Suture versus staple ligation of the dorsal venous complex during robot‐assisted laparoscopic radical prostatectomy

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

OBJECTIVES

To present our operative and postoperative functional outcomes of sutured compared with endovascular staple ligation of the dorsal venous complex (DVC) during robot‐assisted laparoscopic radical prostatectomy (RALP). Ligation of the DVC during RALP with an endovascular stapler has purported advantages of decreased apical positive surgical margin (PSM) rate, blood loss, and operative time when compared with suture ligation.

PATIENTS AND METHODS

In all, 162 patients who underwent RALP between October 2005 and April 2008 by one surgeon (R.B.N.) were assessed. We retrospectively analysed two different treatment groups: group 1 underwent DVC ligation with a single suture, while group 2 underwent endovascular staple ligation.

RESULTS

Of the 162 patients evaluated, 67 had suture ligation (group 1) and 95 had staple ligation (group 2) of the DVC. Baseline patient characteristics (age, body mass index, biopsy Gleason score, clinical stage) and tumour characteristics (specimen weight, tumour volume, pathological Gleason score and stage) did not differ between the groups. Estimated blood loss (494 mL vs 288 mL), time to dissect out, ligate and transect the DVC (30 min vs 24 min), apical PSM rate (13.4% vs 2.1%) differed significantly between groups 1 and 2 respectively, favouring staple ligation of the DVC. At 6 months follow‐up, there was no difference between the groups for PSA recurrence (3.7% vs 0%), complete continence (63.4% vs 55.7%) and Sexual Health Inventory for Men score (8.4 vs 8.6).

CONCLUSIONS

In the present study, staple ligation of the DVC during RALP resulted in improved apical PSM rates, faster operative times and less blood loss.     

Upfront transection and subsequent ligation of the dorsal vein complex during laparoscopic radical prostatectomy

Laparoscopic radical prostatectomy for localized prostate cancer offers several advantages, including creation of a pneumoperitoneum that results in less blood loss than is seen with the corresponding open procedure. Transection of the deep dorsal vein complex remains among the most challenging aspects, however. Safe and secure completion of this procedure is important to minimize blood loss and maximize the chance of cure. Liberal use of coagulation for hemostasis at the dorsal vein complex (DVC) risks thermal damage to the sphincteric muscle. DVC ligation before transection, though commonly performed, can cause loss of some sphincteric fibers and potentially result in delayed recovery of urinary continence. Furthermore, ligation may at times prove difficult, especially in obese patients with a short and broad DVC, a large prostate gland, and a narrow pelvis. The presence of prominent pubic tubercles may further increase the difficulty. We have found that bleeding from the DVC is easily controlled without suture ligation through a combination of a modest pneumoperitoneum with pinpoint coagulation of one or two small arteries that are consistently found in the superficial layer of the complex. Precise, even‐level transection is possible under direct vision with no more than modest blood loss. A stitch in a Z‐shaped fashion is then applied to the entire transected stump of the DVC. This procedure is simple and easily performed, even by those with limited experience. Here we provide an overview of our current technique.     

系统评价机器人辅助腹腔镜与单纯腹腔镜前列腺癌根治术后的控尿功能

目的:评价机器人辅助前列腺癌根治术(robot-assisted laparoscopic prostatectomy,RALP)与单纯腹腔镜前列腺癌根治术(pure laparoscopic radical prostatecomy,LRP)的术后控尿功能。方法:检索PubMed、Web of Science、Cochrane图书馆、CNKI、维普数据库及万方数据库关于RALP和LRP治疗局限性前列腺癌的比较性研究文献,按Cochrane操作员手册筛选文献、提取资料并评价质量后,采用RevMan5.2版本软件进行数据处理分析。结果:系统评价纳入2篇随机对照试验,7篇非随机对照试验,共1 950例患者,其中RALP治疗1 098例,LRP治疗852例。RALP相比LRP术后控尿率,1个月比值比(odds ratio,OR)=2.28,95%可信区间(confidence interval,CI)为(1.68,3.08),3个月OR=1.51,95%CI为(1.21,1.88),6个月OR=1.97,95%CI为(1.44,2.70),12个月OR=1.53,95%CI为(1.11,2.11),两者术后控尿功能差异有统计学意义(P0.05)。结论:在治疗局限性前列腺癌方面,RALP可能术后控尿功能更优。     

The current status of robot-assisted radical prostatectomy

Robot-assisted radical prostatectomy （RARP） is a rapidly evolving technique for the treatment of localized prostate cancer. In the United States, over 65% of radical prostatectomies are robot-assisted, although the acceptance of this technology in Europe and the rest of the world has been somewhat slower. This article reviews the current literature on RARP with regard to oncological, continence and potency outcomes-the so-called ＇trifecta＇. Preliminary data appear to show an advantage of RARP over open prostatectomy, with reduced blood loss, decreased pain, early mobilization, shorter hospital stay and lower margin rates. Most studies show good postoperative continence and potency with RARP; however, this needs to be viewed in the context of the paucity of randomized data available in the literature. There is no definitive evidence to show an advantage over standard laparoscopy, but the fact that this technique has reached parity with laparoscopy within 5 years is encouraging. Finally, evolving techniques of single-port robotic prostatectomy, laser- guided robotics, catheter-free prostatectomy and image-guided robotics are discussed.     

Delayed recovery of urinary continence after laparoscopic radical prostatectomy

AIM: To study the rate at which patients regained urinary continence during our institution's early experience with laparoscopic radical prostatectomy. METHODS: The urinary continence of 34 patients was recorded at various intervals following laparoscopic radical prostatectomy. These data were compared with those from 49 patients who had undergone radical retropubic prostatectomy. RESULTS: For laparoscopic prostatectomy patients, 2.9% had regained urinary continence at 1 month, 29.4% at 3 months, 46.9% at 6 months, 56.0% at 9 months and 60.0% at 12 months. For retropubic prostatectomy patients, the corresponding rates were 22.4% at 1 month, 63.3% at 3 months, 84.1% at 6 months, 92.9% at 9 months and 92.9% at 12 months. Backward stepwise logistic regression analysis indicated that laparoscopic surgery itself significantly predicted urinary incontinence at every interval from 1 to 9 months following surgery (P < 0.05). CONCLUSION: Patients' postoperative recovery of urinary continence was not satisfactory in our early experience with laparoscopic radical prostatectomy. Further efforts to elucidate the reason for this poor functional outcome are mandatory before the procedure is accepted as part of standard practice.     

Outcomes after robot-assisted laparoscopic radical prostatectomy

Robot-assisted laparoscopic radical prostatectomy （RALRP） using the da Vinci surgical system is now in widespread use in many countries where economic conditions allow the installation of this expensive technology. Controversy has surrounded the procedure since it was first performed in 2000, with many critics highlighting the lack of evidence to support its use. However, despite the lack of level I evidence, many large studies of patients have confirmed that the procedure is feasible and safe, with low morbidity. Available longer-term oncological data seem to show that outcomes from the robotic approach at least match those of traditional open radical prostatectomy. Functional outcomes also seem satisfactory, although randomized controlled trials are lacking. This paper reviews the current status of RALRP with respect to perioperative data and complications and oncologic and functional outcomes.     

A matched-pair comparison between bilateral intrafascial and interfascial nerve-sparing techniques in extraperitoneal laparoscopic radical prostatectomy

The aim of this study was to validate the advantages of the intrafascial nerve-sparing technique compared with the interfascial nerve-sparing technique in extraperitoneal laparoscopic radical prostatectomy. From March 2010 to August 2011, 65 patients with localized prostate cancer (PCa) underwent bilateral intrafascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy. These patients were matched in a 1∶2 ratio to 130 patients with localized PCa who had undergone bilateral interfascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy between January 2008 and August 2011. Operative data and oncological and functional results of both groups were compared. There was no difference in operative data, pathological stages and overall rates of positive surgical margins between the groups. There were 9 and 13 patients lost to follow-up in the intrafascial group and interfascial group, respectively. The intrafascial technique provided earlier recovery of continence at both 3 and 6 months than the interfascial technique. Equal results in terms of continence were found in both groups at 12 months. Better rates of potency at 6 months and 12 months were found in younger patients (age ≤65 years) and overall patients who had undergone the intrafascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy. Biochemical progression-free survival rates 1 year postoperatively were similar in both groups. Using strict indications, compared with the interfascial nerve-sparing technique, the intrafascial technique provided similar operative outcomes and short-term oncological results, quicker recovery of continence and better potency. The intrafascial nerve-sparing technique is recommended as a preferred approach for young PCa patients who are clinical stages cT1 to cT2a and have normal preoperative potency.     

腹膜外途径与单孔经膀胱途径前列腺癌根治术治疗低危前列腺癌术后控尿及勃起功能分析

目的:比较保留神经的经腹膜外途径腹腔镜下前列腺癌(PCa)根治术(nsELRP)和经膀胱单孔腹腔镜前列腺癌根治术(TVSSLRP)的手术相关情况及其术后控尿和勃起功能的恢复情况。方法:选取住院治疗符合筛选条件的低危局限性PCa患者50例,随机分为TVSSLRP组和ns ELRP组各25例。收集两组患者以下资料,术前指标:年龄、伴发病、体质指数(BMI)、血清PSA、前列腺体积、穿刺病理Gleason评分、临床分期、IIEF-5评分、阴茎肱动脉压力指数(PBI)及阴茎海绵体动脉血流速度;手术相关指标:手术时间、出血量、输血与否、并发症、手术切缘情况、留置尿管时间、住院日;术后指标:术后病理Gleason评分、病理分期,术后并发症、术后血清PSA、使用尿垫情况、IIEF-5评分、PBI及阴茎海绵体动脉血流速度。结果:两组患者术前一般资料无明显差异,所有手术均顺利完成,无增加辅助通道。手术指标中两组的出血量、输血率、术中并发症及切缘阳性率差异无统计学意义,均未出现术中并发症,手术切缘均为阴性。TVSSLRP组手术时间[(105.92±26.21)min和(151.46±40.68)min]、保留尿管时间[(11.24±1.17)d和(13.01±1.64)d]及住院日[(12.92±4.29)d和(15.76±4.65)d]均明显短于ns ELRP组(P均0.05)。两组患者拔除尿管当日及术后1、3、6个月控尿率分别为84%和52%、100%和84%、100%和96%、100%和96%。术后3、6、12个月勃起功能恢复比率分别为48%和28%、64%和52%、76%和68%,相应IIEF-5评分≥18分,各时间段内TVSSLRP组患者勃起功能恢复比例均更高。所有患者手术前后PBI及阴茎海绵体动脉血流速度差异均无统计学意义。两组术后并发症(Ⅱ级)出现比例分别为32%和40%,差异无统计学意义(P0.05);术后标本病理Gleason评分及临床分期均较术前穿刺病理有升级,但两组间无明显差异(P0.05)。两组术后1年均无生化复发。结论:TVSSLRP术与nsELRP术均适用于低危局限性PCa患者,手术安全,术后恢复快;TVSSLRP术后患者早期控尿功能和勃起功能恢复情况优于nsELRP术。     

Outcomes of robotic assisted radical prostatectomy

Robot-assisted radical prostatectomy (RARP) is a rapidly evolving technique for the treatment of localized prostate cancer. However, cynics point to the increasing role of market forces in the robotic revolution. As yet, Europe has not taken up RARP in large numbers and this may in part relate to the high level of expertise in laparoscopy previously gained. Furthermore, setting up a robotic program is a major undertaking for many surgical units. This article reviews the current literature on RARP with regard to oncologic, continence and potency outcomes – the so called 'trifecta'. Preliminary data appears to show an advantage of RARP over open prostatectomy with reduced blood loss, decreased pain, early mobilization, shorter hospital stay and lower margin rates. Most intra-institutional studies demonstrate good postoperative continence and potency with RARP; however this needs to be viewed in the context of a paucity of randomized data available in the literature. There is no definitive data to show an advantage over standard laparoscopy, but the fact that this technique has reached parity with laparoscopy within 5 years is encouraging.     

Robot-assisted versus three-dimensional laparoscopic radical prostatectomy: 12-month outcomes of a randomised controlled trial

Objectives

To compare functional and oncological outcomes of robot-assisted laparoscopic prostatectomy (RALP) to three-dimensional laparoscopic radical prostatectomy (3D-LRP) at 12 months after surgery.

Patients and methods

Prospective randomised single-centre study of 145 consecutive men referred to radical prostatectomy in a tertiary referral centre in Finland. Patients were randomised 1:1 to the RALP (N = 75) and 3D-LRP (N = 70) groups. The primary outcome was urinary continence evaluated with the Expanded Prostate Cancer Index Composite 26-item version (EPIC-26) incontinence domain score at 12 months after surgery. Secondary outcomes included the use of protective pads at 12 months after surgery, EPIC-26 domain scores of irritative/obstructive, bowel, sexual and hormonal symptoms, positive surgical margin (PSM) rate, and biochemical recurrence (BCR). Complication frequency within the 3-month period after surgery was evaluated according to Clavien–Dindo classification. Statistical significance between groups was analysed using Mann–Whitney, chi-square and Fisher's exact tests. The trial was terminated after interim analysis based on no statistically significant difference in EPIC-26 urinary incontinence domain scores. Altogether 145 patients of the target accrual of 280 patients were recruited.

Results

Postoperative continence at 12 months after surgery according to the EPIC-26 incontinence domain was 79.25 in both groups (P = 0.4). Between group difference was −5.8 (95% confidence interval –15.2 to 3.6). There was no statistically significant difference in the rates of PSM or BCR between the two surgical modality groups.

Conclusion

We were unable to demonstrate a difference between the RALP and 3D-LRP groups for functional and oncological outcomes at 12 months after surgery.     

机器人辅助腹腔镜前列腺癌根治术中神经血管束保留技术的新进展

近年来机器人辅助腹腔镜前列腺癌根治术(RARP)已逐渐成为治疗局限性前列腺癌的一种安全有效措施,但术后性功能障碍一直困扰着患者及泌尿外科医师。本文将从RARP术中保留神经血管束的新技术以及对术后性功能恢复情况作一综述。     

Surgical techniques to improve continence recovery after robot-assisted radical prostatectomy

Radical prostatectomy directly affects urinary continence dynamics with incontinence being a major factor in patients’ quality of life, social and psychological status. In order to help maintain continence after robot-assisted radical prostatectomy (RARP), a number of surgical techniques have been described. In the present narrative review, we summarize the surgical techniques that have been applied during RARP and their effects on incontinence rates and time to continence recovery.