Retropubic,Laparoscopic, and Robot-Assisted Radical Prostatectomy: A Systematic Review and Cumulative Analysis of Comparative Studies

Context

Despite the wide diffusion of laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALP), only few studies comparing the results of these techniques with the retropubic radical prostatectomy (RRP) are currently available.

Objective

To evaluate the perioperative, functional, and oncologic results in the comparative studies evaluating RRP, LRP, and RALP.

Evidence acquisition

A systematic review of the literature was performed in January 2008, searching Medline, Embase, and Web of Science databases. A “free-text” protocol using the term radical prostatectomy was applied. Some 4000 records were retrieved from the Medline database; 2265 records were retrieved from the Embase database;, and 4219 records were retrieved from the Web of Science database. Three of the authors reviewed the records to identify comparative studies. A cumulative analysis was conducted using Review Manager software v.4.2 (Cochrane Collaboration, Oxford, UK).

Evidence synthesis

Thirty-seven comparative studies were identified in the literature search, including a single, randomised, controlled trial.With regard to the perioperative outcome, LRP and RALP were more time consuming than RRP, especially in the initial steps of the learning curve, but blood loss, transfusion rates, catheterisation time, hospitalisation duration, and complication rates all favoured LRP. With regard to the functional results, LRP and RRP showed similar continence and potency rates. Similarly, no significant differences were identified between LRP and RALP, while a single, nonrandomised, prospective study suggested advantages in terms of both continence and potency recovery after RALP, compared with RRP. With regard to the oncologic outcome, LRP and RALP were associated with positive surgical margin rates similar to those of RRP.

Conclusions

The quality of the available comparative studies was not excellent. LRP and RALP are followed by significantly lower blood loss and transfusion rates, but the available data were not sufficient to prove the superiority of any surgical approach in terms of functional and oncologic outcomes. Further high-quality, prospective, multicentre, comparative studies are needed.     

Cost Comparison of Robotic,Laparoscopic, and Open Radical Prostatectomy for Prostate Cancer

Background

Demand and utilization of minimally invasive approaches to radical prostatectomy have increased in recent years, but comparative studies on cost are lacking.

Objective

To compare costs associated with robotic-assisted laparoscopic radical prostatectomy (RALP), laparoscopic radical prostatectomy (LRP), and open retropubic radical prostatectomy (RRP).

Design, setting, and participants

The study included 643 consecutive patients who underwent radical prostatectomy (262 RALP, 220 LRP, and 161 RRP) between September 2003 and April 2008.

Measurements

Direct and component costs were compared. Costs were adjusted for changes over the time of the study.

Results and limitations

Disease characteristics (body mass index, preoperative prostate-specific antigen, prostate size, and Gleason sum score 8–10) were similar in the three groups. Nerve sparing was performed in 85% of RALP procedures, 96% of LRP procedures, and 90% of RRP procedures (p < 0.001). Lymphadenectomy was more commonly performed in RRP (100%) compared to LRP (22%) and RALP (11%) (p < 0.001). Mean length of hospital stay was higher for RRP than for LRP and RALP. The median direct cost was higher for RALP compared to LRP or RRP (RALP: $6752 [interquartile range (IQR): $6283–7369]; LRP: $5687 [IQR: $4941–5905]; RRP: $4437 [IQR: $3989–5141]; p < 0.001). The main difference was in surgical supply cost (RALP: $2015; LRP: $725; RRP: $185) and operating room (OR) cost (RALP: $2798; LRP: $2453; RRP: $1611; p < 0.001). When considering purchase and maintenance costs for the robot, the financial burden would increase by $2698 per patient, given an average of 126 cases per year.

Conclusions

RALP is associated with higher cost, predominantly due to increased surgical supply and OR costs. These costs may have a significant impact on overall cost of prostate cancer care.     

The effect of nerve-sparing surgery on patient-reported continence post-radical prostatectomy

Introduction:

Urinary continence significantly affects quality of life after radical prostatectomy (RP). The impact of nerve-sparing surgery on continence is unclear from the current literature.

Methods:

We identified men with prostate cancer from the University Health Network Prostate Centre database who underwent RP. Preoperatively and at each postoperative visit, patients completed the Patient-Oriented Prostate Utility Scale (PORPUS), a validated psychometric and health utility instrument. Incontinence was defined by a single questionnaire item. Patients with radiotherapy or less than 10 months follow-up were excluded. Chi-squared tests and ANOVA were used to compare groups. Multivariable logistic regression was used to control for effects of nerve-sparing and other covariates.

Results:

Of the 253 eligible patients from 2003 to 2007, 159 patients had bilateral nerve-sparing, 32 had unilateral nerve-sparing and 62 had non-nerve-sparing surgery. Of these patients, 27%, 17% and 34%, respectively, were classified as incontinent at 1 year. These proportions were not significantly different between groups (p = 0.23). Multivariable logistic regression showed baseline urinary continence and urinary frequency to be significant predictors of patient-reported continence at 1 year postoperatively, with odds ratios of 1.7 (95% confidence interval [CI] 1.1–2.9) and 1.5 (95% CI 1.0–2.3), respectively.There was a significant difference in the proportion of PORPUS sexual function scores between nerve-sparing groups after excluding those with baseline sexual dysfunction (p = 0.003). Similarly, health-related utility scores were different across groups (p < 0.001).

Conclusion:

Our results do not suggest a difference in 1-year patient-reported continence based on the type of nerve-sparing RP. However, baseline continence and urinary frequency were significant predictors of continence at 1 year.     

A prospective trial comparing consecutive series of open retropubic and robot-assisted laparoscopic radical prostatectomy in a centre with a limited caseload

Background

Robot-assisted radical prostatectomy (RALP) is performed worldwide, even in institutions with limited caseloads. However, although the results of large RALP series are available, oncologic and functional outcomes as well as complications from low-caseload centres are lacking.

Objective

To compare perioperative, oncologic, and functional outcomes from two consecutive series of patients with localised prostate cancer treated by retropubic radical prostatectomy (RRP) or recently established RALP in our hospital, which has a limited caseload.

Design, setting, and participants

One hundred fifty consecutive patients were enrolled. Their data and outcomes were collected and extensively evaluated.

Intervention

Seventy-five consecutive patients underwent RRP, and 75 consecutive patients underwent RALP, including all patients of the learning curve.

Measurements

Patient baseline characteristics, perioperative and postoperative outcomes, and complications were evaluated. End points were oncologic data (positive margins, prostate-specific antigen [PSA]), perioperative complications, urinary continence, and erectile function at 3- and 12-mo follow-up.

Results and limitations

The preoperative parameters from the two groups were comparable. The positive surgical margin (PSM) rates were 32% for RRP and 16% for RALP (p = 0.002). For RRP and RALP, the PSA value was <0.2 ng/ml in 91% and 88% of patients 3 mo postoperatively (p = 0.708) and in 87% and 89% of patients 12 mo postoperatively (p = 0.36), respectively. Continence rates for RRP and RALP were 83% and 95% at 3-mo follow-up (p = 0.003) and 80% and 89% after 12-mo follow-up (p = 0.092), respectively. Among patients who were potent without phosphodiesterase type 5 inhibitors (PDE5-I) before RRP and RALP, recovery of erectile function with and without PDE5-Is was achieved in 25% (12 of 49 patients) and 68% (25 of 37 patients) 3 mo postoperatively (p = 0.009) and in 26% (12 of 47 patients) and 55% (12 of 22 patients) 12 mo postoperatively (p = 0.009), respectively. Minimal follow-up for RRP was 12 mo; median follow-up for the RALP group was 12 mo (range: 3–12). According to the modified Clavien system, major complication rates for RRP and RALP were 28% and 7% (p = 0.025), respectively; minor complication rates were 24% and 35% (p = 0.744), respectively.

Conclusions

Despite a limited caseload and including the learning curve, RALP offers slightly better results than RRP in terms of PSM, major complications, urinary continence, and erectile function.     

Urinary Symptoms After Robotic Prostatectomy in Men with Median Lobes

Background:

We report on the natural history of lower urinary tract symptoms (LUTS) and urinary continence in patients with median lobe enlargement (MLE) after robotic radical prostatectomy (RP).

Methods:

Patients treated with RP from October 2008 to March 2012 completed American Urological Association symptom index (AUAI) and continence assessments at the preoperative visit and each postoperative visit. Two cohorts were established based on the presence or absence of a median lobe intraoperatively.

Results:

A total of 698 validated questionnaires were completed by 175 patients with a median of 4 AUAI scores per patient. The 36 patients (21%) with MLE required a longer time to achieve urinary continence (P = .05, log-rank test), although ultimately, no difference was seen in long-term continence probability between the two cohorts (P = .63). On multivariate analysis, the presence of a median lobe reduced the odds of early continence recovery (P = .02). By use of a generalized estimating equation, the cohort-average AUAI scores after RP are presented. Patients with MLE had faster improvement in LUTS after surgery, whereas those without MLE had temporary worsening in LUTS before improvement.

Conclusion:

Patients with MLE have a different natural history of LUTS and continence after RP as compared with patients without this finding. Therefore, radiographic or cystoscopic evaluation for the presence of a median lobe before RP may improve patient counseling about urinary outcomes.     

Ultrasensitive Prostate Specific Antigen Assay Following Laparoscopic Radical Prostatectomy – An Outcome Measure for Defining the Learning Curve

INTRODUCTION

Radical retropubic prostatectomy (RRP) performed laparoscopically is a popular treatment with curative intent for organ-confined prostate cancer. After surgery, prostate specific antigen (PSA) levels drop to low levels which can be measured with ultrasensitive assays. This has been described in the literature for open RRP but not for laparoscopic RRP. This paper describes PSA changes in the first 300 consecutive patients undergoing non-robotic laparoscopic RRP by a single surgeon.

OBJECTIVES

To use ultrasensitive PSA (uPSA) assays to measure a PSA nadir in patients having laparoscopic radical prostatectomy below levels recorded by standard assays. The aim was to use uPSA nadir at 3 months'' post-prostatectomy as an early surrogate end-point of oncological outcome. In so doing, laparoscopic oncological outcomes could then be compared with published results from other open radical prostatectomy series with similar end-points. Furthermore, this end-point could be used in the assessment of the surgeon''s learning curve.

PATIENTS AND METHODS

Prospective, comprehensive, demographic, clinical, biochemical and operative data were collected from all patients undergoing non-robotic laparoscopic RRP. We present data from the first 300 consecutive patients undergoing laparoscopic RRP by a single surgeon. uPSA was measured every 3 months post surgery.

RESULTS

Median follow-up was 29 months (minimum 3 months). The likelihood of reaching a uPSA of ≤ 0.01 ng/ml at 3 months is 73% for the first 100 patients. This is statistically lower when compared with 83% (P < 0.05) for the second 100 patients and 80% for the third 100 patients (P < 0.05). Overall, 84% of patients with pT2 disease and 66% patients with pT3 disease had a uPSA of ≤ 0.01 ng/ml at 3 months. Pre-operative PSA, PSA density and Gleason score were not correlated with outcome as determined by a uPSA of ≤ 0.01 ng/ml at 3 months. Positive margins correlate with outcome as determined by a uPSA of ≤ 0.01 ng/ml at 3 months but operative time and tumour volume do not (P < 0.05). Attempt at nerve sparing had no adverse effect on achieving a uPSA of ≤ 0.01 ng/ml at 3 months.

CONCLUSIONS

uPSA can be used as an early end-point in the analysis of oncological outcomes after radical prostatectomy. It is one of many measures that can be used in calculating a surgeon''s learning curve for laparoscopic radical prostatectomy and in bench-marking performance. With experience, a surgeon can achieve in excess of an 80% chance of obtaining a uPSA nadir of ≤ 0.01 ng/ml at 3 months after laparoscopic RRP for a British population. This is equivalent to most published open series.     

Nongenitourinary complications associated with robot-assisted laparoscopic and radical retropubic prostatectomy: A single institution assessment of 1,100 patients over 11 years

Objectives

Robot-assisted laparoscopic prostatectomy (RALP) and radical retropubic prostatectomy (RRP) provide similar outcomes in terms of biochemical recurrence, postoperative continence, and erectile function. Little is known about other complications of these procedures. To further address this, we examined patient outcomes at our institution over an 11-year period.

Developing a Robotic Prostatectomy Service and a Robotic Fellowship Programme – Defining the Learning Curve

Introduction

Robotic radical prostatectomy (RRP) is an established treatment for prostate cancer in selected centres with appropriate expertise. We studied our single-centre experience of developing a RRP service and subsequent training of 2 additional surgeons by the initial surgeon and the introduction of United Kingdom''s first nationally accredited robotic fellowship training programme. We assessed the learning curve of the 3 surgeons with regard to peri-operative outcomes and oncological results.

Patients and Methods

Three hundred consecutive patients underwent RRP between November 2008 and August 2012. Patients were divided into 3 equal groups (Group 1, case 1-100; Group 2, case 101-200; and Group 3, case 201-300). Age, ASA score, preoperative co-morbidities and indications for laparoscopic radical prostatectomy were comparable for all 3 patient groups. Peri-operative and oncological outcomes were compared across all 3 groups to assess the impact of the learning curve for laparoscopic radical prostatectomy. All surgical complications were classified using the Clavien-Dindo system.

Results

The mean age was 60.7 years (range 41-74). There was a significant reduction in the mean console time (p < 0.001), operating time (p < 0.001), mean length of hospital stay (p < 0.001) and duration of catheter (p < 0.001) between the 3 groups as the series progressed. The two most important factors predictive of positive surgical margins (PSM) at RRP were the initial prostate specific antigen (PSA) and tumor stage at diagnosis. The overall PSM rate was 26.7%. For T2/T3 tumors the incidence of PSM reduced as the series progressed (Group 1-22%, Group 2-32% and Group 3-26%). The incidence of major complications i.e. grade Clavien-Dindo system score ≤ III was 2% (6/300).

Conclusion

RRP is a safe procedure with low morbidity. As surgeons progress through the learning curve peri-operative parameters and oncological outcomes improve. This learning curve is not affected by the introduction of a fellowship-training programme. Using a carefully structured mentored approach, RRP can be safely introduced as a new procedure without compromising patient outcomes.Key Words: Robotic radical prostatectomy, Prostate cancer, Learning curve, Fellowship training     

Robot-Assisted Radical Prostatectomy After Previous Prostate Surgery

Background and Objectives:

Our objective is to clarify the effect of previous transurethral resection of the prostate (TURP) or open prostatectomy (OP) on surgical, oncological, and functional outcomes after robot-assisted radical prostatectomy (RARP).

Methods:

Between August 1, 2009, and March 31, 2013, 380 patients underwent RARP. Of these, 25 patients had undergone surgery for primary bladder outlet obstruction (TURP, 20 patients; OP, 5 patents) (group 1). A match-paired analysis was performed to identify 36 patients without a history of prostate surgery with equivalent clinicopathologic characteristics to serve as a control group (group 2). Patients followed up for 12 months were assessed.

Results:

Both groups were similar with respect to preoperative characteristics, as mean age, body mass index, median prostate-specific antigen, prostate volume, clinical stage, the biopsy Gleason score, D''Amico risk, the American Society of Anesthesiologists (ASA) classification score, the International Prostate Symptom Score, continence, and potency status. RARP resulted in longer console and anastomotic time, as well as higher blood loss compared with surgery-naive patients. We noted a greater rate of urinary leakage (pelvic drainage, >4 d) in group 1 (12% vs 2,8%). The anastomotic stricture rate was significantly higher in group 1 (16% vs 2.8%). No difference was found in the pathologic stage, positive surgical margin, and nerve-sparing procedure between the groups. Biochemical recurrence was observed in 12% (group 1) and 11.1% (group 2) of patients, respectively. No significant difference was found in the continence and potency rates.

Conclusions:

RARP after TURP or OP is a challenging but oncologically promising procedure with a longer console and anastomosis time, as well as higher blood loss and higher anastomotic stricture rate.     

Inguinal Hernia After Radical Prostatectomy for Prostate Cancer: Results From a Randomized Setting and a Nonrandomized Setting

Background

Observational data indicate that retropubic radical prostatectomy (RRP) for prostate cancer (PCa) may induce inguinal hernia (IH) formation. Little is known about the influence of robot-assisted radical prostatectomy (RALP) on IH risk.

Objective

To compare the incidence of IH after RRP and RALP to that of nonoperated patients with PCa and to a population control.

Design, setting, and participants

We studied two groups. All 376 men included in the Scandinavian Prostate Cancer Group Study Number 4 constitute study group 1. Patients were randomly assigned RRP or watchful waiting (WW). The 1411 consecutive patients who underwent RRP or RALP at Karolinska University Hospital constitute study group 2. Men without PCa, matched for age and residence to each study group, constitute controls.

Measurements

Postoperative IH incidence was detected through a validated questionnaire. The participation rates were 82.7% and 88.4% for study groups 1 and 2, respectively.

Results and limitations

The Kaplan-Meier cumulative occurrence of IH development after 48 mo in study group 1 was 9.3%, 2.4%, and 0.9% for the RRP, the WW, and the control groups, respectively. There were statistically significant differences between the RRP group and the WW and control groups, but not between the last two. In study group 2 the cumulative risk of IH development at 48 mo was 12.2%, 5.8%, and 2.6% for the RRP, the RALP, and the control group, respectively. There were statistically significant differences between the RRP group and the RALP and control groups, but not between the last two.

Conclusions

RRP for PCa leads to an increased risk of IH development. RALP may lower the risk as compared to open surgery.     

A cost-analysis comparison of laparoscopic radical prostatectomy versus open radical prostatectomy: the McMaster Institute of Urology experience

Introduction:

The objective of this study was to identify and compare the costs of laparoscopic radical prostatectomy (LRP) and radical retropubic prostatectomy (RRP) at our centre.

Methods:

We conducted a retrospective chart review of our first 70 consecutive LRP cases and 70 consecutive RRP cases at St. Joseph’s Healthcare in Hamilton, Ontario, Canada. We performed cost analysis, including operating room costs, disposable instruments, blood transfusions, analgesic requirements and length of hospital stay. Overall expenses were then analyzed and compared.

Results:

Preoperative patient demographics and disease stages were comparable between the LRP and RRP groups. On a per procedure basis, large discrepancies were found in mean disposable instrument costs (LRP = $659.18 vs. RRP = $236.59), operating room costs (LRP = $4278.00 vs. RRP = $3139.00), mean cost of blood transfusions (LRP = $21.00 vs. RRP = $394.34), mean analgesia requirements (LRP = $12.94 vs. RRP = $41.06) and mean hospital stay bed costs (LRP = $3690.00 vs. RRP = $5027.14). Overall, costs for all patients in the LRP and RRP groups, respectively, were $606 307.29 and $618 721.57 with a cost saving of $12 414.28 in favour of the LRP arm.

Conclusion:

At our institution, we found that LRP costs are slightly less than those for RRP. Higher operative time and disposable instrument expenses are offset by the shorter hospital stays, fewer blood transfusions and less analgesic requirements for the LRP group. Further financial advantages for LRP will likely be achieved with additional reduction of operating room time and by minimizing disposables.     

Transperitoneal Robotic-Assisted Laparoscopic Prostatectomy After Prosthetic Mesh Herniorrhaphy

Background and Objectives:

We report our institutional experience performing transperitoneal robotic-assisted laparoscopic prostatectomy (RALP) in patients with prior prosthetic mesh herniorrhaphy to assess the feasibility of this procedure in this patient population.

Methods:

From October 2005 to January 2008, transperitoneal robotic-assisted laparoscopic prostatectomies were performed and prospectively recorded. We retrospectively reviewed 309 patients.

Results:

Twenty-seven patients (8.7%) were found to have a history of prior hernia repair with prosthetic mesh placement. The mean age was 55.7, estimated blood loss (EBL) was 228 mL, operative (console) time was 197 minutes, and length of hospital stay (LOS) was 1.62 days. In contrast, patients undergoing RALP with no history of mesh herniorrhaphy had a mean age of 59.3, EBL of 302 mL, console time of 193 minutes, and LOS of 2.2 days. These differences were not statistically significant. The mesh herniorrhaphy cohort had a lower percentage of organ-confined disease, but no difference was seen in margin status, continence, or potency rates after one year.

Conclusions:

Transperitoneal RALP is a feasible option for previously operated on patients with prosthetic mesh herniorrhaphy. Two areas that we identified as critical were the initial step of gaining access for pneumoperitoneum and port placement, and meticulous dissection to expose the mesh, which can be subsequently avoided and left intact. As RALP continues to gain popularity, urologists will continue to exploit the advantages of robotic surgery to perform increasingly challenging cases.     

Transperineal repair of a persistent rectourethral fistula using a porcine dermal graft

INTRODUCTION

Rectourethral fistula (RUF) is a rare major complication after radical prostatectomy (RP). Management of patients with persistent RUFs after primary repair is controversial and technically challenging.

PRESENTATION OF CASE

We describe the case of a patient with history of RUF secondary to rectal injury during laparoscopic RP and failed trans-abdominal repair. A further attempt to repair the persistent RUF was done through a perineal approach. The fistula was excised, the anterior rectal wall was closed in two layers and the defect at the level of the urethrovesical anastomosis (UVA) was repaired with an interrupted suture. A porcine dermal graft was interposed between the UVA and the rectum and was sutured to the rectal wall. There were neither clinical nor radiological evidences of fistula recurrence at one-year follow-up after transperineal surgical repair.

DISCUSSION

We used, for the first time, a porcine dermal collagen allograft as interposition tissue in a persistent RUF secondary to rectal injury during laparoscopic RP. The use of this allograft allows the potential advantage of less surgical invasivity if compared to gracilis muscle graft.

CONCLUSIONS

Transperineal repair of persistent RUFs with porcine dermal graft interposition is a safe and feasible surgical procedure.     

Impact of Percutaneous Suprapubic Tube Drainage on Patient Discomfort after Radical Prostatectomy

Background

Patients undergoing radical prostatectomy (RP) traditionally require urethral catheterization for adequate bladder drainage in the postoperative period. However, many patients have significant discomfort from the urethral catheter.

Objective

To describe a technique of percutaneous suprapubic tube (PST) bladder drainage after robotic-assisted laparoscopic radical prostatectomy (RALP) and to evaluate patient discomfort, complications, continence, and stricture rate after this procedure.

Design, setting, and participants

Two hundred two patients undergoing RALP were drained with a 14F PST instead of a urethral catheter. The PST was placed robotically at the conclusion of the urethrovesical anastomosis and secured to the skin over a plastic button. Beginning on postoperative day 5, patients clamped the PST, urinated per urethra, and measured the postvoid residual (PVR) drained by PST. The PST was removed when residuals were <30 cm³ per void. The control group consisted of 50 consecutive patients undergoing RALP with urethral catheter drainage.

Measurements

The primary end point was catheter-associated discomfort as measured with the Faces Pain Score-Revised (FPS-R). Secondary end points included use of anticholinergics, complications related to the PST, urinary continence, and urethral stricture.

Results and limitations

When compared with urethral catheter patients, PST patients had significantly decreased catheter-related discomfort on postoperative days 2 and 6 (p < 0.001). Anticholinergic medication was required by one PST and four urethral catheter patients (p < 0.001). Ten patients required urethral catheterization for PST dislodgement (n = 5) or urinary retention (n = 5). No patient has developed a urethral stricture at a mean follow-up of 7 mo.

Conclusions

PST provides adequate urinary drainage following RALP with less patient discomfort and no increased risk of urethral stricture.     

Impact of Fellowship Training on One-Year Outcomes of Robotic-Assisted Prostatectomy

Background and Objectives:

We examined 1-year functional and oncologic outcomes for robotic-assisted laparoscopic prostatectomy (RALP) from a single surgeon entering practice directly from fellowship training.

Methods:

We prospectively analyzed the first 100 RALPs performed by one fellowship-trained robotic surgeon. Data included resident involvement during the procedure, perioperative data, and surgical complications (scored using the Clavien grading system). Health-related quality of life (HRQOL) data were captured using the EPIC questionnaire at baseline (prior to surgery) and at 1-year follow-up.

Results:

Eighty-two patients (82%) had hospital stays of 2 days or less without any postoperative complications, urethral catheter removal was within 14 days of surgery, and none required readmission to the hospital. The overall positive margin rate was 21% (19% for patients with T2 disease). Clavien grades 1 through 4 complication rates, respectively, were 4%, 10%, 1%, and 1%. There were no deaths, reoperations, or bladder neck contractures. One patient (1%) required a blood transfusion within the 90-day perioperative period. At 1-year follow-up, 78% of patients reported wearing no pads; 41.3% of patients with baseline and 1-year follow-up data reported having intercourse.

Conclusions:

We provide baseline data pertaining to the morbidity, oncologic efficacy, continence results, and potency outcomes of new surgeons performing RALP.     

Combined bladder neck preservation and posterior musculofascial reconstruction during robotic assisted radical prostatectomy: effects on early and long term urinary continence recovery

Background

To evaluate the effects of combined bladder neck preservation and posterior reconstruction techniques on early and long term urinary continence in patients treated by robotic assisted radical prostatectomy (RARP).

Methods

Two-hundred ninety-two patients who previously underwent radical prostatectomy were retrospectively selected for a case-control study, excluding those with anastomotic strictures and significant perioperative complications and re-called for a medical follow-up visit after their consent to participate the study. They were divided in 3 different groups according to the surgical technique previously received: radical retropubic prostatectomy (RRP) combined with bladder neck preservation (BNP), RARP with bladder neck resection, and RARP combined with BNP and posterior musculofascial reconstruction (PRec).Functional and oncologic outcomes evaluation were integrated by a questionnaire on urinary continence status, abdominal ultrasound scan, uroflowmetry and post-void urine volume measurement.Urinary continence definition included the terms “no pad” or “safety pad”.

Results

Two hundred thirty-two patients responded to the phone call interview and were enrolled in the study. They presented comparable age, prostate volume and BMI. Differences in comorbidities, ASA score and medications, did not influence the postoperative functional results, focused on continence outcome.Early urinary continence was achieved in 49.38% and 24.73% of patients who previously underwent RARP?+?BNP?+?PRec and simple RARP respectively (p?=?0.000)as well as late 12-months urinary continence was obtained in 92.59% and 79.56% of patients.(p?=?0.01). Late urinary continence in the RRP?+?BNP group was comparable to the result obtained in the simple RARP group. The potential effects of nerve sparing technique on urinary continence have not been evaluated.

Conclusions

The combined technique of RARP?+?BNP?+?PRec seems to be effective to determine early and long term significant effects on urinary continence of patients with comparable body mass index, age and prostate volume. No statistically significant differences were found between the simple RARP and the RRP?+?BNP groups.

     

Bladder neck closure and suprapubic catheter placement as definitive management of neurogenic bladder

Objective

Surgical management for neurogenic bladder may require abandonment of the native urethra due to intractable urinary incontinence, irreparable urethral erosion, severe scarring from previous transurethral procedures, or urethrocutaneous fistula. In these patients, bladder neck closure (BNC) excludes the native urethra and provides continence while preserving the antireflux mechanism of the native ureters. This procedure is commonly combined with ileovesicostomy or continent catheterizable stoma, with or without augmentation enterocystoplasty. Alternatively, BNC can be paired with suprapubic catheter diversion. This strategy does not require a bowel segment, resulting in shorter operative times and less opportunity for bowel-related morbidity. The study purpose is to examine preoperative characteristics, indications, complications, and long-term maintenance of renal function of BNC patients.

Methods

A retrospective review of medical records of 35 patients who underwent BNC with suprapubic catheter placement from 1998 to 2007 by a single surgeon (LKL) was completed.

Results

Neurogenic bladder was attributable to spinal cord injury in 71%, 23% had multiple sclerosis, and 9% had cerebrovascular accident. Indications for BNC included severe urethral erosion in 80%, decubitus ulcer exacerbated by urinary incontinence in 34%, urethrocutaneous fistula in 11%, and other indications in 9%. The overall complication rate was 17%. All but two patients were continent at follow-up. Forty-nine per cent of patients had imaging available for review, none of which showed deterioration of the upper tracts.

Conclusions

Our results suggest that BNC in conjunction with suprapubic catheter diversion provides an excellent chance at urethral continence with a reasonable complication rate.     

Robotic Surgical Education: a Collaborative Approach to Training Postgraduate Urologists and Endourology Fellows

Objective:

Currently, robotic training for inexperienced, practicing surgeons is primarily done vis-à-vis industry and/or society-sponsored day or weekend courses, with limited proctorship opportunities. The objective of this study was to assess the impact of an extended-proctorship program at up to 32 months of follow-up.

Methods:

An extended-proctorship program for robotic-assisted laparoscopic radical prostatectomy was established at our institution. The curriculum consisted of 3 phases: (1) completing an Intuitive Surgical 2-day robotic training course with company representatives; (2) serving as assistant to a trained proctor on 5 to 6 cases; and (3) performing proctored cases up to 1 year until confidence was achieved. Participants were surveyed and asked to evaluate on a 5-point Likert scale their operative experience in robotics and satisfaction regarding their training

Results:

Nine of 9 participants are currently performing robotic-assisted laparoscopic radical prostatectomy (RALP) independently. Graduates of our program have performed 477 RALP cases. The mean number of cases performed within phase 3 was 20.1 (range, 5 to 40) prior to independent practice. The program received a rating of 4.2/5 for effectiveness in teaching robotic surgery skills.

Conclusion:

Our robotic program, with extended proctoring, has led to an outstanding take-rate for disseminating robotic skills in a metropolitan community.     

Penile rehabilitation after radical prostatectomy: patients’ attitude and feasibility in China

Objective

To investigate the behavior of Chinese erectile dysfunction (ED) patients after radical prostatectomy (RP) who were offered the penile rehabilitation and to assess their attitude and feasibility of rehabilitation after RP in China.

Materials and methods

Comprehensive medical and sexual histories of 187 evaluable PCa patients for RP were obtained together with their attitude towards penile rehabilitation. The rehabilitation data was compared between patients who accepted this treatment or not. The successful intercourse rate six months after treatment was also compared among three rehabilitation interventions, including phosphodiesterase type 5 inhibitor (PDE-5i), vacuum erection device (VED) and combination of both.

Results

141 (75.4%) patients reported being sexually active in the six months before RP.122 (65.2%) patients wished to preserve sexual activity and 80 (42.8%) had interest in penile rehabilitation after RP. Penile rehabilitation rate was 30.5%. The patients with younger age (P<0.001), higher IIEF-5 score preoperatively (P=0.03) and no adjuvant therapy post-RP (P=0.01) were more acceptable for rehabilitation. Main reasons for refusal of rehabilitation included lack of sexual interest followed by high cost of treatment. The successful intercourse rate was not significantly different among three rehabilitation interventions (P=0.32).

Conclusions

Less than one-third of Chinese RP patients accepted penile rehabilitation postoperatively. Patients’ attitude towards rehabilitation was conservative because of many reasons from traditional Chinese culture, doctors and patients themselves. Penile rehabilitation was feasible and effective in Chinese RP patients.     

A prospective,non‐randomized trial comparing robot‐assisted laparoscopic and retropubic radical prostatectomy in one European institution

OBJECTIVE

To compare the functional results of two contemporary series of patients with clinically localized prostate cancer treated by robot‐assisted laparoscopic prostatectomy (RALP) or retropubic radical prostatectomy (RRP).

PATIENTS AND METHODS

This was a non‐randomized prospective comparative study of all patients undergoing RALP or RRP for clinically localized prostate cancer at our institution from February 2006 to April 2007.

RESULTS

We enrolled 105 patients in the RRP and 103 in the RALP group; the two groups were comparable for all clinical and pathological variables, except median age. For RRP and RALP the respective median operative duration was 135 and 185 min (P < 0.001), the intraoperative blood loss 500 and 300 mL (P < 0.001) and postoperative transfusion rates 14% and 1.9% (P < 0.01). There were complications in 9.7% and 10.4% of the patients (P = 0.854) after RRP and RALP, respectively; the positive surgical margin rates in pT2 cancers were 12.2% and 11.7% (P = 0.70). For urinary continence, 41% of patients having RRP and 68.9% of those having RALP were continent at catheter removal (P < 0.001). The 12‐month continence rates were 88% after RRP and 97% after RALP (P = 0.01), with the mean time to continence being 75 and 25 days (P < 0.001), respectively. At the 12‐month follow‐up, 20 of 41 patients having bilateral nerve‐sparing RRP (49%) and 52 of 64 having bilateral nerve‐sparing RALP (81%) (P < 0.001) had recovery of erectile function.

CONCLUSIONS

RALP offers better results than RRP in terms of urinary continence and erectile function recovery, with similar positive surgical margin rates.