Combined Robotic Radical Prostatectomy and Robotic Radical Nephrectomy

A 60-year-old man with prostatic adenocarcinoma and an enhancing left-sided renal mass underwent successful combined robotic radical prostatectomy and robotic radical nephrectomy. We describe the initial report of this combined robotic procedure to remove 2 synchronous urological malignancies and describe our technique. An analysis was conducted of the operating room and postanesthesia care unit charges of this procedure compared with the 2 procedures performed independently.     

Periurethral Suspension Stitch During Robot-Assisted Laparoscopic Radical Prostatectomy: Description of the Technique and Continence Outcomes

Background

Several studies have shown that robot-assisted laparoscopic radical prostatectomy (RALP) is feasible, with favorable complication rates and short hospital times. However, the early recovery of urinary continence remains a challenge to be overcome.

Objective

We describe our technique of periurethral retropubic suspension stitch during RALP and report its impact on early recovery of urinary continence.

Design, setting, and participants

We analyze prospectively 331 consecutive patients who underwent RALP, 94 without the placement of suspension stitch (group 1) and 237 with the application of the suspension stitch (group 2).

Surgical procedure

The only difference between the groups was the placement of the puboperiurethral stitch after the ligation of the dorsal venous complex (DVC). The periurethral retropubic stitch was placed using a 12-in monofilament polyglytone suture on a CT-1 needle. The stitch was passed from right to left between the urethra and DVC, and then through the periostium on the pubic bone. The stitch was passed again through the DVC, and then through the pubic bone in a figure eight, and then tied.

Measurements

Continence rates were assessed with a self-administered validated questionnaire (Expanded Prostate Cancer Index Composite [EPIC]) at 1, 3, 6, and 12 mo after the procedure. Continence was defined as the use of no absorbent pads or no leakage of urine.

Results and limitations

In group 1, the continence rate at 1, 3, 6, and 12 mo postoperatively was 33%, 83%, 94.7%, and 95.7%, respectively; in group 2, the continence rate was 40%, 92.8%, 97.9%, and 97.9%, respectively. The suspension technique resulted in significantly greater continence rates at 3 mo after RALP (p = 0.013). The median/mean interval to recovery of continence was also statistically significantly shorter in the suspension group (median: 6 wk; mean: 7.338 wk; 95% confidence interval [CI]: 6.387–8.288) compared to the nonsuspension group (median: 7 wk; mean: 9.585 wk; 95% CI: 7.558–11.612; log rank test, p = 0.02).

Conclusions

The suspension stitch during RALP resulted in a statistically significantly shorter interval to recovery of continence and higher continence rates at 3 mo after the procedure.     

Contemporary Referral Pattern for Robotic Prostatectomy

Background and Objectives:

In spite of the current widespread application of robotic surgery in the treatment of prostate cancer, it remains unclear whether current patterns of use are based on patient benefit or driven by marketing. We sought to investigate this possibility by analyzing the source of our patient population for robot-assisted laparoscopic prostatectomy (RALP).

Methods:

We reviewed 200 consecutive patients who underwent robotic prostatectomy by a single surgeon (RA) at our institution. The source of referral for each patient was analyzed along with individual patient characteristics to identify whether only low-risk or unusually ideal candidates were referred.

Results:

Of the 200 patients, 90.5% were referred by a urologist with only 5.5% being referred by another urologist at our institution. Only 10 patients cited media or marketing sources as the reason for self-referral, and <10 were referred by primary care physicians or other acquaintances. This referral pattern did not change between the first and second 100 patients. Referred patients included those up to 80 years of age, up to 51kg/m² in body mass index, and up to Gleason 9 on biopsy, with 36% of those referred by urologists having some history of previous abdominal or prostate surgery.

Conclusion:

The referral pattern for RALP at our institution may reflect a growing acceptance of robotic surgery among urologists in our region and is unlikely driven by patient-directed marketing. Additionally, urologists may also be more confident in the role of RALP as evidenced by their referral of even complex and higher-risk patients.     

Factors Predicting Early Return of Continence After Radical Prostatectomy

Success of radical prostatectomy is measured by control of cancer and return of urinary and sexual function. Urinary incontinence is generally considered the greatest impairment in immediate postoperative urinary function. Multiple factors are associated with earlier return of urinary continence after radical prostatectomy. These factors can be divided into those known prior to surgery, and therefore possibly not modifiable, and factors that can be controlled during surgery or surgical planning. In addition, various postoperative maneuvers can help hasten urinary continence. This article examines the effect of known factors related to early return of urinary continence after radical prostatectomy.     

Robotic Prostatectomy in a Patient with Hemophilia

Given the rich blood supply to the prostate and the adjacent Santorini''s plexus, radical prostatectomy is associated with significant blood loss even in patients with normal coagulation profiles. In patients with hemophilia, any surgical procedure carries a risk of significant hemorrhage due to a deficiency of factors in the coagulation cascade. For these reasons, hemophiliac patients have often been encouraged to undergo radiation or other forms of nonsurgical treatment for clinically localized prostate cancer. However, the decreased blood loss associated with a laparoscopic/robotic approach and appropriate perioperative factor transfusions can minimize the risk of hemorrhage during robotic-assisted radical prostatectomy. We present the case report of a successful robotic-assisted laparoscopic prostatectomy in a patient with mild hemophilia A, with an estimated blood loss for the procedure of 20mL. We will focus on the perioperative management of the patient''s factor replacement.     

Preservation of Putative Continence Nerves during Radical Retropubic Prostatectomy Leads to More Rapid Return of Urinary Continence

Objectives. Urinary incontinence is a significant complication of radical pelvic surgery. A better understanding of the neuroanatomy of the rhabdosphincter has led to the modification of the radical retropubic prostatectomy to optimize the recovery of postoperative urinary control.Methods. Mock radical retropubic prostatectomy was performed on fresh cadavers to determine which surgical maneuvers could injure what may be the continence nerves. To assess the clinical significance of modifying the radical retropubic prostatectomy based on these anatomic studies, a contemporary series of 60 consecutive patients who underwent radical retropubic prostatectomy with continence nerve preservation was compared with a control group of 38 consecutive patients who had a standard anatomic radical retropubic prostatectomy.Results. At the level of the prostatic apex, both the pelvic and pudendal nerves gave intrapelvic branches that bilaterally coursed to the external urinary sphincter to enter at the 5 and 7 o’clock positions. The mock radical prostatectomy revealed that the nerves to the external urinary sphincter were most prone to injury when a right angle clamp was used to develop a plane between the posterior rhabdosphincter and anterior rectum and if the urethral anastomotic sutures were placed at the 5 and 7 o’clock positions. In addition, blunt dissection of the tips of the seminal vesicles injured the inferior hypogastric plexus. Modifications to preserve the continence nerves were incorporated in the anatomic radical prostatectomy. Although overall continence rates were similar for the two groups (98.3% for continence nerve-preserving radical prostatectomy versus 92.1% for standard prostatectomy), continence nerve preservation decreased the time to achieve continence.Conclusions. During radical retropubic prostatectomy, surgical maneuvers that avoid injury to the continence nerves resulted in the more rapid return of urinary control.     

Transvesical Robotic Simple Prostatectomy: Initial Clinical Experience

Background

Despite significant developments in transurethral surgery for benign prostatic hyperplasia (BPH), simple prostatectomy remains an excellent option for patients with large glands.

Objective

To describe our technique of transvesical robotic simple prostatectomy (RSP).

Design, setting, and participants

From May 2011 to April 2013, 25 patients underwent RSP.

Surgical procedure

We performed RSP using our technique.

Outcome measurements and statistical analysis

Baseline demographics, pathology data, perioperative complications, 90-d complications, and functional outcomes were assessed.

Results and limitations

Mean patient age was 72.9 yr (range: 54–88), baseline International Prostate Symptom Score (IPSS) was 23.9 (range: 9–35), prostate volume was 149.6 ml (range: 91–260), postvoid residual (PVR) was 208.1 ml (range: 72–800), maximum flow rate (Q_max) was 11.3 ml/s, and preoperative prostate-specific antigen was 9.4 ng/ml (range: 1.9–56.3). Eight patients were catheter dependent before surgery. Mean operative time was 214 min (range: 165–345), estimated blood loss was 143 ml (range: 50–350), and the hospital stay was 4 d (range: 2–8). There were no intraoperative complications and no conversions to open surgery. Five patients had a concomitant robotic procedure performed. Early functional outcomes demonstrated significant improvement from baseline with an 85% reduction in mean IPSS (p < 0.0001), an 82.2% reduction in mean PVR (p = 0.014), and a 77% increase in mean Q_max (p = 0.20). This study is limited by small sample size and short follow-up period. One patient had a urinary tract infection; two had recurrent hematuria, one requiring transfusion; one patient had clot retention and extravasation, requiring reoperation.

Conclusions

Our technique of RSP is safe and effective. Good functional outcomes suggest it is a viable option for BPH and larger glands and can be used for patients requiring concomitant procedures.

Patient summary

We describe the technique and report the initial results of a series of cases of transvesical robotic simple prostatectomy. The procedure is both feasible and safe and a good option for benign prostatic hyperplasia with larger glands.     

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     

Risk Stratification and Early Oncologic Outcomes Following Robotic Prostatectomy

Background and Objectives:

Although the popularity of robotic-assisted laparoscopic prostatectomy is assured, little is known about the oncologic outcomes following the procedure.

Methods:

We performed a retrospective cohort study including consecutive patients who underwent the surgery between 2003 and 2007 with at least 6 months of follow-up (n=464). Patients were stratified into low-, intermediate-, and high-risk groups according to D''Amico criteria. Biochemical failure was defined as a PSA ≥0.2 ng/mL.

Results:

Of study patients, 256 (55%), 171 (37%), and 37 (8%) were classified as low-, intermediate-, and high-risk, respectively. Over a mean follow-up of 14.1 months (range, 6.0 to 55.3), 7.3% experienced biochemical failure. Biochemical disease-free survival at 30 months was 94%, 79%, and 73% among patients in the low-, intermediate-, and high-risk groups, respectively, (P<0.001). Preoperative risk stratification was strongly associated with biochemical failure, with hazard ratios of 5.04 (95%: 1.52 to 16.7; P<0.001) and 7.04 (95%: 1.39 to 35.6; P < 0.001) for intermediate- and high- over low-risk groups, respectively. The ability of risk stratification to predict biochemical failure had an area under the receiver operator characteristic curve of 0.74.

Conclusion:

Robotic prostatectomy provides excellent cancer control outcomes for clinically localized disease.