Comparison of oncological outcomes between retropubic radical prostatectomy and robot-assisted radical prostatectomy: an analysis stratified by surgical experience

Objectives

To compare oncological outcomes of a consecutive retropubic radical prostatectomy (RRP) and robot-assisted radical prostatectomy (RARP) series performed by a single surgeon who had performed >750 prior RRPs and was starting to perform RARPs.

Materials and methods

Prospectively collected longitudinal data of 277 RRP and 730 RARP cases over a 5-year period were retrospectively analyzed. The RARP series were divided into 3 subgroups (1st, <250 cases; 2nd, 250–500; and 3rd, >500) according to the surgical period. The positive surgical margin (PSM) and biochemical recurrence-free survival (BCRFS) rates were compared at each pathological stage.

Results

The pT2 PSM rates showed no significant difference between the RRP (7.8 %) and RARP series (1st, 9.5 %; 2nd, 14.1 %; and 3rd, 9.8 %) throughout the study period (P = 0.689, 0.079, and 0.688, respectively). Although the pT3 PSM rates of the 1st (50.6 %) and 2nd RARP series (50.0 %) were higher than that of the RRP series (36.0 %; P = 0.044 and P = 0.069, respectively), the 3rd RARP series had a comparable pT3 PSM rate (32.4 %, P = 0.641). The 3-year BCRFS rates of the RRP and RARP series were similar at each pathological stage (pT2, 92.1 vs. 96.8 %, P = 0.517; pT3, 60.0 vs. 67.3 %, P = 0.265, respectively).

Conclusions

The pT2 PSM and short-term BCRFS rates were similar between RRP and RARP, and RARP showed comparable pT3 PSM rate with RRP after >500 cases of surgical experience. Our data suggest that an experienced robotic surgeon at a high-volume center may achieve comparable oncological outcomes with open prostatectomy even in locally advanced disease.     

Positive surgical margins during robotic radical prostatectomy: a contemporary analysis of risk factors

OBJECTIVE

To determine the risk factors (clinical, pathological and technical) for positive surgical margins (PSMs) after robotically assisted radical prostatectomy (RARP), as a PSM is associated with an increased risk of biochemical recurrence and often responsible for significant patient anxiety.

PATIENTS AND METHODS

Between November 2003 and March 2007, 216 consecutive patients had an RARP by one fellowship‐trained urological oncologist. The surgical pathological specimens were fixed and processed using standard techniques, and assessed by a pathologist at the same institution. A PSM was defined as the presence of cancer adjacent to the inked margin. The clinical charts were reviewed retrospectively under an approved institutional review board protocol. Univariable and multivariable methods, including logistic regression models, were used to analyse the clinical, pathological and technical risk factors for PSM.

RESULTS

The overall prevalence of PSM was 14.8% (32/216), and 5.4% (8/149) for pT2 cancers. The only preoperative factor that was associated with a greater risk of a PSM was the serum prostate‐specific antigen (PSA) level (P = 0.012) and PSA density (P = 0.005). Age, clinical stage and clinical Gleason grade were not predictors of a PSM. The overall and pT2 PSM rate remained constant throughout the series of 216 patients (P = 0.371), indicating that the initial experience for RARP was not associated with a significantly greater risk of a PSM. However, there was a small independent ‘learning curve’ effect, with a lower rate of PSM associated with each increment of 25 patients (odds ratio 0.8, 95% confidence interval 0.6–1.0), supported by the significantly decreasing trend in PSM for pT3 cancers over time (P = 0.031) Although there was no significant increase over time in PSM with the use of an endostapler to control the dorsal venous complex (DVC), there was a significant learning effect, with a decrease in the PSM rate specifically in pT3 cancers using the suture technique (P = 0.005). A nerve‐sparing procedure increased the risk of PSM in multivariable analysis (P = 0.03). As expected, pathological stage and pathological Gleason grade were the strongest predictors of PSM (P < 0.001).

CONCLUSION

The most important risk factors for a PSM after RARP are the preoperative PSA level, PSA density, pathological stage and Gleason grade. PSM rates for a surgeon in their initial experience can be comparable to that of a surgeon experienced in RARP. Using a stapling device to control the DVC does not appear to increase the risk of a PSM, although nerve‐sparing increases the rates of PSM in extraprostatic prostate cancer.     

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.     

Systematic Review and Meta-analysis of Studies Reporting Oncologic Outcome After Robot-assisted Radical Prostatectomy

Context

Despite the large diffusion of robot-assisted radical prostatectomy (RARP), literature and data on the oncologic outcome of RARP are limited.

Objective

Evaluate lymph node yield, positive surgical margins (PSMs), use of adjuvant therapy, and biochemical recurrence (BCR)–free survival following RARP and perform a cumulative analysis of all studies comparing the oncologic outcomes of RARP and retropubic radical prostatectomy (RRP) or laparoscopic radical prostatectomy (LRP).

Evidence acquisition

A systematic review of the literature was performed in August 2011, searching Medline, Embase, and Web of Science databases. A free-text protocol using the term radical prostatectomy was applied. The following limits were used: humans; gender (male); and publications dating from January 1, 2008. A cumulative analysis was conducted using Review Manager software v.4.2 (Cochrane Collaboration, Oxford, UK) and Stata 11.0 SE software (StataCorp, College Station, TX, USA).

Evidence synthesis

We retrieved 79 papers evaluating oncologic outcomes following RARP. The mean PSM rate was 15% in all comers and 9% in pathologically localized cancers, with some tumor characteristics being the most relevant predictors of PSMs. Several surgeon-related characteristics or procedure-related issues may play a major role in PSM rates. With regard to BCR, the very few papers with a follow-up duration >5 yr demonstrated 7-yr BCR-free survival estimates of approximately 80%. Finally, all the cumulative analyses comparing RARP with RRP and comparing RARP with LRP demonstrated similar overall PSM rates (RARP vs RRP: odds ratio [OR]: 1.21; p = 0.19; RARP vs LRP: OR: 1.12; p = 0.47), pT2 PSM rates (RARP vs RRP: OR: 1.25; p = 0.31; RARP vs LRP: OR: 0.99; p = 0.97), and BCR-free survival estimates (RARP vs RRP: hazard ratio [HR]: 0.9; p = 0.526; RARP vs LRP: HR: 0.5; p = 0.141), regardless of the surgical approach.

Conclusions

PSM rates are similar following RARP, RRP, and LRP. The few data available on BCR from high-volume centers are promising, but definitive comparisons with RRP or LRP are not currently possible. Finally, significant data on cancer-specific mortality are not currently available.     

Learning curve of minimally invasive radical prostatectomy: Comprehensive evaluation and cumulative summation analysis of oncological outcomes

Background and objective

The primary objective was to evaluate the learning curve of minimally invasive radical prostatectomy (MIRP) in our institution and analyze the salient learning curve transition points regarding oncological outcomes.

Superior Biochemical Recurrence and Long-term Quality-of-life Outcomes Are Achievable with Robotic Radical Prostatectomy After a Long Learning Curve—Updated Analysis of a Prospective Single-surgeon Cohort of 2206 Consecutive Cases

Background

Our earlier analysis suggested that robot-assisted radical prostatectomy (RARP) achieved superiority over open radical prostatectomy (ORP) in terms of positive surgical margin (PSM) rates and functional outcomes.

Impact of surgical technique (open vs laparoscopic vs robotic-assisted) on pathological and biochemical outcomes following radical prostatectomy: an analysis using propensity score matching

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Thus far, no institution has investigated the impact of the most commonly used surgical techniques – open, laparoscopic and robotic radical prostatectomy – on biochemical outcome. However, recent data from large meta‐analysis suggest that the impact of the chosen surgical technique on biochemical outcome is minimal and statistically not relevant. We are the first to apply the method of propensity score matching in the urology literature to compare three different surgical techniques. This method is intended to simulate a randomized trial which is unlikely to be undertaken for radical prostatectomies. We confirmed previous data that the surgical technique does not seem to have an impact on biochemical outcome following radical prostatectomy.

OBJECTIVE

? To investigate a single institution experience with radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robot‐assisted radical prostatectomy (RARP) with respect to pathological and biochemical outcomes.

PATIENTS AND METHODS

? A group of 522 consecutive patients who underwent RARP between 2003 and 2008 were matched by propensity scoring on the basis of patient age, race, preoperative prostate‐specific antigen (PSA), biopsy Gleason score and clinical stage with an equal number of patients who underwent LRP and RRP at our institution. ? Pathological and biochemical outcomes of the three cohorts were examined.

RESULTS

? Overall positive surgical margin rates were lower among patients who underwent RRP (14.4%) and LRP (13.0%) compared to patients who underwent RARP (19.5%) (P= 0.010). There were no statistically significant differences in positive margin rates between the three surgical techniques for pT2 disease (P= 0.264). ? In multivariate logistic regression analysis, surgical technique (P= 0.016), biopsy Gleason score (P < 0.001) and preoperative PSA (P < 0.001) were predictors of positive surgical margins. ? Kaplan–Meier analysis did not show any statistically significant differences with respect to biochemical recurrence for the three surgical groups.

CONCLUSIONS

? RRP, LRP and RARP represent effective surgical approaches for the treatment for clinically localized prostate cancer. A higher overall positive SM rate was observed for the RARP group compared to RRP and LRP; however, there was no difference with respect to biochemical recurrence‐free survival between groups. ? Further prospective studies are warranted to determine whether any particular technique is superior with regard to long‐term clinical outcomes.     

The impact of nerve sparing on incidence and location of positive surgical margins in radical prostatectomy

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Nerve sparing radical prostatectomy has been associated with increased risk of positive surgical margins due to the close anatomical relationship of the neurovascular bundle to the posterolateral aspect of the prostatic fascia. Our study of 945 men who underwent radical prostatectomy be one experienced surgeon found no increased risk of positive surgical margins, whether the cancer was organ confined or extracapsular extension was present.

OBJECTIVE

• ? To examine whether nerve‐sparing surgery (NSS) is a risk factor for positive surgical margins (PSMs) in patients with either organ‐confined prostate cancer or extracapsular extension (ECE).

PATIENTS AND METHODS

• ? Clinicopathological outcome data on 945 consecutive patients treated with radical prostatectomy (RP) were prospectively collected.
• ? All patients underwent RP (bilateral, unilateral or non‐NSS) by one surgeon between 2002 and 2007.
• ? Risk of PSMs and their locations with respect to NSS was determined by multivariate logistic regression analysis adjusting for preoperative risk factors for PSMs within pT2, pT3a and pT3b tumours.

RESULTS

• ? Overall a PSM was identified in 19.6% of patients in an unscreened population with mean prostate‐specific antigen (PSA) level of 8.1 ng/mL.
• ? There was no significant difference in rates of PSMs between NSS groups on multivariate analysis (P= 0.147).
• ? There was no significant difference in pT2 (P= 0.880), pT3a (P= 0.175) or pT3b (P= 0.354) tumours.
• ? The only significant predictor of PSMs was preoperative PSA level (risk ratio 1.289, P= 0.006).
• ? There was no significant difference in the location of PSMs except for the pT3a group, where the patients that had bilateral NSS were at higher risk of a posterolateral PSM (P= 0.028).

CONCLUSIONS

• ? With appropriate selection of patients, NSS does not increase the risk of PSMs, whether the cancer is organ confined or ECE is present.
• ? The adverse impact of the NSS procedure in the hands of an experienced surgeon is minimal and is a realistic compromise to obtain the increase in health‐related quality of life offered by NSS.

     

Retrograde Release of the Neurovascular Bundle with Preservation of Dorsal Venous Complex During Robot-assisted Radical Prostatectomy: Optimizing Functional Outcomes

BackgroundRobot-assisted laparoscopic radical prostatectomy (RARP) presents consistent oncological outcomes for prostate cancer; yet continence and potency results are not uniform. We present a technical modification for RARP which preserves the nerves and vascular structures anterior to the prostate aiming to optimize functional outcomes.ObjectiveTo present oncological and functional results of a modified technique for RARP.Design, setting, and participantsProspective, noncontrolled case series including 128 consecutive patients undergoing RARP performed by a single surgeon (R.F.C).Surgical procedureRARP with retrograde release of the neurovascular bundle and preservation of dorsal venous complex.MeasurementsPotency was defined as a Sexual Health Inventory for Men score of ≥17; continence was defined as use of no pads. Oncological results analyzed were positive surgical margins (PSM) rates and biochemical recurrence (BCR)-free survival. BCR was defined as prostate-specific antigen >0.2 ng/ml. Complications were graded according to the Clavien-Dindo classification.Results and limitationsMedian patient age was 63.5 yr. Median skin-to-skin time was 78 min. Median length of hospital stay was 1 d, with seven patients (5.5%) hospitalized for more than 24 h. Median intraoperative bleeding was 200 ml and two patients required postoperative blood transfusion (1.6%). Four patients (3.1%) had grade ≥3 complications. Biochemical recurrence (BCR) occurred in nine of 128 patients (7%) and median time to BCR was 6 mo. Overall PSM rate was 13.3% (17 of 128 patients). PSM rate was 9% among patients with pT2 disease (8/89) and 27% in patients with pT3 (9/38). Continence was reached immediately in 85.9% of the patients and 98.4% were continent at1 yr. At 1 mo postoperatively, 60 patients were potent (53%), while 98 patients among 113 (86%) were potent 1 yr after surgery. A limitation of this study is that it was a noncomparative study.ConclusionsRetrograde release of the neurovascular bundle with preservation of dorsal venous complex during RARP is safe and associated with excellent oncological and functional outcomes. Future comparative studies are needed.Patient summaryRobot-assisted radical prostatectomy (RARP) presents consistent oncological outcomes for prostate cancer; yet continence and potency results are not uniform. We present a technical modification for RARP aiming to preserve the nerves and vascular structures anterior to the prostate. We evaluated 128 consecutive patients with clinically localized or locally advanced prostate cancer undergoing RARP with our modified technique of retrograde release of the neurovascular bundles with dorsal vein sparing. We have shown that this technique is safe, effective and associated with early recovery of continence and sexual function after surgery.     

Surgical method influences specimen margins and biochemical recurrence during radical prostatectomy for high-risk prostate cancer: a systematic review and meta-analysis

Purpose

To perform a meta-analysis comparing the rates of positive surgical margins (PSM) and biochemical recurrence (BCR) between open radical prostatectomy (ORP) and robot-assisted radical prostatectomy (RARP) in patients with high-risk prostate cancer.

Methods

A systematic review was performed on Pubmed, Embase and Scopus databases in August 2016, according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. References retrieved were evaluated using the Newcastle–Ottawa scale and the Black and Down’s tool for quality assessment.

Results

Nine retrospective cohorts comparing ORP and RARP were selected and included in the meta-analysis. All studies reported the PSMs. Patients treated with RARP presented less risk of PSMs (risk difference ?0.04, p 0.02) than those treated with ORP. Five articles reported hazard ratios for BCR-free survival. Patients treated with RARP had less risk of BCR (HR 0.72, 95% CI 0.58–0.89) than those treated with ORP. Reports for PSM assessment were considered of adequate quality, while the studies retrieved for BCR assessment were considered limited because of the heterogeneity of their results.

Conclusion

Patients with high-risk prostate cancer treated with RARP have less risk of having PSM and BCR when compared to those treated with ORP. A strong conclusion is precluded due to the observational nature of the studies retrieved for our analysis.

     

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.     

Population-based determinants of radical prostatectomy surgical margin positivity

Study Type – Prognosis (cohort)
Level of Evidence 2b What’s known on the subject? and What does the study add? Prior population and single‐centre studies have assessed incidence of positive surgical margins. The current study derived population‐based positive surgical margin cut‐offs in order to help identify underperforming surgeons who may benefit from further courses and/or self study to improve outcomes.

OBJECTIVE

? To characterize factors associated with positive surgical margins (PSMs) and derive population‐based PSM cutoffs to evaluate surgeon performance in radical prostatectomy (RP).

PATIENTS AND METHODS

? SEER‐Medicare data were used to identify 4247 men diagnosed with prostate cancer during 2004–2005 who underwent RP up to 2006. ? We performed logistic regression to assess the impact of tumour characteristics, surgeon volume and surgical approach on the likelihood of PSMs for pT2 and PT3a disease. ? Moreover, we derived 25th and 10th percentile cutoffs from binomial distribution equations.

RESULTS

? Overall, 19.4% of men experienced PSMs with a pT2 vs pT3a PSM rate of 14.9% vs 42% (P < 0.001). Extrapolating from our population‐based results, a surgeon incurring more than three PSMs in 10 cases of pT2 disease performed below the 25th percentile. ? There was a trend for fewer PSMs with minimally invasive vs open RP (17.4% vs 20.1%, P= 0.086), and the PSM rate also decreased over the study period from 21.3% in 2004 to 16.6% in 2006 (P= 0.028) with significant geographic variation (P < 0.001). ? In adjusted analyses, temporal and geographic variation in PSM persisted, and men with high (odds ratio 3.68, 95% CI 2.82–4.81) and intermediate (odds ratio 2.52, 95% CI 2.03–3.13) vs low‐risk disease were at greater odds to experience PSMs. Notably, neither surgical approach nor surgeon volume was significantly associated with PSMs.

CONCLUSION

? Our population‐based PSM benchmarks allow identification of under‐performing outliers who may seek courses or video self‐study to improve outcomes. There was significant temporal and geographic variation in PSMs but neither surgeon volume nor surgical approach was associated with PSMs.     

Clinical effect of a positive surgical margin without extraprostatic extension after robot-assisted radical prostatectomy

ObjectivesThe aim of this study was to investigate the effect of positive surgical margin (PSM) without extraprostatic extension after robot-assisted radical prostatectomy (RARP).Materials and methodsWe retrospectively reviewed 837 patients who underwent RARP for clinically localized prostate cancer without neoadjuvant endocrine therapy. The pT2+category lesions were defined according to World Health Organization classification. The actuarial probabilities of biochemical recurrence-free survival (BCR-FS) were determined using Kaplan-Meier analysis. Univariate and multivariate Cox proportional hazards regression analyses were also used to identify independent predictors for BCR.ResultsOf the 837 patients, 102 (12.2%) experienced BCR during the follow-up period. The BCR-FS rate was significantly higher in patients with pT2+category tumors than in those with pT3a category tumors, and significantly lower in patients with pT2+category tumors than that in those with pT2 category tumors without PSM. The BCR-FS rate of patients with pT2+category tumors was significantly higher than that with pT3a category tumors with PSM but not significantly different from that with pT3a category tumors without PSM. In a multivariate analysis, the pathological T category considering pT2+category was one of independent predictive factors for BCR.ConclusionsThis study support the hypothesis that the pT2+category disease is associated with a significantly increased risk of BCR in patients with organ-confined prostate cancer after RARP. As PSM can be avoided in some cases, urologists should continually seek to improve their operative skills and to reduce the rate of PSM, especially in patients with organ-confined prostate cancer.     

Predictive Factors for Positive Surgical Margins and Their Locations After Robot-Assisted Laparoscopic Radical Prostatectomy

Background

Positive surgical margin (PSM) after radical prostatectomy (RP) has been shown to be an independent predictive factor for cancer recurrence. Several investigations have correlated clinical and histopathologic findings with surgical margin status after open RP. However, few studies have addressed the predictive factors for PSM after robot-assisted laparoscopic RP (RARP).

Objective

We sought to identify predictive factors for PSMs and their locations after RARP.

Design, setting, and participants

We prospectively analyzed 876 consecutive patients who underwent RARP from January 2008 to May 2009.

Intervention

All patients underwent RARP performed by a single surgeon with previous experience of >1500 cases.

Measurements

Stepwise logistic regression was used to identify potential predictive factors for PSM. Three logistic regression models were built: (1) one using preoperative variables only, (2) another using all variables (preoperative, intraoperative, and postoperative) combined, and (3) one created to identify potential predictive factors for PSM location. Preoperative variables entered into the models included age, body mass index (BMI), prostate-specific antigen, clinical stage, number of positive cores, percentage of positive cores, and American Urological Association symptom score. Intra- and postoperative variables analyzed were type of nerve sparing, presence of median lobe, percentage of tumor in the surgical specimen, gland size, histopathologic findings, pathologic stage, and pathologic Gleason grade.

Results and limitations

In the multivariable analysis including preoperative variables, clinical stage was the only independent predictive factor for PSM, with a higher PSM rate for T3 versus T1c (odds ratio [OR]: 10.7; 95% confidence interval [CI], 2.6–43.8) and for T2 versus T1c (OR: 2.9; 95% CI, 1.9–4.6). Considering pre-, intra-, and postoperative variables combined, percentage of tumor, pathologic stage, and pathologic Gleason score were associated with increased risk of PSM in the univariable analysis (p < 0.001 for all variables). However, in the multivariable analysis, pathologic stage (pT2 vs pT1; OR: 2.9; 95% CI, 1.9–4.6) and percentage of tumor in the surgical specimen (OR: 8.7; 95% CI, 2.2–34.5; p = 0.0022) were the only independent predictive factors for PSM. Finally, BMI was shown to be an independent predictive factor (OR: 1.1; 95% CI, 1.0–1.3; p = 0.0119) for apical PSMs, with increasing BMI predicting higher incidence of apex location. Because most of our patients were referred from other centers, the biopsy technique and the number of cores were not standardized in our series.

Conclusions

Clinical stage was the only preoperative variable independently associated with PSM after RARP. Pathologic stage and percentage of tumor in the surgical specimen were identified as independent predictive factors for PSMs when analyzing pre-, intra-, and postoperative variables combined. BMI was shown to be an independent predictive factor for apical PSMs.     

Should experienced open prostatic surgeons convert to robotic surgery? The real learning curve for one surgeon over 3 years

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

OBJECTIVE

To critically analyse the learning curve for one experienced open surgeon converting to robotic surgery for radical prostatectomy (RP).

PATIENTS AND METHODS

From February 2006 to December 2008, 502 patients had retropubic RP (RRP) while concurrently 212 had robot‐assisted laparoscopic RP (RALP) by one urologist. We prospectively compared the baseline patient and tumour characteristics, variables during and after RP, histopathological features and early urinary functional outcomes in the two groups.

RESULTS

The patients in both groups were similar in age, preoperative prostate‐specific antigen level, and prostatic volume. However, there were more high‐stage (T2b and T3, P= 0.02) and ‐grade (Gleason 9, P= 0.01) tumours in the RRP group. The mean (range) operative duration was 147 (75–330) min for RRP and 192 (119–525) min for RALP (P < 0.001); 110 cases were required to achieve ‘3‐h proficiency’. Major complication rates were 1.8% and 0.8% for RALP and RRP, respectively. The overall positive surgical margin (PSM) rate was 21.2% in the RALP and 16.7% in the RRP group (P= 0.18). PSM rates for pT2 were comparable (11.6% vs 10.1%, P= 0.74). pT3 PSM rates were higher for RALP than RRP (40.5% vs 28.8%, P= 0.004). The learning curve started to plateau in the overall PSM rate after 150 cases. For the pT2 and pT3 PSM rates, the learning curve tended to flatten after 140 and 170 cases, respectively. The early continence rates were comparable (P= 0.07) but showed a statistically significant improvement after 200 cases.

CONCLUSIONS

Our analysis of the learning curve has shown that certain components of the curve for an experienced open surgeon transferring skills to the robotic platform take different times. We suggest that patient selection is guided by these milestones, to maximize oncological outcomes.     

Outcomes of robot-assisted radical prostatectomy in men with previous transurethral resection of prostate

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

OBJECTIVE

? To critically analyze and compare surgical, oncological and functional outcomes of robot‐assisted radical prostatectomy (RARP) in patients with and without previous transurethral resection of prostate (TURP).

PATIENTS AND METHODS

? The study comprised 158 cases of RARP for clinically localized prostate cancer, including 26 cases that had undergone previous TURP (Group A). ? Surgical, oncological and functional (short‐ and intermediate‐term) outcomes of Group A were compared with 132 cases without previous TURP (Group B).

RESULTS

? Post TURP patients were found to have significantly greater blood loss (494 vs 324 mL) and a need for bladder neck reconstruction (26.7% vs 9.7%) compared to the non‐TURP group. ? Surgical time (189 vs 166 min), conversion rate, margin positivity rate and biochemical recurrence rate were also higher. ? Incontinence rates were higher both at 6 (14% vs 11.8%) and 12 (25% vs 8%) months follow‐up.

CONCLUSIONS

? RARP is feasible but challenging after TURP. It entails a longer operating time, greater operative difficulty and compromised oncological or continence outcomes. ? These cases should be handled by an experienced robotic surgeon with the appropriate expertise.     

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.     

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.     

Intraoperative peripheral frozen sections do not significantly affect prognosis after nerve‐sparing radical prostatectomy for prostate cancer

Study Type – Therapy (outcomes research) Level of Evidence 2b What’s known on the subject? and What does the study add? We hypothesized that taking intraoperative frozen section (FS) biopsies of the peripheral margins of resection during radical prostatectomy would allow an intraoperative systematic scan of resection margins. In the case of positive FS, extended resection could be performed with the aim of completely excising residual tumour, improving biochemical recurrence‐free survival of patients with positive surgical margins at the inked specimen. To our knowledge, the prognostic value of achieving a negative resection status by systematically taking intraoperative FS of the peripheral margins of resection during radical prostatectomy has not been established to date.

OBJECTIVE

? To determine the value of systematic intraoperative peripheral frozen sections (FS) with or without extended resection during nerve‐sparing radical prostatectomy for prediction of biochemical recurrence (BCR) compared with inked surgical margins.

PATIENTS AND METHODS

? Between 1999 and 2003, in a prospective study, multiple peripheral FS (median 14; range 5–20) were taken from the urethral stump, circumferentially from the bladder neck, and from the lateral pedicles in 200 consecutive bilateral nerve‐sparing radical prostatectomies for clinically localized prostate cancer by a single surgeon. ? Patients with stage pT3b or more and/or positive lymph nodes were excluded. ? Of the 188 patients, 178 (94.7%) were followed over a median of 82 months (62–124). ? BCR, defined as prostate‐specific antigen (PSA) ≥ 0.2 ng/mL, was related to status of both, inked specimen margins and FS.

RESULTS

? Of all 188 prostatectomy specimens, 49 (26.1%) had positive surgical margins (PSM); these were found posterolaterally in 15 (30.6%), apically in 13 (26.5%), basally in 10 (20.4%) and at multiple sites in 11 (22.4%) specimens. ? Intraoperative peripheral FS were positive in 19 (10.7%) patients, including 6.2% at urethral stump, 3.3% at lateral pedicles and 1.1% at bladder neck. ? In organ‐confined disease, BCR‐free survival was 93.3% (111/119) for patients with negative surgical margins (NSM) and 72% (18/25) for patients with PSM (inked specimen), but negative peripheral FS (P < 0.001). ? Five‐ and 10‐year BCR‐free survival for NSM was 94.9% and 92.8%, for PSM with negative peripheral FS it was 75.3% and 70.6%, and for PSM with positive peripheral FS it was 62.5% and 62.5%, respectively.

CONCLUSIONS

? Frozen section biopsies of peripheral resection margins during nerve‐sparing radical prostatectomy are not reliable in predicting PSM. ? Intraoperative achievement of a locally disease‐free status, as monitored by negative circumferential intraoperative FS of peripheral margins, is not associated with a statistically significant BCR‐free survival benefit compared with patients with negative surgical margins on the prostatectomy specimen. ? Based on these findings, we do not recommend a routine of systematically taking intraoperative FS biopsies during nerve‐sparing radical prostatectomy.