Perioperative, oncological and functional outcomes of the first robotic prostatectomy program in Quebec: Single fellowship-trained surgeon's experience of 250 cases

Quadrifecta outcomes and their predictors following robotic radical prostatectomy: a study of newly established robotic center in India

Active surveillance (AS), radical prostatectomy (RP), and radical radiotherapy (RT) are the three options for localized prostate cancer. Only a few studies have been conducted in developing countries or in centers in their initial learning curve that predict the outcomes of RARP. Therefore, this study aimed to present data from a novice center; how we started and progressed, and to compare our results with the rest of the world. This is a retrospective analysis to study the outcomes following robot-assisted radical prostatectomy and to identify the predictors of quadrifecta outcomes, i.e., the patients who were continent, did not have complications, were biochemical recurrence free with at least 1 year of follow-up and had negative surgical margins. In our data, we excluded the erectile function as one of the parameters as the majority of our patients were not sexually active or did not want to discuss this parameter. Seventy-two patients were included in this study, and 50 (69.4%) of these achieved the quadrifecta outcomes. Of all the factors, studied, seven factors were statistically significantly different between Group I (quadrifecta achieved) and Group II (quadrifecta not achieved), namely, BMI, co-morbidities like CAD, COPD, ASA grade, pre-op D'Amico risk stratification groups, clinical staging, positive lymph-node status, and hospital stay. With this study, we reported outcomes of RARP in a newly established robotic center and the results were fairly comparable with the well-developed center in India and abroad, emphasizing the short learning curve, and so, the requirement of establishing more robotic surgery centers in developing as well as developed countries.

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.

Learning curves in laparoscopic and robot-assisted prostate surgery: a systematic search and review

PURPOSE

To perform a systematic search and review of the available literature on the learning curves (LCs) in laparoscopic and robot-assisted prostate surgery.

METHODS

Medline was systematically searched from 1946 to January 2021 to detect all studies in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, reporting on the LC in laparoscopic radical prostatectomy (LRP), laparoscopic simple prostatectomy (LSP), robot-assisted radical prostatectomy (RARP) and robot-assisted simple prostatectomy (RSP).

RESULTS

In total, 47 studies were included for qualitative synthesis evaluating a single technique (LRP, RARP, LSP, RSP; 45 studies) or two techniques (LRP and RARP; 2 studies). All studies evaluated outcomes on real patients. RARP was the most widely investigated technique (30 studies), followed by LRP (17 studies), LSP (1 study), and RSP (1 study). In LRP, the reported LC based on operative time; estimated blood loss; length of hospital stay; positive surgical margin; biochemical recurrence; overall complication rate; and urinary continence rate ranged 40-250, 80-250, 58-200, 50-350, 110-350, 55-250, 70-350 cases, respectively. In RARP, the corresponding ranges were 16-300, 20-300, 25-200, 50-400, 40-100, 20-250, 30-200, while LC for potency rates was 80-90 cases.

CONCLUSIONS

The definition of LC for laparoscopic and robot-assisted prostate surgery is not well defined with various metrics used among studies. Nevertheless, LCs appear to be steep and continuous. Implementation of training programs/standardization of the techniques is necessary to improve outcomes.

Robot-Assisted Radical Prostatectomy in Low-Volume Regions: Should It Be Abandoned or Adopted? A Multi-Institutional Outcome Study

Purpose: To present multinational experience in robot-assisted radical prostatectomy (RARP) by fellowship-trained expertise in low-volume regions in Gulf Cooperation Council (GCC) countries and to compare the current results with global outcomes reported in recent meta-analyses. Methods: A retrospective review of prospectively collected data was performed for patients undergoing RARP for localized prostate cancer (PCa). Three fellowship-trained surgeons at four academic and referral centers in Saudi Arabia and Kuwait performed all procedures between February 2014 and December 2019. Data on demographics, perioperative characteristics, pathology, and adverse events were collected. Results: A total of 207 patients were included with a median (IQR) follow-up duration of 28 (15-38) months. The median prostate volume and prostate-specific antigen were 42 (32-53) g and 9.1 (5.8-14.1) ng/mL, respectively. While 65.2% of patients had a Gleason score ≥7, 20% had grade group 4 disease, and 7.8% had ≥cT3 disease. The mean ± SD operative time was 203 ± 52 minutes, and the mean estimated blood loss was 158 ± 107 mL. Only 4 (1.9%) patients received perioperative blood transfusions. Positive surgical margins were observed in 21.7% of patients, all of whom had ≥pT3 disease. There were 23 complications in 18 (8.7%) patients, including Clavien-Dindo grade III complications in 2.4%. At the 12-month follow-up, 35.8% of patients were potent, 94.6% were continent, and 9.2% had biochemical recurrence. Conclusions: The safety and efficacy of RARP by fellowship-trained expertise in GCC countries were well established. The outcomes seem promising and comparable to international centers and should improve with increasing case volume and fellowship-trained expertise.

Pathological features of prostate cancer in men treated with robot-assisted radical prostatectomy in the Middle East

Little is known about the pathological features of radical prostatectomy among men living in the Middle East. Although prostate cancer became the most common malignancy among males in some countries in the Middle East, the incidence is much lower compared to western populations. The aim of this study is to analyze pathological features and biochemical recurrence in men who underwent robotic-assisted radical prostatectomy (RARP) in Kuwait. The data on all RARP cases performed by a uro-oncologist (SA) were recorded. A comprehensive database was collected, including demographic, clinical, and pathological data. Between February 2014 and November 2019, 65 RARP cases were performed out of a total of 200 robotic urological procedures. The median follow-up was 41.5 months [inter quartile range (IQR) 27.6-52.7]. Eleven (17%) complications occurred in 7 patients, 64% were early (< 30 days post-operatively) and minor (Clavien I-II). Thirty-five (54%) patients had ≥ pT3 disease. Overall, 12 (18%) patients had a positive surgical margin (PSM), and all had ≥ pT3 disease. Potency and continence rates at 12 months were 82% and 97%, respectively. The mean and SD of the hospital stay were 2.7 ± 1.1 days. Biochemical recurrence (BCR) rate was 10%. Men with prostatic adenocarcinoma treated with RARP in Kuwait show a high incidence of pT3 disease. PSM and BCR rates were similar to multiple reports in the literature. To our knowledge, this is the first report of RARP pathological outcomes in the gulf cooperation council (GCC) region of the Middle East.

Long-term urinary functional outcome of vesicourethral anastomosis with bidirectional poliglecaprone (Monocryl®) vs. barbed polyglyconate suture (V-LocTM 180) in robot-assisted radical prostatectomy

INTRODUCTION

We aimed to evaluate urinary continence recovery following robot-assisted radical prostatectomy (RARP) using monofilament poliglecaprone (Monocryl^®) suture vs. barbed suture (V-Loc^TM 180) during vesicourethral anastomosis (VUA).

METHODS

In this prospective, observational cohort, data were collected on 322 consecutive patients. All patients underwent continuous, bidirectional, single-layer running anastomosis with either 3.0 monofilament suture (n=141) or 3.0 barbed suture (n=181). The primary outcome was continence recovery defined as time to 0 pad at one, three, six, 12, and 24 months following surgery.

RESULTS

Continence rates were significantly better with monofilament VUA at all followup time points up to one year. Median time to continence was one month vs. five months in the monofilament group vs. barbed group, respectively (p<0.001). Continence rates in monofilament suture vs. barbed group at one, three, six, 12, and 24 months were 56% vs. 26% (p<0.001), 73% vs. 36.4% (p<0.001), 84.4% vs. 60.2% (p<0.001), 90.8% vs. 71.9% (p<0.001), and 93.5% vs.87.1% (p=0.1), respectively. Anastomosis time was shorter in the barbed group, with a median of 23 vs. 30 minutes (p<0.001). Patients anastomosed with Monocryl suture had smaller prostate weight (median 42.5 g vs. 50 g; p<0.001) and harbored less advanced disease (T2a-c 76.6 vs. 74%; p=0.01) relative to patients treated with V-Loc 180 suture. However, in a multivariate Cox logistic regression analyses, independent predictors of continence recovery were suture type (hazard ratio [HR] 53; 95% confidence interval [CI] 0.41-0.68; p=0.02] and prostate size (HR 0.99; 95% CI 0.98-0.99; p<0.001).

CONCLUSIONS

Barbed VUA contributed to delayed continence recovery compared to monofilament poliglecaprone suture during the first year post-RARP. However, no statistically significant difference was recorded at two years post-RARP. These results warrant special attention, especially with the widespread use of barbed suture in recent years.

Perioperative predictors for post-prostatectomy urinary incontinence in prostate cancer patients following robotic-assisted radical prostatectomy: Long-term results of a Canadian prospective cohort

INTRODUCTION

We aimed to report the impact of perioperative factors that have not been well-studied on continence recovery following robotic-assisted radical prostatectomy (RARP).

METHODS

We analyzed data of 322 men with localized prostate cancer who underwent RARP between October 2006 and May 2015 in a single Canadian centre. All patients were assessed at one, three, six, 12, and 24 months after surgery. We evaluated risk factors for post-prostatectomy urinary incontinence from a prospectively collected database in multivariate Cox regression analysis. The primary endpoint was continence, defined as 0 pad usage per day.

RESULTS

0-pad continence rates were 126/322 (39%), 187/321 (58%), 222/312 (71%), 238/294 (80%), and 233/257 (91%) at one, three, six, 12, and 24 months, respectively. Bladder neck preservation (hazard ratio [HR] 0.71; 95% confidence interval [CI] 0.5-0.99; p=0.04), and prostate size (HR 0.99; 95% CI 0.98-0.99; p=0.02) were independent predictors of continence recovery after RARP. Smoking at time of surgery predicted delayed continence recovery on multivariate analysis (HR 1.42; 95% CI 1.01-1.99; p=0.04). Neurovascular bundles preservation was associated with continence recovery after 24 months. No statistically significant correlation was found with other variables, such as age, body mass index, Charlson comorbidity index, preoperative oncological baseline parameters, presence of median lobe, or thermal energy use.

CONCLUSIONS

Our results confirmed known predictors of postprostatectomy incontinence (PPI), namely bladder neck resection and large prostate volume. Noteworthy, cigarette smoking at the time of RARP was found to be a possible independent risk factor for PPI. This study is hypothesis-generating.

Does surgical delay for radical prostatectomy affect patient pathological outcome? A retrospective analysis from a Canadian cohort

INTRODUCTION

We sought to assess the impact of surgical wait time (SWT) to robot-assisted radical prostatectomy (RARP) on final pathological outcome.

METHODS

A retrospective review of RARP patient records operated between 2006 and 2015 was conducted. SWT was defined as period from prostate biopsy to surgery. Primary outcome was the impact on postoperative Cancer of the Prostate Risk Assessment (CAPRA-S) score. Patients were stratified according to D'Amico risk categories. Univariate analysis (UVA) and multivariable (MVA) analysis with a generalized linear model was used to evaluate the effect of SWT and other predictive factors on pathological outcome in individual risk group and on the overall sample.

RESULTS

A total of 835 patients were eligible for analysis. Mean SWT was significantly different between the three D'Amico groups, with mean SWT of 180.22 days (95% confidence interval [CI] 169.03; 191.41), 159.14 days (95% CI 152.38; 165.90), and 138.96 days (95% CI 124.60; 153.33) for low-, intermediate-, and high-risk groups, respectively (p<0.001). After stratification by D'Amico risk group, no significant association was observed between SWT and CAPRA-S score in the three risk categories on UVA and MVA. Predictors of higher CAPRA-S score in the multivariable model in the overall cohort were: older age (p=0.014), biopsy Gleason score (p<0.001), percentage of positive cores (p<0.001), and clinical stage (p<0.001).

CONCLUSIONS

In the present study evaluating SWT for RARP in a Canadian socialized system, increased delay for surgery does not appear to impact the pathological outcome. Further studies are required to evaluate the impact of wait time on biochemical recurrence-free survival, cancer-specific survival, and overall survival.

Adding a newly trained surgeon into a high-volume robotic prostatectomy group: are outcomes compromised?

This study evaluates whether a new staff surgeon early in the learning curve can be integrated into a high-volume robotic practice with an established robotic team and mentorship without compromising robot-assisted radical prostatectomy (RARP) outcomes of the practice. We analyzed outcomes of 3064 patients who underwent RARP from 2007 to 2012 at a high-volume tertiary center by a robotic practice comprising three experienced robotic surgeons (2846 patients) and a newly hired surgeon (218 patients) immediately out of training (residency and oncology fellowship with 2 years of RARP exposure). The new surgeon performed RARP with intraoperative mentorship by the senior surgeons during the first year. Complications, biochemical recurrence (BCR), positive surgical margins rate (PSM), operating time (OR time), estimated blood loss (EBL) for the new and senior surgeons were compared. Multivariable linear, logistic and exact logistic regression adjusting for disease and patient characteristics were performed. On regression analyses, case number was the most significant predictor of decrease in probability of major complications (p = 0.025) and BCR (p = 0.004) for the new surgeon. Increasing case number was not associated with decrease in minor complications, PSM, OR time, or EBL (p > 0.05). Inclusion of the new surgeon's outcomes did not adversely impact outcomes of the practice. In conclusion, a new surgeon joining a high-volume robotic prostatectomy program with an established robotic team and mentorship can progress through the learning curve without compromising overall outcomes of the practice. Our results may be relevant for programs hiring newly trained staff to join an established robotic practice.

Feasibility of planned mini-laparotomy and adhesiolysis at the time of robotic-assisted radical prostatectomy in patients with prior major abdominal surgery

INTRODUCTION

Our aim was to report our experience on the feasibility of completing radical prostatectomy robotically after planned open adhesiolysis for prior major abdominal surgery with previous midline laparotomy scar.

METHODS

We searched our prospectively collected database of robotic assisted-radical prostatectomy (RARP) performed between October 2006 and October 2012 by a single fellowship-trained surgeon to identify all patients who underwent planned initial mini-laparotomy for release of abdominal adhesions at time of RARP. Among 250 RARP patients, five patients fulfilled these criteria.

RESULTS

All patients had prostatectomy completed robotically. The mean values of patients' demographics were as follows: Age 61.8 years (range 54-69), body mass index 30.7 (range 24.3-45.3), and prostate volume 41.5 ml (range 30.8-54). Mean operative time was 245 min (range 190-280) and estimated blood loss 410 ml (range 300-650). Median hospital stay was one day (range 1-7). Postoperatively, there was one prolonged ileus, which resolved spontaneously, and one myocardial infarction.

CONCLUSIONS

Robotic completion of radical prostatectomy after open adhesiolysis is feasible. This approach maintains most minimally invasive advantages of RARP, despite a slightly longer hospital stay. In the best interest of patients, robotic surgeons are encouraged to finish the case robotically rather than attempting an open approach.

Factors predicting prolonged operative time for individual surgical steps of robot-assisted radical prostatectomy (RARP): A single surgeon's experience

INTRODUCTION

We evaluated the average time required to complete individual steps of robotic-assisted radical prostatectomy (RARP) by an expert RARP surgeon. The intent is to help establish a time-based benchmark to aim for during apprenticeship. In addition, we aimed to evaluate preoperative patient factors, which could prolong the operative time of these individual steps.

METHODS

We retrospectively identified 247 patients who underwent RARP, performed by an experienced robotic surgeon at our institution. Baseline patient characteristics and the duration of each step were recorded. Multivariate analysis was performed to predict factors of prolonged individual steps.

RESULTS

In multivariable analysis, obesity was a significant predictor of prolonged operative time of: docking (odds ratio [OR] 1.96), urethral division (OR 3.13), and vesico-urethral anastomosis (VUA) (OR 2.63). Prostate volume was also a significant predictor of longer operative time in dorsal vein complex ligation (OR 1.02), bladder neck division (OR 1.03), pedicle control (OR 1.04), urethral division (OR 1.02), and VUA (OR 1.03). A prolonged bladder neck division was predicted by the presence of a median lobe (OR 5.03). Only obesity (OR 2.56) and prostate volume (OR 1.04) were predictors of a longer overall operative time.

CONCLUSIONS

Obesity and prostate volume are powerful predictors of longer overall operative time. Furthermore, both can predict prolonged time of several individual RARP steps. The presence of a median lobe is a strong predictor of a longer bladder neck division. These factors should be taken into consideration during RARP training.

Uroflow Stop Test and Potency Recovery: A Surrogate for Pelvic Floor Integrity Post Robotic-Assisted Radical Prostatectomy?

OBJECTIVE

To study the relation between uroflow Stop Test and early recovery of potency following robot-assisted radical prostatectomy (RARP). We recently showed that the ability to completely stop urine flow during voiding, measured objectively by uroflowmetry at the time of catheter removal (uroflow Stop Test) can predict early urinary continence recovery following RARP.

MATERIALS AND METHODS

In this prospective observational cohort, data were collected on 108 patients operated by a single surgeon (AEH). Eighty patients had a positive uroflow Stop Test (group one) and 28 had a negative Stop Test (group two). Patients were followed for a minimum of 2 years. Covariates included age, body mass index, international prostate symptom score and sexual health inventory for men scores, prostate-specific antigen, tumor stage, prostate volume, nerve sparing status, and estimated blood loss.

RESULTS

Preoperative characteristics were comparable between both groups except nerve sparing and prostate-specific antigen which were statistically higher in group one (P <.05). Early 3- and 6-months recovery of erectile function was significantly higher in group one. Potency rates in group one and two at 1, 3, 6, 9, 12, 18, and 24 months were 25% vs 14.3% (P = .241), 54.5% vs 18.5% (P = .001), 55.4% vs 18.5% (P = .001), 56.4% vs 36% (P = .084), 66.6% vs 50% (P = .141), 65.5% vs 56% (P = .404) and 73.2% vs 57.7% (P = .160) respectively. Uroflow Stop Test was independent predictor of early potency recovery on multivariate regression analysis at 6 months [odds ratio 6.042 (confidence interval 95% 1.496-24.413) P = .012].

CONCLUSION

Uroflow Stop Test is simple and can help predict early potency recovery following RARP.

Predictors of early continence following robot-assisted radical prostatectomy

INTRODUCTION

Functional outcomes after robot-assisted radical prostatectomy (RARP) greatly influence patient quality of life. Data regarding predictors of early continence, especially 1 month following RARP, are limited. Previous reports mainly address immediate or 3-month postoperative continence rates. We examine preoperative predictors of pad-free continence recovery at the first follow-up visit 1 month after RARP.

METHODS

Between January 2007 and January 2013, preoperative and follow-up data were prospectively collected for 327 RARP patients operated on by 2 fellowship-trained surgeons (AEH and KCZ). Patient and operative characteristics included age, body mass index (BMI), staging, preoperative prostate-specific antigen (PSA), prostate weight, International Prostate Symptom Score (IPSS), Sexual Health Inventory for Men (SHIM) score and type of nerve-sparing performed. Continence was defined by 0-pad usage at 1 month follow-up. Univariate and multivariate logistic regression models were used to assess for predictors of early continence.

RESULTS

Overall, 44% of patients were pad-free 1 month post-RARP. In multivariate regression analysis, age (odds ratio [OR] 0.946, confidence interval [CI] 95%: 0.91, 0.98) and IPSS (OR: 0.953, CI 95%: 0.92, 0.99) were independent predictors of urinary continence 1 month following RARP. Other variables (BMI, staging, preoperative PSA, SHIM score, prostate weight and type of nerve-sparing) were not statistically significant predictors of early continence. Limitations of this study include missing data for comorbidities, patient use of pelvic floor exercises and patient maximal activity. Moreover, patient-reported continence using a 0-pad usage definition represents a semiquantitative and subjective measurement.

CONCLUSION

In a broad population of patients who underwent RARP at our institution, 44% of patients were pad-free at 1 month. Age and IPSS were independent predictors of early continence after surgery. Men of advanced age and those with significant lower urinary tract symptoms prior to RARP should be counselled on the increased risk of urinary incontinence in the early stages.

Oncological and functional outcomes of 722 robot-assisted radical prostatectomy (RARP) cases: The largest Canadian 5-year experience

INTRODUCTION

While RARP (robotic-assisted radical prostatectomy) has become the predominant surgical approach to treat localized prostate cancer, there is little Canadian data on its oncological and functional outcomes. We describe the largest RARP experience in Canada.

METHODS

Data from 722 patients who underwent RARP performed by 7 surgeons (AEH performed 288, TH 69, JBL 23, SB 17, HW 15, QT 7, and KCZ 303 patients) were collected prospectively from October 2006 to December 2013. Preoperative characteristics, as well as postoperative surgical and pathological outcomes, were collected. Functional and oncological outcomes were also assessed up to 72 months postoperative.

RESULTS

The median follow-up (Q1-Q3) was 18 months (9-36). The D'Amico risk stratification distribution was 31% low, 58% intermediate and 11% high-risk. The median operative time was 178 minutes (142-205), blood loss was 200 mL (150-300) and the postoperative hospital stay was 1 day (1-23). The transfusion rate was only 1.0%. There were 0.7% major (Clavien III-IV) and 10.1% minor (Clavien I-II) postoperative complications, with no mortality. Pathologically, 445 men (70%) were stage pT2, of which 81 (18%) had a positive surgical margin (PSM). In addition, 189 patients (30%) were stage pT3 and 87 (46%) with PSM. Urinary continence (0-pads/day) returned at 3, 6, and 12 months for 68%, 80%, and 90% of patients, respectively. Overall, the potency rates (successful penetration) for all men at 6, 12, and 24 months were 37%, 52%, and 59%, respectively. Biochemical recurrence was observed in 28 patients (4.9%), and 14 patients (2.4%) were referred for early salvage radiotherapy. In total, 49 patients (8.4%) underwent radio-therapy and/or hormonal therapy.

CONCLUSIONS

This study shows similar results compared to other high-volume RARP programs. Being the largest RARP experience in Canada, we report that RARP is safe with acceptable oncologic outcomes in a Canadian setting.