Anatomic robotic prostatectomy: current best practice

An updated model for predicting side-specific extraprostatic extension in the era of MRI-targeted biopsy

PURPOSE

Accurate prediction of extraprostatic extension (EPE) is pivotal for surgical planning. Herein, we aimed to provide an updated model for predicting EPE among patients diagnosed with MRI-targeted biopsy.

MATERIALS AND METHODS

We analyzed a multi-institutional dataset of men with clinically localized prostate cancer diagnosed by MRI-targeted biopsy and subsequently underwent prostatectomy. To develop a side-specific predictive model, we considered the prostatic lobes separately. A multivariable logistic regression analysis was fitted to predict side-specific EPE. The decision curve analysis was used to evaluate the net clinical benefit. Finally, a regression tree was employed to identify three risk categories to assist urologists in selecting candidates for nerve-sparing, incremental nerve sparing and non-nerve-sparing surgery.

RESULTS

Overall, data from 3169 hemi-prostates were considered, after the exclusion of prostatic lobes with no biopsy-documented tumor. EPE was present on final pathology in 1,094 (34%) cases. Among these, MRI was able to predict EPE correctly in 568 (52%) cases. A model including PSA, maximum diameter of the index lesion, presence of EPE on MRI, highest ISUP grade in the ipsilateral hemi-prostate, and percentage of positive cores in the ipsilateral hemi-prostate achieved an AUC of 81% after internal validation. Overall, 566, 577, and 2,026 observations fell in the low-, intermediate- and high-risk groups for EPE, as identified by the regression tree. The EPE rate across the groups was: 5.1%, 14.9%, and 48% for the low-, intermediate- and high-risk group, respectively.

CONCLUSION

In this study we present an update of the first side-specific MRI-based nomogram for the prediction of extraprostatic extension together with updated risk categories to help clinicians in deciding on the best approach to nerve-preservation.

Effect of a Modified Technique of Posterior Reconstruction by Iliopectineal Ligament Suspension During Robot-assisted Laparoscopic Radical Prostatectomy on Early Continence: A Randomised Controlled Trial

OBJECTIVE

To evaluate the effect of a modified technique of posterior reconstruction by iliopectineal ligament suspension during robot-assisted radical prostatectomy (RARP) on recovery of early continence.

METHODS

A prospective, single surgeon, single centre, randomised controlled trial was performed from August 2018 to March 2020 with 171 patients (92 control vs 79 experimental). The posterior reconstruction was done using a standard technique in the control group and was modified for the experimental group by incorporating not only the "Rocco" stitch between Denonvilliers' fascia and the rhabdosphincter but also the iliopectineal ligaments bilaterally to further improve posterior support with this suspensory 'hammock'. Both groups of patients were followed for a year with questionnaires and 24-hour pad tests.

RESULTS

Both groups were comparable in terms of baseline demographic, clinical, and pathological characteristics. With regards to recovery of urinary continence, no statistically significant differences were found for socially continent (0-1 pads per day) or fully continent (0 pads per day) rates at all time points examined (1, 3, 6, 12 months). Moreover, there were no statistically significant differences between the groups for presence of urinary symptoms, bowel symptoms, sexual function, and hormonal symptoms.

CONCLUSION

The modified technique of posterior reconstruction by iliopectineal ligament suspension is not associated with improved early continence as compared to the standard posterior reconstruction technique during RARP. Future studies may want to explore other variations of suspensory sutures that could strengthen posterior urethral support to achieve earlier recovery of continence.

Lower Detrusor Apron-sparing Robot-assisted Radical Cystectomy and Intracorporeal Neobladder Reconstruction: Technique and Preliminary Outcomes

BACKGROUND

Prior studies on robot-assisted laparoscopic prostatectomy (RALP) have shown that preservation of the anterior periprostatic structures is associated with good functional outcomes in terms of urinary continence and erectile function. With this in mind, we developed a technique for preservation of the lower part of the detrusor apron (LDA) and anterior periprostatic structures at the time of robot-assisted radical cystectomy (RARC) and intracorporeal neobladder (ICNB) reconstruction.

OBJECTIVE

To describe our LDA-sparing RARC technique and to assess its safety and outcomes.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively evaluated 11 patients who underwent LDA-sparing RARC and ICNB reconstruction at our centre from January 2017 to May 2021.

SURGICAL PROCEDURE

In brief, after developing the plane posterior to the bladder and prostate, the dissection proceeds laterally on both sides of the prostate in an effort to identify the prostatic pedicle. At this point, the bladder pedicles are sectioned in an antegrade fashion. Once the prostate is reached, the dissection is continued laterally by developing the plane that was previously identified. The neurovascular bundles and the lateral and anterior periprostatic structures are conserved in toto. Neobladder reconstruction is performed intracorporeally.

OUTCOME MEASUREMENTS

Postoperative complications, urinary continence (UC), and erectile function (EF).

RESULTS AND LIMITATIONS

The median console time was 290 min. The 30-d complication rate was 36%, with two Clavien-Dindo grade II and two grade III complications that were not attributable to the novel surgical technique. At 12 mo, all patients reported daytime UC or use of a safety pad; at night, seven patients were continent or used a safety pad. Regarding 12-mo EF, four patients were potent without a need for medications, while six were potent with the use of oral phosphodiesterase type 5 inhibitors and one with the use of intracavernosal injections. Limitations include the small number of cases.

CONCLUSIONS

LDA-sparing RARC is an applicable and reproducible procedure. Our results suggest that this approach is associated with good functional outcomes in terms of UC and EF.

PATIENT SUMMARY

We describe a novel approach for robot-assisted removal of the bladder that allows greater preservation of nerve bundles and other structures. Our study shows that the technique is safe and associated with good outcomes for urinary function and erectile function for patients eligible for this surgical procedure.

The BETTY Score to Predict Perioperative Outcomes in Surgical Patients

The aim of this study is to evaluate a new user-friendly scoring system, namely the BETTY score, that aims to predict 30-day patient outcomes after surgery. In this first description, we rely on a population of prostate cancer patients undergoing robot-assisted radical prostatectomy. The BETTY score includes the patient's American Society of Anesthesiologists score, the body mass index, and intraoperative data, including operative time, estimated blood loss, any major intraoperative complications, hemodynamic, and/or respiratory instability. There is an inverse relationship between the score and severity. Three clusters assessing the risk of postoperative events were defined: low, intermediate, and high risk of postoperative events. A total of 297 patients was included. The median length of hospital stay was 1 day (IQR1-2). Unplanned visits, readmissions, any complications, and serious complications occurred in 17.2%, 11.8%, 28.3%, and 5% of cases, respectively. We found a statistically significant correlation between the BETTY score and all endpoints analyzed (all p ≤ 0.01). A total of 275, 20, and 2 patients were classified as low-, intermediate-, and high-risk according to the BETTY scoring system, respectively. Compared with low-risk patients, patients at intermediate-risk were associated with worse outcomes for all endpoints analyzed (all p ≤ 0.04). Future studies, in various surgical subspecialties, are ongoing to confirm the usefulness of this easy-to-use score in routine.

Can the prophylactic administration of tranexamic acid reduce the blood loss after robotic-assisted radical prostatectomy? Robotic Assisted Radical Prostatectomy with tranEXamic acid (RARPEX): study protocol for a randomized controlled trial

Background

The prophylactic administration of tranexamic acid reduces blood loss during procedures at high risk of perioperative bleeding. Several studies in cardiac surgery and orthopedics confirmed this finding. The aim of this prospective, double-blind, randomized study is to evaluate the effect of tranexamic acid on peri-and postoperative blood loss and on the incidence and severity of complications.

Methods/design

Based on the results of our pilot study, we decided to conduct this prospective, double-blind, randomized trial to confirm the preliminary data. The primary endpoint is to analyze the effect of tranexamic acid on perioperative and postoperative blood loss (decrease in hemoglobin levels) in robotic-assisted radical prostatectomy. The additional endpoint is to analyze the effect of tranexamic acid on postoperative complications and confirm the safety of tranexamic acid in robotic-assisted radical prostatectomy.

Discussion

No study to date has tested the prophylactic administration of tranexamic acid at the beginning of robotic-assisted radical prostatectomy. This study is designed to answer the question of whether the administration of tranexamic acid might lower the blood loss after the procedure or increase the rate and severity of complications.

Trial registration

ClinicalTrials.gov NCT04319614. Registered on 25 March 2020

The Role of 3D Models Obtained from Multiparametric Prostate MRI in Performing Robotic Prostatectomy

BACKGROUND

mpMRI can provide important information for surgical planning, yet its interpretation is not immediate and imaging consultation at the time of surgery can result in interruptions and delay. The use of 3D models based on mpMRI, might obviate these issues. We aimed to evaluate the role of the prospective integration of 3D models from mpMRI in the robotic console in reducing the rate of PSMs.

MATERIAL AND METHODS

PSMs at our center are evaluated intraoperatively using the NeuroSAFE method. Based on the rate of PSMs on frozen section during the year prior to the implementation of 3D models during surgery (22.5%), we estimated that 151 subjects were needed to detect a statistically significant difference of at least 40%. Patients with biopsy-proven PCa who received a 3T mpMRI at our institution and had a PIRADS≥3 on mpMRI were included.

RESULTS

151 patients were included. Overall, 17(11.3%) patients had a PSM, 6(35%) of them had PSM in an area where the mpMRI did not demonstrate any lesions. The rates of PSMs on both frozen (22.5 vs. 11.3%) and permanent section (13.1 vs. 6.6%) were significantly lower (p≤0.03) compared to the cohort of patients operated during 2018(n=358). No significant differences among clinical characteristics were found between the study cohort and the 2018 cohort (all p>0.05).

CONCLUSIONS

The use of 3D models at the time of surgery was shown to reduce the PSM rate on both frozen and permanent section. Integrating 3D models in the robotic console could lead to improved PCa outcomes.

Robot-Assisted Laparoscopic Radical Prostatectomy 6 Months After Rectal Spacer Hydrogel Injection

Background: SpaceOAR (organ at risk) hydrogel is a hydrogel matrix injected into the perirectal space posterior to the prostate for the purpose of mitigating radiation dose (and hence side effects of radiation) on the rectum. Manufacturer descriptions state that this material is reabsorbed 3 to 6 months after injection. Case Discussion: We encountered a 75-year old male patient who underwent SpaceOAR injection in anticipation for primary external beam radiation treatment for intermediate risk prostate cancer (Gleason score 7 = 4 + 3, prostate specific Antigen [PSA] = 2.32, cT2a). After initiation of androgen deprivation, but before radiotherapy, the patient decided to no longer undergo radiation but rather elected to proceed with surgery. Based on the presence of the SpaceOAR, we delayed his surgery to 6 months after SpaceOAR injection to allow for absorption of the material. A preoperative MRI showed persistent hydrogel matrix in the perirectal space. We performed a robotic radical prostatectomy effectively despite the persistent SpaceOAR hydrogel by modifying our dissection closer to the prostate posteriorly. Conclusion: SpaceOAR hydrogel may alter patient anatomy even 6 months after deployment, however, robotic prostatectomy would be feasible with proper knowledge of anatomy and by following the proper dissection planes above the perirectal space.

The importance of anatomical reconstruction for continence recovery after robot assisted radical prostatectomy: a systematic review and pooled analysis from referral centers

INTRODUCTION

Urinary incontinence is one of the most scared sequelae of robot assisted radical prostatectomy (RARP). Therefore, different surgical modifications, aimed to restore the original anatomy, were proposed to overcome this issue. The purpose of this study is to assess which is the best reconstruction technique (posterior only: PR; anterior only: AR; total: TR) compared to the standard approach for continence recovery after RARP in a tertiary care center.

EVIDENCE ACQUISITION

After establishing an a priori protocol, a systematic electronic literature search was conducted in May 2019. The article selection proceeded in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and was registered (PROSPERO registry number 131667). The risk of bias and the quality assessment of the included studies were performed. Simple pooled analysis was performed for continence rates according to the definition of continence (0 pad vs. 0-1 pad) and the different types of reconstruction at 1, 4, 12, 24, 52 weeks after RARP. Complication rate, operative and console time and estimated blood loss were pooled. Two-side test of proportion and T-test were used to compare rates and mean, respectively.

EVIDENCE SYNTHESIS

Six studies meeting the inclusion criteria were found and included in the analysis. All the included studies were of "poor" or "good" quality. A high or moderate risk of bias was recorded. TR showed higher continence recovery rates, compared to their anterior reconstruction counterpart at 1, 4, 12, 24, 52 weeks (P<0.001 at all time-points). At 12 weeks TR showed the highest continence rates (P<0.001), followed by AR and PR. No statistically significant differences were recorded regarding anastomosis-related complication rates (anastomosis stricture P=0.08; urine leakage P=0.1).

CONCLUSIONS

In patients undergoing RARP, TR facilitates a faster and higher continence recovery compared to standard approach or PR or AR only.

Anatomical robotic prostatectomy: technical factors to achieve superb continence and erectile function

Debate continues as to the superiority of robotic versus open radical prostatectomy for the surgical treatment of localized prostate cancer. Despite this controversy, retrospective data from high volume centres has demonstrated RARP is associated with improved pentafecta outcomes with lower transfusion rates, less incontinence, lower positive surgical margins and improved potency. Advocates of robotic assisted radical prostatectomy (RARP) believe an enhanced visual field, the precision afforded by robotic technology as well as lack of bleeding, sharp dissection and delicate tissue handling lead to improved outcomes. Prostate Cancer is the second most common cancer diagnosed in men, and as the number of post-surgical patients increases, the complications of urinary incontinence and erectile dysfunction not only have a significant negative impact on patients' quality of life, but have become an expanding part of clinical practice. This article outlines what are believed to be the most important strategies based on anatomical knowledge and technical expertise, that allow robotic prostatectomists to achieve superb outcomes in urinary and erectile function.