A comparative study of laparoscopic and robotic assisted radical prostatectomy performed by a single surgeon

ObjectiveTo present the transition from laparoscopic radical prostatectomy (LRP) to robotic-assisted laparoscopic radical prostatectomy (RALP) over 10 years in a medium volume center by a single surgeon.Materials and methodsWe retrospectively reviewed 140 prostate cancer patients who underwent LRP (100 patients) or RALP (40 patients) between May 2005 and May 2015. Preoperative parameters included age, body mass index, and serum prostate specific antigen. Operative course parameters included operative time, estimated blood loss, intraoperative blood transfusion, conversion to open surgery, hospitalization days, duration of Foley catheterization, and complications. Pathological stage, surgical margin status, biochemical recurrence (BCR) rate, and continence rate at 12 months after surgery were reviewed and compared between the LRP and RALP groups.ResultThe operative outcomes revealed significantly less blood loss (143 mL vs. 306 mL, p < 0.001), shorter hospital stay (6.9 days vs. 8.7 days, p = 0.006), and shorter duration of Foley catheterization (9.3 days vs. 11.3 days, p < 0.001) in patients who underwent RALP. Major perioperative complications occurred in four LRP patients (4%), and none were observed in RALP patients. LRP and RALP had similar positive surgical margin rates (p = 0.285) and BCR rates (p = 0.88). RALP resulted in better continence recovery than LRP (55% vs. 82.5%, p = 0.003).ConclusionPatients who underwent RALP had better perioperative and functional outcomes. Oncologic outcomes were similar compared to patients who underwent LRP.     

The Australian laparoscopic radical prostatectomy learning curve

Background

International estimates of the laparoscopic radical prostatectomy (LRP) learning curve extend to as many as 1000 cases, but is unknown for Fellowship‐trained Australian surgeons.

Methods

Prospectively collected data from nine Australian surgeons who performed 2943 consecutive LRP cases was retrospectively reviewed. Their combined initial 100 cases (F100, n = 900) were compared to their second 100 cases (S100, n = 782) with two of nine surgeons completing fewer than 200 cases.

Results

The mean age (61.1 versus 61.1 years) and prostate specific antigen (7.4 versus 7.8 ng/mL) were similar between F100 and S100. D'Amico's high‐, intermediate‐ and low‐risk cases were 15, 59 and 26% for the F100 versus 20, 59 and 21% for the S100, respectively. Blood transfusions (2.4 versus 0.8%), mean blood loss (413 versus 378 mL), mean operating time (193 versus 163 min) and length of stay (2.7 versus 2.4 days) were all lower in the S100. Histopathology was organ confined (pT2) in 76% of F100 and 71% of S100. Positive surgical margin (PSM) rate was 18.4% in F100 versus 17.5% in the S100 (P = 0.62). F100 and S100 PSM rates by pathological stage were similar with pT2 PSM 12.2 versus 9.5% (P = 0.13), pT3a PSM 34.8 versus 40.5% (P = 0.29) and pT3b PSM 52.9 versus 36.4% (P = 0.14).

Conclusion

There was no significant improvement in PSM rate between F100 and S100 cases. Perioperative outcomes were acceptable in F100 and further improved with experience in S100. Mentoring can minimize the LRP learning curve, and it remains a valid minimally invasive surgical treatment for prostate cancer in Australia even in early practice.     

Effects of the learning curve on operative time and lymph node harvesting during robotic gastrectomy

Background

Gastric cancer is the fifth most frequent cancer globally. The introduction of minimally invasive surgery for gastric cancer aimed at reducing post-operative morbidity and hospital length of stay. Although the role of laparoscopic gastrectomy has been established, robotic gastric surgery has only recently gained popularity. The purpose of this study was to evaluate, with a multidimensional analysis, the learning curve of a single surgeon with extensive experience in laparoscopic gastrectomy.

Methods

We prospectively collected data from 104 gastric cancer patients who underwent surgery with a robotic approach from June 2015 to June 2019 by a single surgeon. We performed 21 total gastrectomies (TGs) and 83 subtotal gastrectomies (STGs). A D2 lymphadenectomy was performed in all the patients. Proximal and distal resection margins were tumoour-free in all patients. There were no intraoperative complications, and no conversions occurred.

Results

The plateau of the learning curve based on harvesting lymph nodes and operative time was not reached for TG. The learning curve of operative time for STG could be divided into three different phases: an early or learning phase from 1 to 27 cases, an intermediate or proficiency phase from 28 to 48 cases, and a late or mastery phase from 49 to 83 cases. The learning curve for harvesting lymph nodes was achieved after 41 cases in the STG group.

Conclusion

This study shows that robotic gastrectomy is a complex procedure with a significant multiphasic learning curve. Nevertheless, the robotic learning curve seems to be more rapid than that of conventional laparoscopy. Most importantly, our results suggest that the robotic technique can provide oncological adequacy in terms of lymph node harvesting even in the very first phase of the learning curve.     

The effect of body characteristics on mean operative times while experiencing the learning curve for robotic prostatectomy

We reviewed our series of robotic-assisted radical prostatectomy to assess the effect of certain patient body characteristics on the mean operative time over the course of a single surgeon’s learning curve. The operating room times were recorded for the first 210 cases performed. These cases were broken down into thirds and then patient characteristics were stratified by height, weight, body mass index (BMI) and final prostate volume. Mean body characteristics were equal for all groups. The average time for the first group (70 cases) was 157.9 min, the second group 148.5 min and the third 135.0 min. Times were significantly shorter for the patients <72 in. in height in the first 70 cases (168 vs. 153 min, P < 0.003). Cases were shorter in the first 70 for weight <200 lbs (142 vs. 173 min, P < 0.001). Patients with a BMI of 25–30 had a significantly shorter time (153 min) than those <25 (163 min, P < 0.02) and those >30 (164 min, P < 0.006). With regard to prostate volume, there was a significant shorter operative time for those patients with glands <60 g in the first group. Patients <72 in., <200 lbs, with a BMI of between 25 and 30, and prostate size <60 g had significantly shorter operative times in the first 70 cases of a single surgeon’s learning curve.     

单孔机器人辅助单纯前列腺切除术的初步体会

目的:探讨单孔机器人辅助单纯前列腺切除术（spRASP）治疗良性前列腺增生（BPH）的可行性及临床应用价值。方法:回顾性分析2020年11月—2021年6月上海中医药大学附属曙光医院泌尿中心7例采用spRASP治疗BPH患者的临床资料。平均年龄（67±9）岁。经估算的平均前列腺体积（78.3±12.9） mL;平均残余尿（PVR）(58.0±24.8) mL;平均国际前列腺症状评分（IPSS）(20.9±5.9)分,平均生活质量评分（QOL）(4.7±1.5)分,平均最大尿流率(Q_max)（7.9±3.6） mL/s。比较患者术前和术后3个月的IPSS评分、QOL评分、PVR、Q_max、IIEF等差异,分析评价手术疗效。结果:7例手术均顺利完成。平均手术时间（85.5±25.5） min,平均估计出血量（75.5±25.5） mL,平均留置引流管时间（3.4±0.8） d,平均留置尿管时间（7.5±1.2） d,术后平均住院时间（5.1±3.1） d。术后3个月患者平均IPSS评分（10.8±3.1）分、平均QOL评分（1.6±0.9）分、平...     

模块化进阶式教学法在机器人辅助根治性前列腺切除术培训中的应用

目的:探索模块化进阶式教学法在机器人手术培训中的应用.方法:培训对象为4名完成住院总的住院医师,将手术按照难易程度分为5个模块,逐级培训.观察分析完成每个模块的病例数、手术的输血率、并发症发生率、手术时间、切缘阳性率.结果:4名住院医师顺利完成培训.他们需要52～57例的手术操作才能合格,平均手术时间为(94.62±1...     

Open versus robotic radical prostatectomy: a prospective analysis based on a single surgeon’s experience

The background of this study is to compare prospectively the oncological and functional results of open radical prostatectomy (OP) and robotic prostatectomy (RP) from the experience of a single surgeon. Between June 2002 and June 2007, 422 patients underwent radical prostatectomy (OP 199, RP 223). We divided OP patients into 89 early cases (OP-I) and 110 late cases (OP-II) before and after introduction of a robotic system, and RP patients into 35 early cases (RP-I) and 188 late cases (RP-II). Functional outcomes were measured by use of validated questionnaires completed by the patients. There were no significant differences in preoperative characteristics among the four groups, except that RP-I patients had lower biopsy Gleason scores. In the RP groups the mean estimated blood loss was lower and mean durations of hospital stay and bladder catheterization were shorter compared to those of the OP groups. The frequency of intraoperative complications was significantly lower in the RP-II group. The positive surgical margin rates in the RP-II group were similar to or lower than those in the OP groups when stratified by pathologic stage T2 and T3. From one month after surgery, RP-II patients had higher continence rates than OP-II patients. For patients ≥60 years old, recovery of potency was better in the RP-II group. To conclude, RP by an experienced surgeon may have a similar or lower positive surgical margin rate than OP. Additionally, RP may lead to a shorter duration of bladder catheterization and hospital stay and better recovery of continence and potency than obtainable by OP.     

Robot‐assisted extraperitoneal laparoscopic radical prostatectomy: experience in a high‐volume laparoscopy reference centre

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

OBJECTIVE

To describe our current procedure of robot‐assisted laparoscopic radical prostatectomy (RALP), and to assess the effect of the learning curve on perioperative data, early oncological outcomes and functional results, as RALP has increasingly become a treatment option for men with localized prostate cancer.

PATIENTS AND METHODS

In all, 206 consecutive men had a RALP between July 2001 and November 2008 for localized prostate cancer. Among the overall cohort, the 175 men operated on by the same surgeon were distributed into five groups according to the chronological order of the procedures. The mean follow‐up after RALP was 18.3 months. Patient demographics, surgical data and postoperative variables were collected into a prospective database. Data were compared by chronological groups into single‐surgeon cohort.

RESULTS

The median operative time and blood loss were 140 min and 350 mL, respectively. The complication rate was 8.3%. Cancers were pT3‐4 in 34.5%. The mean hospital stay and duration of bladder catheterization were 4.3 and 8.2 days, respectively. The rate of positive surgical margins (PSMs) was 17.2% in pT2 cancers. The recovery rate of continence was 98% at 12 months. Intraoperative time, blood loss and length of hospital stay were significantly improved after a short learning curve. The continence recovery, the rate and the length of PSM were also improved beyond the learning curve, but difference was not statistically significant.

CONCLUSIONS

RALP is a safe and reproducible procedure and offers a short learning curve for experienced laparoscopic surgeons. Beyond the learning curve, continued experience might also provide further improvements in terms of operative, pathological and functional results.     

Endoscopic extraperitoneal radical prostatectomy: critical analysis of outcomes and learning curve

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

OBJECTIVE

To assess the outcomes and learning curve of extraperitoneal endoscopic radical prostatectomy (EERP) using cumulative summation charts from a single tertiary referral centre.

PATIENTS AND METHODS

The data from 300 consecutive men with localized prostate cancer who underwent EERP at Western General Hospital, Edinburgh, UK, between February 2006 and July 2009 were prospectively maintained in a database. The data collected included demographic details, perioperative outcomes, complications and follow‐up for functional and oncology outcomes. The learning curve was analysed using generalized linear models for complication rate, operative time and blood loss, using procedure experience.

RESULTS

The mean (sd , range) operative duration was 160.52 (40.84, 100–310) min, and the intraoperative blood loss was 229.3 (172, 20–1000) mL. There was no conversion to open surgery and no patient required intraoperative blood transfusion. Only one of 250 (0.3%) patients required a blood transfusion after EERP. The median (range) hospital stay was 3 (2–20) days and the median catheterization time before cystography was 9 days. There was evidence that the complication rate reduced as experience was gained (odds ratio 0.98, 95% confidence interval, CI, 0.97–0.99; P= 0.002), with the estimated probability of a complication decreasing from 29% for the first to <1% for the 250th procedure. Also there was evidence of a decrease in operative duration (?0.0020 rate parameter on log scale; 95% CI ?0.0024 to ?0.0017; P < 0.001) and blood loss (?0.01 rate parameter on log scale; 95% CI ?0.003 to ?0.0002; P= 0.021). The positive surgical margin rate in pT2 disease decreased from 27% in the first 50 to 14.7% in the last 50 operated cases. The continence rate and biochemical recurrence‐free rate at a minimum follow‐up of 1 year for the first 100 patients was 89% and 94%, respectively.

CONCLUSION

The results from this series suggest that the benefits of minimally invasive surgery for localized prostate cancer (EERP) can be replicated after mentored fellowship training of a surgeon. The complication rate reduced substantially as experience was gained, suggesting a continuous surgical learning curve     

Robot‐assisted radical prostatectomy: learning rate analysis as an objective measure of the acquisition of surgical skill

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

OBJECTIVE

To adapt an industrial definition of learning‐curve analysis to surgical learning, and elucidate the rate at which experienced open surgeons acquire skills specific to robot‐assisted radical prostatectomy (RARP) at a community‐based medical centre.

PATIENTS, SUBJECTS AND METHODS

The total procedure time (TPT) of the first 75 RARPs, performed by three surgeons experienced with retropubic RP, was analysed to determine the point at which their learning rate stabilised. Operative characteristics were compared before and after this point to isolate the plateau of learning rate as a mark of acquiring surgical skill. The operative characteristics examined were TPT, estimated blood loss (EBL), bladder neck contractures (BNC), positive margins (PM) and length of hospital stay (LOS).

RESULTS

The mean rate of TPT decrease, for procedures 1–75, was 13.4% per doubling of RARPs performed. After the first 25 procedures the TPT decreased at a rate of 1.8% per doubling, not significantly different from 0 (P > 0.05). There was no significant difference between procedures 1–25 and 26–75 in rates of EBL, BNC and PM. There was a significant change for all surgeons in TPT, with a mean of 303.1 min (RARPs 1–25) vs 213.6 min (26–75) (P < 0.001), and LOS, of 2.1 days (1–25) vs 1.4 days (26–75) (P < 0.001).

CONCLUSIONS

An industrial definition of learning‐curve analysis can be adapted to provide an objective measure of learning RARP. The average learning rate for RARP was found to plateau by the 25th procedure. Also, the learning rate plateau can serve as an objective measure of the acquisition of surgical skill.     

The impact of cavernosal nerve preservation on continence after robotic radical prostatectomy

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Continence after radical prostatectomy (RP) has been linked to surgical techniques including careful dissection of the neurovascular bundles, bladder neck preservation, sparing of the puboprostatic ligaments and reconstruction of the posterior urethral plate or total reconstruction of the vesico‐urethral junction. Several authors have reported that men undergoing bilateral nerve‐sparing have quicker and better recovery of continence than men undergoing partial or non‐nerve‐sparing procedures. Others have reported that preoperative variables have a greater effect than technique on postoperative return to continence. We examine the association between baseline characteristics (age, International Index of Erectile Function [IIEF‐5] score, American Urological Association symptom score, body mass index [BMI], clinical T stage, Gleason score, and prostate‐specific antigen level), nerve‐sparing status, learning curve and overall continence at 1, 3 and 12 months after robotic RP. In addition, nerve‐sparing status was physically verified by comparing the amount of extraprostatic tissue seen on the wide excision side and nerve‐sparing side for unilateral nerve‐sparing procedures. After multivariate analysis, age, IIEF‐5 and BMI were found to affect continence in a statistically significant fashion, while nerve‐sparing status did not significantly affect continence.

OBJECTIVE

? To evaluate associations between baseline characteristics, nerve‐sparing (NS) status and return of continence, as a relationship may exist between return to continence and preservation of the neurovascular bundles for potency during radical prostatectomy (RP).

PATIENTS AND METHODS

? The study included 592 consecutive robotic RPs completed between 2002 and 2007. ? All data were entered prospectively into an electronic database. ? Continence data (defined as zero pads) was collected using self‐administered validated questionnaires. ? Baseline characteristics (age, International Index of Erectile Function [IIEF‐5] score, American Urological Association symptom score, body mass index [BMI], clinical T‐stage, Gleason score, and prostate‐specific antigen level), NS status and learning curve were retrospectively evaluated for association with overall continence at 1, 3 and 12 months after RP using univariate and multivariable methods. ? Any patient taking preoperative phosphodiesterase inhibitors was excluded from the postoperative analysis.

RESULTS

? Complete data were available for 537 of 592 patients (91%). ? Continence rates at 12 months after RP were 89.2%, 88.9% and 84.8% for bilateral NS, unilateral NS and non‐NS respectively (P= 0.56). ? In multivariable analysis age, IIEF‐5 score and BMI were significant independent predictors of continence. ? CavernosalNS status did not significantly affect continence after adjusting for other co‐variables.

CONCLUSION

? After careful multivariable analysis of baseline characteristics age, IIEF‐5 score and BMI affected continence in a statistically significant fashion. This suggests that baseline factors and not the physical preservation of the cavernosal nerves predict overall return to continence.     

An analysis of sexual health information on radical prostatectomy websites

Study Type – Therapy (content analysis) Level of Evidence 3

OBJECTIVE

To define the nature of information posted on websites related to radical prostatectomy (RP), specifically its accuracy and comprehensiveness, as RP is associated with erectile dysfunction (ED).

METHODS

We reviewed 70 robotic RP (RARP) and 20 open RP (ORP) medical centres. Their websites were reviewed for various factors, by two separate reviewers whose reviews were not seen by each other. Websites were graded based on accuracy and comprehensiveness of information by the senior investigator.

RESULTS

Of the academic and community‐based RARP centres, 55% and 79% had specific websites (P < 0.05); 45% of RARP sites had generic information copied directly from the website of Intuitive Surgical (Sunnyvale, CA, USA; the manufacturer of the robotic system). ED was mentioned by only 54% of RARP sites and 45% of ORP sites; 17% of RARP sites were deemed accurate, compared with 30% of ORP sites (P < 0.05). Just over 1% of RARP sites were considered comprehensive, vs 10% of ORP sites (P < 0.05). A third of RARP sites had a direct link to the Intuitive Surgical website (16% academic vs 53% community, P < 0.05), compared to 10% of open sites (P < 0.05). Of most interest was that half of the RARP sites suggested that ED rates were lower for RARP than for ORP; this compared to ED rates being cited as lower for ORP on 5% of the ORP sites (P < 0.05).

CONCLUSIONS

Despite the stature of RP as a treatment option for men with prostate cancer, and the recent increase in the use of RARP, the accuracy of information pertaining to sexual health on RP websites is poor, with many making false statements about the long‐term outcomes for erectile function. This inadequacy appears to be greater on RARP than on ORP websites.     

The learning curve for reducing complications of robotic-assisted laparoscopic radical prostatectomy by a single surgeon

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Between December 2005 and January 2010, 200 consecutive patients with prostate cancer received RALP performed by a single surgeon. Only one case with Clavien grade II complication due to gouty arthritis. The complication rate was 1%. We suggested that patient with history of gouty arthritis need to prescribe preventive colchicine. OBJECTIVE

• ? To analyse the learning curve for reducing complications of robotic‐assisted laparoscopic radical prostatectomy (RALP) performed by a single surgeon in Taiwan.

PATIENTS AND METHODS

• ? Complication rates were prospectively assessed in 200 consecutive patients undergoing RALP (Group I: cases 1–50; Group II: cases 51–100; Group III: cases 101–150 and Group IV: cases 151–200).
• ? Complications were classified using the Clavien system: grade I: deviation normal postoperative course without treatment; grade II: drug or bedside treatment; grade III: endoscopic or surgical intervention; grade IV: life‐threatening problem; and grade V: death.
• ? Operative parameters and peri‐operative complications were evaluated, including operative and console time, blood loss and transfusion rate, Gleason scores, positive surgical margin (PSM) rate, specimen volume, tumour size, tumour percentage, node positive rate and intra‐ and postoperative complications.

RESULTS

• ? RALP console time was gradually lowered from Group I to Group IV (P < 0.05). Significantly less blood loss occurred after every 50 cases of RALP (Group I 275 mL, Group II 179 mL, Group III 145 mL, Group IV 102 mL, P < 0.001).
• ? Blood transfusion incidence was 8%, 4%, 2% and 0% in Groups I, II, III and IV, respectively.
• ? Complication rates were 18%, 12%, 18% and 0% in Groups I, II, III and IV, respectively.
• ? Major complications (grade III–IV) were 6%, 2%, 4% and 0% in Groups I, II, III and IV, respectively.
• ? Bowel injury occurred in three cases (Group II: 1; Group III: 2); one received intra‐operative repair without sequelae and two received a transient colostomy and later colostomy closure.

CONCLUSIONS

• ? The learning curve for every 50 cases of RALP showed significantly less blood loss and blood transfusion rate.
• ? The learning curve for significantly decreasing complications is 150 cases.