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Jaber AR, Moschovas MC, Noel J, Stirt D, Rogers T, Saikali S, Gamal A, Sandri M, Sorce G, Mottrie A, Patel V. Does previous transurethral resection of the prostate affect the outcomes in robotic assisted radical prostatectomy? World J Urol 2024; 42:384. [PMID: 38909142 DOI: 10.1007/s00345-024-05105-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 06/01/2024] [Indexed: 06/24/2024] Open
Abstract
PURPOSE Transurethral resection of the prostate (TURP) is one of the surgical options for treating enlarged prostates with lower urinary symptoms (LUTS). In this older group of patients, concomitant prostate cancer is not uncommon. However, the fibrosis and distortion of the prostate anatomy by prior TURP can potentially hinder surgical efficacy at robotic-assisted radical prostatectomy (RARP). We aim to evaluate functional, and oncologic outcomes of RARP in patients with and without previous TURP. METHODS 231 men with previous TURP underwent RARP (TURP group). These men were propensity score matched using clinicopathological characteristics to men without previous TURP who underwent RARP (Control group). Perioperative and postoperative variables were analysed for significant differences in outcomes between groups. Variables analysed included estimated blood loss (EBL), operative time, catheter time, hospitalization time, postoperative complications, positive surgical margins (PSM) rates, cancer status, biochemical recurrence (BCR), potency, and continence rates. RESULTS Patients in the TURP group showed no statistically significant differences in operative safety measures including median EBL, operative time, catheter time, hospitalization time or postoperative complications. No significant difference between the groups in terms of potency rates and continence rates. Furthermore, there were no statistically significant differences in oncological outcomes, including PSM rates (15% vs 18%, P = 0.3) and BCR. CONCLUSION In RARP after TURP there is often noticeable distortion of the surgical anatomy. For an experienced team the procedure is safe and provides similar oncologic control and functional outcomes to RARP in patients without previous TURP.
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Affiliation(s)
- Abdel Rahman Jaber
- AdventHealth Global Robotics Institute, 380 Celebration Place, Orlando, FL, 34747, USA.
| | - Marcio Covas Moschovas
- AdventHealth Global Robotics Institute, 380 Celebration Place, Orlando, FL, 34747, USA
- University of Central Florida (UCF), Orlando, USA
| | - Jonathan Noel
- AdventHealth Global Robotics Institute, 380 Celebration Place, Orlando, FL, 34747, USA
| | - Daniel Stirt
- University of Central Florida (UCF), Orlando, USA
| | - Travis Rogers
- AdventHealth Global Robotics Institute, 380 Celebration Place, Orlando, FL, 34747, USA
| | - Shady Saikali
- AdventHealth Global Robotics Institute, 380 Celebration Place, Orlando, FL, 34747, USA
| | - Ahmed Gamal
- AdventHealth Global Robotics Institute, 380 Celebration Place, Orlando, FL, 34747, USA
| | - Marco Sandri
- Big and Open Data Innovation Laboratory (BODaI-Lab) and Data Methods and Systems Statistical, Brescia, Italy
| | - Gabriele Sorce
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
| | | | - Vipul Patel
- AdventHealth Global Robotics Institute, 380 Celebration Place, Orlando, FL, 34747, USA
- University of Central Florida (UCF), Orlando, USA
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Ramos-Carpinteyro R, Ferguson E, Soputro N, Chavali JS, Abou Zeinab M, Pedraza A, Mikesell C, Kaouk J. Predictors of Early Continence After Single-port Transvesical Robot-assisted Radical Prostatectomy. Urology 2024; 184:176-181. [PMID: 38048917 DOI: 10.1016/j.urology.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/17/2023] [Accepted: 11/22/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE To identify the factors associated with a short time of return to continence. METHODS We analyzed the first 110 SP TV RARP consecutive cases performed by one surgeon from 2020 to 2022. Continence was defined as zero to one safety pad. Two statistical analyses were done. First, patients were divided: group A (n = 62) included individuals who achieved continence within the initial week postcatheter removal; group B (n = 48) rest of the patients. Descriptive statistics were compared, followed by logistic regression for independent variables. Second, time to continence was analyzed as a continuous variable employing linear regression. The primary outcomes were the independent variables significantly associated with a short time to continence. RESULTS All cases were completed successfully, without additional ports or conversions. Median urinary catheter duration and time to continence were 3 and 3.5days, respectively. Patients achieving continence within 1week significantly presented with fewer preoperative urinary tract symptoms, lower prostate-specific antigen levels, and had smaller specimen weights postoperatively. Multivariable logistic regression established low specimen weight as the sole significant factor (P = .04). Furthermore, linear regression demonstrated that alterations in independent variables accounted for 12.7% of the variance in time to continence (P = .62). CONCLUSION The regionalization of surgery to the bladder employing a retropubic space-sparing extraperitoneal approach during SP TV RARP contributes to a fast return to continence. According to our model, the factors that significantly predict a shorter time to continence include lower preoperative International Prostate Symptom Score, prostate-specific antigen, and postoperative specimen weight.
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Affiliation(s)
| | - Ethan Ferguson
- Cleveland Clinic, Cleveland, OH; Indiana University Health, Indianapolis, IN
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Ferretti S, Dell’Oglio P, Ciavarella D, Galfano A, Schips L, Marchioni M. Retzius-Sparing Robotic-Assisted Prostatectomy: Technical Challenges for Surgeons and Key Prospective Refinements. Res Rep Urol 2023; 15:541-552. [PMID: 38106985 PMCID: PMC10725648 DOI: 10.2147/rru.s372803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/30/2023] [Indexed: 12/19/2023] Open
Abstract
Robotic-assisted radical prostatectomy (RARP) is the gold standard for localized prostate cancer. Several RARP approaches were developed and described over the years, aimed at improving oncological and functional outcomes. In 2010, Galfano et al described a new RARP technique, known as Retzius-sparing RARP (RS-RARP), a posterior approach through the Douglas space that spares the anterior support structures involved with urinary continence and sexual potency. This approach has been used increasingly in many centers around the world comparing its results with those of the most used standard anterior approach. Several randomized controlled trials, systematic reviews and meta-analyses demonstrated an important advantage relative to standard anterior RARP in terms of early urinary continence recovery, with comparable perioperative and long-term oncological outcomes. Several surgeons are concerned regarding RS-RARP because it appears to increase the risk of positive surgical margins (PSMs). However, this statement is based on low-certainty evidence. Indeed, the available studies compared the results of surgeons who had an initial experience with posterior RARP with those who had a solid experience with anterior RARP. Recent evidence strongly suggests that RS-RARP is feasible and safe not only in low- and intermediate-risk prostate cancer patient but also in challenging scenario such as high-risk setting, salvage prostatectomy and after transurethral resection of the prostate.
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Affiliation(s)
- Simone Ferretti
- Department of Medical, Oral and Biotechnological Sciences, G. d’Annunzio University of Chieti, Urology Unit, Chieti, Italy
| | - Paolo Dell’Oglio
- Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Davide Ciavarella
- Department of Medical, Oral and Biotechnological Sciences, G. d’Annunzio University of Chieti, Urology Unit, Chieti, Italy
| | - Antonio Galfano
- Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Luigi Schips
- Department of Medical, Oral and Biotechnological Sciences, G. d’Annunzio University of Chieti, Urology Unit, Chieti, Italy
| | - Michele Marchioni
- Department of Medical, Oral and Biotechnological Sciences, G. d’Annunzio University of Chieti, Urology Unit, Chieti, Italy
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Lin PL, Zheng F, Shin M, Liu X, Oh D, D'Attilio D. CUSUM learning curves: what they can and can't tell us. Surg Endosc 2023; 37:7991-7999. [PMID: 37460815 PMCID: PMC10520215 DOI: 10.1007/s00464-023-10252-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/23/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION There has been increased interest in assessing the surgeon learning curve for new skill acquisition. While there is no consensus around the best methodology, one of the most frequently used learning curve assessments in the surgical literature is the cumulative sum curve (CUSUM) of operative time. To demonstrate the limitations of this methodology, we assessed the CUSUM of console time across cohorts of surgeons with differing case acquisition rates while varying the total number of cases used to calculate the CUSUM. METHODS We compared the CUSUM curves of the average console times of surgeons who completed their first 20 robotic-assisted (RAS) cases in 13, 26, 39, and 52 weeks, respectively, for their first 50 and 100 cases, respectively. This analysis was performed for prostatectomy (1094 surgeons), malignant hysterectomy (737 surgeons), and inguinal hernia (1486 surgeons). RESULTS In all procedures, the CUSUM curve of the cohort of surgeons who completed their first 20 procedures in 13 weeks demonstrated a lower slope than cohorts of surgeons with slower case acquisition rates. The case number at which the peak of the CUSUM curve occurs uniformly increases when the total number of cases used in generation of the CUSUM chart changes from 50 to 100 cases. CONCLUSION The CUSUM analyses of these three procedures suggests that surgeons with fast initial case acquisition rates have less variability in their operative times over the course of their learning curve. The peak of the CUSUM curve, which is often used in surgical learning curve literature to denote "proficiency" is predictably influenced by the total number of procedures evaluated, suggesting that defining the peak as the point at which a surgeon has overcome the learning curve is subject to routine bias. The CUSUM peak, by itself, is an insufficient measure of "conquering the learning curve."
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Affiliation(s)
- Peng-Lin Lin
- Intuitive Surgical, 1020 Kifer Road, Sunnyvale, CA, 94086-5304, USA.
| | - Feibi Zheng
- Intuitive Surgical, 1020 Kifer Road, Sunnyvale, CA, 94086-5304, USA
| | - Minkyung Shin
- Intuitive Surgical, 1020 Kifer Road, Sunnyvale, CA, 94086-5304, USA
| | - Xi Liu
- Intuitive Surgical, 1020 Kifer Road, Sunnyvale, CA, 94086-5304, USA
| | - Daniel Oh
- Intuitive Surgical, 1020 Kifer Road, Sunnyvale, CA, 94086-5304, USA
| | - Daniel D'Attilio
- Intuitive Surgical, 1020 Kifer Road, Sunnyvale, CA, 94086-5304, USA
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Bejrananda T, Karnjanawanichkul W, Tanthanuch M. Comparison of Perioperative, Functional, and Oncological Outcomes of Transperitoneal and Extraperitoneal Laparoscopic Radical Prostatectomy. Minim Invasive Surg 2023; 2023:3263286. [PMID: 36798670 PMCID: PMC9928507 DOI: 10.1155/2023/3263286] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/23/2023] [Accepted: 01/25/2023] [Indexed: 02/10/2023] Open
Abstract
Purpose This study aimed to compare the oncological, functional, and perioperative outcomes of localized and locally advanced prostate cancer treated with intraperitoneal or extraperitoneal laparoscopic radical prostatectomy (LRP). Methods From April, 2008, through December, 2020, 266 patients underwent laparoscopic radical prostatectomy, 168 cases with an extraperitoneal approach (E-LRP) and 98 cases using a transperitoneal approach (T-LRP). The clinical, perioperative, functional, and oncological outcomes were collected and compared between these groups. At the 3-, 12- and 24-monthfollow-ups, the functional outcomes tested were urinary function (urinary domain of EPIC) and sexual function (sexual domain of EPIC). The oncological outcomes of biochemical recurrence, biochemical recurrence-free survival, and positive surgical margin status were evaluated. Univariable and multivariable Cox regression analyses were used to identify factors predictive for biochemical recurrence. All statistical analyses used the R program. Results The patient characteristics were similar between the E-LRP and T-LRP groups except for higher prostatic-specific antigen (PSA) in the T-LRP group. The T-LRP had lower overall operative time (222.5 min vs. 290 min, p 0.001), decreased blood loss (400 ml vs. 800 ml, p < 0.001), and shorter hospital stays (4 days vs. 7 days, p < 0.001) compared to the E-LRP. Early sexual intercourse with penetration at 3 months was higher in the T-LRP group (36.7% vs. 15.5%, p 0.001). Urinary continence (no pads) was not different between the T-LRP and E-LRP groups at 3 and 24 months after surgery but higher in the E-LRP group at 12 months (1% vs. 3%; p=0.419, 85.1 vs. 83.7%; p=0.889, 47.4% vs. 34.6%; p=0.028, respectively). The EPIC questionnaire was used to assess functional outcomes at 3, 12, and 24 months after surgery and found that urinary function was significantly higher in the T-LRP group at 3 and 12 months (p < 0.001) but did not show a difference at 24 months (p=0.734), and sexual function scores were higher in the T-LRP group at 12 and 24 months (p=0.001). The positive surgical margin rate was higher in the E-LRP (38.7% vs. 21.4%; p=0.006). The BCR rate was not different between the groups (36.3% in the E-LRP group and 27.6% in the E-LRP group; p=0.184). Conclusion Transperitoneal laparoscopic radical prostatectomy (T-LRP) was found to be superior to extraperitoneal radical prostatectomy (E-LRP) in perioperative outcomes such as decreased operative time, decreased blood loss, shorter hospital stay, lower positive surgical margin, and improved early sexual intercourse and sexual function. The urinary functional outcome was better in the T-LRP group at 3 and 12 months. These findings support the use of transperitoneal laparoscopic radical prostatectomy, as our study patients exhibited significant benefits from this procedure.
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Affiliation(s)
- Tanan Bejrananda
- Division of Urology, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, Thailand
| | - Watid Karnjanawanichkul
- Division of Urology, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, Thailand
| | - Monthira Tanthanuch
- Division of Urology, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, Thailand
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Joyce DD, Soligo M, Morlacco A, Latuche LJR, Schulte PJ, Boorjian SA, Frank I, Gettman MT, Thompson RH, Tollefson MK, Karnes RJ. Effect of Preoperative Multiparametric Magnetic Resonance Imaging on Oncologic and Functional Outcomes Following Radical Prostatectomy. EUR UROL SUPPL 2022; 47:87-93. [PMID: 36601046 PMCID: PMC9806697 DOI: 10.1016/j.euros.2022.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2022] [Indexed: 12/23/2022] Open
Abstract
Background Advancements in imaging technology have been associated with changes to operative planning in treatment of localized prostate cancer. The impact of these changes on postoperative outcomes is understudied. Objective To compare oncologic and functional outcomes between men who had computed tomography (CT) and those who had multiparametric magnetic resonance imaging (mpMRI) prior to undergoing radical prostatectomy. Design setting and participants In this retrospective cohort study, we identified all men who underwent radical prostatectomy (n = 1259) for localized prostate cancer at our institution between 2009 and 2016. Of these, 917 underwent preoperative CT and 342 mpMRI. Outcome measurements and statistical analysis Biochemical recurrence-free survival, positive margin status, postoperative complications, and 1-yr postprostatectomy functional scores (using the 26-item Expanded Prostate Cancer Index Composite [EPIC-26] questionnaire) were compared between those who underwent preoperative CT and those who underwent mpMRI using propensity score weighted Cox proportional hazard regression, logistic regression, and linear regression models. Results and limitations Baseline and 1-yr follow-up EPIC-26 data were available for 449 (36%) and 685 (54%) patients, respectively. After propensity score weighting, no differences in EPIC-26 functional domains were observed between the imaging groups at 1-yr follow-up. Positive surgical margin rates (odds ratio 1.03, 95% confidence interval [CI] 0.77-1.38, p = 0.8) and biochemical recurrence-free survival (hazard ratio 1.21, 95% CI 0.84-1.74, p = 0.3) were not significantly different between groups. Early and late postoperative complications occurred in 219 and 113 cases, respectively, and were not different between imaging groups. Our study is limited by a potential selection bias from the lack of functional scores for some patients. Conclusions In this single-center study of men with localized prostate cancer undergoing radical prostatectomy, preoperative mpMRI had minimal impact on functional outcomes and oncologic control compared with conventional imaging. These findings challenge the assumptions that preoperative mpMRI improves operative planning and perioperative outcomes. Patient summary In this study, we assessed whether the type of prostate imaging performed prior to surgery for localized prostate cancer impacted outcomes. We found that urinary and sexual function, cancer control, and postoperative complications were similar regardless of whether magnetic resonance imaging or computed tomography was utilized prior to surgery.
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Affiliation(s)
| | - Matteo Soligo
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - Alessandro Morlacco
- Department of Surgical and Oncological Sciences, Clinica Urologica, University of Padova, Padova, Italy
| | - Laureano J. Rangel Latuche
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Phillip J. Schulte
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | | | - Igor Frank
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - R. Jeffrey Karnes
- Department of Urology, Mayo Clinic, Rochester, MN, USA,Corresponding author at: Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Tel. +1 (507) 512-6511; Fax: +1 (507) 284-4951.
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Piramide F, Bravi CA, Turri F, DI Maida F, Andras I, Lambert E, Wuernschimmel C, Knipper S, DE Groote R, Larcher A. Retzius-sparing robot-assisted radical prostatectomy in high-risk prostate cancer: can it be as effective as the anterior approach in such a challenging setting? Minerva Urol Nephrol 2022; 74:807-809. [PMID: 36629812 DOI: 10.23736/s2724-6051.22.05179-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Federico Piramide
- School of Medicine, Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy -
| | - Carlo A Bravi
- ORSI Academy, Ghent, Belgium.,Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
| | - Filippo Turri
- Department of Urology, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | | | - Iulia Andras
- Department of Urology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Edward Lambert
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - Christoph Wuernschimmel
- Martini-Klinik Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sophie Knipper
- Martini-Klinik Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ruben DE Groote
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
| | - Alessandro Larcher
- Division of Experimental Oncology, Department of Urology, Urological Research Institute (URI), IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
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A side-specific nomogram for extraprostatic extension may reduce the positive surgical margin rate in radical prostatectomy. World J Urol 2022; 40:2919-2924. [DOI: 10.1007/s00345-022-04191-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 10/08/2022] [Indexed: 11/09/2022] Open
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Development and Implementation of an Advanced Program for Robotic Treatment of Prostate Cancer-Is Surgical Quality Transferable? Cancers (Basel) 2022; 14:cancers14215261. [PMID: 36358680 PMCID: PMC9657656 DOI: 10.3390/cancers14215261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/21/2022] [Accepted: 10/23/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction: Robot-assisted radical prostatectomy (RARP) is a surgical treatment option for prostate cancer (PC). Quality in RARP depends on the surgeon´s operative volume and expertise. When implementing RARP, it is standard practice to hire a pre-trained surgeon. The aim of our study was to investigate the transferability of quality in RARP. Patients and Methods: We analyzed two consecutive retrospective cohorts of 100 and 108 men, respectively, who underwent RARP at two different centers and on whom surgery was performed by the same surgeon. Results: There were more men with high-grade PC in Cohort 1: 25/100 (25.0%) vs. 9/108 (8.3%), p < 0.01, and infiltration of the seminal vesicles was more frequent (23/100 (23.0%) vs. 10/108 (9.2%), p < 0.01). In Cohort 2, the duration of surgery was shorter and blood loss was lower: 149 (134−174) vs. 172 min (150−196), p < 0.01 and 300 (200−400) vs. 131 (99−188) mL, p < 0.01. No difference was found in the proportion of positive surgical margins in the T2 cohort (8.8% vs. 8.2%, p = 1.00). Conclusion: The procedural and oncological outcome parameters of Cohort 2 do not appear to be inferior to the results obtained for the first cohort. The quality of RARP is transferable if a pre-trained surgeon is hired.
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