and highlight other questions that remain unanswered. This Review critically evaluates the existing literature focused on defining the high-risk population, the management of patients with high-risk prostate cancer, and future directions to optimize care.