Robotic radical prostatectomy in Greece: the learning curve and beyond. The initial 40 cases

Radical prostatectomy is the treatment of choice for management of organ-confined prostate cancer. Minimally invasive treatments, as an alternative, have refined been recently by the introduction of da Vinci robotic technology which has the potential to improve surgical outcomes and reduce the steep learning curve associated with conventional laparoscopic radical prostatectomy. We report on our experience with robotic radical prostatectomy using the first da Vinci robotic system in our country. During 8 months, 40 robotic radical prostatectomies were performed by a single surgical team at Athens Medical Centre (Marousi, Greece). Preoperative data collection included basic demographics, prostate-specific antigen (PSA), clinical stage, and Gleason score. Operative outcomes included operative time, estimated blood loss, and complications. Postoperative outcomes included hospital stay, pain, catheter time, pathology, PSA, return of continence, and potency. Average operative time was 186.25 min with an estimated mean blood loss of 135 ml. There were no intra-operative complications. Ninety per cent of the patients were discharged home on postoperative day 1 with mean haematocrit 36.7 (range 29–43). All patients reported minimal postoperative pain and resumed regular diet on the first postoperative day. Average catheter time was 6.6 days (range 5–10). Early continence was observed in 47.5% of the patients, seven days after catheter removal. Continence at 1, 3, and 6 months was 75, 82.5 and 95%, respectively. The overall positive margin rate was 17.5%. Ninety-five per cent of the patients had undetectable postoperative PSA levels (less than 0.1 ng/ml) at a median follow-up of 6 months. Our initial experience with robotic radical prostatectomy is very promising. The learning curve was approximately 10–12 cases. With a methodical approach we were able to implement the method safely and effectively in our practice, combining minimal morbidity with good oncological and functional outcomes.     

Transient paralysis after robotic prostatectomy

Laparoscopic radical prostatectomy (LARP) has been accepted as first line therapy for clinically localized prostate cancer. Complications have been low and outcomes are comparable to that of open surgery with potential benefits including shorter hospital stay, less pain and quicker return to normal activity. Unexplained paralysis following LARP is a rare entity with no reported cases in the current literature. We report a case of complete motor paralysis following LARP. An extensive multidisciplinary evaluation did not definitively establish a diagnosis. Aggressive multimodality treatment led to a complete recovery. Our understanding of this phenomena with the possible etiology and treatment is discussed.     

Metabolic syndrome and low high-density lipoprotein cholesterol are associated with adverse pathological features in patients with prostate cancer treated by radical prostatectomy

Background

Previous studies have suggested a link between metabolic syndrome (MetS) and prostate cancer (PCa). In the present study, we aimed to assess the association between MetS and markers of PCa aggressiveness on radical prostatectomy (RP).

Seguimiento a largo plazo del cabestrillo AdVance®/AdVanceXP®. ¿Qué piensa el cirujano?, ¿qué piensa el paciente?

Objectives

To analyse the safety, efficacy and quality of life of patients with male stress urinary incontinence after radical prostatectomy treated with the AdVance^® and AdvanceXP^® slings.

Efficacy of Local Treatment in Prostate Cancer Patients with Clinically Pelvic Lymph Node-positive Disease at Initial Diagnosis

Background

There is limited evidence supporting the use of local treatment (LT) for prostate cancer (PCa) patients with clinically pelvic lymph node-positive (cN1) disease.

Robotic Laparoendoscopic Single-Site Radical Prostatectomy: Technique and Early Outcomes

Background

Laparoendoscopic single-site (LESS) surgery is challenging. To help overcome current technical and ergonomic limitations, the da Vinci robotic platform can be applied to LESS.

Objectives

Our aim was to describe the surgical technique and to report the early outcomes of robotic LESS (R-LESS) radical prostatectomy (RP).

Design, setting, and participants

A retrospective review of prospectively captured R-LESS RP data was performed between May 2008 and May 2010. A total of 20 procedures were scheduled (12 with and 8 without pelvic lymph node dissection).

Surgical procedure

R-LESS prostatectomy was performed using the methods outlined in the paper and in the supplemental video material.

Interventions

All patients underwent R-LESS RP by one high-volume surgeon. Single-port access was achieved via a commercially available multichannel port. The da Vinci S and da Vinci Si surgical platform was used with pediatric and standard instruments.

Measurements

Preoperative, perioperative, pathologic, and functional outcomes data were analyzed.

Results and limitations

The mean age was 60.4 yr; body mass index was 25.4 kg/m². The mean operative time was 189.5 min; estimated blood loss was 142.0 ml. The average length of stay was 2.7 d, and the visual analog pain score at discharge was 1.4 of 10. Four focal positive margins were encountered, with two occurring during the first three cases. Pathology revealed a Gleason score of 3 + 3 in 3 patients, 3 + 4 in 11 patients, 4 + 3 in 4 patients, and 4 + 4 in 2 patients. There were a total of four complications according to the Clavien system including one grade 1, two grade 2, and one grade 4. The median follow-up has been 4 mo (range: 1–24 mo). Study limitations include the small sample size, the short follow-up, and the lack of comparative cohort.

Conclusions

The R-LESS RP is technically feasible and reduces some of the difficulties encountered with conventional LESS RP.     

Low Quality of Evidence for Robot-Assisted Laparoscopic Prostatectomy: Results of a Systematic Review of the Published Literature

Background

Robot-assisted laparoscopic prostatectomy (RALP) is displacing radical retropubic prostatectomy as the gold standard surgical approach for clinically localised prostate cancer in the United States and is also being increasingly used in Europe and other parts of the world. This trend has occurred despite the paucity of high-quality evidence to support its relative superiority to more established treatment modalities.

Objective

We performed this study to critically assess the quality of published evidence on RALP to support this major shift in practice patterns.

Design, setting, and participants

We conducted a systematic review of the published literature through Medline and Embase (1966 to December 2008). All original research publications on RALP were included. Editorials, letters to the editor, and review articles were excluded.

Measurements

Two reviewers independently performed the data abstraction using a standardised form derived from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria.

Results and limitations

Seventy-five original research publications met eligibility criteria. Fifty-five (73.3%) studies were published between 2005 and 2008, and 20 studies (26.7%) were published between 2001 and 2004. Approximately three-quarters of the studies were case series (74.7%), and only two (2.7%) randomised, controlled trials (RCT) were identified. Twelve authors cowrote 72% (54 of 75) of the published studies. Reporting of STROBE criteria ranged from 100.0% (scientific rationale/background explained) to 1.3% (consideration of sample size), with no improvement over time. The study was limited to published literature in the English language.

Conclusions

The published RALP literature is limited to observational studies of mostly low methodologic quality. Our findings draw into question to what extent valid conclusions about the relative superiority or equivalence of RALP to other surgical approaches can be drawn and whether published outcomes can be generalised to the broader community. There is an urgent need to raise the methodologic standards for clinical research on new urologic procedures and devices.     

耻骨上前列腺切除术中应用聚维酮碘纱带填塞前列腺腺窝止血100例效果观察

目的 探讨聚维酮碘纱带填塞前列腺腺窝止血在耻骨上前列腺切除术中的应用效果.方法 对2000年5月-2011年10月行耻骨上前列腺切除术中应用聚维酮碘纱带填塞前列腺腺窝止血100例的临床资料进行回顾性分析.结果 本组平均手术时间42min,术中平均出血量90ml.术后均未进行膀胱冲洗,未发生膀胱痉挛性疼痛.切口Ⅰ期愈合,未发生并发症.结论 聚维酮碘纱带填塞前列腺腺窝上血是简便、有效、安全的开放性前列腺切除术止血方法.     

Prediction of Gleason score upgrading in low-risk prostate cancers diagnosed via multi (≥12)-core prostate biopsy

Objectives  A paucity of data exists on actual pathology of the contemporary patients strictly categorized as having low-risk prostate cancer. We tried to identify useful preoperative predictors of Gleason score upgrading in patients who underwent radical retropubic prostatectomy (RRP) for low-risk prostate cancer diagnosed via multi-core prostate biopsy. Methods  A total of 203 patients who underwent radical RRP for low-risk prostate cancer, as defined by D’Amico et al.'s classification (clinical stage ≤T2a, biopsy Gleason sum ≤6, and PSA ≤10 ng/ml), detected via multi (≥12)-core prostate biopsy were enrolled. We reviewed patients preoperative and pathological data. Results  Among all subjects, 81 (39.9%) were upgraded to Gleason score ≥7 after RRP, whereas no downgrading was observed. In multivariate analysis, only preoperative PSA level (P = 0.024) and number of positive cores (P = 0.027) were observed to be independent predictors of Gleason score upgrading following RRP. Also, Gleason core upgrading was observed to be significantly associated with extraprostatic extension of tumor (P < 0.001) and positive surgical margin (P = 0.002). Conclusions  A significant proportion of patients with low-risk prostate cancer as defined by D’Amico et al.’s classification diagnosed via multi-core prostate biopsy in contemporary period may have Gleason score upgrading following RRP. For patients with low-risk prostate cancer, preoperative PSA level and number of positive cores may be useful predictors of Gleason score upgrading, which was observed to significantly associated with other adverse pathologic features.     

Analysis of T1c prostate cancers treated at very low prostate-specific antigen levels

Background

The Prostate Cancer Prevention Trial (PCPT) has challenged the validity of recommended prostate-specific antigen (PSA) thresholds for prostate biopsy (>2.5 ng/ml) given the 17% prostate cancer (pCA) detection rate at PSA of 1.1–2.0. The outcome of patients treated at PSA ≤2.5 is poorly defined, and advantages associated with such an early diagnosis are uncertain.

Objective

Compare the outcome of patients with T1c pCA with pretreatment PSA ≤2.5 and 2.6–4.0.

Design, setting, and participants

Since 1998, 351 patients with clinical stage T1c and PSA ≤4.0 have been treated at our institution; 84 (24%) of those patients had PSA ≤2.5. Clinical information was obtained from a prospective database. Treatment was radical prostatectomy (RP), brachytherapy, and external-beam radiotherapy (EBRT) in 261 (74%), 67 (19%), and 23 (7%) patients, respectively.

Intervention

Definitive therapy for clinically localized pCA.

Measurements

Progression-free probability and pathologic end points.

Results and limitations

No significant differences between the groups were observed in terms of biopsy (18% vs 22%) or specimen Gleason score 7–8 (44% vs 56%), non–organ-confined cancer (11% vs 13%), indolent cancer (34% vs 24%), or 5-yr progression-free probability (89% vs 93%; p > 0.1 for all). More biologically unimportant cancers (defined as pathologically organ-confined and Gleason ≤6) were identified among patients with PSA ≤2.5 (55% vs 41%, p = 0.050), and indolent cancers were three times more frequent than non–organ-confined cancers among these patients (p = 0.003).

Conclusions

The pathologic features and outcome of patients treated at low PSA levels are favorable and similar for patients with PSA ≤2.5 versus 2.6–4.0. However, >50% of the former have potentially biologically unimportant cancer. We failed to identify a therapeutic benefit to the diagnosis of cancers below accepted PSA thresholds for biopsy.