{Table 1} At least theoretically, preservation of the arteries within the DVC, as well as the accessory pudendal arteries found in 30% of men, might also lead to better postoperative potency, and the ...author has started to see a trend that supports this, although longer follow-up supported by patient-reported outcome questionnaires is needed to clarify this observation. ...recent analysis of the author's first 320 cases Table 2 showed similar operating time for prostates <70 g and >70 g (179 min and 177 min; P ≤ 0.001), a similar transfusion rate (3 units and 1 unit; P = 0.94), a similar postoperation hospital stay (1.9 nights and 1.8 nights; P = 1.00), similar Clavien 1, 2, and 3 complications (8, 3, 7 patients and 5, 1, 2 patients; P = 0.98, 0.94, and 0.76, respectively), and similar positive surgical margin (PSM) rates for pT2/pT3 disease (18.7%/38.8% and 11.8%/29.4%; P = 0.98/0.13). To date, dissemination of RS-RARP has not matched the interest in this technique because first it is difficult to do laparoscopically with straight laparoscopic instruments (the author has attempted eight cases and has successfully completed four of these entirely laparoscopically) and second even in more affluent healthcare environments where robotic surgery is financially viable the lack of landmarks, cramped workspace, and proximity of the ureters are reasons enough to put off even experienced RP surgeons, as is a lack of suitable mentors. {Figure 1} The inability to look inside the bladder during RS-RARP, together with the proximity of the distal ureters to the lateral pedicles of the prostate, has led to a number of published6 as well as unpublished ureteric injuries. Since ureteric injury is also a recognized complication of AA-RARP, it would be unreasonable to criticize a relatively new technique prematurely because of this.
Abstract Objectives To analyse the indications and long-term results of endoscopic and minimal access approaches for the treatment of ureteropelvic junction (UPJ) obstruction and to compare them to ...open surgery. Methods A review of the literature from 1950 to January 2007 was conducted using the Ovid Medline database. Results A lack of standardisation of techniques used to diagnose UPJ obstruction and to follow up treated patients introduces a degree of inaccuracy in interpreting the success rates of the various modalities of treatment. However, there is no indication that any one of these techniques is affected by this to a greater or lesser extent than another. Open pyeloplasty achieves very good (90–100% success) results, endopyelotomy and balloon disruption of the UPJ fail to match these results by 15–20%, and minimal access pyeloplasty produces results that are at least as good as those of open surgery but with the advantages of a minimal access approach. Conclusions Minimal access pyeloplasty is likely to gradually replace endopyelotomy and balloon disruption of the UPJ for the treatment of UPJ obstruction. The much higher cost of robotic pyeloplasty and greater availability of laparoscopic expertise in teaching centres are likely to limit the dissemination of robotic pyeloplasty.
Abstract Background Positive surgical margins (PSMs) are a known risk factor for biochemical recurrence in patients with prostate cancer (PCa) and are potentially affected by surgical technique and ...volume. Objective To investigate whether radical prostatectomy (RP) modality and volume affect PSM rates. Design, setting, and participants Fourteen institutions in Europe, the United States, and Australia were invited to participate in this study, all of which retrospectively provided margins data on 9778 open RP, 4918 laparoscopic RP, and 7697 robotic RP patients operated on between January 2000 and October 2011. Outcome measurements and statistical analyses The outcome measure was PSM rate. Multivariable logistic regression analyses and propensity score methods identified odds ratios for risk of a PSM for one modality compared with another, after adjustment for age, preoperative prostate-specific antigen, postoperative Gleason score, pathologic stage, and year of surgery. Classic adjustment using standard covariates was also implemented to compare PSM rates based on center volume for each minimally invasive surgical cohort. Results and limitations Open RP patients had higher-risk PCa at time of surgery on average and were operated on earlier in the study time period on average, compared with minimally invasive cohorts. Crude margin rates were lowest for robotic RP (13.8%), intermediate for laparoscopic RP (16.3%), and highest for open RP (22.8%); significant differences persisted, although were ameliorated, after statistical adjustments. Lower-volume centers had increased risks of PSM compared with the highest-volume center for both laparoscopic RP and robotic RP. The study is limited by its nonrandomized nature; missing data across covariates, especially year of surgery in many of the open cohort cases; lack of standardized histologic processing and central pathology review; and lack of information regarding potential confounders such as patient comorbidity, nerve-sparing status, lymph node status, tumor volume, and individual surgeon caseload. Conclusions This multinational, multi-institutional study of 22 393 patients after RP suggests that PSM rates might be lower after minimally invasive techniques than after open RP and that PSM rates are affected by center volume in laparoscopic and robotic cases. Patient summary In this study, we compared the effectiveness of different types of surgery for prostate cancer by looking at the rates of cancer cells left at the margins of what was removed in the operations. We compared open, keyhole, and robotic surgery from many centers across the globe and found that robotic and keyhole operations appeared to have lower margin rates than open surgeries. How many cases a center and surgeon do seems to affect this rate for both robotic and keyhole procedures.
Abstract Context Over the last two decades, minimally invasive treatment options for ureteropelvic junction obstruction (UPJO) have been developed and popularized. Objective To critically analyze the ...current status of laparoscopic and robotic repair of UPJO. Evidence acquisition A systematic literature review was performed in November 2012 using PubMed. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria. Evidence synthesis Multiple series of laparoscopic pyeloplasty have demonstrated high success rates and low perioperative morbidity in pediatric and adult populations, with both the transperitoneal and retroperitoneal approaches. Data on pediatric robot-assisted pyeloplasty are increasingly becoming available. A larger number of cases have also been reported for adult patients, confirming that robotic pyeloplasty represents a viable option for either primary or secondary repair. Robot-assisted redo pyeloplasty has been mostly described in the pediatric population. Different technical variations have been implemented with the aim of tailoring the procedure to each specific case. The type of stenting, retrograde versus antegrade, continues to be debated. Internal-external stenting as well as a stentless approach have been used, especially in the pediatric population. Comparative studies demonstrate similar success and complication rates between minimally invasive and open pyeloplasty in both the adult and pediatric setting. A clear advantage in terms of hospital stay for minimally invasive over open pyeloplasty was observed only in the adult population. Conclusions Laparoscopy represents an efficient and effective less invasive alternative to open pyeloplasty. Robotic pyeloplasty is likely to emerge as the new minimally invasive standard of care whenever robotic technology is available because its precise suturing and shorter learning curve represent unique attractive features. For both laparoscopy and robotics, the technique can be tailored to the specific case according to intraoperative findings and personal surgical experience.
PURPOSESalvage radical prostatectomy is rare due to the risk of postoperative complications. We compare salvage Retzius-sparing robotic assisted radical prostatectomy (SRS-RARP) with salvage standard ...robotic assisted radical prostatectomy (SS-RARP). MATERIALS AND METHODSA total of 72 patients across 9 centers were identified (40 SRS-RARP vs 32 SS-RARP). Demographics, perioperative data, and pathological and functional outcomes were compared using Student's t-test and ANOVA. Cox proportional hazard models and Kaplan-Meier curves were constructed to assess risk of incontinence and time to continence. Linear regression models were constructed to investigate postoperative pad use and console time. RESULTSMedian followup was 23 vs 36 months for SRS-RARP vs SS-RARP. Console time and estimated blood loss favored SRS-RARP. There were no differences in complication rates or oncologic outcomes. SRS-RARP had improved continence (78.4% vs 43.8%, p <0.001 for 0-1 pad, 54.1% vs 6.3%, p <0.001 for 0 pad), lower pads per day (0.57 vs 2.03, p <0.001), and earlier return to continence (median 47 vs 180 days, p=0.008). SRS-RARP was associated with decreased incontinence defined as >0-1 pad (HR 0.28, 95% CI 0.10-0.79, p=0.016), although not when defined as >0 pad (HR 0.56, 95% CI 0.31-1.01, p=0.053). On adjusted analysis SRS-RARP was associated with decreased pads per day. Lymph node dissection and primary treatment with stereotactic body radiation therapy were associated with longer console time. CONCLUSIONSSRS-RARP is a feasible salvage option with significantly improved urinary function outcomes. This may warrant increased utilization of SRS-RARP to manage men who fail nonsurgical primary treatment for prostate cancer.
Objective
To investigate the learning curve for performing extended pelvic lymphadenectomy (ePLND) during laparoscopic radical prostatectomy (LRP) in patients with intermediate‐ and high‐risk ...prostate cancer.
Patients and methods
In all, 500 patients underwent ePLND for intermediate‐ or high‐risk prostate cancer by one surgeon during a 48‐month period. A transperitoneal laparoscopic approach was used in all patients to allow adequate access to the internal iliac vessels.
The variables chosen as being the most important discriminators of the quality of ePLND were operating time, complication rate and lymph node (LN) yield.
The learning curves for ePLND were calculated using the cumulative sum and cumulative average methods and the number of procedures performed until attainment of acceptable failure rates (competence levels) was calculated. LN parameters were compared with the results from the preceding 311 cases where limited PLND was undertaken.
Results
The median (range) preoperative PSA level was 8.0(1–62.5) ng/mL and biopsy Gleason score was 7(6–10). In all, 64% of patients had intermediate‐risk and 36% had high‐risk prostate cancer. There were no intraoperative blood transfusions and no conversions to open surgery. The median (range) blood loss was 200(10–1400) mL and the postoperative transfusion rate was 1.6%.
The operating time fell at a steady rate of 2.7% after the 15th case and plateaued after 130 patients. At competence levels of 5% and 10%, the learning curve for all complications ended after 346 and 136 patients, respectively.
At a 5% competence level the learning curve for PLND‐specific complications was 40 cases and there was no learning curve at a 10% competence level.
The overall complication rate was 7.2% of which almost half (47%) were deemed to be PLND‐specific. The cumulative average of the LN counts plateaued after 150 procedures. Furthermore, the median LN count after ePLND was more than double that of the authors' historical standard PLND controls (14 vs 6, P < 0.001) and increased with experience up to the end of the series (9 to 20).
The likelihood of LN involvement (LNI) correlated with biopsy and pathological Gleason grade, clinical and pathological stage and d'Amico risk group.
Conclusions
This study suggests a learning curve of ≈130 cases for operating time, 136 cases for all complications, 40 cases for PLND‐specific complications and 150 cases for LN yield.
The risk of LNI for patients with intermediate‐ and high‐risk prostate cancer was 8.4% and 19.4%, respectively, which suggests that a significant proportion would benefit from ePLND. It also shows that ePLND can be safely incorporated into LRP, and therefore also into robot‐assisted RP, in a high‐volume setting.
Objective:
The purpose of this study was to investigate urinary continence four weeks following Retzius-sparing robot-assisted radical prostatectomy.
Patients and methods:
Forty patients with T2–T3 ...prostate cancer underwent Retzius-sparing-robot-assisted radical prostatectomy and their results were compared with those from the 40 patients having robot-assisted radical prostatectomy done by the same surgeon immediately prior to the adoption of Retzius-sparing-robot-assisted radical prostatectomy.
Results:
Patients in the two groups had similar age, body mass index, prostate specific antigen, biopsy Gleason sum, clinical stage, d’Amico risk profile, blood loss, prostate weight and post-operative hospital stay. Median operating time (200 (interquartile range=155–266) vs 223 (interquartile range=100–238) min; p=0.05) and catheterisation (8 (interquartile range=8–8) vs 14 (interquartile range=14–14) days; p<0.0001) were shorter in the Retzius-sparing group, many of whom had suprapubic catheters inserted. The overall complication rate was lower in Retzius-sparing patients (2.5% vs 8.0%; p=0.36). Positive surgical margin rates were similar for Retzius-sparing and non-Retzius-sparing patients and decreased with greater experience with the Retzius-sparing technique: 16.7% vs 7.7% for pT2 ( p=0.65) and 31.8% vs 14.3% for pT3 ( p=0.44). Initial prostate specific antigen was <0.1 ng/ml in 97.5% and 100%, respectively ( p=1.00). At four weeks post-operation 0, 1 and 2 pads/day were needed in the Retzius-sparing group in 90.0%, 7.5% and 2.5% of patients, compared to 37.5% ( p<0.0001), 32.5% ( p=0.01) and 30% ( p=0.002) of men having conventional surgery.
Conclusion:
Retzius-sparing-robot-assisted radical prostatectomy is faster than the anterior approach to the prostate, allows a shorter catheterisation time and produces dramatically better continence results at four weeks with 90% of patients being pad-free and 97.5% of patients needing 0–1 pads/day.
Study Type – Therapy (case series) Level of Evidence 4
OBJECTIVE
To investigate the effect of extended vs standard pelvic lymphadenectomy (sPLND) for patients with intermediate‐ and high‐risk ...prostate cancer undergoing laparoscopic radical prostatectomy (LRP).
PATIENTS AND METHODS
Of a total of 1269 patients who underwent LRP during a 109 month period, 374 (30%) had a PLND; 253 men had a sPLND (2000 to March 2008) and 121 had an extended PLND (ePLND; after April 2008) for intermediate‐ or high‐risk prostate cancer. An extraperitoneal approach was used in all patients having sPLND and a transperitoneal approach in patients having ePLND.
RESULTS
Patient age, body mass index, gland weight, prostate‐specific antigen level and Gleason grade were similar in the two groups. The ePLND group had a greater proportion of patients with cT3 disease (9.9% vs 4.2%, P = 0.046) and was associated with a longer operating time of 206.5 vs 180.0 min (P < 0.001) and a higher node count of 17.5 vs 6.1 (P = 0.002). Blood loss, hospital stay, transfusion and complication rates were similar in the two groups. Lymph node positivity was significantly greater (P = 0.018) in patients with pathological Gleason grade 7 tumours who had ePLND (9.6% vs 1.0%) but was similar for other grades of tumour.
CONCLUSION
Based on these findings, and the results of other studies which show a reduction of prostate cancer‐specific mortality of 23% if lymph nodes are positive and 15% if they are negative after ePLND, and the correlation between surgical experience, lymph node yield and positivity, we recommend that all patients undergo ePLND if they are being treated with curative intent for intermediate‐ and high‐risk prostate cancer; ePLND should replace sPLND and surgeons performing <35 cases of RP a year should stop performing RP.
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