Retropubic, laparoscopic, and robot-assisted radical prostatectomy: surgical, oncological, and functional outcomes: a systematic review

Comparison of the effectiveness of open, laparoscopic, and robotic-assisted radical prostatectomies based on complication rates: a retrospective observational study with administrative data from Switzerland

BACKGROUND

Radical prostatectomies can be performed using open retropubic, laparoscopic, or robot-assisted laparoscopic surgery. The literature shows that short-term outcomes (in particular, inpatient complications) differ depending on the type of procedure. To date, these differences have only been examined and confirmed in isolated cases based on national routine data.

METHODS

The data was based on the Swiss Medical Statistics from 2016 to 2018 from a national survey of administrative data from all Swiss hospitals. Cases with the coded main diseases neoplasm of the prostate (ICD C61) and the main treatments of laparoscopic (CHOP 60.5X.20) or retropubic (CHOP 60.5X.30) radical prostatectomies were included, resulting in a total sample size of 8,593 cases.

RESULTS

A procedure-related complication occurred in 998 cases (11.6%). By surgical procedure, complication rates were 10.1% for robotic-assisted laparoscopic radical prostatectomy 9.0% for conventional laparoscopic radical prostatectomy and 17.1% for open retropubic radical prostatectomy (p < 0.001). Conventional and robotic-assisted laparoscopic radical prostatectomies had a significantly lower risk of complications than retropubic procedures. Moreover, the risk of a procedure-related complication was almost twice as high in cases operated on retropubically; however, no significant difference was found between conventional and robotic-assisted laparoscopic cases.

DISCUSSION

The use of a surgical robot showed no advantages in radical prostatectomies regarding procedure-related during the hospital stay. However, both conventional and robotic-assisted laparoscopically operated radical prostatectomies show better results than open retropubic procedures. Further studies on the long-term course of patients based on claims data are needed to confirm the inherent benefits of surgical robots in tandem with them being increasingly employed in hospitals.

Oncologic and functional outcomes following robot assisted radical prostatectomy: 15-Year experience in a Latin American referral center

BACKGROUND

Prostate cancer is the most common cancer in men with more than 52,000 cases diagnosed every year on average. With the introduction of robotic surgery, robotic assisted radical prostatectomy (RARP) has become a popular treatment option in recent years. Achieving oncological control, urinary continence and satisfactory erectile sexual function after RP is the main goal also known as "trifecta". All these outcomes are highly influenced by surgical experience and caseload. The main objective of this study is to analyze oncological and functional outcomes in RARP after 15 years of experience.

METHODS

From 2008 until December 2023, 1790 RARP for localized prostate cancer were performed. A retrospective analysis was conducted based on prospectively collected data correlated with electronic medical records.

RESULTS

Subgroup analyses were conducted in order to evaluate oncological and functional outcomes (n: 1400). Red blood cell transfusion and conversion to open surgery rate was 1.9 % and 0.1 %, respectively. Mean surgical time was 194 min. Mean follow-up time was 69.5 months, 23.8 % patients experienced biochemical recurrence and 1 % died, primarily due to disease progression. Estimated 10-year recurrence-free survival was 68.7 % (95 % CI 67.2-72.2) while estimated 10-year overall survival was 97.9 % (95 % CI 96.3-99.4). Overall urinary continence rate at 2 years was 86.9 % while satisfactory erectile function rate at 18 months was 56.8 %.

CONCLUSIONS

Robotic-assisted radical prostatectomy has become a standard surgical technique in our urological practice for the management of clinically localized and locally advanced prostate tumors in selected cases. After 15 years since the inception of our robotic surgery program, we can conclude that our results are comparable to those published in the international literature, enabling patients to maintain satisfactory sexual function with a high continence rate within the first year of surgery.

Comparative assessment of safety and efficacy between the AirSeal system and conventional insufflation system in robot-assisted laparoscopic radical prostatectomy: a systematic review and meta-analysis

This meta-analysis aimed to compare perioperative outcome measures between the AirSeal system and conventional insufflation system in robot-assisted laparoscopic prostatectomy. Up to May 2024, comprehensive searches were conducted across various prominent databases worldwide, such as PubMed, Embase, and Google Scholar, focusing solely on English-language materials. Reviews and protocols devoid of published data were excluded, along with conference abstracts and articles unrelated to the study's aims. Primary outcome measures encompassed operative duration and hospitalization length, while secondary outcome measures included estimated blood loss and complications. The meta-analysis included five cohort studies, encompassing a total of 1503 patients. In comparison to the conventional insufflation system group, the AirSeal group displayed shorter operative times (WMD - 15.62, 95% CI - 21.87 to - 9.37; p < 0.00001) and reduced hospital stays (WMD - 0.45, 95% CI - 0.60 to - 0.30; p < 0.00001). Fewer major complications (OR 0.15, 95% CI 0.03 to 0.66; p = 0.01). Notably, there were no significant differences observed in estimated blood loss or overall complications between the two groups. Compared to conventional insufflation systems, employing the AirSeal system in robot-assisted laparoscopic radical prostatectomy appears to potentially decrease operative time and hospital length of stay without a concurrent rise in estimated blood loss or complication rates.

Comparison of incidence of acute kidney injury after robot-assisted radical prostatectomy with that after open retropubic and extraperitoneal laparoscopic radical prostatectomies in patients with prostate cancer

Background

We retrospectively evaluated the postoperative renal function in patients who had undergone radical prostatectomy to compare the incidences of postoperative acute kidney injury (AKI) among the patients who had undergone robot-assisted radical prostatectomy (RARP), retropubic radical prostatectomy (RRP), and extraperitoneal laparoscopic radical prostatectomy (exLRP).

Materials and methods

Patients with prostate cancer who had undergone radical prostatectomy at our institution between 2008 and 2014 were included. Robot-assisted radical prostatectomy was performed using an intraperitoneal approach in a 25-degree Trendelenburg position, whereas other procedures were performed with the patient in the supine position. We evaluated the serum creatinine levels and estimated glomerular filtration rates immediately after surgery and on postoperative day 1. We evaluated the incidence of AKI after prostatectomy using the Acute Kidney Injury Network criteria of the Kidney Disease: Improving Global Outcomes guidelines.

Results

A total of 150 consecutive patients were included, with each of the 3 groups (RARP, RRP, and exLRP) comprising 50 patients. Postoperative AKI was observed in 15 (30.0%), 1 (2.0%), and 3 (6.0%) patients in the RARP, RRP, and exLRP groups, respectively. Stage 1 AKI was observed in all the patients except one. The incidence of AKI in RARP group was significantly higher than that in the other groups (p < 0.001). In the RARP group, the serum creatinine level was significantly elevated immediately after the surgery; however, it returned to baseline on postoperative day 1. Surgical procedures were the only independent factor associated with AKI incidence.

Conclusions

This study suggest that compared with RRP and exLRP, RARP is associated with a higher incidence of postoperative AKI, although most patients recover rapidly. Intra-abdominal pneumoperitoneum may contribute to AKI onset.

The association of smoking with urinary and sexual function recovery following radical prostatectomy for localized prostate cancer: a systematic review and meta-analysis

BACKGROUND

Urinary and sexual dysfunction after radical prostatectomy remains a major cause of morbidity, despite widespread availability of pharmacological and rehabilitative treatments. Smoking is a modifiable risk factor known to correlate with erectile and urinary dysfunction and we hypothesise that smoking cessation may improve post-prostatectomy urinary and sexual function recovery. Our objective is to systematically evaluate literature describing the association of smoking status with urinary and sexual function in men following radical prostatectomy.

METHODS

In total, 310 unique records were identified through a systematic search of the MEDLINE, EMBASE, Scopus, Web of Science, CINAHL and CENTRAL databases up to February 2023. Nine studies reported smoking status and post radical prostatectomy urinary and sexual function outcomes in men with localized prostate cancer. Risk of bias was assessed and meta-analysis included six studies.

RESULTS

Smokers had inferior erectile function after prostatectomy compared to non-smokers (OR 0.73, [95% CI 0.56-0.95]) during follow-up, while urinary incontinence was not statistically different between groups (OR 1.20, [95% CI 0.75-1.91]). Smoking cessation improved the EPIC-26 sexual domain score with 6.6 points on average [p = 0.03] to a clinically significant maximum of 12.5 points at 18-24 months.

CONCLUSIONS

Smoking is associated with impaired sexual function recovery after radical prostatectomy and quitting may improve sexual function >18 months. Current evidence shows no such association for urinary outcomes. Further studies are needed to corroborate findings.

Acute kidney injury after robot-assisted laparoscopic prostatectomy: A meta-analysis

BACKGROUND

We investigated the rates of acute kidney injury (AKI) post robot-assisted laparoscopic prostatectomy (RALP).

METHODS

A comprehensive search was conducted to identify studies that reported the rates of AKI post-RALP. A random effects model was used, and the pooled rates of AKI were calculated.

RESULTS

We identified 10 studies with 60,937 patients to be included. The mean age was 65.1 years. The mean anaesthesia time was 234.3 min (95% CI: 177.8-290.9). The mean operation time was 212.2 min (95% CI: 188.7-235.6). The mean estimated blood loss was 314.1 mL (95% CI: 153-475.3). The mean intraoperative IV fluids administered were 1985 mL (95% CI: 1516.3-2453.7). The pooled rate of AKI post RALP was 7.2% (95% CI 19-23.9).

CONCLUSIONS

The rates of AKI after RALP are significant. Further studies are needed to detect the risk factors for AKI and to determine the rates of chronic kidney disease post-RALP.

Robotic-assisted radical prostatectomy: a multicenter experience with the Senhance Surgical System

PURPOSE

Robotic-assisted surgery for radical prostatectomy is becoming a standard treatment, and respective implementations are expanding. The Senhance Surgical System is a robotic system with existing but limited data on radical prostatectomy, including a lack of multicenter study experiences. The TRUST study aims to fill this gap and explores observations for radical prostatectomy with the Senhance Surgical System.

METHODS

Between August 2019 and November 2022, 375 patients met inclusion criteria from two European sites. Patients' surgical procedure times, data on conversion, malfunction, adverse events, and pain scores were registered and evaluated. Outcomes were calculated for both sides, combined as a total and compared between the initial (1st-150th case) and later (> 150th case) period.

RESULTS

The median operating time was 190 min (IQR: 167.5-215.0) and the median docking time was 3 min (IQR: 2.0-5.0). Eighteen cases (4.8%) were converted to standard laparoscopy and two (0.5%) to open. Two perioperative (0.5%) and eleven postoperative adverse events (2.9%) occurred, mostly (83.3%) categorized as mild. Pain scores were reduced from an average of 3.4 (± 1.4) on the postoperative day to 0.9 (± 0.7) at discharge. Compared to our previous data and based on a comparison between our initial and later period, operating time seems to plateau. However, docking time, complication, and conversion rates were successfully reduced.

CONCLUSION

We demonstrate progressing safety and efficiency for robotic-assisted radical prostatectomy with the Senhance Surgical System.

Robotic urologic surgery using the KangDuo-Surgical Robot-01 system: A single-center prospective analysis

BACKGROUND

The KangDuo-Surgical Robot-01 (KD-SR-01) system is a new surgical robot recently developed in China. The aim of this study was to present our single-center experience and mid-term outcomes of urological procedures using the KD-SR-01 system.

METHODS

From August 2020 to April 2023, consecutive urologic procedures were performed at Peking University First Hospital using the KD-SR-01 system. The clinical features, perioperative data, and follow-up outcomes were prospectively collected and analyzed.

RESULTS

A total of 110 consecutive patients were recruited. Among these patients, 28 underwent partial nephrectomy (PN), 41 underwent urinary tract reconstruction (26 underwent pyeloplasty, 3 underwent ureteral reconstruction and 12 underwent ureterovesical reimplantation [UR]), and 41 underwent radical prostatectomy (RP). The median operative time for PN was 112.5 min, 157.0 min for pyeloplasty, 151.0 min for ureteral reconstruction, 142.5 min for UR, and 138.0 min for RP. The median intraoperative blood loss was 10 mL for PN, 10 mL for pyeloplasty, 30 mL for ureteral reconstruction, 20 mL for UR, and 50 mL for RP. All procedures were successfully completed without conversion, and there were no major complications in any patient. The median warm ischemia time of PN was 17.3 min, and positive surgical margin was not noted in any patient. The overall positive surgical margin rate of RP was 39% (16/41), and no biochemical recurrence was observed in any RP patient during the median follow-up of 11.0 months. The surgical success rates of pyeloplasty and UR were 96% (25/26) and 92% (11/12) during the median follow-up of 29.5 months and 11.5 months, respectively.

CONCLUSION

The KD-SR-01 system appears feasible, safe, and effective for most urological procedures, based on our single-center experience.

The Potential Preventive and Therapeutic Roles of NSAIDs in Prostate Cancer

Prostate cancer (PC) is the second most common type of cancer and the leading cause of death among men worldwide. Preventing the progression of cancer after treatments such as radical prostatectomy, radiation therapy, and hormone therapy is a major concern faced by prostate cancer patients. Inflammation, which can be caused by various factors such as infections, the microbiome, obesity and a high-fat diet, is considered to be the main cause of PC. Inflammatory cells are believed to play a crucial role in tumor progression. Therefore, nonsteroidal anti-inflammatory drugs along with their effects on the treatment of inflammation-related diseases, can prevent cancer and its progression by suppressing various inflammatory pathways. Recent evidence shows that nonsteroidal anti-inflammatory drugs are effective in the prevention and treatment of prostate cancer. In this review, we discuss the different pathways through which these drugs exert their potential preventive and therapeutic effects on prostate cancer.

Predictors of urinary outcomes following robotic-assisted laparoscopic prostatectomy

Introduction

Incontinence and urgency are common after prostatectomy. The University of Virginia prostatectomy functional outcomes program (PFOP) was developed to comprehensively assess and optimise continence outcomes following robotic-assisted laparoscopic prostatectomy (RALP). Patients are prospectively evaluated by a Female Pelvic Medicine and Reconstructive Surgery specialist. This study assessed for predictors of 3- and 6-month stress urinary incontinence (SUI) and urgency symptom outcomes following RALP.

Methods

We performed a post hoc review of patients from our PFOP receiving a minimum of 6-month follow-up. Urinary symptoms are prospectively assessed using the validated International Consultation on Incontinence Questionnaire-Male Lower Urinary Tract Symptoms (ICIQ-MLUTS) questionnaire and daily pad use (pads per day [PPD]). Primary study outcomes included ICIQ-MLUTS SUI and urgency domain scores and PPD. Multivariable linear regression was performed to identify variables associated with outcomes at 3 and 6 months postoperatively. Variables included patient, oncologic and surgical factors. Each variable was run in a separate model with pelvic floor muscle therapy and surgeon to reduce confounding and prevent overfitting.

Results

Forty men were included. In assessment of ICIQ-MLUTS SUI domain score, at 3 months, body mass index (BMI) was associated with worse scores, and at 6 months, BMI, hypertension and estimated blood loss (EBL) were associated with worse scores, whereas bilateral nerve-sparing technique was associated with better scores. For ICIQ-MLUTS Urgency domain score, at 3 months, preoperative use of benign prostatic hyperplasia (BPH) medication was associated with better scores. No covariates predicted 6-month ICIQ-MLUTS Urgency domain scores. For PPD use, at both 3 and 6 months, BMI was a positive predictor, while preoperative use of BPH medication was a negative predictor.

Conclusion

Increased BMI, EBL and hypertension are associated with worsened SUI outcomes following RALP, whereas bilateral nerve-sparing technique and preoperative BPH medication are associated with improved SUI outcomes. These data may inform patient counselling and help identify patients who may benefit from closer surveillance and earlier anti-incontinence intervention.

A Prospective Randomized Controlled Trial of the Effect of Maintenance of Continuous Cuff Pressures (20 cmH2O vs 30 cmH2O) on Postoperative Airway Symptoms in Laparoscopic Surgeries

INTRODUCTION

Recently, laparoscopic surgery has been used in many fields of surgery. It has been reported that cuff pressure becomes high during laparoscopic surgery. Increased cuff pressure may cause postoperative sore throat and hoarseness. Considering previous reports, we hypothesized that maintenance of a fixed low cuff pressure during laparoscopic surgery might be associated with low grades of postoperative sore throat and hoarseness.

METHODS

The participants were 100 patients between 20 and 80 years of age who were scheduled to undergo laparoscopic surgery lasting over 2 hours. Patients were randomly allocated to two groups with endotracheal tube cuff pressures fixed at 20 cmH2O (low-pressure group; LPG) and 30 cmH2O (high-pressure group; HPG). We evaluated mainly sore throat and hoarseness on postoperative day 1 using a visual analog scale (VAS; 0-10 cm). Statistical comparisons of values were performed using the unpaired t-test, Mann-Whitney U-test, and chi-square test with values of p < 0.05 considered statistically significant.

RESULTS

There were no significant differences in background characteristics between the two groups. Median postoperative scores for the LPG and HPG were 1 (interquartile range, 0-3) and 0 (0-2; p = 0.560) for sore throat and 2 (0-4) and 1 (0-3; p = 0.311) for hoarseness, respectively, and the differences were not significant.

CONCLUSION

The effects of maintenance of a fixed low cuff pressure and a fixed high cuff pressure on the degrees of postoperative sore throat and hoarseness after laparoscopic surgery were the same and the grades were low.

Preliminary results of the implementation of robotic radical prostatectomy in a major ambulatory surgery regimen

OBJECTIVE

To report our initial experience with robotic radical prostatectomy as an outpatient procedure.

MATERIAL AND METHODS

Retrospective analysis of patients who underwent RRP as MAS (Major Ambulatory Surgery) at our center between March 2021 and May 2022. We collected baseline patient characteristics, intraoperative outcomes and postoperative data (need for unplanned medical care and complications at one month after surgery). Oncologic characteristics at disease diagnosis (PSA, staging, ISUP, MRI) and postoperative pathologic outcomes were collected.

RESULTS

We identified a total of 35 patients with an average age of 60,8 ± 6,88 years and a BMI of 27 ± 2,9 Kg/m². All patients had a low anesthetic risk and 25.71% had undergone previous abdominal surgery. The surgical time was 151,66 ± 42,15 min and the average blood loss was 301,2 ± 184,38 mL. Two patients (5.7%) were admitted for one night and 7 patients (20%) consulted the emergency department in the following month, of which 3 (8.57%) were readmitted. We recorded one intraoperative complication, seven mild postoperative complications (Clavien I-II) and one severe complication (Clavien IIIb). The severe complication occurred on the eighth postoperative day and was not related to the procedure being ambulatory.

CONCLUSION

The absence of serious complications in the immediate postoperative period supports RRP in MAS as a safe technique for selected patients.

Patient-reported outcomes after curative treatment for prostate cancer with prostatectomy, primary radiotherapy or salvage radiotherapy

BACKGROUND

Trials reporting adverse health outcomes (AHOs) in terms of patient-reported outcome measures (PROMs) after contemporary curative treatment of prostate cancer (PC) are hampered by study heterogeneity and lack of new treatment techniques. Particularly, the evidence regarding toxicities after radiotherapy (RT) with the volumetric arc therapy (VMAT) technique is limited, and comparisons between men treated with surgery, primary radiotherapy (PRT) and salvage radiotherapy (SRT) are lacking. The aim of the study was to evaluate change in PROMs 3 months after treatment with robotic-assisted laparoscopic prostatectomy (RALP), PRT and SRT administered with VMAT.

MATERIAL AND METHODS

A prospective cohort study of men with PC who received curative treatment at the University Hospital of North Norway between 2012 and 2017 for RALP and between 2016 and 2021 for radiotherapy was conducted. A cohort of 787 men were included; 406 men treated with RALP, 265 received PRT and 116 received SRT. Patients completed the validated PROM instrument EPIC-26 before (pre-treatment) and 3 months after treatment. EPIC-26 domain summary scores (DSSs) were analysed, and changes from pre-treatment to 3 months reported. Changes were deemed clinically relevant if exceeding validated minimally clinically important differences (MCIDs).

RESULTS

Men treated with RALP reported clinically relevant declining urinary incontinence DSS (-41.7 (SD 30.7)) and sexual DSS (-46.1 (SD 30.2)). Men who received PRT reported worsened urinary irritative DSS (-5.2 (SD 19.6)), bowel DSS (-8.2 (SD 15.1)) and hormonal DSS (-9.6 (SD 18.2)). Men treated with SRT experienced worsened urinary incontinence DSS (-7.3 (SD 18.2)), urinary irritative DSS (-7.5 (SD 14.0)), bowel DSS (-12.5 (SD 16.1)), sexual DSS (-14.9 (SD 18.9)) and hormonal DSS (-23.8 (SD 20.9)).

CONCLUSION

AHOs 3 months after contemporary curative treatment for PC varied according to treatment modality and worsened in all treatment groups, although most in SRT.

The impact of killer cell immunoglobulin-like receptor (KIR) genes and human leukocyte antigen (HLA) class I ligands on predisposition or protection against prostate cancer

Natural killer (NK) cell development largely depends on killer cell immunoglobulin-like receptors (KIRs) and human leukocyte antigen (HLA) class I ligands. In the current study, we investigated the role of KIR genes, HLA ligands, and KIR-HLA combinations in vulnerability or protection against prostate cancer (PC). To analyze the frequency of 16 KIR genes and 5 HLA ligands, polymerase chain reaction with sequence-specific primers (PCR-SSP) was conducted in 150 PC patients and 200 healthy controls (CNs). KIR2DL5 (p = 0.0346, OR = 0.606, CI = 0.3916-0.9336), KIR2DS5 (p = 0.0227, OR = 0.587, CI = 0.3793-0.9139), HLA-B Bw4^Thr80 (p = 0.0401, OR = 0.3552, CI = 0.1466-0.9059), HLA Bw4 (p = 0.0190, OR = 0.4744, CI = 0.2656-0.8521), and T4 gene cluster (including KIR2DS5-2DL5-3DS1-2DS1 genes) (p = 0.0194, OR = 0.5575, CI = 0.3449-0.8938) had a lower frequency in the PC patients compared to the control group. Moreover, a lower frequency of the genotypes contacting activating KIR (aKIR) > inhibitory KIR (iKIR) (p = 0.0298, OR = 0.5291, CI = 0.3056-0.9174) and iKIR + HLA < aKIR + HLA (p = 0.0183, OR = 0.2197, CI = 0.0672-0.7001) in PC patients compared to the CNs implies a protective role for aKIR genes. In the case of KIR-HLA interactions, we detected a significant association between KIR3DS1⁺ + HLA-A Bw4⁺ (p = 0.0113, OR = 0.5093, CI = 0.3124-0.8416) and KIR3DL1^- + HLA-A Bw4⁺ (p = 0.0306, OR = 0.1153, CI = 0.0106-0.6537) combinations and resistance to prostate cancer. In contrast, the presence of KIR3DL1 in the absence of HLA-A Bw4 (p = 0.0040, OR = 2.00, CI = 1.264-3.111), HLA Bw4 (p = 0.0296, OR = 2.066, CI = 1.094-3.906), and HLA-Bw4^Thr80 (p = 0.0071, OR = 2.505, CI = 1.319-4.703) genes probably predisposes to prostate cancer. Carrying the CxT4 genotype in PC patients was positively associated with lower tumor grades (Gleason score ≤ 6) (p = 0.0331, OR = 3.290, and CI = 1.181-8.395). Altogether, our data suggest a protective role for aKIRs, HLA-B Bw4^Thr80, and HLA Bw4 ligands as well as a predisposing role for certain KIR-HLA combinations in prostate cancer. The findings of this study offer new insight into the population's risk assessment for prostate cancer in men. Additionally, predicting immunotherapy response based on KIR-HLA combinations aids in implementing the most effective therapeutic approach in the early stages of the disease.

Clinicopathological Significances of Positive Surgical Resection Margin after Radical Prostatectomy for Prostatic Cancers: A Meta-Analysis

Background and Objectives: This study aims to elucidate the positive rate and the clinicopathological significance of surgical margin after radical prostatectomy (RP) through a meta-analysis. Materials and Methods: This meta-analysis finally used 59 studies, including the information about the positive surgical margin (PSM) and those clinicopathological significances after RP. The subgroup analysis for the estimated rates of PSM was evaluated based on types of surgery, grade groups, and pathological tumor (pT) stages. We compared the clinicopathological correlations between positive and negative surgical margins (NSM). Results: The estimated PSM rate was 25.3% after RP (95% confidence interval [CI] 21.9-29.0%). The PSM rates were 26.0% (95% CI 21.5-31.1%) 28.0% (95% CI 20.2-37.5%) in robot-assisted RP and nerve-sparing RP, respectively. The PSM rate was significantly higher in high-grade groups than in low-grade groups. In addition, the higher pT stage subgroup had a high PSM rate compared to the lower pT stage subgroups. Patients with PSM showed significantly high PSA levels, frequent lymphovascular invasion, lymph node metastasis, and extraprostatic extension. Biochemical recurrences (BCRs) were 28.5% (95% CI 21.4-36.9%) and 11.8% (95% CI 8.1-16.9%) in PSM and NSM subgroups, respectively. Patients with PSM showed worse BCR-free survival than those with NSM (hazard ratio 2.368, 95% CI 2.043-2.744%). Conclusions: Our results showed that PSM was significantly correlated with worse clinicopathological characteristics and biochemical recurrence-free survival. Among the results in preoperative evaluations, grade group and tumor stage are useful for the prediction of PSM.

Cost-Effectiveness Analysis of Robotic-Assisted Radical Prostatectomy for Localized Prostate Cancer From the Brazilian Public System Perspective

OBJECTIVES

Radical prostatectomy (RP) is the gold standard for the surgical treatment of localized prostate cancer, presenting better results than radiotherapy especially for high-risk patients. Although it has clinical and technical benefits compared with open and laparoscopic techniques, the robotic-assisted RP is not publicly funded in Brazil. The objective of this study was to calculate the cost-effectiveness of the robotic-assisted RP from the Brazilian public system perspective.

METHODS

A state transition model was built to simulate the life of a patient undergoing RP. A total of 3 arms were compared: robotic-assisted, laparoscopic, and open surgeries. The assumed time horizon was 20 years; discounts were applied to both costs and health outcomes. Events and transition probabilities were obtained in the literature, and costs were obtained in official government databases. The results were reported as incremental cost-utility ratios.

RESULTS

Robotic-assisted surgery was found to be costlier but more effective than both open and laparoscopic techniques, resulting in Brazilian reals 4518 per quality-adjusted life-year and Brazilian reals 3631 per quality-adjusted life-year incremental cost-effectiveness ratios, respectively.

CONCLUSIONS

This study gives relevant inputs for decision making regarding the inclusion of robotic-assisted RP in the Brazilian public formularies. The study demonstrates that the technology is cost-effective even when considering willingness-to-pay thresholds lower than the traditionally used ones.

[The first clinical experience of using the new Senhance remote-controlled robotic system in general surgery in Russia]

Until recently, clinical studies in the field of robotic-assisted surgery have been conducted in Russia only on the basis of the DaVinci system. The advent of a new robotic system separated the concept of «robotic surgery» from DaVinci. An increase in the number of alternative surgical robots will expand the possibilities of studying the functionality of these systems, differences in their operation, safety and efficiency for patients, and convenience for surgeons.

OBJECTIVE

Evaluation of own initial experience of using Senhance robotic surgical system in the work of the general surgery department.

MATERIAL AND METHODS

A prospective collection of data on the surgical treatment of patients with various pathologies using the Senhance robotic system was carried out, followed by its analysis in relation to the duration of the operation, the incidence of intraoperative complications and the need for conversion, as well as the volume of blood loss and early postoperative complications.

RESULTS AND DISCUSSION

Now, only perioperative, and early postoperative data are available for analysis. While accumulating our own experience with the Senhance system, we concluded that, since the transition from robotic to manual laparoscopic surgery and vice versa does not require changing of access points and is performed quickly, it is practically expedient to perform some stages of the operation manually, and others using surgical robot. For example, with the help of manual laparoscopy, it is more ergonomic to perform wide tractions and movements of organs and tissues. At the same time, robotic surgery has undeniable advantages when performing lymph node dissection, performing manual sutures, including anastomoses, which does not lead to an increase in the duration of the intervention.

CONCLUSION

Presented experience of using the Senhance system has shown that it meets the declared indicators of convenience, efficiency and safety of operations in general surgery.

Effect of Neuromuscular Blockade on Intraoperative Respiratory Mechanics and Surgical Space Conditions during Robot-Assisted Radical Prostatectomy: A Prospective Randomized Controlled Trial

The aim of this study was to investigate whether deep neuromuscular blockade (NMB) may affect intraoperative respiratory mechanics, surgical condition, and recovery profiles in patients undergoing robot-assisted radical prostatectomy (RARP). Patients were randomly assigned to the moderate or deep NMB groups. Pneumoperitoneum was maintained with carbon dioxide (CO₂) insufflation at 15 mmHg during surgery. The primary outcome was peak inspiratory pressure (PIP) after CO₂ insufflation. Mean airway pressure (P_mean) and dynamic lung compliance (C_dyn) were also recorded. The surgeon rated the surgical condition and surgical difficulty on a five-point scale (1 = extremely poor; 2 = poor; 3 = acceptable; 4 = good; 5 = optimal). Recovery profiles, such as pulmonary complications, pain scores, and recovery time, were recorded. We included 58 patients in this study. No significant differences were observed regarding intraoperative respiratory mechanics including PIP, P_mean and C_dyn, between the two groups. The number of patients with optimal surgical conditions was significantly higher in the deep than in the moderate NMB group (29 vs. 20, p = 0.014). We found no differences in recovery profiles. In conclusion, deep NMB had no significant effect on the intraoperative respiratory mechanics but resulted in optimal endoscopic surgical conditions during RARP compared with moderate NMB.

Robotic-assisted radical prostatectomy with the Senhance® robotic platform: single center experience

OBJECTIVE

To describe our institution's initial experience with robot-assisted radical prostatectomy (RARP) using the Senhance^® robotic system.

PATIENTS AND METHODS

A prospective analysis of 127 robot-assisted radical prostatectomies was performed. Patient demographics, preoperative and intraoperative parameters, histopathological examination results, intraoperative and early postoperative complications were obtained and analyzed.

RESULTS

The median patient age was 61.0 ± 6.36 (from 37 to 73) years, with a mean body mass index of 26.2 ± 3.79 kg/m². Of 127 patients, 16.5% (n = 21) underwent a pelvic lymph node dissection, 29.1% (n = 37) underwent one sided or bilateral nerve sparing. Post-operative extracapsular invasion (≥ pT3) was found in 15% (n = 19) of the cases and a Gleason score ≥ 7 in 74.8% of all patients. Our median operative time was 180 ± 41.98 min [interquartile range (IQR) 150-215], and median blood loss was 250 ± 236 (IQR 175-430) ml. Of 127 patients, 33.9% (n = 43) had positive margins, of them 28.7% in pT2 and 57.9% in pT3. Fifteen patients (11.8%) experienced complications, of them only three had Clavien-Dindo ≥ 3. Operation time decreased by about 60 min and estimated blood loss decreased by about 200 ml from the initial experience of each surgeon.

CONCLUSIONS

Robotic prostatectomy using a Senhance^® robotic system is feasible, and warrants further study to determine whether it can improve patient outcomes.

Measuring Quality of Life Following Robot-Assisted Radical Prostatectomy

BACKGROUND

Prostate cancer (PCa) represents the most common solid organ malignancy in men. Fortunately, at the time of diagnosis, the majority of cases are staged as localized or regional disease, conferring excellent 5- and 10-year cure rates. There are several first line treatment options including surgical approaches such as robot-assisted radical prostatectomy (RARP) and radiation therapy (RT) available to patients with localized disease that offer similar PCa oncologic outcomes but are associated with potentially significant side effects which may impact health-related quality of life (HRQOL) domains. Recently, clinicians and investigators have sought to better understand these changes in HRQOL metrics with the utilization of patient-reported outcomes (PRO). Given that RARP represents the most common surgical treatment for PCa in the United States, there has been a particular interest in assessing these outcomes derived by patient perspectives to more fully appreciate treatment-related impact on quality of life following RARP.

OBJECTIVE

This narrative review sought to explore the instruments available to measure quality of life after RARP, a review of the PRO data after RARP, and future directions for assessing and improving quality of life outcomes following this surgery.

CLINICAL USE

There are several treatment options for men diagnosed with local and regional prostate cancer with similar oncologic outcomes but differing patterns of side effects affecting post-treatment quality of life. Understanding data reported directly by patients following RARP about their side effects and quality of life gives providers additional information for appropriate preoperative counseling for patients choosing between treatment options for their prostate cancer.

Laparoscopic surgery experience does not influence oncological and functional results of robotic-assisted laparoscopic prostatectomy

INTRODUCTION

Surgery is one of the treatment alternatives for prostate cancer, and robotic-assisted laparoscopic prostatectomy (RALP) has become the new trend in the past decade. There is no consensus yet for surgeons who will perform RALP whether they need to be trained or experienced in laparoscopy. In this study, it was aimed to investigate the effectiveness of the surgeon's laparoscopy experience in the perioperative and postoperative results of RALP patients.

MATERIAL AND METHOD

Patients who underwent RALP were retrospectively screened. The first 20 cases done by surgeons in both groups and 40 cases in total were included in the study. Surgeons with laparoscopy training were designated as group 1, and surgeons without laparoscopy training were designated as group 2. Patient's age, preoperative prostate-specific antigen (PSA) value, prostate biopsy pathology, radical prostatectomy pathology, surgical margin positivity, extracapsular extension, and seminal vesicle invasion status, blood transfusion rate, operation time, length of hospital stay, and 1-year follow-up potency and urinary incontinence rates were compared.

RESULTS

There was no difference between the two groups in terms of age, preoperative PSA, preoperative biopsy results, blood transfusion rates, operation times, and the length of hospital stay of the patients. When the postoperative oncological and functional results of the patients were examined, there was no difference between the two groups in the prostatectomy pathology (p = 0.895), extracapsular extension (pT3a) (p = 0.519), positive surgical margin (pSM) (p = 0.723), and seminal vesicle invasion (pT3b) (p = 0.756). Potency and urinary incontinence rates were similar in both groups at the end of one year follow-up (p = 0.327, 0.500 respectively).

CONCLUSIONS

Based on our study, it is clearly seen that regardless of the surgeon's experience of laparoscopy, it can be safely preferred when looking at the oncological and functional results of RALP.

Comparison of 1-Year Health Care Costs and Use Associated With Open vs Robotic-Assisted Radical Prostatectomy

IMPORTANCE

With the current patterns of adoption and use of robotic surgery and improvement in the overall survival of patients with prostate cancer, it is important to evaluate the immediate and long-term cost implications of treatments for patients with prostate cancer.

OBJECTIVE

To compare health care costs and use 1 year after open radical prostatectomy (ORP) vs robotic-assisted radical prostatectomy (RARP).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used a US commercial claims database from January 1, 2013, to December 31, 2018. A total of 11 457 men aged 18 to 64 years who underwent inpatient radical prostatectomy for prostate cancer and were continuously enrolled with medical and prescription drug coverage from 180 days before to 365 days after inpatient prostatectomy were identified. An inverse probability of treatment weighting analysis was performed to examine the differences in costs and use of health care services by surgical modality. Data analysis was conducted from September 2019 to July 2020.

EXPOSURES

Type of surgical procedure: ORP vs RARP.

MAIN OUTCOMES AND MEASURES

Three outcomes within 1 year after the inpatient prostatectomy were investigated: (1) total health care costs, including reimbursement paid by insurers and out of pocket by patients; (2) health care use, including inpatient readmission, emergency department, hospital outpatient, and office visits; and (3) estimated days missed from work due to health care use.

RESULTS

Of the 11 457 patients who underwent inpatient prostatectomy, 1604 (14.0%) had ORP and 9853 (86.0%) had RARP and most patients (8467 [73.9%]) were aged 55 to 64 years. Compared with patients who underwent ORP, those who received RARP had a higher cost at the index hospitalization (mean difference, $2367; 95% CI, $1821-$2914; P < .001), but similar total cumulative costs were observed within 180 days (mean difference, $397; 95% CI, -$582 to $1375; P = .43) and 1 year after discharge (-$383; 95% CI, -$1802 to $1037; P = .60). One-year postdischarge health care use was significantly lower in the RARP compared with ORP group for mean numbers of emergency department visits (-0.09 visits; 95% CI, -0.11 to -0.07 visits; P < .001) and hospital outpatient visits (-1.5 visits; -1.63 to -1.36 visits; P < .001). The reduction in use of health care services among patients who underwent RARP translated into additional savings of $2929 (95% CI, $1600-$4257; P < .001) and approximately 1.69 fewer days (95% CI, 1.49-1.89 days; P < .001) missed from work for health care visits.

CONCLUSIONS AND RELEVANCE

Total cumulative cost in this study was similar between ORP and RARP 1 year post discharge; this finding suggests that lower postdischarge health care use after RARP may offset the higher costs during the index hospitalization.

Comparison between laparoscopic and open prostatectomy: Oncological progression analysis

INTRODUCTION

There are very few Spanish studies that compare oncological outcomes following radical prostatectomy (RP) based on surgical approach, and their methodology is not appropriate.

OBJECTIVE

To compare oncological outcomes in terms of surgical margins (SM) and biochemical recurrence (BR) between open radical prostatectomy (ORP) and laparoscopic radical prostatectomy (LRP).

MATERIAL AND METHODS

Comparison of two cohorts (307 with ORP and 194 with LRP) between 2007-2015. Surgical margin status was defined as positive or negative, and BR as a PSA rise of >0.4 ng/ml after surgery. To compare the qualitative variables, we employed the Chi-squared test, and ANOVA was used for quantitative variables. We performed a multivariate analysis using logistic regression to evaluate the predictive factors of SM, and a multivariate analysis using Cox regression to evaluate the predictive factors of BR.

RESULTS

Gleason 7 (3+4) was determined in the surgical specimens of 43.5% of patients, and 31.7% had positive SM. The most frequent pathological stage was pT2c, on the 61.9% of the cases. No significant differences were found between both groups, except for extracapsular extension (p=0.001), more frequent in LRP. The median follow-up was 49 months. BR was seen in the 23% of patients, without significant differences between groups. In the multivariable analysis, only the D'Amico risk group behaved as an independent predictive factor of positive SM, and Gleason score and positive SM acted as independent predictive factors of BR.

CONCLUSION

The surgical approach did not influence SM status or BR.

Comparison between laparoscopic and open prostatectomy: Postoperative urinary continence analysis

INTRODUCTION

There are very few articles comparing open radical prostatectomy (ORP) vs. laparoscopic radical prostatectomy (LRP) and their functional results or urinary continence (UC), which is one of the most important objectives to pursue after oncological results.

OBJECTIVES

To compare postoperative UC in patients with localized prostatic adenocarcinoma treated with OPR or LRP.

MATERIAL AND METHODS

Comparison between two patient cohorts (312 for ORP and 206 for LRP) between 2007-2015. The UC was evaluated at 3, 6, 12, 18 and 24months. Continence was defined and classified as follows: a)UC, no need of pads, and b)urinary incontinence (UI), use of pads. To compare the qualitative variables, we employed the chi-squared test and ANOVA for quantitative variables. We performed a multivariate analysis using logistic regression with dependent qualitative variable UI. Statistical significance when P<.05.

RESULTS

Nerve-sparing was performed in 51.7% cases. At 24months after surgery, 72.4% patients had UC, of which 87.7% were from the ORP group and 78.1% in the LRP group (P=.004). 22,7% of patients experienced biochemical recurrence (BR), with 83% treated with salvage radiotherapy (SRT), presenting greater UI percentage (P=.036). ORP patients showed a higher percentage of anastomosis stricture (P=.03).

CONCLUSIONS

LRP, non-nerve sparing, and SRT were directly related to postoperative UI.

Continuous poliglecaprone suture versus bidirectional barded suture for urethrovesical anastomosis during laparoscopic radical prostatectomy: a single-institute retrospective analysis of Chinese patients

BACKGROUND

To compare the outcomes of bidirectional barbed suture and continuous poliglecaprone suture for urethrovesical anastomosis (UVA) during laparoscopic radical prostatectomy (LRP).

METHODS

Single-needle poliglecaprone suture was used for UVA in Group 1 (n=27), and double-needle bidirectional barbed suture was used for UVA (n=27) in Group 2. Age, body mass index (BMI), prostate-specific antigen (PSA) level, prostate volume, operative time, anastomosis time, estimated blood loss, Gleason score, number of hospitalization days, and urinary continence at postoperative month 1, 3, 6, and 12 were analyzed statistically.

RESULTS

There were no significant differences in age, BMI, prostate volume, PSA level, Gleason score, and indwelling catheter time between the two groups. However, bidirectional barbed suture was associated with a significantly shorter anastomosis time (P=0.007), operation time (P=0.008) and hospitalization duration (P<0.001), and a significantly lower blood loss volume (P=0.005). At the first-month follow-up, urinary continence was achieved in 5 (19%) and 15 (56%) patients in Group 1 and 2, respectively (P=0.005); postoperative third month: 11 (41%) and 23 (85%) patients in Group 1 and 2 respectively (P=0.001); postoperative sixth month: 21 (78%) and 25 (93%) patients in Group 1 and 2 respectively (P=0.250); postoperative first year: 25 (93%) and 27 (100%) patients in Group 1 and 2 respectively (P=0.471). Multivariate regression analysis showed that anastomosis time (HR =0.636; P<0.001) was an independent predictor of postoperative continence.

CONCLUSIONS

The current findings show that bidirectional barbed suture for UVA during LRP can shorten UVA time and provide better outcomes in terms of early urinary continence recovery.

Radical prostatectomy versus deferred treatment for localised prostate cancer

BACKGROUND

Prostate cancer is a common cancer but is oftentimes slow growing. When confined to the prostate, radical prostatectomy (RP), which involves removal of the prostate, offers potential cure that may come at the price of adverse events. Deferred treatment, involving observation and palliative treatment only (watchful waiting (WW)) or close monitoring and delayed local treatment with curative intent as needed in the setting of disease progression (active monitoring (AM)/surveillance (AS)) might be an alternative. This is an update of a Cochrane Review previously published in 2010.

OBJECTIVES

To assess effects of RP compared with deferred treatment for clinically localised prostate cancer.

SEARCH METHODS

We searched the Cochrane Library (including CDSR, CENTRAL, DARE, and HTA), MEDLINE, Embase, AMED, Web of Science, LILACS, Scopus, and OpenGrey. Additionally, we searched two trial registries and conference abstracts of three conferences (EAU, AUA, and ASCO) until 3 March 2020.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared RP versus deferred treatment in patients with localised prostate cancer, defined as T1-2, N0, M0 prostate cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of references and extracted data from included studies. The primary outcome was time to death from any cause; secondary outcomes were: time to death from prostate cancer; time to disease progression; time to metastatic disease; quality of life, including urinary and sexual function; and adverse events. We assessed the certainty of evidence per outcome using the GRADE approach.  MAIN RESULTS: We included four studies with 2635 participants (average age between 60 to 70 years). Three multicentre RCTs, from Europe and USA, compared RP with WW (n = 1537), and one compared RP with AM (n = 1098). Radical prostatectomy versus watchful waiting RP probably reduces the risk of death from any cause (hazard ratio (HR) 0.79, 95% confidence interval (CI) 0.70-0.90; 3 studies with 1537 participants; moderate-certainty evidence). Based on overall mortality at 29 years, this corresponds to 764 deaths per 1000 men in the RP group compared to 839 deaths per 1000 men in the WW group. RP probably also lowers the risk of death from prostate cancer (HR 0.57, 95% CI 0.44-0.73; 2 studies with 1426 participants; moderate-certainty evidence). Based on prostate cancer-specific mortality at 29 years, this corresponds to 195 deaths from prostate cancer per 1000 men in the RP group compared with 316 deaths from prostate cancer per 1000 men in the WW group. RP may reduce the risk of progression (HR 0.43, 95% CI 0.35-0.54; 2 studies with 1426 participants; I² = 54%; low-certainty evidence); at 19.5 years, this corresponds to 391 progressions per 1000 men for the RP group compared with 684 progressions per 1000 men for the WW group) and probably reduces the risk of developing metastatic disease (HR 0.56, 95% CI 0.46-0.70; 2 studies with 1426 participants; I² = 0%; moderate-certainty evidence); at 29 years, this corresponds to 271 metastatic diseases per 1000 men for RP compared with 431 metastatic diseases per 1000 men for WW. General quality of life at 12 years' follow-up is probably similar for both groups (risk ratio (RR) 1.0, 95% CI 0.85-1.16; low-certainty evidence), corresponding to 344  patients with high quality of life per 1000 men for the RP group compared with 344 patients with high quality of life per 1000 men for the WW group. Rates of urinary incontinence may be considerably higher (RR 3.97, 95% CI 2.34-6.74; low-certainty evidence), corresponding to 173 incontinent men per 1000 in the RP group compared with 44 incontinent men per 1000 in the WW group, as are rates of erectile dysfunction (RR 2.67, 95% CI 1.63-4.38; low-certainty evidence), corresponding to 389 erectile dysfunction events per 1000 for the RP group compared with 146 erectile dysfunction events per 1000 for the WW group, both at 10 years' follow-up. Radical prostatectomy versus active monitoring Based on one study including 1098 participants with 10 years' follow-up, there are probably no differences between RP and AM in time to death from any cause (HR 0.93, 95% CI 0.65-1.33; moderate-certainty evidence). Based on overall mortality at 10 years, this corresponds to 101 deaths per 1000 men in the RP group compared with 108 deaths per 1000 men in the AM group. Similarly, risk of death from prostate cancer probably is not different between the two groups (HR 0.63, 95% CI 0.21-1.89; moderate-certainty evidence). Based on prostate cancer-specific mortality at 10 years, this corresponds to nine prostate cancer deaths per 1000 men in the RP group compared with 15 prostate cancer deaths per 1000 men in the AM group. RP probably reduces the risk of progression (HR 0.39, 95% CI 0.27-0.56; moderate-certainty evidence; at 10 years, this corresponds to 86 progressions per 1000 men for RP compared with 206 progressions per 1000 men for AM) and the risk of developing metastatic disease (RR 0.39, 95% CI 0.21-0.73; moderate-certainty evidence; at 10 years, this corresponds to 24 metastatic diseases per 1000 men for the RP group compared with 61 metastatic diseases per 1000 men for the AM group).The general quality of life during follow-up was not different between the treatment groups. However, urinary function (mean difference (MD) 8.60 points lower, 95% CI 11.2-6.0 lower) and sexual function (MD 14.9 points lower, 95% CI 18.5-11.3 lower) on the Expanded Prostate Cancer Index Composite-26 (EPIC-26) instrument, were worse in the RP group.

AUTHORS' CONCLUSIONS

Based on long-term follow-up, RP compared with WW probably results in substantially improved oncological outcomes in men with localised prostate cancer but also markedly increases rates of urinary incontinence and erectile dysfunction. These findings are largely based on men diagnosed before widespread PSA screening, thereby limiting generalisability. Compared to AM, based on follow-up to 10 years, RP probably has similar outcomes with regard to overall and disease-specific survival yet probably reduces the risks of disease progression and metastatic disease. Urinary function and sexual function are probably decreased for the patients treated with RP.

Contemporary Comparison of Open to Robotic Prostatectomy at a Veteran's Affairs Hospital

INTRODUCTION

Among veterans, prostate cancer is the most common malignancy and has a higher incidence compared to the rest of the nation. No study has compared the effectiveness of Robotic-assisted-laparoscopic radical prostatectomy (RALP) vs. open radical prostatectomy (ORP) in the Veteran's Affairs (VA) hospital setting during the adoption of RALP.

METHODS

Institutional Review Board approval was obtained. Retrospective review was completed on Veterans with prostate cancer who underwent ORP or RALP from March 2011 to January 2017 during the introduction of RALP at one VA hospital. Perioperative and functional outcomes between ORP and RALP were compared as well as between the initial 50 and final 53 RALPs.

RESULTS

Among 91 ORPs and 153 RALPs, RALP had significant reductions in blood transfusions [2(1.3%) vs. 44(40%), p < 0.001], length of stay [2 days(1-2) vs. 3 days(2-4), p < 0.001], Clavien grade >2 complications [1(0.7%) vs. 20 (22.0%), p < 0.001], urine leak [2(1.3%) vs. 11 (12.1%), p < 0.001], and ICU readmissions [0(0%) vs. 3(3.3%), p < 0.001]. There were no significant differences in positive margin status or functional outcomes. Compared to the first 50 cases, the last 53 RALPs demonstrated a shorter operative time (349 vs. 292 min, p < 0.001), lower EBL (300 vs. 150 mL, p < 0.001), more frequent 1-day length of stay (34% vs. 60%, p = 0.02), and fewer composite adverse events (82% vs. 51%, p = 0.004). Operative time for the final 53 RALPs (292 minutes) was shorter than that of ORP (325 minutes, p = 0.013).

CONCLUSIONS

During the introduction of RALP at one VA hospital, RALP was associated with several improved parameters compared to ORP and similar operative times were noted after the first 100 cases of RALPs. RALP is safe to introduce in a VA setting without compromising outcomes.

Laparoscopic radical prostatectomy compared to open radical prostatectomy: Comparison between surgical time, complications and length of hospital stay

INTRODUCTION

There are very few articles comparing open radical prostatectomy (OPR) with laparoscopic radical prostatectomy (LRP).

OBJETIVES

To compare the surgical time, the postoperative complications and the hospital stay in patients with localized prostate cancer treated with ORP or LRP.

MATERIAL AND METHODS

Comparison between two patients cohorts (312 with ORP and with 206 LRP) between 2007-2015. Postoperative complications were collected as defined in to the EAU Guidelines recommendations and they were classified according to the Clavien-Dindo classification. To compare the qualitative variables, we employed the chi-squared test and ANOVA for quantitative variables. We performed a multivariate analysis using logistic regression with dependent qualitative variables and a lineal regression with dependent continuous variables.

RESULTS

The mean duration of ORP was 3:05hours and 4:35hours for LRP (p=.0001). The 26.4% of the patients presented any postoperative complication. 31.2% of ORP and 19.3% of LRP (p=.003). The mean of hospital stay was 4 days. In ORP group was 4 days in contrast to LRP with 3 days (p=.008). The LRP (p=.0001), lymphadenectomy (p=.02) and nerve-sparing (p=.01) were independent predictor factors of extension of surgical time. LRP was a protector independent factor of complications (OR=0.48 p=.007). The type of prostatectomy didn't influence in the length of hospital stay.

CONCLUSIONS

LRP showed higher surgical time, less complications and it didn't influence the hospital stay.

Comparison of surgical, oncological, and functional outcomes of robot-assisted and laparoscopic radical prostatectomy in patients with prostate cancer

OBJECTIVE

To compare the oncological and functional outcomes of robot-assisted radical prostatectomy (RARP) and laparoscopic radical prostatectomy (LRP).

MATERIAL AND METHODS

We compared patients who underwent the RARP (n=778) and LRP (n=48) techniques for prostate cancer between January 2008 and July 2017 in our clinic. Patient demographics, preoperative and postoperative data, pathologic evaluation, continence, and potency rates were collected and analyzed retrospectively.

RESULTS

The preoperative and demographic data of the patients we included in our study were similar. The mean operation time estimated blood loss, length of hospitalization, and catheterization time were significantly shorter in the RARP group. The statistical analysis was in favor of robotic prostatectomy in the terms of the mean length of hospitalization, catheterization time, and early (<30 days) and intermediate (31-90 days) complications. Positive surgical margins and biochemical recurrence rates, and recovery of continence and erectile function, were similar in both groups.

CONCLUSION

RARP and LRP in organ-confined prostate cancer are safe and effective methods. Robotic prostatectomy has a shorter operative time, length of hospitalization, catheterization time, and lower early and late complication rates.

Perioperative outcomes of robotic-assisted laparoscopic radical prostatectomy, laparoscopic radical prostatectomy and open radical prostatectomy: 10 years of cases at Ramathibodi Hospital

Background

This study aims to compare the perioperative and pathological outcomes of open radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP), and robotic-assisted laparoscopic radical prostatectomy (RALRP) at Ramathibodi Hospital within Mahidol University in Thailand.

Methods

From January 2008 to July 2017, 679 RPs were performed. Patients' data were collected retrospectively to evaluate their perioperative and pathological outcomes. This data included the age, body mass index (BMI), serum prostate specific antigen (PSA) level, clinical stage, Gleason score (GS) from biopsy, operative time, estimated blood loss (EBL), perioperative complications, blood transfusion rate, adjacent organ injury rate, length of hospital stay, pathological stage, GS of the biopsy specimen, specimen weight (g), and marginal status of the patients.

Results

Of the 679 RPs performed, 128 (19.28%) were ORPs, 241 (36.30%) were LRPs, and 295 (44.43%) were RALRPs. Patients who underwent a RALRP had a significant advantage in EBL (1,600, 500, and 300 mL for ORPs, LRPs, and RALRPs, respectively), overall complications, and blood transfusion rate. As they are minimally invasive techniques, LRP and RALRP presented an advantage in terms of the length of hospital stay (an average of 9, 6, and 6 days for ORPs, LRPs, and RALRPs, respectively) and adjacent organ injury rate. ORPs also had the shortest operative time (160, 210, and 200 min for ORPs, LRPs, and RALRPs, respectively). However, the specimen weight and marginal status were similar in all of the techniques.

Conclusions

Minimally invasive RP techniques, such as LRPs and RALRPs, appear to be safe, have significantly better perioperative outcomes than ORPs, and have comparable pathological outcomes to those of ORPs.

Incidence and Risk Factors of Pulmonary Complications after Robot-Assisted Laparoscopic Prostatectomy: A Retrospective Observational Analysis of 2208 Patients at a Large Single Center

Robot-assisted laparoscopic prostatectomy (RALP) is a minimally invasive technique for the treatment of prostate cancer. RALP requires the patient to be placed in the steep Trendelenburg position, along with pneumoperitoneum, which may increase the risk of postoperative pulmonary complications (PPCs). This large single-center retrospective study evaluated the incidence and risk factors of PPCs in 2208 patients who underwent RALP between 2014 and 2017. Patients were divided into those with (PPC group) and without (non-PPC group) PPCs. Postoperative outcomes were evaluated, and univariate and multivariate logistic regression analyses were performed to assess risk factors of PPCs. PPCs occurred in 682 patients (30.9%). Risk factors of PPCs included age (odds ratio [OR], 1.023; p = 0.001), body mass index (OR, 1.061; p = 0.001), hypoalbuminemia (OR, 1.653; p = 0.008), and positive end-expiratory pressure (PEEP) application (OR, 0.283; p < 0.001). The incidence of postoperative complications, rate of intensive care unit (ICU) admission, and duration of ICU stay were significantly greater in the PPC group than in the non-PPC group. In conclusion, the incidence of PPCs in patients who underwent RALP under pneumoperitoneum in the steep Trendelenburg position was 30.9%. Factors associated with PPCs included older age, higher body mass index, hypoalbuminemia, and lack of PEEP.

Main Inflammatory Cells and Potentials of Anti-Inflammatory Agents in Prostate Cancer

Prostate cancer is the most common type of cancer and the leading cause of cancer deaths among men in many countries. Preventing progression is a major concern for prostate cancer patients on active surveillance, patients with recurrence after radical therapies, and patients who acquired resistance to systemic therapies. Inflammation, which is induced by various factors such as infection, microbiome, obesity, and a high-fat diet, is the major etiology in the development of prostate cancer. Inflammatory cells play important roles in tumor progression. Various immune cells including tumor-associated neutrophils, tumor-infiltrating macrophages, myeloid-derived suppressor cells, and mast cells promote prostate cancer via various intercellular signaling. Further basic studies examining the relationship between the inflammatory process and prostate cancer progression are warranted. Interventions by medications and diets to control systemic and/or local inflammation might be effective therapies for prostate cancer progression. Epidemiological investigations and basic research using human immune cells or mouse models have revealed that non-steroidal anti-inflammatory drugs, metformin, statins, soy isoflavones, and other diets are potential interventions for preventing progression of prostate cancer by suppressing inflammation. It is essential to evaluate appropriate indications and doses of each drug and diet.

Robot-assisted and laparoscopic vs open radical prostatectomy in clinically localized prostate cancer: perioperative, functional, and oncological outcomes: A Systematic review and meta-analysis

BACKGROUND

To perform a systematic review and meta-analysis evaluating the perioperative, functional, and oncological outcomes and cost of robot-assisted radical prostatectomy (RARP), or laparoscopic radical prostatectomy (LRP) comparing with open radical prostatectomy (ORP) in men with clinically localized prostate cancer through all prospective comparative studies.

METHODS

A comprehensive literature search was performed in August 2018 using the Pubmed, Medline, Embase, and Cochrane databases. Only randomized controlled trials (RCTs) and prospective studies including patients with clinically localized prostate cancer were eligible for study inclusion. Cumulative analysis was conducted using Review Manager v. 5.3 software.

RESULTS

Two RCTs and 9 prospective studies were included in this systematic review. There were no significant differences between RARP/LRP and ORP in overall complication rate, major complication rate, overall positive surgical margin (PSM) rate, ≤pT2 tumor PSM rate, ≥pT3 tumor PSM rate. Moreover, RARP/LRP and ORP showed similarity in biochemical recurrence (BCR) rate at 3, 12, 24 months postoperatively. Urinary continence and erectile function at 12 months postoperatively between RARP and ORP are also comparable. RARP/LRP were associated with significantly lower estimated blood loss [mean difference (MD) -749.67, 95% CI -1038.52 to -460.82, P = .001], lower transfusion rate (OR 0.17, 95% CI 0.10 to 0.30, P < .001) and less hospitalization duration (MD -1.18, 95% CI -2.18 to -0.19, P = .02). And RARP/LRP required more operative time (MD 50.02, 95% CI 6.50 to 93.55, P = .02) and cost.

CONCLUSION

RARP/LRP is associated with lower blood loss, transfusion rate and less hospitalization duration. The available data were insufficient to prove the superiority of any surgical approach in terms of postoperative complications, functional and oncologic outcomes.

When the Evidence Basis Breeds Controversies: Exploring the Value Profile of Robotic Surgery Beyond the Early Introduction Phase

This article investigates qualitatively the value profile of the da Vinci® surgical robot after almost two decades of extensive clinical use and research. We aimed to understand whether the swiftly growing body of published studies on robotic prostate surgery can now, that is, beyond an early stage, guide decisions on the acquisition, procurement, and public provision of this innovation. We explored both published studies and the perspectives of diverse stakeholders in the Netherlands. Both arenas represent conflicting, often polarised arguments on the (added) value of da Vinci surgery. What was unclear a decade ago due to lack of evidence is now unclear because of controversies about evidence. The article outlines controversial value issues and indicates the unlikelihood that awaiting more research - amid the mantra "further studies are needed" - will resolve the controversy. The study underscores multi-stakeholder deliberation to resolve controversies regarding the value of advanced medical innovations.

On the feasibility of transperineal 3D ultrasound image guidance for robotic radical prostatectomy

PURPOSE

Prostate cancer is the most prevalent form of male-specific cancers. Robot-assisted laparoscopic radical prostatectomy (RALRP) using the da Vinci surgical robot has become the gold-standard treatment for organ-confined prostate cancer. To improve intraoperative visualization of anatomical structures, many groups have developed techniques integrating transrectal ultrasound (TRUS) into the surgical workflow. TRUS, however, is intrusive and does not provide real-time volumetric imaging.

METHODS

We propose a proof-of-concept system offering an alternative noninvasive transperineal view of the prostate and surrounding structures using 3D ultrasound (US), allowing for full-volume imaging in any anatomical plane desired. The system aims to automatically track da Vinci surgical instruments and display a real-time US image registered to preoperative MRI. We evaluate the approach using a custom prostate phantom, an iU22 (Philips Healthcare, Bothell, WA) US machine with an xMATRIX X6-1 transducer, and a custom probe fixture. A novel registration method between the da Vinci kinematic frame and 3D US is presented. To evaluate the entire registration pipeline, we use a previously developed MRI to US deformable registration algorithm.

RESULTS

Our US calibration technique yielded a registration error of 0.84 mm, compared to 1.76 mm with existing methods. We evaluated overall system error with a prostate phantom, achieving a target registration error of 2.55 mm.

CONCLUSION

Transperineal imaging using 3D US is a promising approach for image guidance during RALRP. Preliminary results suggest this system is comparable to existing guidance systems using TRUS. With further development and testing, we believe our system has the potential to improve patient outcomes by imaging anatomical structures and prostate cancer in real time.

Infectious Complications of Conventional Laparoscopic vs Robotic Laparoscopic Prostatectomy: A Systematic Literature Review and Meta-Analysis

BACKGROUND

Recent studies have shown that using minimally invasive surgical techniques (conventional laparoscopy or robotic) for prostatectomy is associated with lower perioperative complication rates compared with open radical retropubic prostatectomy. However, differences in infectious complications between these minimally invasive approaches are not well characterized. To study this further, we performed a systematic review of the literature and meta-analysis of the infectious complications of prostatectomy, comparing robotic prostatectomy (RP) with conventional laparoscopic prostatectomy (LP).

METHODS

We searched PubMed, CINAHL, CDSR, and EMBASE through September 2018 for studies evaluating minimally invasive prostatectomy and infectious complications. We employed random-effect models to obtain pooled odds ratio (pOR) estimates. Heterogeneity was evaluated with I² estimation and the Cochran Q statistic. pORs were calculated separately based on the indication for prostatectomy.

RESULTS

Fifteen studies were included in the final review for the meta-analysis with 14,121 patients undergoing minimally invasive prostatectomy. There was no statistically significant difference in the number of infectious complication events between RP and LP (pOR 0.94; 95% CI 0.50, 1.76). When we performed a stratified analysis, similar results were found with no statistically significant difference in infectious complications comparing RP with LP among patients with prostate cancer (pOR 0.73; 95% CI 0.43, 1.24). We observed that infectious complications were nearly threefold higher with the robotic approach in earlier studies (published between 2007 and 2012, pOR 2.81; 95% CI 1.07, 7.39), but no significant difference was found in later studies (between 2013 and 2018, pOR 0.80, 95% CI 0.40, 1.57).

CONCLUSIONS

The rate of infectious complications associated with RP was no different than that associated with conventional LP.

90-Day readmission after radical prostatectomy-a prospective comparison between robot-assisted and open surgery

Purpose: All types of surgery are associated with complications. The debate is ongoing whether robot-assisted radical prostatectomy can lower this risk compared to open surgery. The objective of the present study was to evaluate post-operative adverse events leading to readmissions, using clinical records to classify these adverse events systematically. Materials and methods: A prospective controlled trial of men who underwent robot-assisted laparoscopic (RALP) or retropubic radical prostatectomy (RRP) at 14 departments of Urology (LAPPRO) between 2008 and 2011. Data on all readmissions within 3 months of surgery were collected from the Patient registry, Swedish Board of Health and Welfare. For each readmission the highest Clavien-Dindo grade was listed. Results: A total of 4003 patients were included in the LAPPRO trial and, after applying exclusion criteria, 3706 patients remained for analyses. The results showed no statistically significant difference in the overall readmission rates (8.1 vs. 7.1%) or readmission due to major complications (Clavien-Dindo ≥3b, 1.7 vs. 1.9%) between RALP and RRP within 90 days after surgery. Patients subjected to lymph-node dissection (LND) had twice the risk for readmission as men not undergoing LND, irrespective RALP or RRP technique. Blood transfusion was significantly more frequent during and within 30 days of RRP surgery (16 vs. 4%). Abdominal symptoms were more common after RALP. Conclusions: There is a substantial risk for hospital readmission after prostate-cancer surgery, regardless of technique; although major complications are rare. Regardless of surgical technique, attention should be focused on specific types of complications.

Exploring pathways towards improving patient experience of robot-assisted radical prostatectomy (RARP): assessing patient satisfaction and attitudes

OBJECTIVE

To determine patient satisfaction and experience after robot-assisted radical prostatectomy (RARP) for prostate cancer, using a convergent mixed-method qualitative analysis approach.

PATIENTS AND METHODS

412 patients who underwent RARP between January 2014 and June 2016 were mailed questionnaires and invited to participate in focus groups. Qualitative data was thematically analysed using NVivo. Descriptive statistics were obtained from the questionnaire using SPSS.

RESULTS

214 patients responded (52% of sample size) of whom 97.6% were satisfied and 91.1% would likely recommend RARP. Key themes from the qualitative data highlighted the psychosocial impacts of the diagnosis and RARP process. The importance of early recovery, the benefits of pelvic floor exercises and educational resources were emphasised.

CONCLUSION

Patients were overwhelmingly satisfied with RARP, largely due to relevance and timeliness of the information and support provided both before and after surgery. With an increased understanding of the factors and outcomes that are most important to patients regarding all aspects of hospital care, we can create more targeted care pathways. Key themes will help inform the implementation of an enhanced recovery after surgery (ERAS) protocol to further improve recovery and early return to function.

Effect of prostate gland weight on the surgical and oncological outcomes of extraperitoneal robot-assisted radical prostatectomy

Background

Robot-assisted radical prostatectomy (RARP) is performed by urologists as one of the surgical procedures for treating prostate cancer. Numerous studies have been published with regard to the impact of prostate weight on performing RARP but were limited by the insufficient number of patients and use of the transperitoneal approach. This study aimed to determine the effect of prostate gland weight on the surgical and short-term oncological outcomes of RARP using the extraperitoneal approach.

Methods

In total, 1168 patients who underwent extraperitoneal RARP (EP-RARP) performed by a single surgeon at Yonsei University Severance Hospital between May 2009 and May 2016 were included in the study. The patients were divided into 4 groups according to the prostate weight measured by transrectal ultrasonography preoperatively. Intraoperative and postoperative outcomes were analyzed retrospectively. One-way analysis of variance and the chi-square test were used in the statistical analyses.

Results

Age, the Gleason score, clinical stage, and pathological stage were significantly different. Patients with a larger prostate size had a longer console time and higher estimated blood loss (P < 0.05). There were no significant differences between the 4 groups in length of hospital stay, duration of catheterization, blood transfusion, body mass index, prostate-specific antigen (PSA) level, history of abdominal surgery, intraoperative complications, positive surgical margin, incidence of lymphocele, and PSA recurrence after 1 year.

Conclusions

The console time and estimated blood loss were significantly increased with a larger prostate size. However, there were no significant differences in the oncologic outcome and intraoperative complications, suggesting that EP-RARP requires meticulous bleeding control in patients with a prostate weighing > 75 g, and if appropriate management is implemented for blood loss intraoperatively, EP-RARP can be performed regardless of the prostate size.

Robotic surgery improves transfusion rate and perioperative outcomes using a broad implementation process and multiple surgeon learning curves

INTRODUCTION

Data from a randomized trial suggest transfusion rates are similar for robotic and open prostatectomy. The objective of this study was to compare perioperative outcomes of robotic and open prostatectomy at a Canadian academic centre.

METHODS

A retrospective review of all prostatectomies performed by all surgeons at The Ottawa Hospital between 2009 and 2016 was completed. Cases and outcomes were identified using an administrative data warehouse. Extracted data included patient factors (age, body mass index, American Society of Anesthesiologists score, Elixhauser comorbidity score), operative factors (length of operation, surgical approach, anesthesia type), and perioperative outcomes (length of recovery room and hospital stay, transfusion rate, hospital cost). Baseline characteristics and outcomes were compared between robotic and open surgical approaches. The primary outcome was transfusion during the index admission.

RESULTS

A total of 1606 prostatectomies were performed by 12 surgeons during the study period (840 robotic, 766 open). The rate of transfusion was lower in patients undergoing robotic compared to open surgery (0.6% vs. 11.2%; p<0.001). The robotic prostatectomy cohort had a shorter length of stay in the recovery room (155.7 vs. 231.1 minutes; p<0.001) and shorter length of hospital admission (1.4 vs. 2.8 days; p<0.001). Hospital costs per case were approximately $800 more for robotic prostatectomy ($11 475 vs. $10 656; p<0.001).

CONCLUSIONS

This hospital-wide analysis revealed that robotic prostatectomy is associated with a lower transfusion rate compared to the open approach. Further studies emphasizing patient-reported outcomes are needed.

3D versus 2D laparoscopic radical prostatectomy for organ confined prostate cancer: Our experience

Objective:

Three-dimensional (3D) laparoscopy was developed to overcome the main limitations of traditional laparoscopy. The aim of our study was to compare operative, functional and oncological results of 3D and two-dimensional (2D) laparoscopic radical prostatectomy.

Materials and methods:

A total of 102 consecutive patients with clinically localised prostate cancer underwent laparoscopic radical prostatectomy. Patients were randomly assigned into two groups, 2D high definition (HD) camera (50 patients) for the first and 3D HD camera (52 patients) for the second group. Total operative time, anastomosis time, blood loss, complications and pentafecta rates for both groups were compared. All patients had at least one year of follow-up.

Results:

Total operative time was, respectively, 143 ± 17 and 118 ± 15 minutes, with a mean anastomosis time of 31± 12 and 23 ± 12 minutes. Mean blood loss was 230 ± 30 ml with 2D vision and 175 ± 40 with 3D vision. Pentafecta was reached, respectively, by 46% and 50% of patients at 3 months and 60% and 67.3% at 12 months. 3D vision offers an increased speed if compared with traditional vision ( P=0.02). Pentafecta results were significantly better in the 3D group ( P=0.03).

Conclusion:

We believe that 3D laparoscopy offers important advantages for surgeons and patients; its use should be encouraged.

Level of evidence:

1c

Is the adjustable transobturator system ATOMS® useful for the treatment of male urinary incontinence in low to medium volume urological centers?

INTRODUCTION

Urinary incontinence (UI) is a complication of radical prostatectomy (RP) and transurethral resection of the prostate (TURP). The gold-standard treatment is the artificial urinary sphincter, however, new treatments have been investigated.

OBJECTIVE

To examine the outcome of an adjustable transobturator male system (ATOMS^®) in men with UI after prostatic surgery in a low to medium volume continence center.

MATERIALS AND METHODS

Twenty-five men with UI were implanted with ATOMS^® system between 2012 and 2014. The most common indication was UI after RP (92%), followed by UI after TURP (8%). Eleven patients (44%) had received adjuvant external beam radiotherapy (RT). Patients were considered to be 'dry' if they stopped wearing pads or needed just one protective pad per day; and improved if the daily number of pads used decreased by at least half. The Incontinence Quality of Life questionnaire (ICIQ-SF) was used, adding a verbal question about the satisfaction of the patient considering the outcome.

RESULTS

After a mean follow-up of 21.56 months, 64% were dry and 8% revealed a significant improvement. The success of the procedure was negatively correlated with the severity of the previous UI and with previous treatment with RT. Concerning patients satisfaction, 84% of the patients would repeat the procedure.

CONCLUSION

ATOMS^® offers good rates of cure and improvement of UI after prostatic surgery with a reasonable rate of minor complications. The results of this study, performed in a low to medium volume continence center, are comparable to the results achieved in high volume continence centers.

Pathological outcomes and biochemical recurrence-free survival after radical prostatectomy for high-risk prostate cancer in the Indian population

Introduction:

We analyzed the biochemical recurrence-free survival (BRFS) of patients with high-risk prostate cancer (HRCaP) as per the D’Amico classification undergoing radical prostatectomy (RP) at our center. We aimed to determine whether the number and type of risk factors (cT2c-T3b, prostate-specific antigen >20 ng/ml, Gleason score >7) are associated with biochemical recurrence (BCR) in HRCaP patients undergoing RP in the Indian population.

Methods:

Between 2006 and 2017, 192 patients underwent RP (open RP [ORP], laparoscopic RP [LRP], and robotic RP [RRP]) at our center, of which 109 had D’Amico HR disease. Preoperative, postoperative, and pathological outcome data were analyzed for patients with HR disease as per the D’Amico classification. Subgroups were formed to determine whether an increasing number of risk factors (1, 2, or 3) were associated with poorer oncological results and early BCR. The Kaplan–Meier method with log-rank test was used to test the difference in BRFS between the groups. Univariate and multivariate analyses were done to find significant variable against BCR.

Results:

According to the D’Amico criteria, 109 patients had HR, 63 patients had intermediate-risk, and 19 patients had low-risk disease. These 109 patients with HR disease were analyzed in our study (50 RRP, 33 ORP, and 26 LRP). A total of 59 (54.1%) patients had one HR factor (1HR), 44 (40%) had two HR factors (2HR), and 6 (5.5%) had three HR factors (3HR). The mean follow-up for our patient population was 21.5 ± 19 months (median 18 months; range, 0–108). Overall, the 2-year and 5-year BRFS was 45% and 35%, respectively (mean BRFS 46 ± 6 months). Two-year BRFS was 63%, 23%, and 22%, respectively, for 1HR, 2HR, and 3HR (logrank, P < 0.0001). The prognostic substratification based on the three risk factors was significantly predictive for adverse pathologic features and oncologic outcomes.

Conclusion:

Substratification based on the three well-defined criteria leads to a better identification of the more aggressive cancers and prediction of need for additional treatment modalities. Localized HRCaP includes a heterogeneous population of patients with variable oncological outcomes.

Retropubic, Laparoscopic, and Robot-Assisted Radical Prostatectomy: A Comparative Analysis of the Surgical Outcomes in a Single Regional Center

Background

To compare the surgical outcomes of radical prostatectomy (RP) performed via 3 different approaches: retropubic (RRP), laparoscopic-assisted (LRP), and robot-assisted (RARP), in a single non-academic regional center by a single surgeon.

Materials and Methods

The data of patients undergoing RP from 2005 to 2014 were reviewed. The standard approach changed through the years: RRP (n = 380, years 2005 to 2008), LRP (n = 240, years 2009 to 2011), and RARP (n = 262, years 2012 to 2014). Our analysis included the last consecutive 100 RP for each surgical technique by a single surgeon. A logistic regression model adjusted for pre-and postoperative variables was done to evaluate whether transfusion, conversion, and post-operative complication rates were influenced by the approach.

Results

RARP was associated with significantly lower blood loss (400 vs. 600 and 600 ml, respectively), transfusion (6 vs. 21 and 21%, respectively), and shorter hospital stay (6 vs. 7 and 8 days, respectively), compared to LRP and RRP, and a lower conversion rate (1 vs. 12%) compared to LRP. Multivariate analysis adjusted for confounders confirmed that the risk of transfusion and conversion was significantly lower in the RARP group compared to the LRP and RRP groups. The RARP group was also associated with a significantly lower risk of complications compared to the RRP group and with a trend in favor of the RARP group compared to the LRP group. The 1-year continence rate was significantly higher in the RARP group compared to the RRP and LRP groups (80 vs. 72 and 68%, respectively).

Conclusion

The surgical approach affected the operative outcomes in a regional setting. The advantages of RARP over RRP (complications, transfusion, conversion, hospital stay, 1-year continence) were over LRP as well, with the only exception being complications.

Laparoscopic and robot-assisted vs open radical prostatectomy for the treatment of localized prostate cancer: a Cochrane systematic review

OBJECTIVE

To determine the effects of laparoscopic radical prostatectomy (LRP), or robot-assisted radical prostatectomy (RARP) compared with open radical prostatectomy (ORP) in men with localized prostate cancer.

MATERIALS AND METHODS

We performed a comprehensive search using multiple databases (CENTRAL, MEDLINE, EMBASE) and abstract proceedings, with no restrictions on the language of publication or publication status, up until 9 June 2017. We included all randomized or pseudo-randomized controlled trials that directly compared LRP and RARP with ORP. Two review authors independently examined full-text reports, identified relevant studies, assessed the eligibility of studies for inclusion, extracted data and assessed risk of bias. We performed statistical analyses using a random-effects model and assessed the quality of the evidence according to Grading of Recommendations Assessment, Development and Evaluation (GRADE). The primary outcomes were prostate cancer-specific survival, urinary quality of life and sexual quality of life. Secondary outcomes were biochemical recurrence-free survival, overall survival, overall surgical complications, serious postoperative surgical complications, postoperative pain, hospital stay and blood transfusions.

RESULTS

We included two unique studies in a total of 446 randomized participants with clinically localized prostate cancer. All available outcome data were short-term (up to 3 months). We found no study that addressed the outcome of prostate cancer-specific survival. Based on one trial, RARP probably results in little to no difference in urinary quality of life (mean difference [MD] -1.30, 95% confidence interval [CI] -4.65 to 2.05; moderate quality of evidence) and sexual quality of life (MD 3.90, 95% CI: -1.84 to 9.64; moderate quality of evidence). No study addressed the outcomes of biochemical recurrence-free survival or overall survival. Based on one trial, RARP may result in little to no difference in overall surgical complications (risk ratio [RR] 0.41, 95% CI: 0.16-1.04; low quality of evidence) or serious postoperative complications (RR 0.16, 95% CI: 0.02-1.32; low quality of evidence). Based on two studies, LRP or RARP may result in a small, possibly unimportant improvement in postoperative pain at 1 day (MD -1.05, 95% CI: -1.42 to -0.68; low quality of evidence) and up to 1 week (MD -0.78, 95% CI: -1.40 to -0.17; low quality of evidence). Based on one study, RARP probably results in little to no difference in postoperative pain at 12 weeks (MD 0.01, 95% CI: -0.32 to 0.34; moderate quality of evidence). Based on one study, RARP probably reduces the length of hospital stay (MD -1.72, 95% CI: -2.19 to -1.25; moderate quality of evidence). Based on two studies, LRP or RARP may reduce the frequency of blood transfusions (RR 0.24, 95% CI: 0.12-0.46; low quality of evidence). Assuming a baseline risk for a blood transfusion to be 8.9%, LRP or RARP would result in 68 fewer blood transfusions per 1,000 men (95% CI: 78-48 fewer).

CONCLUSIONS

There is no evidence to inform the comparative effectiveness of LRP or RARP compared with ORP for oncological outcomes. Urinary and sexual quality of life appear similar. Overall and serious postoperative complication rates appear similar. The difference in postoperative pain may be minimal. Men undergoing LRP or RARP may have a shorter hospital stay and receive fewer blood transfusions.

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.

Ocular blood flow in steep Trendelenburg positioning during robotic-assisted radical prostatectomy

Purpose:

Several ischemic optic neuropathies that occurred during robotic-assisted laparoscopic radical prostatectomy (RALRP) have been reported to be due to the Trendelenburg position, which lowers ocular perfusion pressure (OPP). We examined changes in pulsatile ocular blood flow (POBF) and its correlation with OPP during RALRP in the steep Trendelenburg position.

Methods:

Pulsatile ocular blood flow and intraocular pressure (IOP) were measured in 50 patients by the OBF Langham System 5 times during RALRP. The mean arterial blood pressure (MAP), heart rate, plateau airway pressure, and end-tidal CO2 (EtCO2) at each time point were recorded. Ocular perfusion pressure was calculated from simultaneous IOP and MAP measurements.

Results:

Pulsatile ocular blood flow was 15.53 ± 3.32 µL/s at T0, 18.99 ± 4.95 µL/s at T1, 10.04 ± 3.24 µL/s at T2, 11.45 ± 3.02 µL/s at T3, and 15.07 ± 3.81 µL/s at T4. Ocular perfusion pressure was 70.15 ± 5.98 mm Hg at T0, 64.21 ± 6.77 mm Hg at T1, 57.71 ± 7.07 mm Hg at T2, 51.73 ± 11.58 mm Hg at T3, and 64.21 ± 12.37 mm Hg at T4. Repeated-measures analysis of variance on POBF and OPP was significant (p>0.05). This difference disappeared when the correlation between MAP and POBF, EtCO2 and POBF, and EtCO2 and OPP were considered, while correlation between MAP and OPP confirmed the difference. The regression analysis between POBF and OPP showed a statistically significant difference at T0 and T3 (r = 0.047, p = 0.031 and r = 0.096, p = 0.002, respectively).

Conclusions:

Pulsatile ocular blood flow and OPP reached the lowest level at the end of surgery.