Robotic vs. Retropubic radical prostatectomy in prostate cancer: A systematic review and an meta-analysis update

The impact of the Ontario quality-based procedures funding model on radical prostatectomy outcomes

INTRODUCTION

In 2015, radical prostatectomy (RP) in Ontario transitioned to the quality-based procedures (QBP) funding model, which assigns disbursement from surgical quality indicator (QI) outcome performance. The objective of this study was to assess the QBP QI outcomes before and after implementation of the QBP funding model for RP, and to determine whether changes seen were attributable to the QBP model.

METHODS

We conducted a population-based, retrospective cohort study including all men who underwent RP for prostate cancer in Ontario from 2010-2019. We used administrative data from Ontario's health databases to gather surgical and QI outcome data. Our primary outcomes were the five measurable QBP QIs outlined by the province. We performed a pre- and post-intervention comparison, in addition to an interrupted-time series (ITS) analysis.

RESULTS

Two of the five QIs improved after implementation of the QBP model (complication rate: 11.89% vs. 9.96%, p<0.001; proportion meeting length of stay target: 78.11% vs. 86.84%, p<0.001). ITS analysis revealed that there was no difference in trend in either outcome between pre- and post-implementation periods (p=0.913 and p=0.249, respectively). Two QIs were worse in the post-implementation period (unplanned visit rate: 23.45% vs. 25%, p=0.015; proportion meeting Wait 2 target: 94.39% vs. 92.88%, p<0.001). ITS revealed no significant trend changes post-implementation (p=0.260 and p=0.272, respectively). There was no difference in re-operation rate (2.84% vs. 2.45%, p=0.107).

CONCLUSIONS

The QBP model for RP corresponds with mixed QI changes, but further analysis suggests that these changes were pre-existing trends and not attributable to the model.

Intelligent medicine in focus: the 5 stages of evolution in robot-assisted surgery for prostate cancer in the past 20 years and future implications

Robot-assisted surgery has evolved into a crucial treatment for prostate cancer (PCa). However, from its appearance to today, brain-computer interface, virtual reality, and metaverse have revolutionized the field of robot-assisted surgery for PCa, presenting both opportunities and challenges. Especially in the context of contemporary big data and precision medicine, facing the heterogeneity of PCa and the complexity of clinical problems, it still needs to be continuously upgraded and improved. Keeping this in mind, this article summarized the 5 stages of the historical development of robot-assisted surgery for PCa, encompassing the stages of emergence, promotion, development, maturity, and intelligence. Initially, safety concerns were paramount, but subsequent research and engineering advancements have focused on enhancing device efficacy, surgical technology, and achieving precise multi modal treatment. The dominance of da Vinci robot-assisted surgical system has seen this evolution intimately tied to its successive versions. In the future, robot-assisted surgery for PCa will move towards intelligence, promising improved patient outcomes and personalized therapy, alongside formidable challenges. To guide future development, we propose 10 significant prospects spanning clinical, research, engineering, materials, social, and economic domains, envisioning a future era of artificial intelligence in the surgical treatment of PCa.

Comparing the lifespan of virgin artificial urinary sphincters in radiated patients: transcorporal vs. standard placement

PURPOSE

To compare the lifespan of first transcorporal cuff (TC) placement of an artificial urinary sphincter (AUS) versus standard placement (SP) in patients with prior radiotherapy (RT) for prostate cancer (PCa).

METHODS

We reviewed first (virgin) AUS placements from two high-volume care centers between 1/2011 and 1/2021, including PCa patients with RT history. AUS lifespan was assessed via the hazard ratio of device explantation and/or revision within a ten-year timeframe for the TC vs. SP approaches. Chi-square, Fisher's exact, and t-tests compared clinicodemographic variables. Kaplan-Meier curve compared TC and SP lifespan.

RESULTS

85/314 men with AUS met inclusion criteria, with 38.8% (33/85) in the TC group and 61.2% (52/85) in the SP group. Median ages were 69.8 (IQR = 65.2-73.6) and 67.1 (61.6-72.9), respectively, p = 0.17. Over a median follow up of 51.9 (15.8-86.1) and 80.4 (28.1-128.3) months for the TC and SP, overall, 12 (36.4%) TC devices were removed (four [12.1%] due to mechanical failures; eight [24.2%] erosions, and two [6.1%] infections) vs. 29 (55.8%) in the SP group (14 [26.9%] mechanical failures; 11 [21.1%] erosions, and five [9.6%] infections). No statistically significant differences were observed between the two approaches, with HR = 0.717, 95% CI 0.37-1.44, p = 0.35. The calculated device survival probabilities for the TC vs. SP at one, five, and 10 years were 78.8% vs. 76.9%, 69.3% vs. 58.7%, and 62.1% vs. 46.7%, respectively.

CONCLUSIONS

TC cuff insertion for the first AUS implantation in pre-radiated patients showed to be comparable to SP when it comes to device survival, with comparable complication rates. Current guidance for approach selection is primarily based on patient selection and surgeon preference.

Robot-assisted versus open radical prostatectomy: a systematic review and meta-analysis of prospective studies

The study aims to synthesize all available prospective comparative studies and reports the latest systematic analysis and updated evidence comparing robot-assisted radical prostatectomy (RARP) with open radical prostatectomy (ORP) for perioperative, functional, and oncological outcomes in patients with clinically localized prostate cancer (PCa). PubMed, Embase, Web of Science, and the Cochrane Library were retrieved up to March 2023. Only randomized controlled trials (RCTs) and prospective comparative studies were included, and weighted mean differences (WMD) and odds ratios (OR) were used to evaluate the pooled results. Twenty-one articles were included in the present meta-analysis. The results indicated that compared to ORP, RARP had longer operative time (OT) (WMD: 51.41 min; 95%CI: 28.33, 74.48; p < 0.0001), reduced blood loss (WMD: -516.59 mL; 95%CI: -578.31, -454.88; p < 0.00001), decreased transfusion rate (OR: 0.23; 95%CI: 0.18, 0.30; p < 0.00001), shorter hospital stay (WMD: -1.59 days; 95%CI: -2.69, -0.49; p = 0.005), fewer overall complications (OR: 0.61; 95%CI: 0.45, 0.83; p = 0.001), and higher nerve sparing rate (OR: 1.64; 95%CI: 1.26, 2.13; p = 0.0003), as well as was more beneficial to postoperative erectile function recovery and biochemical recurrence (BCR). However, no significant disparities were noted in major complications, postoperative urinary continence recovery, or positive surgical margin (PSM) rates. RARP was superior to ORP in terms of hospital stay, blood loss, transfusion rate, complications, nerve sparing, postoperative erectile function recovery, and BCR. It is a safe and effective surgical approach to the treatment of clinically localized PCa.

A comparative evaluation of radical prostatectomy using laparoscopic and open method in view of surgical margins

Introduction

A positive surgical margin (PSM) in the radical prostatectomy (RP) specimen is associated with biochemical recurrence (BCR) and the need for adjuvant radiation therapy, and is an analysis of surgical procedure quality. We present data describing the identification, anatomy, and management of PSM after RP performed via an open operation and laparoscopically. The aim of the study was to compare assessment of RP (open vs. laparoscopic) in terms of analysis of PSM in postoperative histopathological tissue.

Material and methods

Patients with pT1 to pT3b prostate cancer with detailed surgical margin parameters and BCR status were analysed. The patients were divided into groups depending on the stage of neoplastic disease and the choice of operative procedure.

Results

In total, we obtained data from 140 PC patients. Positive surgical margins were confirmed in 11 cases treated with open surgery and in 7 cases treated with laparoscopic procedure. There was no statistically significant (p >0.05) relationship between the frequency of positive margins and the type of procedure. There was no statistically significant (p >0.05) relationship between the frequency of positive margins and the type of procedure in subgroups according to the Gleason score. There was a statistically significant (p <0.05) relationship between the clinical stage of the tumor and the type of margin. This particularly refers to tumours with stage T3b (more numerous in the group of open surgeries) and T2c (more numerous in the laparoscopic group).

Conclusions

There was no statistically significant correlation between the type of surgery and the incidence of a positive surgical margin.

Effect of fast-track surgery on postoperative wound pain in patients with prostate cancer: A meta-analysis

Fast track surgery (FTS) is widely used in many procedures and has been shown to reduce complications and accelerate recovery. However, no studies have been conducted to assess their effectiveness in treating wounds after radical prostatectomy (RP). The objective of this study was to evaluate the impact of FTS on RP. We went through 4 major databases. A study was conducted by PubMed, the Cochrane Library, Embase, and the Web of Science to determine the effect of comparison of FTS versus conventional surgery in RP on postoperative wound complications as of 1 July 2023. Based on the review of literature, data extraction and literature quality assessment, we conducted meta-analyses with RevMan 5.3. In the course of the study, the researchers selected 6 of the 404 studies to be analysed according to exclusion criteria. Data analysis showed that the FTS method reduced the postoperative pain associated with VAS and also decreased the rate of postoperative complications in post-surgical patients. However, there was no significant difference between FTS and conventional surgery in terms of blood loss, operation time, and postoperative infection rate. Therefore, generally speaking, FTS has less impact on postoperative complications in patients with minimal invasive prostatic cancer, but it does reduce postoperative pain and total postoperative complications.

Do Swiss urologists and Swiss internists screen themselves and their relatives for prostate cancer? A questionnaire study

PURPOSE

Prostate-specific antigen (PSA) screening for men at risk of prostate cancer is controversial. The current recommendation is to raise awareness of prostate cancer and offer PSA screening in accordance with shared decision- making. Whether the possibility of a PSA screen is discussed with the patient depends on the treating physician, but data on physicians' attitudes towards PSA screening are scarce. This study aimed to examine internists' and urologists' personal PSA screening activity as an indicator of their attitude towards PSA screening.

MATERIALS AND METHODS

Members of the Swiss Society of Urology and the Swiss Society of General Internal Medicine were asked in 08/2020 to anonymously complete an online survey about personal PSA screening behaviour for themselves, their fathers, brothers and partners. Categorical and continuous variables were compared by chi-squared tests and t-tests, respectively.

RESULTS

In total, 190/295 (response rate: 64%) urologists and 893/7400 (response rate: 12%) internists participated in the survey. Of the participants, 297/1083 (27.4%) were female. Male urologists >50 years of age screened themselves more often than male internists >50 years of age (89% vs 70%, p <0.05). Furthermore, urologists reported recommending screening statistically significantly more often than internists to their brother, father or partner regardless of their sex (men: 38.1% vs 18.5%; p <0.05; women: 81.8% vs 32.2%; p <0.05).   CONCLUSIONS: Most participating male physicians >50 years of age have screened themselves for prostate cancer. Furthermore, PSA screening of relatives was significantly associated with the urology specialty. The reasons physicians screen themselves substantially more often than the public and why male and female urologists as well as male internists perform PSA screening more frequently in their private environment than female internists should be further examined.

Robotic surgery in comparison to the open and laparoscopic approaches in the field of urology: a systematic review

To establish the feasibility of robotic surgical procedures in urology in terms of the applications, merits, and demerits as well as the postoperative and oncological outcomes while comparing it with the conventional approaches. A systematic search of electronic databases was performed to identify Randomized Controlled Trials and Cohort studies on Robot-Assisted urological surgical procedures in comparison with the conventional methods. The quality assessment of included studies was performed using the Newcastle-Ottawa Scale and the revised Cochrane "Risk of Bias" tool. A qualitative narrative synthesis of the data extracted from the studies was performed and presented in tabulated form. After screening, 39 studies were included in our review (7 Randomized Controlled Trials and 32 Cohort studies). Robot-Assisted Prostatectomy appears to be associated with lower estimated blood loss and shorter length of hospital stay. For Robot-Assisted Cystectomy, the results suggest longer operative time and fewer complications. Robot-Assisted Radical Nephrectomy was found to be associated with fewer perioperative complications and longer mean operative time while Robot-Assisted Partial Nephrectomy was associated with less positive surgical margins and reduced need for postoperative analgesia. The mean operative time was longer while the length of stay was shorter for the robotic approach in inguinal lymphadenectomy and ureteral reimplantation. The feasibility of Robot-Assisted surgery varied for different outcome measures as well as for different procedures. Some common advantages were a shorter length of stay, lesser blood loss, and fewer complications while the drawbacks included longer operative time.Study protocol PROSPERO database (Registration Number: CRD42021256623).

A Matched-Pair Analysis after Robotic and Retropubic Radical Prostatectomy: A New Definition of Continence and the Impact of Different Surgical Techniques

Background: Radical prostatectomy is considered the gold-standard treatment for patients with localized prostate cancer. The literature suggests there is no difference in oncological and functional outcomes between robotic-assisted radical prostatectomy (RARP) and open (RRP). (2) Methods: The aim of this study was to compare continence recovery rates after RARP and RRP measured with 24 h pad weights and the International Consultation on Incontinence Questionnaire—Short Form (ICIQ-SF). After matching the population (1:1), 482 met the inclusion criteria, 241 patients per group. Continent patients with a 24 h pad test showing <20 g of urinary leakage were considered, despite severe incontinence, and categorized as having >200 g of urinary leakage. (3) Results: There was no difference between preoperative data. As for urinary continence (UC) and incontinence (UI) rates, RARP performed significantly better than RRP based on objective and subjective results at all evaluations. Univariable and multivariable Cox Regression Analysis pointed out that the only significant predictors of continence rates were the bilateral nerve sparing technique (1.25 (CI 1.02,1.54), p = 0.03) and the robotic surgical approach (1.42 (CI 1.18,1.69) p ≤ 0.001). (4) Conclusions: The literature reports different incidences of UC depending on assessment and definition of continence “without pads” or “social continence” based on number of used pads per day. In this, our first evaluation, the advantage of objective measurement through the weight of the 24 h and subjective measurement with the ICIQ-SF questionnaire best demonstrates the difference between the two surgical techniques by enhancing the use of robotic surgery over traditional surgery.

Evaluation of Biochemical Recurrence and Correlation with Various Parameters After Robotic-Assisted Radical Prostatectomy: a Single Center Experience

Introduction

Biochemical recurrence (BCR) is widely used as an early end point to assess treatment success and frequently prompts the initiation of secondary therapy after radical prostatectomy. We conducted an observational, ambispective study to evaluate BCR after robotic-assisted radical prostatectomy (RARP) for clinically localized prostate cancer. We also analyzed correlation of BCR with pre-operative PSA level, D'Amico classification, pathological stage, post-operative GS, and positive surgical margins after RARP.

Material and Methods

A total of 90 patients with clinically localized carcinoma prostate (≤ T 2), who underwent RARP between April 2012 and April 2017 at our institute with 3 year of minimum follow-up were included in our study. Patients having locally advanced disease on clinical staging or died of unrelated cause in follow up or lost to follow up were excluded from study. Patients who had persistent detectable PSA (> 0.20 ng/ml) at 6 week with a second confirmatory level of PSA greater than 0.2 ng/ml at 3rd month were excluded from study.

Results

The age of the patient ranges from 46 to 79 years with the mean age of 65.36 ± 6.55 years. The mean PSA was 24.36 ± 26.68 ng/ml with range between 1.8 and 126.6 ng/ml. Nine patients (10%) developed BCR at 1-year follow-up and 81 patients were BCR-free. Thus, 1-year BCRFS and BCR rate were 90% and 10%, respectively in our study. Total 17 patients (18.9%) developed BCR during a 2-year period and 73 patients were free of BCR. Thus, 2-year BCRFS and BCR rate were 81.1% and 18.9%, respectively. A total of 29 patients (32.2%) had BCR and 61 patients were free of BCR at 3 years of follow-up. Thus, overall 3-year BCR rate and 3-year BCRFS rate were 32.2% and 67.8%, respectively. There was significant correlation of BCR with pre-operative PSA level, D'Amico classification, pathological stage, post-operative GS, and positive surgical margins.

Conclusions

There is relative paucity of data regarding the BCR rate after RARP in the Indian scenario. The BCR rate in our study was similar to previously published Western and limited Indian data on RARP series in localized prostate cancer. There was significant correlation of BCR with PSA, post-operative GS, pathological stage, PSM, and D'Amico classification.

Prostate cancer: understanding patients' treatment options

Prostate cancer is the most common cancer among men in the UK. It is a disease with no specific preventable risk factors, no specific signs and symptoms, and a significant health burden. This article explains the various treatment options available for patients with prostate cancer, with the aim of assisting nurses in supporting person-centred decision-making. It also discusses the risk factors, signs and symptoms, diagnosis, staging, grading and risk stratification of prostate cancer.

Comparison of surgical approaches to radical prostatectomy in our series beyond oncological and functional outcomes

OBJECTIVES

To evaluate the outcomes of robot-assisted radical prostatectomy (RARP) compared to those of open (ORP) and laparoscopic (LRP) surgery. The interest lies fundamentally in the quality-of-life (QoL) evaluation, postoperative recovery, and personal satisfaction of patients with the intervention (PS) beyond oncological and functional outcomes.

METHODS

Six hundred eighty-five RPs were performed in our center between 2011-2018 (17,8% ORP, 22,2% LRP and 60% RARP). Patients were prospectively assessed through follow-up until April 2020 and a multiple questionnaire at 12-months post-RP that included ICIQ-SF, SHIM, IPSS, IQL and questions about pain, postoperative recovery and PS. Also baseline and postoperative patient- and treatment-related data were collected, and binomial logistic regressions were performed for the 1 vs.1 comparisons (ORP vs. RARP and LRP vs. RARP).

RESULTS

RARP patients have overall fewer comorbidities, less tumor aggressiveness, more operative time requirements and more positive surgical margins than ORP and LRP patients. Nevertheless, RARP outperforms ORP in: hospital stay (days) (OR 0,86; 95% CI: 0,80-0,94), hemoglobin loss (OR 0,38; 95% CI: 0,30-0,47), transfusion rate (OR 0,18; 95% CI: 0,09-0,34), early complications (p = 0,001), IQL (OR 0,82; 95% CI: 0,69-0,98), erectile function (OR 0,41; 95% CI: 0,21-0,79), pain control (OR 0,82; 95% CI: 0,75-0,89), postoperative recovery (p < 0,001) and choice of a different approach (OR 5,55; 95% CI: 3,14-9,80). RARP is superior to LRP in: urinary continence (OR 0,55; 95% CI: 0,37-0,82), IPSS (OR 0,96; 95% CI: 0,93-0,98), IQL (OR 0,76; 95% CI: 0,66-0,88), erectile function (OR 0,52; 95% CI: 0,29-0,93), postoperative recovery (p = 0,02 and 0,004), PS (p = 0,005; 0,002; and 0,03) and choice of a different approach (OR 7,79; 95% CI: 4,63-13,13).

CONCLUSIONS

The findings of our study globally endorse a positive effectiveness of RARP over ORP and/or LRP, both on functional issues, postoperative recovery, QoL and PS. Oncologic results should still be improved.

The AdVance Sling and Male Sexual Function: A Prospective Analysis on the Impact of Pelvic Mesh on Erectile and Orgasmic Domains in Sexually Active Men With Postprostatectomy Stress Urinary Incontinence

Background

Transvaginal pelvic mesh surgery has been shown to cause female sexual dysfunction.

Aim

To evaluate the sexual function impact of AdVance male sling (MS) on erectile and orgasmic domains.

Methods

A review of a prospectively collected database was conducted in all sexually active men who underwent AdVance MS for postprostatectomy stress urinary incontinence between 2012 and 2018.

Outcomes

Patient demographics, clinical outcomes, and validated questionnaires such as the Brief Male Sexual Function Inventory (BMSFI), International Index of Erectile Function (IIEF) and Patient Global Impression of Improvement (PGI-I) were reviewed at 6, 12 and 24 months.

Results

Of the total of 65 men who received AdVance sling, an increase in IIEF-5 score ≥5 points were reported in 10 (15%) patients with no patients complained of deteriorating erectile function at 24 months. The improvement in orgasmic function (Question 10 on IIEF-15) was reported in 22 (34%) patients while 3 (5%) patients reported lower orgasmic scores. The sexual domains scores in BMSFI were higher in 40 (62%) patients, especially with regards to sexual desire (Question 1 and 2) and satisfaction with sex life (Question 11). No patient reports pelvic or urethral pain. The reported improvement in erectile and orgasm scores remained similar throughout the 24-months follow-up period. All 20 patients with preoperative climacturia reported resolution of their symptoms during sexual activity. The overall PGI-I was 1.4 (1–3) and men with a higher continence rate were more likely to report better male sexual function (P = .044).

Clinical implications

AdVance MS appears to improve erectile and orgasmic domains, and there is a positive correlation between urinary continence and male sexual function.

Strengths and limitations

Strengths of this study include the prospective large patient population analyzed regarding the impact of MS on male sexual function with the use of validated instruments for erectile, orgasmic, and urinary domains. Limitations include single-centre data, relatively short-term follow-up study and lack of a comparative arm.

Conclusion

Despite the reported adverse effect of sexual dysfunction following pelvic mesh in the female population, the AdVance PMS appears to improve male sexual function with regards to erectile and orgasm domains.

Chung E, Wang J. The AdVance Sling and Male Sexual Function: A Prospective Analysis on the Impact of Pelvic Mesh on Erectile and Orgasmic Domains in Sexually Active Men With Postprostatectomy Stress Urinary Incontinence. Sex Med 2022;10:100529.

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.

Robot-Assisted Minimally Invasive Breast Surgery: Recent Evidence with Comparative Clinical Outcomes

In recent times, robot-assisted surgery has been prominently gaining pace to minimize overall postsurgical complications with minimal traumatization, due to technical advancements in telerobotics and ergonomics. The aim of this review is to explore the efficiency of robot-assisted systems for executing breast surgeries, including microsurgeries, direct-to-implant breast reconstruction, deep inferior epigastric perforators-based surgery, latissimus dorsi breast reconstruction, and nipple-sparing mastectomy. Robot-assisted surgery systems are efficient due to 3D-based visualization, dexterity, and range of motion while executing breast surgery. The review describes the comparative efficiency of robot-assisted surgery in relation to conventional or open surgery, in terms of clinical outcomes, morbidity rates, and overall postsurgical complication rates. Potential cost-effective barriers and technical skills were also delineated as the major limitations associated with these systems in the clinical sector. Furthermore, instrument articulation of robot-assisted surgical systems (for example, da Vinci systems) can enable high accuracy and precision surgery due to its promising ability to mitigate tremors at the time of surgery, and shortened learning curve, making it more beneficial than other open surgery procedures.

The prognostic nutritional index predicts the biochemical recurrence of patients treated with robot-assisted laparoscopic radical prostatectomy

OBJECTIVE

To evaluate the prognostic nutritional index (PNI) in predicting the biochemical recurrence (BCR) of patients treated with robot-assisted laparoscopic radical prostatectomy (RALP).

METHODS

The clinical data of 136 patients treated with RALP in the Department of Urology, The Third Xiangya Hospital of Central South University were retrospectively analyzed. The endpoint of observation was BCR. The area under the receiver operating characteristic (ROC) curve was evaluated to determine the optimal cutoff value of PNI. The correlation of the PNI with BCR was estimated using Kaplan-Meier analysis and Cox proportional hazards model.

RESULTS

The optimal cutoff value of the PNI was 46.03 according to the ROC curve. (95% confidence interval: 0.604-0.805, Youden index = 0.401, sensitivity = 82.5%, specificity = 57.6%, p < 0.01). Multivariate Cox analysis showed that clinical staging, prostate-specific antigen, and PNI were independent prognostic factors for predicting BCR in patients treated with RALP.

CONCLUSION

PNI is an independent prognostic factor for predicting BCR in patients treated with RALP. The incorporation of the PNI into risk assessments may provide additional prognostic information.

Radical or Not-So-Radical Prostatectomy: Do Surgical Margins Matter?

Simple Summary

Prostate cancer is the second most common noncutaneous malignancy in men. Prostatectomy is a commonly used treatment modality for selected patients. The prostate’s ill-defined borders and its vicinity with vital structures complicate the wide excision of the organ, resulting in positive margins of resection. Neoplastic infiltration of margins of resection in prostatectomy specimens affects patients’ prognosis. The surgical technique and surgeons’ expertise affect the incidence of margin positivity. The location and the extent of positive margins diversify the risk of recurrence, with basal infiltration and multifocal foci of positive margins behaving more aggressively. Pathologists are encouraged to thoroughly report the status of margins of resection, as they provide important information for patients’ prognosis and enable the clinician to decide upon the most appropriate subsequent therapeutic steps.

Abstract

Prostate cancer is the second most common malignancy in men, and prostatectomy is the treatment of choice for most patients with at least low risk of progression. The presence of positive margins in the radical prostatectomy specimen is considered an adverse pathologic feature, and may prompt additional therapeutic intervention in the patients. The absence of a distinct capsule around the prostate and intraoperative manipulations that aim to minimize postoperative adverse effects, complicate its wide removal. Proper handling of the specimen during the gross processing is essential for accurate determination of the status of margins or resection. Positive margins, defined as the presence of neoplastic glands in the highlighted-with-ink margin of resection, range from 6–38%. The surgical technique, surgeon’s expertise and tumor (i.e., grade and stage) and patients’ (i.e., BMI) characteristics affect the rate of margin positivity. Extensive or multifocal and nonanterior/nonapical positive margins are linked with higher recurrence rates, especially in organ-confined disease, underscoring the need for treating these patients more aggressively. In summary, detailed description of the status of the margins should be performed in every pathology report to determine patients’ prognosis and the most appropriate therapeutic plan.

Combined Open Prostatectomy and Kidney Surgery: Feasibility and 12-Month Outcome

Purpose

There are only a few case reports and case series that investigated combined laparoscopic or robotic surgery for simultaneous prostate and kidney cancer. In this study, we want to close a gap in existing research to assess the feasibility and oncological outcome of combined open prostatectomy and kidney surgery.

Methods

We retrospectively analyzed patients who underwent a combined open prostatectomy and either a partial or complete nephrectomy from 2013 to 2020. Descriptive statistics were used to assess perioperative parameters and the 12-month functional and oncological outcomes after combined surgery.

Results

We identified 10 patients undergoing combined open surgery. Partial nephrectomy was performed in 4, radical nephrectomy in 6 patients. For prostate cancer, histopathological analysis showed a tumor stage ≥ pT2c in all 10 patients. For renal tumors, histopathological analysis showed clear cell renal cell carcinoma in 8 patients and oncocytoma in 2 patients. Operating time was 177 ± 36 minutes. Two perioperative complications (Clavien 2a and 3) were observed. Three months postoperatively, the International Index of Erectile Function (IIEF-5) score was 5.6 ± 5.9, the ICIQ-SF score was 7.3 ± 5.6 and were using 1.9 ± 2.2 pads per day. This improved after 12 months postoperatively, as patients had an IIEF-5 score of 6.33 ± 6.5, an ICIQ-SF score of 4.4 ± 5.7 and were using pads 0.9 ± 1.7 per day.

Conclusion

In this study, we showed that open surgery is a safe and valid approach for combined prostatectomy and renal surgery with acceptable complications and oncological outcomes. The combined open approach could be a good alternative to combined laparoscopic/robotic surgery in this field, especially to treat patients with advanced renal tumors or previous abdominal surgery or radiation.

Effects of enhanced recovery after surgery on robotic radical prostatectomy: a systematic review and meta-analysis

BACKGROUND

Enhanced recovery after surgery (ERAS) has been shown to be an effective, reliable and practical clinical nursing method to support operations on a range of physiological systems, but its effects on robotic radical prostatectomy (RRP) are still unclear. This study assesses the clinical effects of ERAS in RRP.

METHODS

Various databases including PubMed, EMBASE, Web of Science and China National Knowledge were searched for relevant studies, in particular full-text articles comparing ERAS groups and conventional groups for RRP. All included articles were subject to a quality assessment, and the data analysis was conducted with Review Manager (5.3). Forest plots, sensitivity analyses, and bias analyses were also prepared based on the included articles.

RESULTS

In total, 8 studies were identified that met the inclusion criteria. The results showed that ERAS groups exhibited significantly reduced time of flatus [mean difference (MD) =-0.58; 95% confidence interval (CI): -0.88, -0.29; P=0.0001], time of catheter removal (MD =-1.65; 95% CI: -2.15, -1.16; P<0.00001), and length of stay (LOS) (MD =-1.49; 95% CI: -2.65, -0.34; P=0.01), and there was no significant difference in terms of postoperative complications between ERAS groups and conventional groups (P=0.07).

DISCUSSION

This study provides further evidence that ERAS improves postoperative recovery in patients undergoing RRP through reduced time of first flatus, time of catheter removal and LOS. Given the limited quality and quantity of the articles included in this study, further work is needed to validate these findings.

Increased body mass index is associated with operative difficulty during robot‐assisted radical prostatectomy

Objective

This study aimed to identify factors associated with surgeon perception of robot‐assisted radical prostatectomy (RARP) difficulty.

Patients and Methods

This study surveyed surgeons performing RARP between 2017 and 2018 and asked them to rate operative conditions and difficulty as optimal, good, acceptable, or poor. These answers were stratified as optimal or suboptimal for this study. Associations between surgeon responses and variables hypothesized to affect surgical difficulty, including anatomic factors such as pelvic diameter and prostate volume:pelvic diameter ratio, were assessed.

Results

Between November 2017 and September 2018, a total of 100 patients were prospectively enrolled in the study of which 58 cases were rated as optimal and 42 were rated as suboptimal. Of the evaluated variables, only increasing clinical T stage (odds ratio [OR] 1.49, 95% confidence interval [CI] 1.03–2.15, p = 0.03) and increasing body mass index (BMI) (OR 1.14, 95% CI 1.03–1.26, p = 0.01) were associated with increased difficulty; 90‐day complication rates were similar between the optimal and suboptimal cohorts (17.3% vs. 23.8%, respectively; p = 0.5). The number of patients with previous surgery, pelvic diameter, and prostate size:pelvic diameter ratio were not significantly different between cohorts (p > 0.05 for all). Operative time (ρ = 0.23, p = 0.02) and estimated blood loss (EBL) (ρ = 0.38, p = 0.0001) were correlated with suboptimal difficulty.

Conclusion

The factors associated with surgeon‐reported RARP difficulty were patient BMI and clinical T stage among surgeons with significant RARP experience. These data should be incorporated into surgical decision making and patient counseling prior to performing a RARP.

Current Management of Post-radical Prostatectomy Urinary Incontinence

Prostate cancer is the second most common cancer in men worldwide. Radical prostatectomy and radiation beam therapy are the most common treatment options for localized prostate cancer and have different associated complications. The etiology of post prostatectomy incontinence is multifactorial. There is evidence in the literature that anatomic support and pelvic innervation are important factors in the etiology of post-prostatectomy incontinence. Among the many surgical and technical factors proposed in the literature, extensive dissection during surgery, damage to the neurovascular bundle and the development of postoperative fibrosis have a substantial negative impact on the continence status of men undergoing RP. Sparing of the bladder neck and anterior, and possibly posterior, fixation of the bladder-urethra anastomosis are associated with better continence rates. Overactive bladder syndrome (OAB) is multifactorial and the exact role of prostate surgery in the development of OAB is still under debate. There are several variables that could contribute to detrusor overactivity. Detrusor overactivity in patients after radical prostatectomy has been mainly attributed to a partial denervation of the bladder during surgery. However, together with bladder denervation, other hypotheses, such as the urethrovesical mechanism, have been described. Although there is conflicting evidence regarding the importance of conservative treatment after post-prostatectomy urinary incontinence, pelvic floor muscle training (PFMT) is still considered as the first treatment choice. Duloxetin, either alone or in combination with PFMT, may hasten recovery of urinary incontinence but is often associated with severe gastrointestinal and central nervous side effects. However, neither PFMT nor duloxetine may cure male stress urinary incontinence. The therapeutic decision and the chosen treatment option must be individualized for each patient according to clinical and social factors. During the recent years, the development of new therapeutic choices such as male sling techniques provided a more acceptable management pathway for less severe forms of urinary incontinence related to radical prostatectomy. Following this perspective, technological improvements and the emergence of new dedicated devices currently create the premises for a continuously positive evolution of clinical outcomes in this particular category of patients.

Cost-effectiveness analysis of robotic-assisted versus retropubic radical prostatectomy: a single cancer center experience

Prostate cancer (PCa) treatment has been greatly impacted by the robotic surgery. The economics literature about PCa is scarce. We aim to carry-out cost-effectiveness and cost-utility analyses of the robotic-assisted radical prostatectomy (RALP) using the "time-driven activity-based cost" methodology. Patients who underwent radical prostatectomy in 2013 were retrospectively analyzed in a cancer center over a 5-year period. Fifty-six patients underwent RALP and 149 patients underwent retropubic radical prostatectomy (RRP). The amounts were subject to a 5% discount as correction of monetary value considering time elapsed. Calculation of the Incremental Cost-Effectiveness Ratios (ICER) related to events avoided and the Incremental Cost-Utility Ratio (ICUR) related to "QALY saved" were performed. QALY was performed using values of utility and "disutility" weights from the "Cost-Effectiveness Analysis Registry". Hypothetical cohorts were simulated with 1000 patients in each group, based on the treatment outcomes. Total and average costs were R$1,903,671.93, and R$12,776.32 for the RRP group, and R$1,373,987.26, and R$24,535.49 for the RALP group, respectively. The costs to treat the hypothetical cohorts were R$10,010,582.35 for RRP, and R$19,224,195.90 for RALP. ICER calculation evidenced R$9,213,613.55 of difference between groups. ICUR was R$ 22,690.83 per QALY saved. Limitations were the lack of cost-effectiveness analyses related to re-hospitalization rates and complications, single center perspective, and currency-translation differences. Medical fees were not included. RALP showed advantages in cost-effectiveness and cost-utility over RRP in the long term. Despite the increased costs to the introduction of robotic technology, its adoption should be encouraged due to the gains.

Risks and complications of robot-assisted radical prostatectomy (RARP) in patients receiving antiplatelet and/or anticoagulant therapy: a retrospective cohort study in a single institute

The objective of the study was to evaluate the risk of bleeding complications in patients undergoing robot-assisted radical prostatectomy (RARP) while taking antiplatelet (AP) and/or anticoagulant (AC) agents. We analyzed the data of 334 patients undergoing RARP from May 2015 to May 2019. Patients were categorized into AP, AC, and control groups; the bleeding complications were compared among them. The end points were the estimated blood loss, decrease in hemoglobin level, and bleeding complications. The patient characteristics did not differ significantly among groups, with the exception of ASA scores, which were significantly higher in the AP and AC groups vs. the control group. The estimated blood loss and hemoglobin decrease were not significantly different between the AP and AC groups and the control group. The frequency of bleeding complications did not differ significantly between the AP and the control groups, but was significantly higher in the AC vs. the control group (4.3% in the AP and 23.5% in the AC group vs. 3.7% in the control group; P = 0.63 and P < 0.01, respectively). There was no significant difference in bleeding complications between the AP continuation (continuation of a single AP) and the AP interruption group or between the heparin bridging and the AC interruption group. All bleeding complications observed in the AC group occurred after resuming AC therapy. RARP can be performed safely with continuation of a single AP, and in patients taking ACs by interrupting these agents or via heparin bridging, without increasing intraoperative bleeding, whereas postoperative bleeding complications may increase after resuming ACs.

Surgeon heterogeneity significantly affects functional and oncological outcomes after radical prostatectomy in the Swedish LAPPRO trial

Objectives

To evaluate how surgeon heterogeneity – the variation in outcomes between individual surgeons – influences functional and oncological outcomes after robot‐assisted laparoscopic prostatectomy (RALP) and retropubic radical prostatectomy (RRP), and to assess whether surgeon heterogeneity affects the comparison between RALP and RRP.

Patients and Methods

Laparoscopic Prostatectomy Robot Open (LAPPRO) is a prospective, controlled, non‐randomized trial performed at 14 Swedish centres with 68 operating surgeons. A total of 4003 men with localized prostate cancer were enrolled between 2008 and 2011. The endpoints were urinary incontinence, erectile dysfunction (ED) and recurrence at 24 months after surgery. Logistic regression models were built to evaluate surgeon heterogeneity and, secondarily, surgeon‐specific factors were added to the models to investigate their influence on heterogeneity and the comparison between RALP and RRP.

Results

Among surgeons who performed at least 20 surgeries during the study period (n=25), we observed statistically significant heterogeneity for incontinence (P = 0.001), ED (P < 0.001) and rate of recurrent disease (P < 0.001). The significant heterogeneity remained when analysing only experienced surgeons with a stated experience of at least 250 radical prostatectomies (n=12). Among all participating surgeons (n=68), differences in surgeon volume explained 42% of the observed heterogeneity for incontinence (P = 0.003), 11% for ED (P = 0.03) and 19% for recurrence (P = 0.01). Taking surgeon volume into account when comparing RALP and RRP had a significant impact on the results. The effect was greatest for functional outcomes, and the additional adjustments for the surgeons' previous experience changed whether the difference between techniques was statistically significant or not. The surgeons’ annual volume had the greatest effect on the recurrence rate.

Conclusions

There was a large degree of heterogeneity among surgeons regarding both functional and oncological outcomes and this had a significant impact on the results when comparing RALP and RRP. Some of the observed heterogeneity was explained by differences in surgeon volume. Efforts to decrease heterogeneity are warranted and variation among surgeons must be accounted for when conducting comparative analyses between surgical techniques.

Risk of Recurrent Disease 6 Years After Open or Robotic-assisted Radical Prostatectomy in the Prospective Controlled Trial LAPPRO

Background

Conclusive evidence of superiority in oncological outcome for robot-assisted laparoscopic prostatectomy (RALP) over retropubic radical prostatectomy (RRP) is lacking.

Objective

To compare RALP and RRP regarding recurrent disease and to report the mortality rate 6 yr after surgery.

Design, setting, and participants

A total of 4003 men with localized prostate cancer were enrolled between 2008 and 2011 in Laparoscopic Prostatectomy Robot Open (LAPPRO)— a prospective, controlled, nonrandomized trial performed at 14 Swedish centers.

Outcome measurements and statistical analysis

Data were collected at visits and by patient questionnaires at 3, 12, and 24 mo, and through a structured telephone interview at 6 yr. Cause of death was retrieved from the National Cause of Death Register in Sweden. The modified Poisson regression approach was used for analyses.

Results and limitations

After adjustment for patient-, tumor-, and surgeon-related confounders, no statistically significant difference was observed between RALP and RRP in biochemical recurrence rate (14 vs 16%, relative risk [RR] 0.77, 95% confidence interval [CI] 0.56–1.06) or in not cured endpoint (22% vs 23%, RR 0.82, 95% CI 0.6–1.11). Stratified by D’Amico risk group, a significant benefit for RALP existed for recurrent disease in high-risk patients (RR 0.47, 95% CI 0.26–0.86, p = 0.02). All-cause mortality was 3% (n = 96). Prostate cancer–specific mortality was 0.6% (n = 21) overall, 0.3% (n = 8) after RALP, and 1.5% (n = 13) after RRP. The nonrandomized design is a limitation.

Conclusions

No significant difference was observed for cancer recurrence rate between RALP and RRP 6 yr after surgery. However, in a subgroup analysis, we found a significant benefit for RALP regarding recurrence rate in the high-risk group. Larger studies with longer follow-up are needed to make a firm conclusion and to evaluate a possible survival benefit.

Patient summary

In general, the oncological outcome is comparable between robotic and open radical prostatectomy 6 yr after surgery. For high-risk patients, our findings indicate that there is an advantage for robotics, but further studies with longer follow-up time is needed to make a firm conclusion.

Retzius-sparing robot-assisted radical prostatectomy versus open retropubic radical prostatectomy: a prospective comparative study with 19-month follow-up

BACKGROUND

The aim of the present study was to compare the surgical outcomes of retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and open retropubic radical prostatectomy (ORP).

METHODS

We included patients with clinically localized prostate cancer who underwent RS-RARP or ORP and met our inclusion criteria. We compared the perioperative, oncological, and continence outcomes between both surgical approaches. Continence function was assessed using the validated International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form. Continence was defined as using 0-1 safety pad per day. Biochemical recurrence (BCR) was defined as two consecutive rises in serum PSA more than 0.2 ng/mL. Events of local recurrence, distant metastasis, and cancer death were reported and compared using Kaplan-Meier survival analysis.

RESULTS

Between 1 June 2013 and 1 October 1 2016, 184 men were enrolled, of whom 125 underwent RS-RARP and 59 underwent ORP. Baseline demographic and pathological characteristics were similar between both groups (P>0.05). Patients in RS-RARP group had significantly lower blood loss, fewer transfusion rates, lower VAS score, and shorter hospital stay than patients in ORP group (P<0.05). Major complications (≥grade 3b) did not differ between both groups (P=0.121). Positive surgical margins were 28.8% and 24.8% in ORP and RS-RARP, respectively (P=0.494). The BCR free-survival rates in ORP and RS-RARP at 1-year was 87.3% and 92.3%, respectively (Log-rank, P=0.740). At 1-, 6-, and 12-month after surgery, 42.4%, 79.7%, and 84.7% of men undergoing ORP were continent, compared with 72.8%, 90.4%, and 92% undergoing RS-RARP, respectively. Men in RS-RARP group achieved faster recovery of urinary continence compared to men in ORP group (Log-rank, P=0.001).

CONCLUSIONS

RS-RARP had better perioperative outcomes and faster recovery of urinary continence compared with ORP. Short-term oncological outcomes were comparable between both surgical approaches.

Can online support groups address psychological morbidity of cancer patients? An artificial intelligence based investigation of prostate cancer trajectories

Background

Online Cancer Support Groups (OCSG) are becoming an increasingly vital source of information, experiences and empowerment for patients with cancer. Despite significant contributions to physical, psychological and emotional wellbeing of patients, OCSG are yet to be formally recognised and used in multidisciplinary cancer support programs. This study highlights the opportunity of using Artificial Intelligence (AI) in OCSG to address psychological morbidity, with supporting empirical evidence from prostate cancer (PCa) patients.

Methods

A validated framework of AI techniques and Natural Language Processing (NLP) methods, was used to investigate PCa patient activities based on conversations in ten international OCSG (18,496 patients- 277,805 conversations). The specific focus was on activities that indicate psychological morbidity; the reasons for joining OCSG, deep emotions and the variation from joining through to milestones in the cancer trajectory. Comparative analyses were conducted using t-tests, One-way ANOVA and Tukey-Kramer post-hoc analysis.

Findings

PCa patients joined OCSG at four key phases of psychological distress; diagnosis, treatment, side-effects, and recurrence, the majority group was ‘treatment’ (61.72%). The four groups varied in expression of the intense emotional burden of cancer. The ‘side-effects’ group expressed increased negative emotions during the first month compared to other groups (p<0.01). A comparison of pre-treatment vs post-treatment emotions showed that joining pre-treatment had significantly lower negative emotions after 12-months compared to post-treatment (p<0.05). Long-term deep emotion analysis reveals that all groups except ‘recurrence’ improved in emotional wellbeing.

Conclusion

This is the first empirical study of psychological morbidity and deep emotions expressed by men with a new diagnosis of cancer, using AI. PCa patients joining pre-treatment had improved emotions, and long-term participation in OCSG led to an increase in emotional wellbeing, indicating a decrease in psychological distress. It is opportune to further investigate AI in OCSG for early psychological intervention as an adjunct to conventional intervention programs.

Reducing preoperative blood orders and costs for radical prostatectomy

Aim: A maximum surgical blood order schedule (MSBOS) was implemented at our institution to optimize preoperative blood ordering and reduce unnecessary blood preparation for patients undergoing radical prostatectomy (RP), a common urologic procedure. Materials & methods: We conducted a retrospective review of patients who underwent RP from 2010 to 2016 and categorized patients by date of RP (pre- or post-MSBOS) and compared preoperative blood-ordering practices. Results: After MSBOS implementation, preoperative blood orders changed from predominantly type and cross-match 2 units (53%) to no sample (56%) for robot-assisted laparoscopic RP, and from mostly type and cross-match 2 units (62%) to type and screen (75%) for open RP with resultant cost savings. Conclusion: MSBOS implementation and compliance decreases unnecessary preoperative blood orders.

Robotic Surgery: A Novel Approach for Breast Surgery and Reconstruction

Supplemental Digital Content is available in the text.

Background:

Breast cancer is the most prevalent cancer and second leading cause of cancer-related deaths in both the US and UK female population, a prominent cause of morbidity and cost to both health services. All surgically fit patients are offered breast reconstruction following the initial surgery, and this is traditionally an open approach: either implant-based or an autologous tissue flap. Both lead to scarring that is difficult to conceal. This paper aims to evaluate the novel minimally invasive technique of robotic-assisted surgery.

Methods:

A systematic review was conducted using Medline (OvidSP) and Embase (OvidSP) to evaluate the current application of robotic-assisted surgery in breast surgery and reconstruction.

Results:

Twenty-one articles were identified and discussed, composing of level 4 and 5 evidence comparing different surgeons' experiences, techniques, and outcomes. To date, the robotic system has been utilized to harvest the latissimus dorsi muscle for use as a tissue flap (total harvest time of 92 minutes), to perform nipple-sparing mastectomy with immediate breast reconstruction (total operation time 85 minutes) and lately to harvest a deep inferior epigastric perforator flap via an intraabdominal approach.

Conclusions:

Robotic-assisted surgery can successfully and reproducibly perform a nipple-sparing mastectomy with breast reconstruction. It can minimize the size of scarring and is superior to the laparoscopic technique, with improved 3-dimensional visualization, dexterity, and range of motion able to guide around the curvature of the breast. The main limiting factors are the lack of the US Food and Drug Administration approval, cost of the robot, and specialized skills required.

Effect of Bladder Neck Preservation on Long-Term Urinary Continence after Robot-Assisted Laparoscopic Prostatectomy: A Systematic Review and Meta-Analysis

This study aimed to evaluate the effect of bladder neck preservation (BNP) on long-term urinary continence after robot-assisted laparoscopic prostatectomy (RALP). We systematically searched the PubMed, Embase, and Cochrane Library databases to identify studies that assessed the difference in urinary continence and oncologic outcomes between patients who underwent RALP with BNP and those who underwent RALP without BNP. Four trials (1880 cases with BNP, 727 controls without BNP) were considered suitable for meta-analysis. BNP was associated with significantly better urinary continence outcomes at 3–4 months (odds ratio (OR), 2.88; 95% confidence interval (CI), 1.52–5.48; p = 0.001), 12 months (OR, 2.03; 95% CI, 1.10–3.74; p = 0.02), and 24 months (OR, 3.23; 95% CI, 1.13–9.20; p = 0.03) after RALP. There was no difference in the rate of overall positive surgical margin (PSM) (OR, 1.00; 95% CI, 0.72–1.39; p = 0.99) and that of PSM at the prostate base (OR, 0.49; 95% CI, 0.21–1.13; p = 0.09) between the two groups. The BNP technique during RALP leads to early return of urinary continence and long-term urinary continence without compromising the oncologic outcomes.

Survival After Robotic-Assisted Prostatectomy for Localized Prostate Cancer: An Epidemiologic Study

BACKGROUNDS

To determine the potential survival benefit associated with robotic-assisted laparoscopic prostatectomy (RALP) compared to open radical prostatectomy (ORP) for prostate cancer.

SUMMARY OF BACKGROUND DATA

RALP has become the dominant surgical approach for localized disease in the absence of randomized clinical evidence and despite of the factor that RALP is more expensive than ORP.

METHODS

We performed a cohort study involving patients who underwent RALP and ORP for localized prostate cancer at the Commission on Cancer-accredited hospitals in the United States. Overall survival was analyzed using the Kaplan-Meier method, log-rank test, Cox proportional hazards models, and propensity score-matched analyses. An interrupted time-series analysis using the surveillance, epidemiology, and end results program database was also performed.

RESULTS

From 2010 to 2011, 37,645 patients received RALP and 12,655 patients received ORP. At a median follow-up of 60.7 months, RALP was associated with improved overall survival by both univariate [hazard ratio (HR), 0.69; P < 0.001] and multivariate analysis (HR, 0.76; P < 0.001) compared with ORP. Propensity score-matched analysis demonstrated improved 5-year all-cause mortality (3.9% vs 5.5%, HR, 0.73; P < 0.001) for RALP. The interrupted time-series analysis demonstrated the adoption of robotic surgery coincided with a systematic improvement in the 5-year cancer-specific survival rate of 0.17% (95% confidence interval, 0.06-0.25) per year after 2003 (P = 0.004 for change of trend), as compared to the time before adoption of RALP (1998-2003, annual percentage change, 0.01%; 95% confidence interval, -0.06 to 0.08). Sensitivity analysis suggested that the results from the interrupted time-series analysis were consistent with the improvement in the all-cause mortality demonstrated in the survival analysis (P = 0.87).

CONCLUSIONS

In this epidemiologic analysis, RALP was associated with a small but statistically significant improvement in 5-year all-cause mortality compared to ORP for localized prostate cancer. This is the first time in the literature to report a survival benefit with RALP. Our findings have significant quality and cost implications, and provide assurance regarding a dominant adoption of more expensive technology in the absence of randomized controlled trials.

Evaluation of benefits and harms of surgical treatments for post-radical prostatectomy urinary incontinence: a systematic review and meta-analysis protocol

Background: Post-radical prostatectomy urinary incontinence (PPI) is a frequent and feared complication that can affect approximately 25% of patients. Between 1 and 10% of patients suffering from PPI will require surgery. The effectiveness of the available surgical interventions has only been compared in a few randomized controlled trials and the available reviews have important limitations regarding both benefits and harms that make them insufficient to inform decision-making. The aim of the study is to provide systematic summaries of benefits and harms of contemporary surgical treatment options for PPI through systematic review and meta-analysis using GRADE methodology and reporting in accord with the PRISMA-P statement. Methods: Studies pertaining to bulking agents, male synthetic slings, compressive balloon systems (ProACT) or artificial urinary sphincters (AUS) used for the treatment of patients suffering from PPI will be included. A systematic search will be conducted using the OVID and PubMED platforms in MEDLINE, Embase and Cochrane databases, and reference lists of relevant reviews and guidelines. Trained independent reviewers will conduct study selection and data extraction. Outcomes will include the number of pads used per day, the 24-h pad weight test, the Patient Global Impression of Improvement (PGI-I) and the Incontinence Quality of Life (IQOL) as possible benefits and the reoperations, the Clavien-Dindo complications and the other reported adverse events as the harms. When possible, pooled analyses will be completed. Risk of bias will be assessed using the CLARITY tools and a new tool for the before-and-after studies without a control group. Finally, study heterogeneity will be assessed, publication bias will be evaluated with funnel plots and quality of evidence rated for each outcome. Discussion: Our study will address patient-important outcomes and will be useful in clinical decision-making as well as identifying key elements for future research. Study registration: PROSPERO: CRD42018073923 05/12/2018.

Robot-Assisted Surgery in Urology: The Show Must Go On

Initially, robot-assisted surgery (RAS) was developed by the USA forces as a tele-surgery tool in order to perform procedures in war zones without endangering the surgeon [...]

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.

Robotic-assisted vs. open radical prostatectomy: A machine learning framework for intelligent analysis of patient-reported outcomes from online cancer support groups

BACKGROUND

The advantages of Robot-assisted laparoscopic prostatectomy (RARP) over open radical prostatectomy (ORP) in Prostate cancer perioperatively are well-established, but quality of life is more contentious. Increasingly, patients are utilising online cancer support groups (OCSG) to express themselves. Currently there is no method of analysis of these sophisticated data sources. We have used the PRIME-2 (Patient Reported Information Multidimensional Exploration version 2) framework for automated identification and intelligent analysis of decision-making, functional and emotional outcomes in men undergoing ORP vs. RARP from OCSG discussions.

METHODS

The PRIME-2 framework was developed to retrospectively analyse individualised patient-reported information from 5,157 patients undergoing RARP and 579 ORP. The decision factors, side effects, and emotions in 2 groups were analysed and compared using Chi-squared, t tests, and Pearson correlation.

RESULTS

There were no differences in Gleason score, Prostate Specific Antigen (PSA), and age between the groups. Surgeon experience and preservation of erectile function (P < 0.01) were important factors in the decision making process. There were no significant differences in urinary, sexual, or bowel symptoms between ORP and RARP on a monthly basis during the initial 12 months. Emotions expressed by patients undergoing RARP were more consistent and positive while ORP expressed more negative emotions at the time of surgery and 3 months postsurgery (P < 0.05), due to pain and discomfort, and during ninth month due to fear and anxiety of pending PSA tests.

CONCLUSIONS

ORP and RARP demonstrated similar side effect profiles for 12 months, but PRIME-2 enables identification of important quality of life features and emotions over time. It is timely for clinicians to accept OCSG as an adjunct to Prostate cancer care.

Expanding the indications of robotic surgery in urology: A systematic review of the literature

Objectives

To evaluate the recent developments in robotic urological surgery, as the introduction of robotic technology has overcome many of the difficulties of pure laparoscopic surgery enabling surgeons to perform complex minimally invasive procedures with a shorter learning curve. Robot-assisted surgery (RAS) is now offered as the standard for various surgical procedures across multiple specialities.

Methods

A systematic search of MEDLINE, PubMed and EMBASE databases was performed to identify studies evaluating robot-assisted simple prostatectomy, salvage radical prostatectomy, surgery for urolithiasis, distal ureteric reconstruction, retroperitoneal lymph node dissection, augmentation ileocystoplasty, and artificial urinary sphincter insertion. Article titles, abstracts, and full text manuscripts were screened to identify relevant studies, which then underwent data extraction and analysis.

Results

In all, 72 studies evaluating the above techniques were identified. Almost all studies were retrospective single-arm case series. RAS appears to be associated with reduced morbidity, less blood loss, reduced length of stay, and comparable clinical outcomes in comparison to the corresponding open procedures, whilst having a shorter operative duration and learning curve compared to the equivalent laparoscopic techniques.

Conclusion

Emerging data demonstrate that the breadth and complexity of urological procedures performed using the da Vinci® platform (Intuitive Surgical Inc., Sunnyvale, CA, USA) is continually expanding. There is a gaining consensus that RAS is producing promising surgical results in a wide range of procedures. A major limitation of the current literature is the sparsity of comparative trials evaluating these procedures.

Neuro-anatomic basis of potency recovery after radical prostatectomy: an expert's point of view

INTRODUCTION

From 25% to 95% of those who have undergone radical prostatectomy (RP) report erectile dysfunction 12 months after surgery. We attempt a review of the available evidence regarding the anatomy of the cavernous nerves and the surgical refinements to enhance sexual function recovery after surgery.

EVIDENCE ACQUISITION

The PubMed/Medline database was searched. Duplicates were removed. Studies were selected by the authors according to the aim of the present review.

EVIDENCE SYNTHESIS

The cavernous nerves are deemed responsible for erections, but their exact function is still a matter of debate. They do not necessarily have the same distribution in all individuals: in most the cases, these nerves are located posterolaterally, however, it is not uncommon to find some fibers on the anterolateral aspects of the prostate, especially towards the apex. Several technical strategies were proposed in order to intraoperatively identify and spare the neurovascular bundles: despite all efforts, clinical results are still only partially satisfying.

CONCLUSIONS

The recovery of potency is one of the most unpredictable outcomes after RP. The advent of the robotic surgical system seems to have brought a trend towards a faster recovery of erectile function.

Robot-assisted extended lymphadenectomy in prostate cancer

INTRODUCTION

The extent of lymph node dissection (LND) and its potential survival benefit are still a matter of debate. Aim of our review was to summarize the latest literature data regarding the surgical templates, the potential oncological benefits, the functional outcomes and the complications of extended lymph node dissection (eLND) during robot-assisted radical prostatectomy (RARP).

EVIDENCE ACQUISITION

We systematically reviewed all relevant studies using PubMed, MEDLINE, Embase, American Urological Association (AUA), European Society of Medical Oncology (ESMO) and European Association of Urology (EAU) guidelines.

EVIDENCE SYNTHESIS

A narrative synthesis of all relevant publications on surgical templates, complications, oncological and functional outcomes of robot assisted eLND was undertaken.

CONCLUSIONS

A great deal of evidence supports that an extended template of LND is not only technically feasible but also safe in the context of RARP. It is really promising that in the era of minimally invasive surgery, parameters like the lymph node yield and the detection rates of positive lymph nodes during LND have become highly comparable with open series. The extended approach has already proved its benefits in terms of proper patient staging but more studies are needed with regard to functional outcomes and oncological benefits of this procedure.

Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: 24-month outcomes from a randomised controlled study

BACKGROUND

Previous trials have found similar early outcomes after robot-assisted laparoscopic prostatectomy and open radical retropubic prostatectomy. We report functional and oncological postoperative outcomes up to 24 months after surgery for these two surgical techniques.

METHODS

In this randomised controlled phase 3 study, men who had newly diagnosed clinically localised prostate cancer and who had chosen surgery as their treatment approach, and were aged between 35 years and 70 years were eligible and recruited from the Royal Brisbane and Women's Hospital (Brisbane, QLD, Australia). Participants were randomly assigned (1:1) to have either robot-assisted laparoscopic prostatectomy or open radical retropubic prostatectomy. Randomisation was computer generated and occurred in blocks of ten. This was an open trial; however, study investigators involved in data analysis were masked to each patient's surgical treatment. Primary outcomes were urinary function (urinary domain of Expanded Prostate Cancer Index Composite [EPIC]) and sexual function (sexual domain of EPIC and International Index of Erectile Function Questionnaire [IIEF]) at 6 months, 12 months, and 24 months and oncological outcome (biochemical recurrence and imaging evidence of progression). The trial was powered to assess health-related and domain-specific quality-of-life outcomes over 24 months. All analyses were done on a per-protocol basis. The trial was registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000661976.

FINDINGS

Between Aug 23, 2010, and Nov 25, 2014, 326 men were enrolled, of whom 163 were randomly assigned to robot-assisted laparoscopic prostatectomy and 163 to open radical retropubic prostatectomy. 18 withdrew (12 assigned to radical retropubic prostatectomy and six assigned to robot-assisted laparoscopic prostatectomy); thus, 151 in the radical retropubic prostatectomy group and 157 in the robot-assisted laparoscopic prostatectomy group proceeded to surgery. At the 24-month follow-up time point, 150 men remained in the robot-assisted laparoscopic prostatectomy group and 146 remained in the open radical retropubic prostatectomy group. Urinary function scores did not differ significantly between robot-assisted laparoscopic prostatectomy and open radical retropubic prostatectomy at 6 months post-surgery (88·68 [95% CI 86·79-90·58] vs 88·45 [86·54-90·36]; p1<0·0001, p2<0·0001), 12 months post-surgery (90·76 [88·89-92·62] vs 91·53 [90·07-92·98]; p1<0·0001, p2<0·0001), or 24 months post-surgery (91·33 [89·64-93·03] vs 90·86 [89·01-92·70]; p1<0·0001, p2<0·0001). Sexual function scores were not significantly different between robot-assisted laparoscopic prostatectomy and open radical retropubic prostatectomy at 6 months post-surgery (EPIC: 37·40 [33·60-41·19] vs 38·63 [34·76-42·49], p1=0·0001, p2<0·0001; IIEF: 29·75 [26·66-32·84] vs 29·78 [26·41-33·16], p1<0·0001, p2<0·0001), 12 months post-surgery (EPIC: 42·28 [38·05-46·51] vs 42·51 [38·29-46·72], p1<0·0001, p2<0·0001; IIEF: 33·10 [29·59-36·61] vs 33·50 [29·87-37·13], p1=0·0002, p2<0·0001), or 24 months post-surgery (EPIC: 45·70 [41·17-50·23] vs 46·90 [42·20-51·60], p1=0·0003, p2<0·0001; IIEF: 33·95 [30·11-37·78] vs 33·89 [29·82-37·96], p1=0·0003, p2=0·0004). Equivalence testing on the difference between the proportion of biochemical recurrences between the two groups (13 [9%] in the open radical retropubic prostatectomy group vs four [3%] in the robot-assisted laparoscopic prostatectomy group) showed that equality between the two techniques could not be established based on a 90% CI with a prespecified margin of 10%. However, a superiority test showed that the two proportions were significantly different (p=0·0199). Equivalence testing on the proportion of patients who had imaging evidence of progression revealed that the two groups were not significantly different (p=0·2956).

INTERPRETATION

Robot-assisted laparoscopic prostatectomy and open radical retropubic prostatectomy yielded similar functional outcomes at 24 months. We advise caution in interpreting the oncological outcomes of our study because of the absence of standardisation in postoperative management between the two trial groups and the use of additional cancer treatments. Clinicians and patients should view the benefits of a robotic approach as being largely related to its minimally invasive nature.

FUNDING

Cancer Council Queensland.

Review of optimal techniques for robotic-assisted radical prostatectomy

PURPOSE OF REVIEW

Robotic-assisted radical prostatectomy has been rapidly adopted and is now the standard of care in the surgical management of prostate cancer. Since the initial description in 2001, the technique has evolved to optimize oncological functional outcomes. Herein, we review key techniques for the robotic-assisted radical prostatectomy.

RECENT FINDINGS

With the current influx of new technology such as focal therapy, stereotactic body radiation therapy and prostate-sparing treatments, there is greater emphasis on maximizing outcomes of robotic-assisted radical prostatectomy. The evidence-based techniques of optimizing oncological outcomes including the lymph node dissection and improving cancer control through minimizing positive surgical margins are reviewed. Improvements in functional recovery has also been seen with technical modifications such as nerve sparing, preservation of the urethral support structures and the bladder neck and the urethra-vesical reconstruction.

SUMMARY

Robotic prostatectomy has demonstrated adequate long-term oncologic success and satisfactory functional recovery. As technology and techniques in robotic-assisted surgery evolve, surgeons will continue to optimize techniques to maximize functional outcome recovery and cancer control. Further studies are actively being conducted to provide level one evidence in multiple aspects of the robotic-assisted radical prostatectomy.

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.