In the present study, we present comparative outcomes of radical prostatectomy after whole-gland therapy (wg-SRARP) and focal gland therapy (f-SRARP). The study assessed 339 patients who underwent ...salvage robot-assisted radical prostatectomy (SRARP); 145 patients who had primary focal therapy and 194 patients who had primary whole-gland treatment. SRARP was performed in all cases using a standardized technique developed at respective institutes with the da Vinci Xi Surgical System. Our primary endpoint was the comparison of the functional and oncological outcomes between the groups. Cox proportional hazard was used to study the functional and oncological outcomes. The median total operative time for f-SRARP was 18 min higher than wg-RARP (
p
< 0.001). Higher rates of nerve-sparing were performed in f-SRARP (focal vs whole gland; bilateral—15.2% vs 9.3%; unilateral 49% vs 28.4%;
p
< 0.001). wg-SRARP had higher rates of ISUP 5 (26.3% vs 19.3%;
p
< 0.001) and deferred ISUP score due to altered pathology (14.8% vs 0.7;
p
< 0.001), while f-SRARP had higher rates of ISUP 4 (11.7% vs 10.7%;
p
< 0.001) and ≥ pT3a (64.8% vs 51.6%;
p
< 0.001). Positive margins were significantly higher with f-SRARP (26.2% vs 10.3%;
p
< 0.001). Functional outcomes were poor in both the groups. However, postoperative continence was higher and faster in patients who had f-SRARP compared to wg-SRARP (69% vs. 54.6%;
p
= 0.013). We could not identify statistically significant difference in postoperative potency recovery and biochemical recurrence. We present the largest multi-institutional analyses of f-SRARP and wg-SRARP. SRARP is challenging wherein patients have adverse pathological features and increased surgical complexity irrespective of the primary treatment. Focal therapy group had higher rates of nerve-sparing, however, with increased positive surgical margins. Both groups had poor functional outcomes regardless of nerve-sparing degree, indicating significant ipsilateral and contralateral damage to tissues surrounding the prostate during primary treatment. We believe that this analysis is crucial for counseling patients regarding expected outcomes before performing a salvage treatment following ablative therapy failure.
Abstract Background Positive surgical margin (PSM) after radical prostatectomy (RP) has been shown to be an independent predictive factor for cancer recurrence. Several investigations have correlated ...clinical and histopathologic findings with surgical margin status after open RP. However, few studies have addressed the predictive factors for PSM after robot-assisted laparoscopic RP (RARP). Objective We sought to identify predictive factors for PSMs and their locations after RARP. Design, setting, and participants We prospectively analyzed 876 consecutive patients who underwent RARP from January 2008 to May 2009. Intervention All patients underwent RARP performed by a single surgeon with previous experience of >1500 cases. Measurements Stepwise logistic regression was used to identify potential predictive factors for PSM. Three logistic regression models were built: (1) one using preoperative variables only, (2) another using all variables (preoperative, intraoperative, and postoperative) combined, and (3) one created to identify potential predictive factors for PSM location. Preoperative variables entered into the models included age, body mass index (BMI), prostate-specific antigen, clinical stage, number of positive cores, percentage of positive cores, and American Urological Association symptom score. Intra- and postoperative variables analyzed were type of nerve sparing, presence of median lobe, percentage of tumor in the surgical specimen, gland size, histopathologic findings, pathologic stage, and pathologic Gleason grade. Results and limitations In the multivariable analysis including preoperative variables, clinical stage was the only independent predictive factor for PSM, with a higher PSM rate for T3 versus T1c (odds ratio OR: 10.7; 95% confidence interval CI, 2.6–43.8) and for T2 versus T1c (OR: 2.9; 95% CI, 1.9–4.6). Considering pre-, intra-, and postoperative variables combined, percentage of tumor, pathologic stage, and pathologic Gleason score were associated with increased risk of PSM in the univariable analysis ( p < 0.001 for all variables). However, in the multivariable analysis, pathologic stage (pT2 vs pT1; OR: 2.9; 95% CI, 1.9–4.6) and percentage of tumor in the surgical specimen (OR: 8.7; 95% CI, 2.2–34.5; p = 0.0022) were the only independent predictive factors for PSM. Finally, BMI was shown to be an independent predictive factor (OR: 1.1; 95% CI, 1.0–1.3; p = 0.0119) for apical PSMs, with increasing BMI predicting higher incidence of apex location. Because most of our patients were referred from other centers, the biopsy technique and the number of cores were not standardized in our series. Conclusions Clinical stage was the only preoperative variable independently associated with PSM after RARP. Pathologic stage and percentage of tumor in the surgical specimen were identified as independent predictive factors for PSMs when analyzing pre-, intra-, and postoperative variables combined. BMI was shown to be an independent predictive factor for apical PSMs.
Many centers have recently implemented posterior rhabdosphincter reconstruction (PRR) into robot-assisted radical prostatectomy (RARP) with the objective of earlier continence recovery. We ...comprehensively review the anatomic and functional changes occurring post prostatectomy along with the reconstructive techniques and published outcomes of PRR. Several case control studies show a better continence rate within the first 3 months, whereas the only randomized control trial presents a conflicting conclusion. Unfortunately, all reported studies lack uniform surgical technique, continence definition, and measures, making comparison difficult. Although initial results appear favorable, the true continence benefit of PRR remains debatable and requires further research.
Different groups described the single-port surgery since its first report in laparoscopic procedures. However, the acceptance of this technique among urologists, even after the robotic approach, was ...reduced in the past years. Therefore, to overcome the challenges related to the single-port surgery, a new robotic platform named da Vinci SP was created with exclusive single port technology. We performed a non-systematic literature review regarding the single port technique in urologic surgeries since the first laparoscopic report until the da Vinci SP robotic platform. Three different periods were described (laparoscopy, robotic, and da Vinci SP), and we focused in our experience with this new single port robot. We selected different articles and summarized the information regarding the use of single-site surgery in laparoscopic procedures and the challenges of this approach. We also reported the experience of different groups using the single port robotic technique and some recent reports of the da Vinci SP approach. In our experience with this new console, we described some critical points related to our radical prostatectomy technique and the lessons learned during the introduction of this novel platform. Previous single-site procedures described some common challenges that limited the technique expansion. However, our experience with the da Vinci SP described feasible and safe procedures with acceptable intraoperative outcomes. The introduction of this platform is recent in the market, and the literature still lacks a high level of evidence describing the long-term outcomes of this new technology.
Robot-assisted laparoscopic radical prostatectomy (RALP) has become the standard of surgical care in the USA and around the world. Over the past 18 years, we have performed 13,000 radical ...prostatectomies, and our surgical technique has evolved over time. We discuss this evolution and how it has helped us achieve optimal patient outcomes.
Study Type – Therapy (case series) Level of Evidence 4
OBJECTIVE
• To evaluate early trifecta outcomes after robotic‐assisted radical prostatectomy (RARP) performed by a high‐volume surgeon.
PATIENTS ...AND METHODS
• We evaluated prospectively 1100 consecutive patients who underwent RARP performed by one surgeon. In all, 541 men were considered potent before RARP; of these 404 underwent bilateral full nerve sparing and were included in this analysis.
• Baseline and postoperative urinary and sexual functions were assessed using self‐administered validated questionnaires.
• Postoperative continence was defined as the use of no pads; potency was defined as the ability to achieve and maintain satisfactory erections for sexual intercourse >50% of times, with or without the use of oral phosphodiesterase type 5 inhibitors; Biochemical recurrence (BCR) was defined as two consecutive PSA levels of >0.2 ng/mL after RARP.
• Results were compared between three age groups: Group 1, ≤55 years, Group 2, 56–65 years and Group 3, >65 years.
RESULTS
• The trifecta rates at 6 weeks, 3, 6, 12, and 18 months after RARP were 42.8%, 65.3%, 80.3%, 86% and 91%, respectively.
• There were no statistically significant differences in the continence and BCR‐free rates between the three age groups at all postoperative intervals analysed.
• Nevertheless, younger men had higher potency rates and shorter time to recovery of sexual function when compared with older men at 6 weeks, 3, 6 and 12 months after RARP (P < 0.01 at all time points).
• Similarly, younger men had higher trifecta rates at 6 weeks, 3 and 6 months after RARP compared with older men (P < 0.01 at all time points).
CONCLUSION
• RARP offers excellent short‐term trifecta outcomes when performed by an experienced surgeon.
• Younger men had higher overall trifecta rates when compared with older men at 6 weeks, 3 and 6 months after RARP.
Objective
To analyse the continence outcomes of robot‐assisted radical prostatectomy (RARP) in suboptimal patients that have challenging continence recovery factors such as enlarged prostates, ...elderly patients, higher body mass index (BMI), salvage prostatectomy, and bladder neck procedures before RARP.
Patients and Methods
From January 2008 through November 2012, 4 023 patients underwent RARP by a single surgeon at our institution. Retrospective analysis of prospectively collected data identified 3 362 men who had minimum of 1‐year follow‐up. This cohort of patients was stratified into six groups: Group I, aged ≥70 years (451 patients); Group II, BMI ≥35 kg/m2 (197); Group III, prior bladder neck procedures (103); Group IV, prostate weight ≥80 g (280); and Group V, salvage prostatectomy (41). Group VI consisted of patients (2 447) with none of these risk factors. Continence outcomes at follow‐up were analysed for all groups.
Results
The continence rate at 1 year and mean (sd) time to continence in different groups were: for patients aged ≥70 years, 85.6% and 3.2 (4.5) months; BMI of ≥35 kg/m2, 87.8% and 3.1 (4.5) months; prior bladder neck treatment, 82.4% and 3.4 (4.7) months; prostate weight of ≥80 g, 85.8% and 3.3 (4.4) months; salvage procedures, 51.3% and 6.6 (8.3) months; and in Group VI (none of the risk factors), 95.1% and 2.4 (3.2) months. The continence rate was significantly higher in group VI compared with the salvage group (group V) at the different follow‐up intervals (P < 0.001). When compared with the other groups (I–IV), the continence rate, although higher, was not statistically significant at the different intervals in group VI (no risk). The mean time to continence was significantly lower in group VI compared with the other groups (I–V; P < 0.001).
Conclusions
This study has shown that selected risk factors adversely affect the time to return of continence after RARP, yet aside from salvage patients, there was no statistically significant difference demonstrated between the adverse‐risk groups included. Patients undergoing salvage RP had significantly lower continence rates at the various intervals compared with the other groups. Patients with the risk factors identified should be counselled concerning expectations for achieving urinary continence.
Purpose With the exponential growth of robotic urological surgery, particularly with robot assisted radical prostatectomy, guidelines for safe initiation of this technology are a necessity. Currently ...no standardized credentialing system exists to our knowledge to evaluate surgeon competency and safety with robotic urological surgery performance. Although proctoring is a modality by which such competency can be evaluated, other training tools and guidelines are needed to ensure that the requisite knowledge and technical skills to perform this procedure have been acquired. We evaluated the current status of proctoring and credentialing in other surgical specialties to discuss and recommend its application and implementation specifically for robot assisted radical prostatectomy. Materials and Methods We reviewed the literature on safety and medicolegal implications of proctoring and the safe introduction of surgical procedures to develop recommendations for robot assisted radical prostatectomy proctoring and credentialing. Results Proctoring is an essential mechanism for robot assisted radical prostatectomy institutional credentialing and should be a prerequisite for granting unrestricted privileges on the robot. This should be differentiated from preceptoring, wherein the expert is directly involved in hands-on training. Advanced technology has opened new avenues for long-distance observation through teleproctoring. Although the medicolegal implications of an active surgical intervention by a proctor are not clearly defined, the role as an observer should grant immunity from malpractice liability. Conclusions The implementation of guidelines and proctoring recommendations is necessary to protect surgeons, proctors, institutions and, above all, the patients who are associated with the institutional introduction of a robot assisted radical prostatectomy program. With no current guidelines we anticipate this article will serve as a catalyst of interorganizational discussion to initiate regulatory oversight of surgeon certification and proctorship.
Nerve-sparing procedures during robot-assisted radical prostatectomy (RARP) have demonstrated improved postoperative functional outcomes. This article provides an overview of clinically applied ...prostatic neuro-anatomy, various techniques of nerve sparing (NS), and recent innovations in NS and potency outcomes of NS RARP. We retrieved and reviewed all listed publications within PubMed using keywords: nerve sparing, robotic radical prostatectomy, prostate cancer, outcomes, pelvic neuroanatomy and potency. Studies reporting potency outcomes of NS RARP (comparative and non-comparative) were analysed using the Delphi method with an expert panel of urological robotic surgeons. Herein, we outline the published techniques of NS during RARP. Potency and continence outcomes of individual series are discussed in light of the evidence provided by case series and published trials. The potency outcomes of various comparative and non-comparative series of NS RARP have also been mentioned. There are numerous NS techniques reported for RARP. Each method is complimented with benefits and constrained by idiosyncratic caveats, and thus, careful patient selection, a wise intraoperative clinical judgment and tailored approach for each patient is required, when decision for nerve sparing is made. Further large prospective multi-institutional randomized controlled trials are required to evaluate potency and continence outcomes of these techniques, using a rigid standard patient selection criteria and definition of potency are warranted in the new era of functional outcome-driven research.
To review the most used intracorporeal orthotopic ileal neobladder (ICONB) after radical cystectomy for bladder cancer and create a unified compendium of the different alternatives, including new ...consistent images.
We performed a non-systematic review of the literature with the keywords “bladder cancer”, “urinary diversion”, “radical cystectomy”, and “neobladder”.
Forty studies were included in the analysis. The most frequent type of ICONB was the modified Studer “U” neobladder (70%) followed by the Hautmann “W” modified neobladder (7.5%), the “Y” neobladder (5%), and the Padua neobladder (5%). The operative time to perform a urinary diversion ranged from 124 to 553 min. The total estimated blood loss ranged from 200 to 900 mL. The rate of positive surgical margins ranged from 0% to 8.1%. Early minor and major complication rates ranged from 0% to 100% and from 0% to 33%, respectively. Late minor and major complication rates ranged from 0% to 70% and from 0% to 25%, respectively.
The most frequent types of ICONB are Studer “U” neobladder, Hautmann “W” neobladder, “Y” neobladder, and the Padua neobladder. Randomized studies comparing the performance of the different types of ICONB, the performance in an intra or extracorporeal manner, or the performance of an ICONB versus ICIC are lacking in the literature. To this day, there are not sufficient quality data to determine the supremacy of one technique. This manuscript represents a compendium of the most used ICONB with detailed descriptions of the technical aspects, operative and perioperative outcomes, and new consistent images of each technique.
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