Consumerism and its impact on robotic-assisted radical prostatectomy

Study Type – Therapy (prevalence) Level of Evidence 2b

OBJECTIVES

? Many experts consider that media coverage, marketing and/or direct‐to‐consumer advertising, particularly Internet‐based forms, are fundamental to the widespread adoption of robotic‐assisted prostatectomy (RARP). However, this has not been explored previously. ? The primary objective of the present study was to delineate the role of media coverage and marketing of RARP on the Internet, whereas the secondary goal focused on website quality with respect to the presentation of prostatectomy.

MATERIALS AND METHODS

? Website content was evaluated for direct‐to‐consumer advertising after the retrieval of the first 50 websites using Google and Yahoo for each of the terms: ‘robotic prostatectomy, laparoscopic prostatectomy (LP) and open radical prostatectomy (ORP)’. ? A linear regression analysis was performed for the annual number of Internet news hits over the last decade for each procedure. Website quality assessment was performed using WHO Honesty on the Internet (HON) code principles.

RESULTS

? Of the retrieved sites, the proportion containing direct‐to‐consumer advertising for RARP vs LP vs ORP using Google was 64% vs 14% vs 0%, respectively (P < 0.001) and, using Yahoo, 80% vs 16% vs 0%, respectively (P < 0.001). ? In a linear regression analysis, the r² values for news hits for each year over the last 10 years were 0.89, 0.74 and 0.76 for RARP, LP and ORP, respectively. ? Website quality assessment found that a minority of the websites were accredited with HONcode principles, with no difference between procedure types (P > 0.05).

CONCLUSIONS

? Media coverage and marketing of RARP on the Internet is more widespread compared to LP and ORP. ? Disturbingly, the quality of websites using any technique for prostatectomy was of poor quality when using principles of honest information presenting and such findings need to be discussed with respect to obtaining informed consent from patients.     

Return to work following robot-assisted laparoscopic and open retropubic radical prostatectomy: A single-center cohort study to compare duration of sick leave

Purpose

To compare the duration of sick leave in patients with localized prostate cancer after robot-assisted radical prostatectomy (RARP) and open retropubic RP (ORP) at a German high-volume prostate cancer center.

Hospitalization Costs for Radical Prostatectomy Attributable to Robotic Surgery

Background

With health technology innovation responsible for higher health care costs, it is essential to have accurate estimates regarding the differential costs between robot-assisted radical prostatectomy (RARP) and open radical prostatectomy (ORP).

Objective

To describe the total hospitalization costs attributable to robotic and open surgery for radical prostatectomy (RP).

Design, setting, and participants

Using a population-based cohort by merging the Nationwide Inpatient Sample (NIS) and the American Hospital Association (AHA) survey from 2006 to 2008, we identified 29 837 prostate cancer patients who underwent RP.

Interventions

ORP and RARP.

Outcome measurements and statistical analysis

The primary outcome was total hospitalization costs adjusted to year 2008 US dollars. Generalized estimating equations were used to identify patient and hospital characteristics associated with total hospitalization costs and to estimate costs of ORP and RARP adjusted for case mix and hospital teaching status, location, and annual case volume.

Results and limitations

Overall, 20 424 (68.5%) patients were surgically treated with RARP, and 9413 (31.5%) patients underwent ORP. Compared to ORP, patients undergoing RARP had shorter median length of stay (1 d vs 2 d; p < 0.001) and were less likely to experience any postoperative complications (8.2% vs 11.3%; p < 0.001). However, patients undergoing RARP had higher median hospitalization costs ($10 409 vs $8862; p < 0.001). After adjusting for patient and hospital features, RARP was associated with higher total hospitalization costs compared to ORP ($11 932 vs $9390; p < 0.001). Our results are limited by a study design using retrospective population-based data.

Conclusions

Despite RARP having lower complications and shorter length of stay than ORP, total hospitalization costs are higher for patients treated with RARP compared with those treated with ORP.     

Community-based Outcomes of Open versus Robot-assisted Radical Prostatectomy

Background

Identifying the optimal surgical approach for patients with localized prostate cancer (PCa) managed in the community setting remains controversial due to the lack of robust, prospective data.

The impact of preoperative erectile dysfunction on survival after radical prostatectomy

Study Type – Prognosis (case series)
Level of Evidence 4

PURPOSE

Erectile dysfunction (ED) and cardiovascular disease (CVD) share etiology and pathophysiology. The underlying pathology for preoperative ED may adversely affect survival following radical prostatectomy (RP). We examined the association between preoperative ED and survival following RP.

MATERIALS AND METHODS

Between 1983 and 2000, a single surgeon performed RP on 2511 men, with preoperative ED (ED group, n= 231, 9.2%) or without ED (No ED group, n= 2280, 90.8%). We retrospectively analysed their CVD‐specific survival (CVDSS), prostate cancer‐specific survival (PCSS), non‐PCSS (NPCSS) and overall survival (OS) from time of surgery.

RESULTS

With median follow‐up of 13 years after RP, 449 men (18%) died (140 from prostate cancer, 309 from other causes). Kaplan–Meier analyses demonstrated significant differences in CVDSS (P < 0.001), NPCSS (P < 0.001) and OS (P < 0.001), but not in PCSS (P= 0.12), between the ED group vs No ED group. In univariate proportional hazards analyses, preoperative ED was associated with a significant decrease in OS, hazard ratio (HR), 1.71 (95% CI, 1.34–2.23), P < 0.001. However, in multivariable analyses, the association of ED with survival became non‐significant (HR, 1.25 (95% CI, 0.97–1.66), P= 0.111) after adjusting for other prognostic factors, such as age, preoperative prostate‐specific antigen (PSA) level, Gleason score, pathologic stage, body mass index and Charlson Comorbidity Index.

CONCLUSIONS

Preoperative ED is associated with decreased overall survival and survival from causes other than prostate cancer following RP. However, preoperative ED was not an independent predictor of overall survival after adjusting for other predictors of survival. Urologists should carefully assess pretreatment ED status to enhance appropriate treatment recommendation for men with prostate cancer.     

Comparative Effectiveness of Robot-assisted Versus Open Radical Prostatectomy Cancer Control

Background

Robot-assisted radical prostatectomy (RARP) remains controversial, and no improvement in cancer control outcomes has been demonstrated over open radical prostatectomy (ORP).

Objective

To examine population-based, comparative effectiveness of RARP versus ORP pertaining surgical margin status and use of additional cancer therapy.

Design, setting, and participants

This was a retrospective observational study of 5556 RARP and 7878 ORP cases from 2004 to 2009 from Surveillance Epidemiology and End Results–Medicare linked data.

Intervention

RARP versus ORP.

Outcome measurements and statistical analysis

Propensity-based analyses were performed to minimize treatment selection biases. Generalized linear regression models were computed for comparison of RP surgical margin status and use of additional cancer therapy (radiation therapy [RT] or androgen deprivation therapy [ADT]) by surgical approach.

Results and limitations

In the propensity-adjusted analysis, RARP was associated with fewer positive surgical margins (13.6% vs 18.3%; odds ratio [OR]: 0.70; 95% confidence interval [CI], 0.66–0.75), largely because of fewer RARP positive margins for intermediate-risk (15.0% vs 21.0%; OR: 0.66; 95% CI, 0.59–0.75) and high-risk (15.1% vs 20.6%; OR: 0.70; 95% CI, 0.63–0.77) disease. In addition, RARP was associated with less use of additional cancer therapy within 6 mo (4.5% vs 6.2%; OR: 0.75; 95% CI, 0.69–0.81), 12 mo (OR: 0.73; 95% CI, 0.62–0.86), and 24 mo (OR: 0.67; 95% CI, 0.57–0.78) of surgery. Limitations include the retrospective nature of the study and the absence of prostate-specific antigen levels to determine biochemical recurrence.

Conclusions

RARP is associated with improved surgical margin status relative to ORP for intermediate- and high-risk disease and less use of postprostatectomy ADT and RT. This has important implications for quality of life, health care delivery, and costs.

Patient summary

Robot-assisted radical prostatectomy (RP) versus open RP is associated with fewer positive margins and better early cancer control because of less use of additional androgen deprivation and radiation therapy within 2 yr of surgery.     

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.

Interval from prostate biopsy to robot‐assisted radical prostatectomy: effects on perioperative outcomes

OBJECTIVE

To determine whether shorter intervals (<4 and 6 weeks) between prostate biopsy and robot‐assisted radical prostatectomy (RARP) have a detrimental effect on perioperative outcomes, as recent studies showed that open RP shortly after prostate biopsy does not adversely influence surgical difficulty or efficacy, but RARP relies solely on visual cues rather than tactile sensation to determine posterior surgical planes of dissection.

PATIENTS AND METHODS

A series of 559 patients undergoing RARP from March 2004 to July 2007 was retrospectively reviewed. The interval between prostate biopsy and RARP was determined and patients with intervals of ≤4 weeks were compared to those >4 weeks. Patient characteristics and perioperative outcomes were analysed to determine statistically significant differences between the groups. This comparison was then repeated with a ≤6‐ vs >6‐week interval, and examined with a multivariate logistic regression analysis.

RESULTS

In the ≤4‐week group (27 patients) vs the >4‐week group (509 patients), there was a significantly (P < 0.05) higher rate of complications (18.5% vs 6.9%). In the ≤6‐week group (81 patients) vs the >6‐week group (455 patients) there was a smaller but still significantly higher rate of complications (13.6% vs 6.4%). These results were still significant when controlling for patient and disease characteristics and the ‘learning curve’. There was also a significantly higher rate of transfusion in the ≤6‐week group (3.7%) than the >6‐week group (0.7%).

CONCLUSIONS

Our data suggest that RARP should be delayed after prostate biopsy; RARP within 6 weeks of biopsy was associated with a greater risk of complications even when controlling for disease and patient characteristics.     

Adequacy of lymphadenectomy among men undergoing robot‐assisted laparoscopic radical prostatectomy

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To compare rates of lymph node dissection (LND) and nodal yields between patients treated with open radical retropubic prostatectomy (ORRP) and robot‐assisted RRP (RARP) in a contemporary single‐institution series.

PATIENTS AND METHODS

Data from 1278 consecutive patients (716 ORRP and 562 RARP) from one institution were accrued prospectively in an institutional database, and the data analysed retrospectively. Disease risk was assessed using the Cancer of the Prostate Risk Assessment (CAPRA) score. The likelihood of LND, nodal yield, and likelihood of node positivity were compared between ORRP and RARP.

RESULTS

Of patients treated with ORRP and RARP, 47.8% and 31.8% had LND, respectively, with more receiving LND over time in both surgical approaches. Men undergoing LND had a higher disease risk than those not undergoing LND (mean CAPRA score 4.3 vs 2.1, P < 0.01), and there was no difference in risk between those undergoing ORRP or RARP (mean CAPRA score 3.0 vs 2.9, P = 0.29). The mean (sd ) nodal yield was 14.4 (8.7) for ORRP and 9.3 (5.4) for RARP (P < 0.01). Among patients undergoing LND, 5.8% of ORRP and 4.1% of RARP patients had positive nodes (P < 0.01).

CONCLUSIONS

The indications for LND and template dissection should be the same regardless of surgical approach. The nodal yield was adequate using both approaches; the yield was higher among ORRP than RARP patients, but the difference was not large, and is less remarkable than the wide variation in yield within each approach. Several factors might explain this variation.     

Robot‐assisted radical prostatectomy: learning rate analysis as an objective measure of the acquisition of surgical skill

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To adapt an industrial definition of learning‐curve analysis to surgical learning, and elucidate the rate at which experienced open surgeons acquire skills specific to robot‐assisted radical prostatectomy (RARP) at a community‐based medical centre.

PATIENTS, SUBJECTS AND METHODS

The total procedure time (TPT) of the first 75 RARPs, performed by three surgeons experienced with retropubic RP, was analysed to determine the point at which their learning rate stabilised. Operative characteristics were compared before and after this point to isolate the plateau of learning rate as a mark of acquiring surgical skill. The operative characteristics examined were TPT, estimated blood loss (EBL), bladder neck contractures (BNC), positive margins (PM) and length of hospital stay (LOS).

RESULTS

The mean rate of TPT decrease, for procedures 1–75, was 13.4% per doubling of RARPs performed. After the first 25 procedures the TPT decreased at a rate of 1.8% per doubling, not significantly different from 0 (P > 0.05). There was no significant difference between procedures 1–25 and 26–75 in rates of EBL, BNC and PM. There was a significant change for all surgeons in TPT, with a mean of 303.1 min (RARPs 1–25) vs 213.6 min (26–75) (P < 0.001), and LOS, of 2.1 days (1–25) vs 1.4 days (26–75) (P < 0.001).

CONCLUSIONS

An industrial definition of learning‐curve analysis can be adapted to provide an objective measure of learning RARP. The average learning rate for RARP was found to plateau by the 25th procedure. Also, the learning rate plateau can serve as an objective measure of the acquisition of surgical skill.     

Perioperative outcomes of robot-assisted radical prostatectomy compared with open radical prostatectomy: results from the nationwide inpatient sample

Background

Prior to the introduction and dissemination of robot-assisted radical prostatectomy (RARP), population-based studies comparing open radical prostatectomy (ORP) and minimally invasive radical prostatectomy (MIRP) found no clinically significant difference in perioperative complication rates.

Objective

Assess the rate of RARP utilization and reexamine the difference in perioperative complication rates between RARP and ORP in light of RARP's supplanting laparoscopic radical prostatectomy (LRP) as the most common MIRP technique.

Design, setting, and participants

As of October 2008, a robot-assisted modifier was introduced to denote robot-assisted procedures. Relying on the Nationwide Inpatient Sample between October 2008 and December 2009, patients treated with radical prostatectomy (RP) were identified. The robot-assisted modifier (17.4x) was used to identify RARP (n = 11 889). Patients with the minimally invasive modifier code (54.21) without the robot-assisted modifier were classified as having undergone LRP and were removed from further analyses. The remainder were classified as ORP patients (n = 7389).

Intervention

All patients underwent RARP or ORP.

Measurements

We compared the rates of blood transfusions, intraoperative and postoperative complications, prolonged length of stay (pLOS), and in-hospital mortality. Multivariable logistic regression analyses of propensity score–matched populations, fitted with general estimation equations for clustering among hospitals, further adjusted for confounding factors.

Results and limitations

Of 19 462 RPs, 61.1% were RARPs, 38.0% were ORPs, and 0.9% were LRPs. In multivariable analyses of propensity score–matched populations, patients undergoing RARP were less likely to receive a blood transfusion (odds ratio [OR]: 0.34; 95% confidence interval [CI], 0.28–0.40), to experience an intraoperative complication (OR: 0.47; 95% CI, 0.31–0.71) or a postoperative complication (OR: 0.86; 95% CI, 0.77–0.96), and to experience a pLOS (OR: 0.28; 95% CI, 0.26–0.30). Limitations of this study include lack of adjustment for tumor characteristics, surgeon volume, learning curve effect, and longitudinal follow-up.

Conclusions

RARP has supplanted ORP as the most common surgical approach for RP. Moreover, we demonstrate superior adjusted perioperative outcomes after RARP in virtually all examined outcomes.     

Neoadjuvant chemohormonal therapy followed by robot-assisted and minimum incision endoscopic radical prostatectomy in patients with high-risk prostate cancer: comparison of perioperative and oncological outcomes at single institution

Purpose

Optimal management strategies for patients with high-risk prostate cancer (PCa) have not been established. This study aimed to estimate the impact of surgical procedures on perioperative and oncological outcomes in patients with high-risk PCa who received neoadjuvant chemohormonal therapy (CHT) prior to radical prostatectomy (RP).

Methods

In this retrospective study, we focused on patients with high-risk PCa who received neoadjuvant CHT followed by RP. The enrolled patients were divided into the following two groups according to surgical procedure: the robot-assisted RP (RARP) group and minimum incision endoscopic RP (MIE-RP) group. The primary endpoint was biochemical recurrence-free survival (BRFS).

Results

A total of 522 high-risk PCa patients were enrolled in this study. The median operating time was significantly shorter in the MIE-RP group than in the RARP group. The median estimated blood loss was significantly lower in the RARP group than in the MIE-RP group. The rates of positive surgical margins (PSMs) were not statistically significant in either group. During the follow-up period, biochemical recurrence (BCR) without clinical recurrence occurred in 60 (23.9%) patients in the MIE-RP group and 5 (1.8%) in the RARP group. The 5-year BRFS rate was 76.5% in the MIE-RP group and 97.6% in the RARP group (P?<?0.001). On multivariate analysis, RARP, PSM, pathological T stage, and initial prostate-specific antigen were significantly associated with BCR.

Conclusions

Neoadjuvant CHT with subsequent RARP may decrease the risk of BCR when compared to MIE-RP.

     

Robotic vs open prostatectomy in a laparoscopically naive centre: a matched‐pair analysis

OBJECTIVE

To compare the early oncological, perioperative and functional outcomes of robotic‐assisted radical prostatectomy (RARP) vs open retropubic RP (RRP) in a laparoscopically naive centre, as robotic assistance aids the laparoscopically naive surgeon in minimally invasive prostate surgery, by offering magnification and superior dexterity.

PATIENTS AND METHODS

From 1 November 2006 to 31 December 2007, 120 patients had RARP; this group was followed prospectively and evaluated for early oncological, perioperative and functional outcomes (measured at 3, 6 and 12 months after surgery), and compared to a historical control group of consecutive patients who had RRP from 20 May 2004 to 28 February 2007. All patients were operated by the same laparoscopically naive surgeons. The comparison was by matched‐pair analysis.

RESULTS

The baseline characteristics of the two groups were equivalent, although there was a higher percentage of patients with pT3/pT4 disease in the RRP group. As a proxy for oncological outcome, positive surgical margins were equivalent in the two groups (22% RARP vs 25% RRP, P = 0.77). The overall mean (range) surgical duration was significantly longer in RARP group, at 215 (165–450) min vs 160 (90–240) min in the RRP group (P < 0.001). However, RARP had a statistically significant advantage over RRP for estimated blood loss, of 200 vs 800 mL (P < 0.001), duration of catheterization (6 vs 7 days P < 0.001) and length of stay (3 vs 6 days, P < 0.001) The 3, 6 and 12‐month continence rates were 70%, 93% and 97% vs 63%, 83% and 88% after RARP and RRP, respectively (P = 0.15, 0.011 and 0.014). The 3, 6 and 12 month overall potency recovery rate was 31%, 43% and 61% vs 18%, 31% and 41%, after RARP and RRP, respectively (P = 0.006, 0.045 and 0.003).

CONCLUSION

Our initial experience showed the feasibility of RARP in a laparoscopically naive centre. RRP seems to be a faster procedure, whereas RARP provided better results in terms of estimated blood loss, hospitalization and functional results. The early oncological outcome seemed to be equivalent in the two groups.     

Open Versus Robotic Radical Prostatectomy in Obese Men

Objectives

Robotic-assisted radical prostatectomy (RARP) has been shown to reduce blood loss, peri-operative complications and length of stay when compared to open radical prostatectomy (ORP). We sought to determine whether the reported benefits of RARP over ORP translate to obese patients.

Patients and Methods

We utilized the 2009–2010 Nationwide Inpatient Sample to identify all obese men with prostate cancer who underwent ORP and RARP. Our primary outcome was the presence of a peri-operative adverse event (i.e. blood transfusion, complication, prolonged length of stay). We fit multivariable logistic regression models to examine whether RARP in obese patients was independently associated with decreased odds of all three outcomes.

Results

We identified 9,108 obese patients who underwent radical prostatectomy. On multivariable analysis, the use of RARP in the obese population was not independently associated with decreased odds of developing a peri-operative complication (OR = 0.81, CI: 0.58–1.13, p = 0.209). RARP was, however, associated with decreased odds of blood transfusion (OR = 0.17, CI: 0.10–0.30, p < 0.001) and prolonged length of stay (OR = 0.28, CI: 0.20–0.40, p < 0.001).

Conclusion

Our findings suggest that in obese patients, the use of RARP may reduce length of stay and blood transfusions compared to ORP. Both approaches, however, are associated with similar odds of developing a complication.Key Words: Obesity, Prostatectomy, Prostate cancer, Robotic surgery     

Laser robotically assisted nerve-sparing radical prostatectomy: a pilot study of technical feasibility in the canine model

OBJECTIVES

To examine the feasibility of using laser energy during nerve‐sparing robotically assisted radical prostatectomy (RARP), as the energy sources currently used for haemostasis in RARP adversely affect cavernous nerve function, while clips require application by a skilled assistant, but laser energy potentially allows precise dissection with minimal collateral tissue injury.

MATERIALS AND METHODS

We used laser‐based RARP in 10 dogs, using the da Vinci S system (Intuitive Surgical, Sunnyvale, CA, USA) and a prototype robotic laser instrument. The potassium‐titanyl‐phosphate laser was used for dissection at 2–6 W, with intermittent use of the neodymium‐doped yttrium‐aluminium‐garnet laser at 5 W for coagulating larger vessels. The peak intracavernosal pressure response to nerve stimulation was recorded as a percentage of mean arterial pressure (ICP%MAP) before and after RARP. Five dogs were killed immediately after RARP and five were maintained alive for 72 h; the haemoglobin and haematocrit levels were measured before and after RARP in the latter five dogs.

RESULTS

All 10 procedures were performed solely using laser energy and no additional haemostatic manoeuvres. The median prostate excision time was 65 min. The ICP%MAP before and after RARP (median 98.5% and 77.0%, P = 0.12) were not significantly different; similarly, the respective haemoglobin (median 14.4 vs 12.6 g/dL, P = 0.06) and haematocrit levels (45.1% vs 40.2%, P = 0.06) were not significantly different. Two dogs had catheter‐related complications and one had an anastomotic leak. There were no laser‐related complications or postoperative haemorrhage.

CONCLUSIONS

Laser RARP is feasible in dogs and further assessment is warranted.     

Superior Quality of Life and Improved Surgical Margins Are Achievable with Robotic Radical Prostatectomy After a Long Learning Curve: A Prospective Single-surgeon Study of 1552 Consecutive Cases

Background

Comparative studies suggest functional and perioperative superiority of robot-assisted radical prostatectomy (RARP) over open radical prostatectomy (ORP).

Objective

To determine whether high-volume experienced open surgeons can improve their functional and oncologic outcomes with RARP and, if so, how many cases are required to surpass ORP outcomes and reach the learning curve plateau.

Design, setting, and participants

A prospective observational study compared two surgical techniques: 1552 consecutive men underwent RARP (866) or ORP (686) at a single Australian hospital from 2006 to 2012, by one surgeon with 3000 prior ORPs.

Outcome measurements and statistical analysis

Demographic and clinicopathologic data were collected prospectively. The Expanded Prostate Cancer Index Composite quality of life (QoL) questionnaire was administered at baseline, 1.5, 3, 6, 12, and 24 mo. Multivariate linear and logistic regression modelled the difference in QoL domains and positive surgical margin (PSM) odds ratio (OR), respectively, against case number.

Results and limitations

A total of 1511 men were included in the PSM and 609 in the QoL analysis. RARP sexual function scores surpassed ORP scores after 99 RARPs and increased to a mean difference at 861st case of 11.0 points (95% confidence interval [CI], 5.9–16.1), plateauing around 600–700 RARPs. Early urinary incontinence scores for RARP surpassed ORP after 182 RARPs and increased to a mean difference of 8.4 points (95% CI, 2.1–14.7), plateauing around 700–800 RARPs. The odds of a pT2 PSM were initially higher for RARP but became lower after 108 RARPs and were 55% lower (OR: 0.45; 95% CI, 0.22–0.92) by the 866th RARP. The odds of a pT3/4 PSM were initially higher for RARP but decreased, plateauing around 200–300 RARPs with an OR of 1.15 (0.68–1.95) at the 866th RARP. Limitations include single-surgeon data and residual confounding.

Conclusions

RARP had a long learning curve with inferior outcomes initially, and then showed progressively superior sexual, early urinary, and pT2 PSM outcomes and similar pT3 PSM and late urinary outcomes. Learning RARP was worthwhile for this high-volume surgeon, but the learning curve may not be justifiable for late-career/low-volume surgeons; further studies are needed.     

Continence,potency and oncological outcomes after robotic‐assisted radical prostatectomy: early trifecta results of a high‐volume surgeon

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

? To evaluate early trifecta outcomes after robotic‐assisted radical prostatectomy (RARP) performed by a high‐volume surgeon.

PATIENTS AND METHODS

? We evaluated prospectively 1100 consecutive patients who underwent RARP performed by one surgeon. In all, 541 men were considered potent before RARP; of these 404 underwent bilateral full nerve sparing and were included in this analysis. ? Baseline and postoperative urinary and sexual functions were assessed using self‐administered validated questionnaires. ? Postoperative continence was defined as the use of no pads; potency was defined as the ability to achieve and maintain satisfactory erections for sexual intercourse >50% of times, with or without the use of oral phosphodiesterase type 5 inhibitors; Biochemical recurrence (BCR) was defined as two consecutive PSA levels of >0.2 ng/mL after RARP. ? Results were compared between three age groups: Group 1, ≤55 years, Group 2, 56–65 years and Group 3, >65 years.

RESULTS

? The trifecta rates at 6 weeks, 3, 6, 12, and 18 months after RARP were 42.8%, 65.3%, 80.3%, 86% and 91%, respectively. ? There were no statistically significant differences in the continence and BCR‐free rates between the three age groups at all postoperative intervals analysed. ? Nevertheless, younger men had higher potency rates and shorter time to recovery of sexual function when compared with older men at 6 weeks, 3, 6 and 12 months after RARP (P < 0.01 at all time points). ? Similarly, younger men had higher trifecta rates at 6 weeks, 3 and 6 months after RARP compared with older men (P < 0.01 at all time points).

CONCLUSION

? RARP offers excellent short‐term trifecta outcomes when performed by an experienced surgeon. ? Younger men had higher overall trifecta rates when compared with older men at 6 weeks, 3 and 6 months after RARP.     

Multicenter evaluation of guideline adherence for pelvic lymph node dissection in patients undergoing open retropubic vs. laparoscopic or robot assisted radical prostatectomy according to the recent German S3 guideline on prostate cancer

Purpose

Pelvic lymph node dissection (PLND) is recommended for patients with prostate cancer (PCa) and significant risk for nodal metastases. This study aimed to assess guideline adherence regarding PLND according to the German S3 guideline as example for a national but highly used guideline on prostate cancer and to compare the rate of complications different approaches for radical prostatectomy (RP).

Methods

Patients undergoing open (RRP), laparoscopic (LARP) or robot-assisted (RARP) RP in six centers in Germany and Austria were included. The primary endpoint was the total number of removed lymph nodes (LN) between the different surgical approaches according to recent guideline recommendations. Secondary endpoints were the number of patients undergoing a sufficient PLND, defined as a removal of at least 10 LN and associated complication rates.

Results

2634 patients undergoing RP were included (RRP: 66%, RARP/LARP: 34%). PLND was performed in 88% (RRP: 88.5%, RARP/LARP: 86.8%, p = 0.208). In intermediateor high risk PCa, PLND was performed in 97.2% (RRP: 97.7%, RARP/LARP: 96.2, p = 0.048). Of those, the mean number of LN was 19 (RRP: 19 vs. RARP/LARP: 17, p < 0.005) and sufficient PLND was observed in 84.6% of RRP compared to 77.2% of RARP/LARP (p < 0.005). Symptomatic lymphoceles requiring surgical treatment occurred more often in RRP than in RARP/LARP (4.0% vs. 1.6%, p = 0.001).

Conclusions

The general guideline adherence regarding performing PNLD and the LN yield is high, regardless of the surgical approach. As expected, lymph node yield was higher when very experienced surgeons conducted the procedure. This should be considered in patients’ counseling.

     

The impact of nerve‐sparing robot‐assisted radical prostatectomy on lower urinary tract function: Prospective assessment of patient‐reported outcomes and frequency volume charts

Aims

To elucidate the effects of a nerve‐sparing (NS) procedure on lower urinary tract symptoms (LUTS) and urinary function after robot‐assisted radical prostatectomy (RARP), the associations between the NS procedure and LUTS and urinary function were investigated.

Methods

The participants in this study were 200 consecutive patients who underwent RARP. These patients were categorized into unilateral and bilateral NS groups and the non‐NS group. The International Prostate Symptom Score (IPSS), quality of life (QOL) index, frequency‐volume chart, uroflowmetry, 1‐h pad test, and the 5‐item International Index of Erectile Function (IIEF‐5) questionnaire were evaluated before and after RARP.

Results

The total IPSS score was significantly lower in the unilateral (P = 0.03) and bilateral NS groups (P = 0.03) than in the non‐NS group after RARP. Diurnal maximum voided volume (MVV) values were significantly greater in the bilateral NS group than in the non‐NS group after RARP (P = 0.002). Nocturnal frequency was significantly decreased in the unilateral NS group than in the non‐NS group after RARP (3 months P = 0.01, 12 months P = 0.01). Erectile function was significantly better in both the unilateral NS group (P < 0.0001) and the bilateral NS group (P = 0.02) than in the non‐NS group 12 months after RARP.

Conclusions

The NS procedure in RARP has the possibility to improve not only erectile function, but also LUTS, owing to both the increase of MVV and the decrease of nocturia. Therefore, the NS procedure is also recommended from the viewpoint of early improvement of LUTS and lower urinary tract dysfunction after RARP.     

Early oncological outcomes of robot‐assisted radical prostatectomy for high‐grade prostate cancer

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To evaluate the oncological outcomes of patients with specimen Gleason 8 and 9 prostate cancers and to determine factors that predict biochemical recurrence‐free survival (BCRFS) after robot‐assisted radical prostatectomy (RARP).

PATIENTS AND METHODS

Of 4156 patients who underwent RARP from January 2001 to 2009, we identified 368 men with Gleason 8 or 9 tumours who met the inclusion criteria. BCR was defined as a PSA level of ≥0.2 ng/mL with a second rising value. The Kaplan–Meier method and log‐rank test were used to compare BCRFS while factors that predict BCRFS were determined by Cox proportional hazards modelling.

RESULTS

The median age and PSA level were 62 years and 6.4 ng/mL for men with Gleason 8, and 63 years and 6.7 ng/mL for Gleason 9 cancers. The median (interquartile range, IQR) overall follow‐up was 23 (10–46) months and 19 (7–37) months for Gleason 8 and 9 tumours, respectively. At 60 months the mean (se ) overall BCRFS was 36 (5)% and for Gleason 8 it was 47 (6)% and for Gleason 9 it was 21 (7)% (P < 0.001). At 5 years, extraprostatic extension (pT3a) resulted in BCRFS of 52 (9)% for Gleason 8 tumours and 21 (11)% for Gleason 9 (P= 0.012). On multivariable analysis, lymph node invasion, specimen Gleason score, pathological stage and tumour volume predicted BCRFS.

CONCLUSIONS

Early results suggest RARP monotherapy performs comparably to RP for BCRFS in men with high‐grade prostate cancer. There are significant oncological differences between Gleason 8 and 9 tumours.