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Carlos AF, Dario VM, Popescu RI, Mariela C, Venancio CA. Robot-Assisted Radical Prostatectomy (RARP) Trifecta Learning Curve for Surgeons with Previous Experience in Laparoscopy. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1032. [PMID: 39064461 PMCID: PMC11279117 DOI: 10.3390/medicina60071032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 06/18/2024] [Accepted: 06/19/2024] [Indexed: 07/28/2024]
Abstract
Background and Objectives: Robot-assisted radical prostatectomy (RARP) is a complex surgery with a steep learning curve (LC). No clear evidence exists for how previous laparoscopic experience affects the RARP LC. We report the LC of three surgeons with vast experience in laparoscopy (more than 400 procedures), analyzing the results of functional and oncological outcomes under the "Trifecta" concept (defined as the achievement of continence, potency, and oncological control free of biochemical recurrence). Materials and Methods: The surgical experience of the three surgeons from September 2021 to December 2022, involving 146 RARP consecutive patients in a single institution center, was evaluated prospectively. Erectile disfunction patients were excluded. ANOVA and chi-square test were used to compare the distribution of variables between the three surgeons. LC analysis was performed using the cumulative sum control chart (CUSUM) technique to achieve trifecta. Results: The median age was 65.42 (±7.34); the clinical stage were T1c (68%) and T2a (32%); the biopsy grades were ISUP 1 (15.9%), ISUP 2 (47.98), and ≥ISUP 3 (35%). The median surgical time was 132.8 (±32.8), and the mean intraoperative bleeding was 186 cc (±115). Complications included the following: Clavien-Dindo I 8/146 (5.47%); II 9/146 (6.16%); and III 3/146 (2.05%). Positive margins were reported in 44/146 (30.13%). The PSA of 145/146 patients (99%) at 6 months was below 0.08. Early continence was achieved in 101/146 (69.17%), 6-month continence 126/146 (86%), early potency 51/146 (34.9%), and 6-month potency 65/146 (44%). Surgeons "a", "b", and "c" performed 50, 47, and 49 cases, respectively. After CUSUM analysis, the "Trifecta" LC peak was achieved at case 19 in surgeon "a", 21 in surgeon "b", and 20 in surgeon "c". Conclusions: RARP LC to accomplish "Trifecta" can be significantly reduced in surgeons with previous experience in laparoscopy and be achieved at around 20 cases.
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Affiliation(s)
- Altez-Fernandez Carlos
- Service of Urology, Universitary Hospital of La Coruña, 15006 A Coruña, Spain; (A.-F.C.); (V.-M.D.); (C.-A.V.)
| | - Vazquez-Martul Dario
- Service of Urology, Universitary Hospital of La Coruña, 15006 A Coruña, Spain; (A.-F.C.); (V.-M.D.); (C.-A.V.)
| | - Răzvan-Ionut Popescu
- Department of Urology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Urology, “Prof. Dr. Th. Burghele” Clinical Hospital, 061344 Bucharest, Romania
| | - Corrales Mariela
- Service d’Urologie, Assistance-Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, 75005 Paris, France;
| | - Chantada-Abal Venancio
- Service of Urology, Universitary Hospital of La Coruña, 15006 A Coruña, Spain; (A.-F.C.); (V.-M.D.); (C.-A.V.)
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Uchida T, Hasegawa M, Umemoto T, Nakajima N, Nitta M, Kawamura Y, Shoji S, Miyajima A. Predictors of surgical difficulty according to surgical proficiency in robot-assisted radical prostatectomy. Surg Endosc 2024; 38:3416-3424. [PMID: 38724645 DOI: 10.1007/s00464-024-10850-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 04/10/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Robot-assisted radical prostatectomy (RARP) is a standard treatment for localized prostate cancer. We previously reported that a large amount of pelvic visceral fat and a small working space, as measured by three-dimensional image analysis, were significantly associated with prolonged console time in RARP, and these factors could be alternatives to the more clinically practical body mass index (BMI) and pelvic width (PW), respectively. Herein, we further investigated whether surgical proficiency affected surgical difficulty as measured by console time. METHODS Medical records of 413 patients who underwent RARP between 2014 and 2020 at our institution were reviewed. Surgeons who had experience with over and under 100 cases were defined as "experienced" and "non-experienced," respectively. Multivariate logistic regression analyses were performed to identify factors that prolonged console time. RESULTS The median console times for RARP by experienced and non-experienced surgeons were 87.5 and 149.0 min, respectively; a difficult case was defined as one requiring time greater than the median. Among inexperienced surgeons, higher BMI (p < 0.001, odds ratio: 1.89) and smaller PW (p = 0.001, odds ratio: 1.86) were significant factors that increased console time; the complication rate was increased in patients with these factors. However, these factors did not significantly affect the console time or complication rate among experienced surgeons. CONCLUSION This study demonstrates that experienced surgeons may be able to overcome obesity- and small workspace-related surgical difficulties. The current analysis may provide useful information regarding unpredictable surgical risks and identify suitable cases for novices.
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Affiliation(s)
- Takato Uchida
- Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Masanori Hasegawa
- Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.
| | - Tatsuya Umemoto
- Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Nobuyuki Nakajima
- Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Masahiro Nitta
- Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Yoshiaki Kawamura
- Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Sunao Shoji
- Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Akira Miyajima
- Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
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Flammia RS, Bologna E, Anceschi U, Tufano A, Licari LC, Antonelli L, Proietti F, Alviani F, Gallucci M, Simone G, Leonardo C. "Single Knot-Single Running Suture" Vesicourethral Anastomosis with Posterior Musculofascial Reconstruction during Robot-Assisted Radical Prostatectomy: A Step-by-Step Guide of Surgical Technique. J Pers Med 2023; 13:1072. [PMID: 37511685 PMCID: PMC10381871 DOI: 10.3390/jpm13071072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 06/23/2023] [Accepted: 06/28/2023] [Indexed: 07/30/2023] Open
Abstract
Background: Our aim is to describe Gallucci's (VV-G) technique for vesicourethral anastomosis and posterior musculofascial reconstruction (PMFR) during robot-assisted radical prostatectomy (RARP) and to assess early urinary continence recovery and perioperative outcomes. VV-G consists of a "single knot-single running suture" vesicourethral anastomosis with PMFR. Methods: Between September 2019 and October 2021, we prospectively compared VV-G vs. conventional Van Velthoven anastomosis (VV-STD) during RARP. We excluded patients with urinary incontinence, pelvic radiotherapy, and urethral and BPH surgery prior to RARP. Social continence (SC) recovery, perioperative complications, and length of hospital stay (LOS) were compared between VV-G vs. VV-STD. SC was defined as 0-1 pad/die. We applied 1:1 propensity score matching (PSM) adjusting for different covariates (age, Charlson Comorbidity Index, BMI, prostate volume, nerve-sparing and lymph node dissection). Results: From 166 patients, 1:1 PSM resulted in two equally sized groups of 40 patients each with no residual differences (all p ≥ 0.2). VV-G yielded higher 3-month SC rates than VV-STD (97.5 vs. 55.0%, p < 0.001). A tiny difference was still recorded at one-year follow-up (97.5 vs. 80.0%, p = 0.029, HR: 2.90, 95% CI: 1.74-4.85, p < 0.001). Conversely, we observed no differences in any perioperative complications (15.0 vs. 22.5%, OR: 0.61, 95% CI 0.19-1.88, p = 0.4) and LOS (3 vs. 4 days, Δ: -0.69 ± 0.61, p = 0.1). Conclusions: VV-G significantly improved early SC recovery without increasing perioperative morbidity. In our opinion, VV-G represents an easy-to-learn and easy-to-teach technique due to its single-suture, single-knot, and symmetrical design.
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Affiliation(s)
- Rocco Simone Flammia
- Department of Maternal-Child and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00161 Rome, Italy
- Department of Urology, "Regina Elena" National Cancer Institute, 00128 Rome, Italy
| | - Eugenio Bologna
- Department of Maternal-Child and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00161 Rome, Italy
| | - Umberto Anceschi
- Department of Urology, "Regina Elena" National Cancer Institute, 00128 Rome, Italy
| | - Antonio Tufano
- Department of Maternal-Child and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00161 Rome, Italy
| | - Leslie Claire Licari
- Department of Maternal-Child and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00161 Rome, Italy
| | - Luca Antonelli
- Department of Maternal-Child and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00161 Rome, Italy
| | - Flavia Proietti
- Department of Maternal-Child and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00161 Rome, Italy
- Department of Urology, "Regina Elena" National Cancer Institute, 00128 Rome, Italy
| | - Federico Alviani
- Department of Maternal-Child and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00161 Rome, Italy
| | - Michele Gallucci
- Department of Urology, "Regina Elena" National Cancer Institute, 00128 Rome, Italy
| | - Giuseppe Simone
- Department of Urology, "Regina Elena" National Cancer Institute, 00128 Rome, Italy
| | - Costantino Leonardo
- Department of Maternal-Child and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00161 Rome, Italy
- Department of Urology, "Regina Elena" National Cancer Institute, 00128 Rome, Italy
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Tatenuma T, Ebara S, Kawase M, Sasaki T, Ikehata Y, Nakayama A, Toide M, Yoneda T, Sakaguchi K, Teishima J, Inoue T, Kitamura H, Saito K, Koga F, Urakami S, Koie T, Makiyama K. Association of hospital volume with perioperative and oncological outcomes of robot-assisted laparoscopic radical prostatectomy: a retrospective multicenter cohort study. BMC Urol 2023; 23:14. [PMID: 36721169 PMCID: PMC9887802 DOI: 10.1186/s12894-023-01178-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 01/25/2023] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND This retrospective multicenter cohort study investigated the association of hospital volume with perioperative and oncological outcomes in patients treated with robot-assisted radical prostatectomy (RARP). METHODS We collected the clinical data of patients who underwent RARP at eight institutions in Japan between September 2012 and August 2021. The patients were divided into two groups based on the treatment site-high- and non-high-volume hospitals. We defined a high-volume hospital as one where RARP was performed for more than 100 cases per year. RESULTS After excluding patients who received neoadjuvant therapy, a total of 2753 patients were included in this study. In the high-volume hospital group, console time and estimated blood loss were significantly (p < 0.001) lower than that of the non-high-volume hospital group. However, the continence rate at 3 months after RARP, positive surgical margins, and prostate-specific antigen (PSA)-relapse-free survival showed no significant differences between the two groups. Furthermore, the console time was significantly shorter after 100 cases in the non-high-volume hospital group but not in the high-volume hospital group. CONCLUSIONS A higher hospital volume was significantly associated with shorter console time and less estimated blood loss. However, oncological outcomes and early continence recovery appear to be comparable regardless of the hospital volume in Japan.
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Affiliation(s)
- Tomoyuki Tatenuma
- grid.470126.60000 0004 1767 0473Department of Urology, Yokohama City University Hospital, 3-9 Fukuura, Kanazawaku, Yokohama, Kanagawa 2360004 Japan
| | - Shin Ebara
- Department of Urology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Makoto Kawase
- grid.256342.40000 0004 0370 4927Department of Urology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takeshi Sasaki
- grid.260026.00000 0004 0372 555XDepartment of Nephro-Urologic Surgery and Andrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yoshinori Ikehata
- grid.267346.20000 0001 2171 836XDepartment of Urology, University of Toyama, Toyama, Japan
| | - Akinori Nakayama
- grid.416093.9Department of Urology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Masahiro Toide
- grid.415479.aDepartment of Urology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Tatsuaki Yoneda
- grid.415466.40000 0004 0377 8408Department of Urology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Kazushige Sakaguchi
- grid.410813.f0000 0004 1764 6940Department of Urology, Toranomon Hospital, Tokyo, Japan
| | - Jun Teishima
- grid.257022.00000 0000 8711 3200Department of Urology, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Takahiro Inoue
- grid.260026.00000 0004 0372 555XDepartment of Nephro-Urologic Surgery and Andrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hiroshi Kitamura
- grid.267346.20000 0001 2171 836XDepartment of Urology, University of Toyama, Toyama, Japan
| | - Kazutaka Saito
- grid.416093.9Department of Urology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Fumitaka Koga
- grid.415479.aDepartment of Urology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Shinji Urakami
- grid.410813.f0000 0004 1764 6940Department of Urology, Toranomon Hospital, Tokyo, Japan
| | - Takuya Koie
- grid.256342.40000 0004 0370 4927Department of Urology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kazuhide Makiyama
- grid.470126.60000 0004 1767 0473Department of Urology, Yokohama City University Hospital, 3-9 Fukuura, Kanazawaku, Yokohama, Kanagawa 2360004 Japan
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Kitamura K, China T, Nagata M, Isotani S, Muto S, Sakamoto Y, Horie S. Prediction of recovery time of urinary incontinence following robot-assisted laparoscopic prostatectomy. Int J Urol 2023; 30:77-82. [PMID: 36305653 DOI: 10.1111/iju.15064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 09/19/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Postoperative urinary incontinence recovery following robot-assisted laparoscopic prostatectomy is an important outcome. We investigated whether factors that affect urinary incontinence can predict the duration of postoperative incontinence recovery. METHODS A total of 310 patients underwent robot-assisted laparoscopic prostatectomy. Continence recovery was defined as either pad-free or a safety pad only status. Univariate and multivariate analyses were performed on clinical variables to identify those that were associated with continence recovery. A scoring system to predict recovered continence was constructed using statistically significant variables. The validity of this tool was tested in a new cohort of 273 patients. RESULTS Factors associated with recovery of urinary incontinence were membranous urethral length, preservation of bilateral neurovascular bundles, and a preoperative Prostate Imaging Reporting and Data System score of ≥3 in the apex. Age was related only to incontinence recovery at 1 month. To prepare the score, weighting was performed using the estimated values. Using the developed scoring system, participants in the verification set were divided into three groups. The early recovery group had a median incontinence recovery of 4 (4-12) weeks, the medium recovery group, 12 (4-24) weeks, and the late recovery group, 24 (24-48) weeks, which was a significant difference (p < 0.001). CONCLUSIONS The applied scoring system based on preoperative factors related to incontinence and derived from patient groups was significantly associated with continence recovery time. In patients undergoing robot-assisted laparoscopic prostatectomy, our unit-weighted regression model of clinical variables can predict the duration of continence recovery.
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Affiliation(s)
- Kosuke Kitamura
- Department of Urology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Toshiyuki China
- Department of Urology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Masayoshi Nagata
- Department of Urology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Shuji Isotani
- Department of Urology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Satoru Muto
- Department of Urology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Yoshiro Sakamoto
- Department of Urology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Shigeo Horie
- Department of Urology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
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Kulis T, Hudolin T, Penezic L, Zekulic T, Saic H, Knezevic N, Kastelan Z. Comparison of extraperitoneal laparoscopic and extraperitoneal Senhance radical prostatectomy. Int J Med Robot 2021; 18:e2344. [PMID: 34662926 DOI: 10.1002/rcs.2344] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/10/2021] [Accepted: 10/15/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Senhance is novel robotic platform which can be used to perform radical prostatectomy (RP). We compare our results of robotic RP to similar patients operated with laparoscopic technique. PATIENTS AND METHODS A prospective study of 61 patients operated laparoscopically and 107 patients operated using the Senhance robotic system. We have analysed operative and postoperative results in both groups. RESULTS There was no difference in the operative time, estimated blood loss, positive surgical margins, length of hospitalisation and catheterisation. There were 4 (6.5%) Clavien-Dindo grade I complications, and 5 (8.1%) late complications in laparoscopy. There were 6 (5.6%) Clavien-Dindo grade I, 3 (2.8%) grade II, 1 (0.9%) grade IV complications and 2 (1.9%) late complications in robotic group. CONCLUSION Senhance robot-assisted RP is safe, feasible and offers good and comparable functional and oncological outcomes to laparoscopy. The transition to robotic surgery with a relatively fast learning curve can be done effectively for surgeons with previous laparoscopic experience.
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Affiliation(s)
- Tomislav Kulis
- Department of Urology, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Tvrtko Hudolin
- Department of Urology, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Luka Penezic
- Department of Urology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Toni Zekulic
- Department of Urology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Hrvoje Saic
- Department of Urology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Nikola Knezevic
- Department of Urology, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Zeljko Kastelan
- Department of Urology, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
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Grivas N, Zachos I, Georgiadis G, Karavitakis M, Tzortzis V, Mamoulakis C. Learning curves in laparoscopic and robot-assisted prostate surgery: a systematic search and review. World J Urol 2021; 40:929-949. [PMID: 34480591 DOI: 10.1007/s00345-021-03815-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/17/2021] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Nikolaos Grivas
- Department of Urology, University General Hospital of Heraklion, University of Crete, Medical School, Heraklion, Crete, Greece
| | - Ioannis Zachos
- Department of Urology, University Hospital of Larissa, University of Thessaly, Medical School, Larissa, Greece
| | - Georgios Georgiadis
- Department of Urology, University General Hospital of Heraklion, University of Crete, Medical School, Heraklion, Crete, Greece
| | - Markos Karavitakis
- Department of Urology, University General Hospital of Heraklion, University of Crete, Medical School, Heraklion, Crete, Greece
| | - Vasilis Tzortzis
- Department of Urology, University Hospital of Larissa, University of Thessaly, Medical School, Larissa, Greece
| | - Charalampos Mamoulakis
- Department of Urology, University General Hospital of Heraklion, University of Crete, Medical School, Heraklion, Crete, Greece.
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