Intraoperative red blood cell salvage and autologous transfusion during open radical retropubic prostatectomy: a cost-benefit analysis

INTRODUCTION

Open radical retropubic prostatectomy (RRP) has an average blood loss of over 1,000ml. This has been reported even from high volume centres of excellence.^1–4 We have looked at the clinical and financial benefits of using intraoperative cell salvage (ICS) as a method of reducing the autologous blood transfusion requirements for our RRP patients.

MATERIALS AND METHODS

Group A comprised 25 consecutive patients who underwent RRP immediately prior to the acquisition of a cell saver machine. Group B consisted of the next 25 consecutive patients undergoing surgery using the Dideco Electa (Sorin Group, Italy) cell saver machine. Blood transfusion costs for both groups were calculated and compared.

RESULTS

The mean postoperative haemoglobin was similar in both groups (11.1gm/dl in Group A and 11.4gm/dl in Group B). All Group B patients received autologous blood (average 506ml, range: 103–1,023ml). In addition, 5 patients (20%) in Group B received a group total of 16 units (average 0.6 units) of homologous blood. For Group A the total cost of transfusing the 69 units of homologous blood was estimated as £9,315, based on a per blood unit cost of £135. This cost did not include consumables or nursing costs.

CONCLUSIONS

We found no evidence that autologous transfusions increased the risk of early biochemical relapse or of disease dissemination. ICS reduced our dependence on donated homologous blood.     

Safety,efficacy and cost of intra-operative cell salvage during open radical prostatectomy

BackgroundWe aim to examine the safety and efficacy of intra-operative cell salvage (ICS) in radical prostatectomy.MethodsA retrospective cohort study was performed, enrolling consecutive patients undergoing open radical prostatectomy at two institutions during 01/01/18–31/12/19. Patients were grouped by ICS use. Primary outcomes were allogeneic transfusion rates, and biochemical recurrence (prostate specific antigen >0.2 mg/mL). Secondary outcomes were use of adjuvant therapies, Clavien-Dindo complications and transfusion-related cost (allogeneic transfusion + ICS setup + ICS reinfusion).ResultsIn total, 168 men were enrolled. Patients were grouped based on whether they received no blood conservation technique (126 men) or ICS (42 men). Groups were similar in median age, pre- and post-operative haemoglobin and length of stay. They also had similar post-operative tumour Gleason score, TNM-stage and positive surgical margin rates. Compared with controls, the ICS group had shorter follow up (336 vs. 225 days; P=0.003). The groups had similar rates of biochemical recurrence (17% vs. 14%; P=0.90), adjuvant therapy use (30% vs. 29%; P=0.85) and complications (14% vs. 19% patients; P=0.46). There was no metastatic progression or cancer-specific mortality in either group. Although a similar proportion of patients received allogenic transfusion (2.4% vs. 4.8%; P=0.33) and units of packed red blood cells (PRBC) (9 vs. 5 units), transfusion-related costs were higher amongst the ICS group (AUD $11,422 vs. $43,227).ConclusionsICS use in radical prostatectomy was not associated with altered rates of allogeneic transfusion, complications, biochemical recurrence or adjuvant or salvage therapies. Transfusion related costs were higher in the ICS group.     

Oncologic outcomes following radical prostatectomy with intraoperative cell salvage

Purpose

To evaluate oncologic outcomes following the use of intraoperative cell salvage (IOCS) as a blood loss management strategy during open radical prostatectomy (RP).

Methods

We retrospectively reviewed all open retropubic RP cases performed by a single surgeon. Patients were identified who received IOCS blood and evaluated for an increased risk of biochemical recurrence (BCR) and overall mortality.

Results

The study cohort consisted of 1,862 men, 395 (21.2%) of whom received IOCS blood. At a median follow-up of 47.0?months, men who received IOCS blood were not at an increased risk of BCR (P?=?0.323) or all-cause mortality (P?=?0.892). IOCS use did not confer an increased risk of BCR within any D??Amico preoperative risk category (low risk, P?=?0.592; intermediate risk, P?=?0.107; and high risk, P?=?0.697).

Conclusions

IOCS is safe for the management of blood loss during RP. At long-term follow-up, IOCS use was not associated with an increased risk of BCR or death. While it remains preferable to avoid any form of blood transfusion, we advocate for the use of IOCS in place of allogeneic blood. These conclusions are drawn from our study of the largest and longest followed cohort patients who received IOCS blood during RP.     

Karolinska prostatectomy: a robot-assisted laparoscopic radical prostatectomy technique

OBJECTIVE: The last decade has witnessed an increasing trend towards minimally invasive management of prostate cancer, including laparoscopic and, more recently, robot-assisted laparoscopic prostatectomy. Several different laparoscopic approaches have been continuously developed during the last 5 years and it is still unclear which technique yields the best outcome. We present our current technique of robot-assisted laparoscopic radical prostatectomy. MATERIAL AND METHODS: The technique described has evolved during the course of >400 robotic prostatectomies performed by the robotic team since the robot-assisted laparoscopic radical prostatectomy program was introduced at Karolinska University Hospital in January 2002. SURGICAL PROCEDURE: Our procedure comprises several modifications of previously reported ones, and we utilize fewer robotic instruments to reduce costs. An extended posterior dissection is performed to aid in the bladder neck-sparing dissection. In nerve-sparing procedures the vesicles are divided to avoid damage to the erectile nerves. In order to preserve the apical anatomy the dorsal venous complex is incised sharply and is first over-sewn after the apical dissection is completed. CONCLUSIONS: Our technique enables a more fluent dissection than previously described robotic techniques. Minimizing changes of instruments and the camera not only cuts costs but also reduces inefficient operating maneuvers, such as switching between 30 degrees and 0 degrees lenses during the procedure. We present a technique which in our hands has achieved excellent functional and oncological results.     

Laparoscopic radical prostatectomy: technique

Ongoing progress in laparoscopy has permitted extension of its indications for performance of complex oncologic and reconstructive surgeries such as radical prostatectomy. Laparoscopic radical prostatectomy is now feasible when performed by urologists trained in laparoscopy. Although the procedure is technically rewarding, it is more important to evaluate it in regards to efficacy. The short-term oncologic and functional efficacy rates (regarding urinary continence) seem equivalent to the rates for open surgery. Longer follow-up is needed to assess the preservation of potency with the laparoscopic technique. The integration and application of open nerve-sparing techniques to the laparoscopic approach should be feasible owing to the excellent visual accuracy at the prostatic apex. Initially, the operating time is lengthy (> 7 hours), but the length improves considerably with each series of 20 or more cases. Overall, the learning curve for laparoscopic radical prostatectomy is approximately 50 cases. Whether the laparoscopic approach will ever be as time efficient for the urologist as open radical prostatectomy remains to be seen. The authors' preliminary impression from the patient's perspective is that laparoscopic prostatectomy may offer significant advantages over open surgery in terms of the immediate postoperative quality-of-life concerns.     

Cavernous nerve graft reconstruction during radical prostatectomy or radical cystectomy: safe and technically feasible

High local stage prostate and bladder cancers frequently require wide local resection and sacrifice of one or both cavernous nerves to achieve a negative surgical margin, thus resulting in erectile dysfunction. This is a report on preliminary experience with cavernous nerve graft reconstruction using sural nerve grafts with radical prostatectomy or radical cystectomy.Pre-operative evaluation was performed and consent was obtained in 14 potent men with prostate (11) or bladder (three) cancer. Sural nerve grafts of resected cavernous nerves were performed using a microsurgical technique. Post-operative treatment (Sildenafil or Alprostadil) was pursued until return of spontaneous function, documented by interview and adequate scores (>20) in the erectile function (EF) domain of the International Index of Erectile Function (IIEF).Twelve unilateral nerve grafts were performed, 10 during radical prostatectomy and two during radical cystoprostatectomy. Two procedures were technically not possible because of locally advanced disease. Mean age was 57.5 y (36-68 y). Mean follow up was 16.1 months (7-28 months). Pathological stage of prostate cancer was pT2 in 2, pT3 in 7 and pT4 in one. Surgical margins were positive in five out of 10 (50%), and two (20%%) had positive lymph nodes. Four patients (three post prostatectomy and one post cystectomy) were fully potent. Additionally, one patient post prostatectomy had improving partial erections. Six patients post prostatectomy and one patient post cystectomy had no erections. The only complication was one superficial wound infection in the sural nerve donor site. Preliminary experience shows that sural nerve grafts are feasible and safe after radical prostatectomy and cystectomy. However, candidates usually present with high stage disease, high risk for recurrence and frequent requirement for adjuvant therapy that further compromises erectile function. Randomized studies with more patients and long follow-up periods are necessary in order to define the ideal candidate for nerve graft procedures.     

Intraoperative ultrasonography with a surgeon‐manipulated microtransducer during robotic radical prostatectomy

Intraoperative transrectal ultrasonography during laparoscopic radical prostatectomy has been reported to lead to a reduction in surgical margin rates. However, the use of a surgeon‐controlled ultrasound probe that allows for precise manipulation and direct interpretation of the image by a console surgeon has yet to be studied. The aim of the present study was to show initial feasibility using the microtransducer with 9‐mm scan length controlled by the console surgeon during robot‐assisted radical prostatectomy in 10 patients. The transducer is designed as a drop‐in probe with a flexible cord for insertion through a laparoscopic port, and is controlled by a robotic arm with the ultrasonographic image shown as a console Tile‐pro display. Intraoperative localization of the biopsy‐proven cancerous hypoechoic lesion was feasible in four out of four cases. The microtransducer facilitated identification of the bladder neck as well as the appropriate level of neurovascular bundle release. Negative surgical margin was achieved in all 10 cases (100%), even though five of 10 patients (50%) had extraprostatic (pT3) disease. Recovery of erectile function and continence was encouraging. In conclusion, intraoperative ultrasound navigation using a drop‐type microtransducer is a novel technique that could enhance the incremental value of the standard information.     

Intraoperative frozen section analysis during nerve sparing laparoscopic radical prostatectomy: feasibility study

PURPOSE: Nerve sparing radical prostatectomy may allow preservation of potency but it can increase positive surgical margins. We used intraoperative frozen section (IFS) analysis to monitor the nerve sparing procedure in laparoscopic prostatectomy. MATERIALS AND METHODS: A total of 100 patients with localized prostatic carcinoma underwent bilateral intrafascial nerve sparing laparoscopic prostatectomy with IFS. A wedge of tissue was cut from base to apex in the region of the neurovascular bundles (NVBs) and analyzed on frozen section. If carcinoma was detected at the inked margin, the corresponding NVB was resected. Definitive margin status was evaluated after permanent section analysis of IFS prostatectomy specimens and eventually NVB specimens. RESULTS: IFS analysis was positive in 24 patients, as confirmed in all by permanent section of the wedges. Three of these patients had positive margins in the prostate specimen at another site. Of the 76 tumors with negative IFSs 1 had positive margins on permanent sections of the wedges and 8 had positive margins on the prostate specimen at another site. IFS led to a decrease in the overall positive margin status from 33% to 12% and from 26.1% to 7.9% in pT2 tumors. Tumor was found on NVB resection in 8 cases (33%). CONCLUSIONS: These results suggest that IFS analysis is a reliable method by which to monitor nerve sparing during laparoscopic prostatectomy. IFS could allow the surgeon to offer a nerve sparing procedure more frequently without compromising cancer control.     

Adjuvant and salvage radiotherapy after radical prostatectomy

After radical prostatectomy is important to identify patients who have a high risk of microscopic residual disease without micrometastatic disease. Adjuvant RT, in retrospective studies, reduce the risk of recurrence and is more efficacious than salvage RT and can improve PSA relapse-free survival and should have an impact on long-term overall survival. The benefit of androgen suppression could be due to a synergistic interaction and may possibly eliminate occult systemic disease. Appropriate selection to identify subgroups of patients who may benefit from salvage RT, even for those patients at the highest risk; and whether some form of hormone ablation should accompany. To predict the biochemical failure and the risk of metastatic disease after salvage RT. We analyze the references to select an appropriate therapy. Improved outcomes will need to be tested in randomized trials.