Comparison of lymph node yield in robot‐assisted laparoscopic prostatectomy with that in open radical retropubic prostatectomy

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

OBJECTIVE

? To investigate both the feasibility and the adequacy of pelvic lymph node dissection (PLND) during robot‐assisted laparoscopic prostatectomy (RALP) by comparing lymph node yields obtained during RALP with those obtained during traditional open retropubic radical prostatectomy (RRP).

PATIENTS AND METHODS

? We retrospectively reviewed 1047 patients who underwent radical prostatectomy between 2001 and 2009. ? In all, 626 patients underwent RALP while 421 patients had traditional open RRP. All patients undergoing bilateral PLND were included in our analysis. ? Lymph node yields and lymph node involvement for each surgical approach were calculated and examined. ? PLND‐related complications were analysed.

RESULTS

? Of the 1047 patients, 816 patients underwent bilateral PLND of whom 473 underwent RALP, while 343 underwent RRP. The mean lymph node yields for the RALP cohort (7.1, interquartile range 4–10) was significantly higher (P < 0.001) than for the RRP cohort (6.0, interquartile range 3–8). ? The percentage of patients with nodal involvement was 1.1 for RALP and 2.3 for RRP (P= 0.167). ? Mean age, preoperative PSA values, and pre‐ and postoperative Gleason scores were similar between the two cohorts. ? PLND‐related complications were similar between both cohorts.

CONCLUSIONS

? In patients undergoing RALP, PLND is feasible and provides lymph node yields comparable with those of the standard open approach. ? PLND should be strongly considered in all radical prostatectomy patients when clinically indicated, regardless of surgical technique.     

Penile rehabilitation protocol after robot‐assisted radical prostatectomy: assessment of compliance with phosphodiesterase type 5 inhibitor therapy and effect on early potency

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

OBJECTIVE

To evaluate factors that affect compliance in men who enrol in a phosphodiesterase type 5 inhibitor (PDE5I) protocol after nerve‐sparing robot‐assisted prostatectomy (RAP), and report on short‐term outcomes, as PDE5Is may help restore erectile function after RAP and patient adherence to the regimen is a factor that potentially can affect outcome.

PATIENT AND METHODS

We prospectively followed 77 men who had nerve‐sparing RAP and enrolled in a postoperative penile rehabilitation protocol. The men received either sildenafil citrate or tadalafil three times weekly. The minimum follow‐up was 8 weeks. Potency was defined as erection adequate for penetration and complete intercourse. Compliance was defined as men adhering to the regimen for ≥2 months.

RESULTS

The mean age of the cohort was 57.8 years and the median follow‐up was 8 months. In all, 32% of the men discontinued the therapy <2 months after RAP and were deemed noncompliant with an additional 39% discontinuing therapy by 6 months, with the high cost of medication being the primary reason (65%). Long‐term compliance and preoperative erectile dysfunction were independent predictors of potency return after adjusting for age and nerve sparing.

CONCLUSIONS

The high cost of medication remains a significant barrier to maintaining therapy. Noncompliance to PDE5I therapy in a tertiary care centre was much higher than reported in clinical trial settings. With longer‐term follow‐up, we need to further define the factors that improve overall recovery of sexual function after RAP.     

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.     

Robot‐assisted radical prostatectomy in men aged ≥70 years

OBJECTIVES

To assess the outcomes of elderly men with prostate cancer treated with robot‐assisted radical prostatectomy (RARP), because more healthy elderly men will present with localized prostate cancer and many will seek surgical treatment as the population ages.

PATIENTS AND METHODS

Between 2005 and 2008, 203 men had RARP performed by one surgeon; patients were categorized into two groups based on their age (≥70 vs <70 years). All data were recorded prospectively in an institutional approved database.

RESULTS

Of the 203 men, 23 (11%) were aged ≥70 years; the older men had similar baseline characteristics as younger men, and had characteristics during and after surgery comparable to those in younger men. The pathological RARP Gleason grade was significantly greater in older men. Surgical complications were not significantly different between the groups. Continence rates were significantly lower in older men at 6 months after surgery, but returned to levels equivalent to those in younger men within 12 months after surgery. Older patients took significantly longer to be capable of driving after surgery.

CONCLUSIONS

The outcomes of RARP in elderly men are largely comparable to those in younger men, with the exception of higher pathological Gleason grade, a transient delay in return of continence, and taking longer to return to driving after surgery. Advanced chronological age should not be a contraindication for RARP in patients with clinically localized prostate cancer, but expectations should be managed preoperatively.     

Outcomes after radical prostatectomy in men receiving previous pelvic radiation for non‐prostate malignancies

OBJECTIVE

To report the perioperative and functional outcomes of nine patients treated at our institution who had radical prostatectomy (RP) after previous pelvic radiotherapy (RT) for non‐prostate malignancies.

PATIENTS AND METHODS

From 1993 to 2007, nine patients had RP after external beam RT for testicular seminoma (six), anorectal cancer (two) and colon cancer (one). Clinical information was obtained from a prospective prostate cancer database.

RESULTS

RP was completed with no identifiable injury to adjacent structures in all nine patients. Four patients had significant pelvic fibrosis, and three required bilateral neurovascular bundle (NVB) resection. The NVB was preserved in the remaining six patients, four with good preoperative erectile function. However, no patient recovered erectile function after RP at a median (range) follow‐up of 75 (12–172) months. Of seven men continent before RP, four required one or fewer pads daily and three were completely dry, achieving complete urinary control at a median (range) time of 7.5 (2–20) months. Two patients developed an anastomotic stricture, one being associated with concomitant ureteric stricture.

CONCLUSIONS

RP after pelvic RT for non‐prostate malignancies was not associated with increased intraoperative morbidity. However, rates of anastomotic stricture, erectile dysfunction and urinary incontinence appeared to be higher than those reported after RP in men with no previous RT, and comparable with those seen in the salvage RP setting.     

Role of robot‐assisted radical prostatectomy in locally advanced prostate cancer

Locally advanced prostate cancer is regarded as a very high‐risk disease with a poor prognosis. Although there is no definitive consensus on the definition of locally advanced prostate cancer, radical prostatectomy for locally advanced prostate cancer as a primary treatment or part of a multimodal therapy has been reported. Robot‐assisted radical prostatectomy is currently carried out even in high‐risk prostate cancer because it provides optimal outcomes. However, limited studies have assessed the role of robot‐assisted radical prostatectomy in patients with locally advanced prostate cancer. Herein, we summarize and review the current knowledge in terms of the definition and surgical indications of locally advanced prostate cancer, and the surgical procedure and perisurgical/oncological outcomes of robot‐assisted radical prostatectomy and extended pelvic lymphadenectomy for locally advanced prostate cancer.     

Impact of robot‐assisted radical prostatectomy on health‐related quality of life in patients with lower urinary tract symptoms

Objective: Lower urinary tract symptoms (LUTS) are a common complaint in patients with prostate cancer. We attempted to elucidate the effect of robot‐assisted radical prostatectomy (RARP) on patients having different preoperative LUTS severity through analysis of postoperative health‐related quality of life. Methods: From 1/2006 to 9/2009, over 500 patients underwent RARP at our institution. Preoperative American Urologic Association Symptom Score (AUA‐SS), preoperative Sexual Health Inventory for Men, and postoperative Expanded Prostate Cancer Index Composite were available in 183 of them. These patients were divided into three subgroups based on their AUA‐SS as follows: mild AUA‐SS (score 0–7) group, moderate AUA‐SS (8–19) group, and severe AUA‐SS (20–35) group. Results: Of the 183 men, 94 (51.4%), 70 (38.2%), and 19 (10.4%) were in the mild, moderate, and severe group, respectively. In the comparison of Expanded Prostate Cancer Index Composite domain subscales with mean score, only urinary domain had significant differences among subgroups. Patients with high preoperative LUTS persistently showed a statistical trend for decreased urinary function (P = 0.056) and suffered more from urinary bother postoperatively (P < 0.01). In the analysis of urinary bother items, all items except “bleeding with urination” showed statistically significant differences among the subgroups (P < 0.05). Conclusions: Even after RARP, patients with severe preoperative LUTS continue to have significant symptoms postoperatively. In analyzing urinary bother items, all LUTS items, including dysuria, storage symptoms, and postmicturition or voiding symptoms, were higher in patients with high preoperative AUA‐SS.