Karolinska prostatectomy: A robot-assisted laparoscopic radical prostatectomy technique

The Effect of Adverse Surgical Margins on the Risk of Biochemical Recurrence after Robotic-Assisted Radical Prostatectomy

Positive surgical margins (PSM) after radical prostatectomy are associated with a greater risk of biochemical recurrence (BCR). However, not all PSM harbour the same prognosis for recurrence. We aim to determine the impact of different PSM characteristics and their coexistence on the risk of BCR. This retrospective study included 333 patients that underwent robotic-assisted radical prostatectomy for prostate cancer between 2015−2020 at a single institution. The effect of PSM and their adverse characteristics on the risk of BCR was assessed using Cox proportional hazard models. Kaplan−Meier was used to represent BCR-free survival stratified by margin status. With a median follow-up of 34.5 months, patients with PSM had a higher incidence of BCR, higher risk of relapse and lower BCR-free survival than negative margins (p < 0.001). We established as adverse characteristics: PSM length ≥ 3 mm, multifocality and Gleason at margin > 3. PSM ≥ 3 mm or multifocal PSM were associated with an increased risk for BCR compared to favourable margins (HR 3.50; 95% CI 2.05−5.95, p < 0.001 and HR 2.18; 95% CI 1.09−4.37, p = 0.028, respectively). The coexistence of these two adverse features in the PSM also conferred a higher risk for biochemical relapse and lower BCR-free survival. Adverse Gleason in the margin did not confer a higher risk for BCR than non-adverse margins in our models. We concluded that PSM are an independent predictor for BCR and that the presence of adverse characteristics, such as length and focality, and their coexistence in the PSM are associated with a greater risk of recurrence. Nevertheless, subclassifying PSM with adverse features did not enhance the model’s predictive performance in our cohort.

The risk of inguinal hernia repair after radical prostatectomy - a population-based cohort study

OBJECTIVES

A nationwide population-based register study will evaluate the risk of postoperative inguinal hernia repair after primary curative-intent treatment of prostate carcinoma (PCa).

BACKGROUND

Several previous studies have suggested an increased risk of inguinal hernia repair after prostatectomy. Only a few studies have compared the risk by PCa treatment modalities.

METHODS

Data were collected between the years 1998 and 2016 from the national hospital discharge database HILMO and between the years 1998 and 2015 from the Finnish cancer registry to identify all men with prostate cancer with data on primary treatment available and information on inguinal hernia diagnoses and procedures among them. The risk of inguinal hernia repair among men managed with prostatectomy was compared to those treated with radiation therapy. Participants treated with prostatectomy were analyzed as a whole and separately stratified into subgroups managed with mini-invasive or open surgery. Multivariate Cox regression with adjustment for age and comorbidities was used for analysis.

RESULTS

A total of 7207 cases of PCa were included in the study. 4595 men were treated with radical prostatectomy and 2612 with radiation therapy. Overall, the risk of hernia repair was higher among men treated with prostatectomy compared to men who received radiation therapy as the primary PCa treatment (HR 1.42, 95% CI 1.14-1.77). The risk did not differ markedly by the prostatectomy method.

CONCLUSION

Prostate cancer treatment with prostatectomy is associated with an increased risk of inguinal hernia surgery than external beam radiation therapy treatment. This risk should be taken into account when planning PCa treatment.

Early outcomes of robot-assisted radical prostatectomy following completion of a structured training curriculum: a single surgeon cohort study

Objective:

Technical skills in robot-assisted radical prostatectomy (RARP) are not mandated by the Intercollegiate Surgical Curriculum Programme. The European Association of Urology Robotic Urology Section (ERUS) developed a structured curriculum; however, surgeons’ outcomes data from subsequent independent practice are limited. We describe the initial post-ERUS curriculum RARP outcomes for a United Kingdom (UK)-based surgeon.

Patients and methods:

This was a prospective single surgeon cohort study of 272 patients who underwent RARP between February 2016 and October 2019 in a high-volume UK centre and who were followed up at approximately 3 and 12 months. Positive surgical margins (PSMs), and 3- and 12-month continence rates were obtained and used to generate learning curves, with point of plateau estimated from logarithmic trendlines.

Results:

Overall (⩾3 mm) PSM rate for pT2 was 14.9% (5.4%) and pT3 was 22.6% (3.2%). Where data were available, 70.5% (of n=251) and 95.5% (of n=154) patients achieved social continence (0–1 pads) at 3 and 12 months, respectively. PSM and 3-month social continence rates plateaued at ~175 and ~100 cases, respectively.

Conclusion:

Following completion of the ERUS RARP curriculum, early oncological and functional outcomes consistent with published standards are rapidly achievable in independent practice. These data exemplify the potential value of a standardised RARP training curriculum to mitigate possible compromises in outcomes.

Level of evidence:

IV

3D laparoscopic prostatectomy: A prospective single-surgeon learning curve in the first 200 cases with oncologic and functional results

BACKGROUND

Studies for 3D-laparoscopic prostatectomy (3D-LRP) learning curve and surgical results are lacking. Combining 3D vision to LRP attenuates differences compared to Robotic assisted laparoscopic prostatectomy (RALP) with similar mini-invasiveness but lower costs.

MATERIALS AND METHODS

Two hundred consecutive men with localized prostate cancer underwent 3D-LRP at Seinäjoki central hospital between 2013 and 2018. Oncological and functional results were documented. Long-term functional evaluation was done using EPIC-26 survey. Clavien-Dindo classification was used to assess complications during first 3 months. All operations were performed by a single surgeon (M.R.) with no experience of LRP or 3D-LRP. The learning curve was assessed by evaluating urethral anastomosis- and total operative time. Perioperative and postoperative data was collected prospectively during surgery and at subsequent control visits up to minimum of 1 year.

RESULTS

A plateau in anastomosis time was reached after 30 cases and in operative time after 60 cases. Median operative time was 114 min (78-258 min) and median time for anastomosis was 25 min (11-90 min). Median blood loss was 150 ml (10-800 ml); 93.5% of the patients were discharged within the first 3 days. Clavien-Dindo ≥3a complications occurred in 6.5%. Positive surgical margins occurred in 23%. One-year after the operation, 93.3% had PSA ≤ 0.1; 91.9% of the patients were dry or used one daytime pad. EPIC-26 scores were as follows: Urinary incontinence 79.25 (14.5-100), urinary irritative/obstructive 93.75 (31.25-100), bowel 100 (33.33-100), sexual 36.17 (0-100) and hormonal 95 (37.5-100).

CONCLUSION

The learning curve for 3D laparoscopic prostatectomy is comparable to RALP, which makes it a cost-effective alternative with comparable oncological and functional results.

Oncologic Outcomes After Robot-assisted Radical Prostatectomy: A Large European Single-centre Cohort with Median 10-Year Follow-up

BACKGROUND

Robot-assisted radical prostatectomy (RARP) for prostate cancer (PCa) treatment has been widely adopted with limited evidence for long-term (>5 yr) oncologic efficacy.

OBJECTIVE

To evaluate long-term oncologic outcomes following RARP.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study of 885 patients who underwent RARP as monotherapy for PCa between 2002 and 2006 in a single European centre and followed up until 2016.

INTERVENTION

RARP as monotherapy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Biochemical recurrence (BCR)-free survival (BCRFS), salvage therapy (ST)-free survival (STFS), prostate cancer-specific survival (CSS), and overall survival (OS) were estimated using the Kaplan-Meier method, and event-time distributions were compared using the log-rank test. Variables predictive of BCR and ST were identified using Cox proportional hazards models.

RESULTS AND LIMITATIONS

We identified 167 BCRs, 110 STs, 16 PCa-related deaths, and 51 deaths from other/unknown causes. BCRFS, STFS, CSS, and OS rates were 81.8%, 87.5%, 98.5%, and 93.0%, respectively, at median follow-up of 10.5 yr. On multivariable analysis, the strongest independent predictors of both BCR and ST were preoperative Gleason score, pathological T stage, positive surgical margins (PSMs), and preoperative prostate-specific antigen. PSM >3mm/multifocal but not ≤3mm independently affected the risk of both BCR and ST. Study limitations include a lack of centralised histopathologic reporting, lymph node and post-operative tumour volume data in a historical cohort, and patient-reported outcomes.

CONCLUSIONS

RARP appears to confer effective long-term oncologic efficacy. The risk of BCR or ST is unaffected by ≤3mm PSM, but further follow-up is required to determine any impact on CSS.

PATIENT SUMMARY

Robot-assisted surgery for prostate cancer is effective 10 yr after treatment. Very small (<3mm) amounts of cancer at the cut edge of the prostate do not appear to impact on recurrence risk and the need for additional treatment, but it is not yet known whether this affects the risk of death from prostate cancer.

Intraoperative workload in robotic surgery assessed by wearable motion tracking sensors and questionnaires

BACKGROUND

The introduction of robotic technology has revolutionized radical prostatectomy surgery. However, the potential benefits of robotic techniques may have trade-offs in increased mental demand for the surgeon and the physical demand for the assisting surgeon. This study employed an innovative motion tracking tool along with validated workload questionnaire to assess the ergonomics and workload for both assisting and console surgeons intraoperatively.

METHODS

Fifteen RARP cases were collected in this study. Cases were performed by 10 different participants, six primarily performed console tasks and four primarily performed assisting tasks. Participants had a median 12 (min-3, max-25) years of surgical experience. Both console and assisting surgeons performed robotic prostatectomy cases while wearing inertial measurement units (IMUs) that continuously track neck, shoulder, and torso motion without interfering with the sterile environment. Postoperatively, participants completed a workload questionnaire (SURG-TLX) and a body part discomfort questionnaire.

RESULTS

Twenty-six questionnaires were completed from 13 assisting and 13 console surgeons over the 15 cases. Postoperative pain was reported highest for the right shoulder and neck. Mental demands were 41 % higher for surgeons at the console than assisting (p < 0.05), while physical demands were not significantly different. Assisting surgeons worked in demanding neck postures for 58 % of the procedure compared to 24 % for the console surgeon (p < 0.01). Surgeons at the console were primarily static and showed 2-5 times fewer movements than assisting surgeons (p < 0.01).

CONCLUSIONS

Postures were more ergonomic during console tasks than when assisting by the bedside; however, the console may constrain postures leading to static loads that have been associated with musculoskeletal symptoms for the neck, torso, and shoulders. The IMU sensors were effective at quantifying ergonomics in robotic prostatectomies, and these methods and findings have broad applications to other robotic procedures.

Urinary Incontinence and Erectile Dysfunction After Robotic Versus Open Radical Prostatectomy: A Prospective, Controlled, Nonrandomised Trial

BACKGROUND

Robot-assisted laparoscopic radical prostatectomy (RALP) has become widely used without high-grade evidence of superiority regarding long-term clinical outcomes compared with open retropubic radical prostatectomy (RRP), the gold standard.

OBJECTIVE

To compare patient-reported urinary incontinence and erectile dysfunction 12 mo after RALP or RRP.

DESIGN, SETTING, AND PARTICIPANTS

This was a prospective, controlled, nonrandomised trial of patients undergoing prostatectomy in 14 centres using RALP or RRP. Clinical-record forms and validated patient questionnaires at baseline and 12 mo after surgery were collected.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES

Odds ratios (ORs) were calculated with logistic regression and adjusted for possible confounders. The primary end point was urinary incontinence (change of pad less than once in 24h vs one time or more per 24h) at 12 mo. Secondary end points were erectile dysfunction at 12 mo and positive surgical margins.

RESULTS AND LIMITATIONS

At 12 mo after RALP, 366 men (21.3%) were incontinent, as were 144 (20.2%) after RRP. The unadjusted OR was 1.08 (95% confidence interval [CI], 0.87–1.34). Erectile dysfunction was observed in 1200 men (70.4%) 12 mo after RALP and 531 (74.7%) after RRP. The unadjusted OR was 0.81 (95% CI, 0.66–0.98).

CONCLUSIONS

In a Swedish setting, RALP for prostate cancer was modestly beneficial in preserving erectile function compared with RRP, without a statistically significant difference regarding urinary incontinence or surgical margins.

PATIENT SUMMARY

We compared patient-reported urinary incontinence after prostatectomy with two types of surgical technique. There was no statistically significant improvement in the rate of urinary leakage, but there was a small improvement regarding erectile function after robot-assisted operation.

Does robotic prostatectomy meet its promise in the management of prostate cancer?

Following Walsh's advances in pelvic anatomy and surgical technique to minimize intraoperative peri-prostatic trauma more than 30 years ago, open retropubic radical prostatectomy (RRP) evolved to become the gold standard treatment of localized prostate cancer, with excellent long-term survival outcomes [1•]. However, RRP is performed with great heterogeneity, even among high volume surgeons, and subtle differences in surgical technique result in clinically significant differences in recovery of urinary and sexual function. Since the initial description of robotic-assisted radical prostatectomy (RARP) in 2000 [2], and U.S. Food and Drug Administration approval shortly thereafter, RARP has been rapidly adopted and has overtaken RRP as the most popular surgical approach in the management of prostate cancer in the United States [3]. However, the surgical management of prostate cancer remains controversial. This is confounded by the idolatry of new technologies and aggressive marketing versus conservatism in embracing tradition. Herein, we review the literature to compare RRP to RARP in terms of perioperative, oncologic, and quality-of-life outcomes as well as healthcare costs. This is a particularly relevant, given the absence of randomized trials and long-term (more than 10-year) follow-up for RARP biochemical recurrence-free survival.

Radical prostatectomy, sparing of the seminal vesicles, and painful orgasm

INTRODUCTION

Erectile dysfunction has been widely investigated as the major factor responsible for sexual bother in patients after radical prostatectomy (RP); painful orgasm (PO) is one element of this bother, but little is known about its prevalence and its effects on sexual health.

AIM

This study aims to investigate the prevalence of PO and to identify potential risk factors.

MAIN OUTCOME MEASURES

A total of 1,411 consecutive patients underwent open (radical retropubic prostatectomy) or robot-assisted laparoscopic RP between 2002 and 2006. The patients were asked to complete a study-specific questionnaire.

METHODS

Of a total of 145 questions, 5 dealt with the orgasmic characteristics. The questionnaire was also administered to a comparison group of 442 persons, matched for age and area of residency.

RESULTS

The response rate was 91% (1,288 patients). A total of 143 (11%) patients reported PO. Among the 834 men being able to have an orgasm, the prevalence was 18% vs. 6% in the comparison group (relative risk [RR] 2.8, 95% confidence interval [CI] 1.7-4.5). When analyzed as independent variables, bilateral seminal vesicle (SV)-sparing approach (RR 2.33, 95% CI 1.0-5.3, P = 0.045) and age <60 years were significantly related to the presence of PO (95% CI 0.5-0.9, P = 0.019). After adjustment for age, bilateral SV-sparing still remained a significant predictor for occurrence of PO.

CONCLUSIONS

We found that PO occurs significantly more often in patients undergoing bilateral SV-sparing RP when compared with age-matched comparison population.

Sequential robotic-assisted bladder diverticulectomy and radical prostatectomy. Technique and review of the literature

INTRODUCTION

Acquired bladder diverticula (BD) in men over the age of 60 are usually due to bladder outlet obstruction (BOO) secondary to prostatic enlargement. In cases of clinical significant BD with persistent symptoms or complications surgical excision should be considered. In the treatment of BD it is important to address the BOO with a bladder outlet procedure either simultaneously or in a staged fashion.

PRESENTATION OF CASE

We present to the best of our knowledge, the first case of sequential robotic-assisted bladder diverticulectomy (RABD) combined with robotic-assisted radical prostatectomy (RARP) in a patient with large diverticula and malignant prostate enlargement as the cause of BOO.

DISCUSSION

Concomitant open radical prostatectomy and bladder diverticulectomy series have been described, while minimal invasive procedures combining BD excision with relive of BOO especially due to benign prostatic enlargement have been reported to be safe and effective.

CONCLUSION

Concomitant RABD with RARP is a safe and effective procedure with excellent oncological and functional results.

Robotic-assisted laparoscopic vesiculectomy for lower urinary tract obstruction by a large seminal vesicle cyst

INTRODUCTION

Seminal vesicle (SV) cysts are rare, benign lesions. Most of them are congenital in origin and are usually diagnosed incidentally due to extensive imaging. When symptomatic, surgical excision is recommended.

PRESENTATION OF CASE

We describe the case of a 17.2cm seminal vesicle cyst removed using a transperitoneal, robotic-assisted laparoscopic approach in a 45-year old male with lower urinary tract symptoms and no other genitourinary abnormality.

DISCUSSION

Laparoscopic excision of seminal vesicle cysts is a minimal invasive alternative to the open technique with single-center studies reporting high success rates. With the advent of the robotic platform, urologists have shifted to this approach especially for confined anatomical spaces such as the pelvis. To our knowledge this is the largest seminal vesicle cyst described in the literature that has been managed by minimally invasive surgery.

CONCLUSION

With the advantage of combined 3D vision and wristed instrumentation, excision of large seminal vesicle cysts by robotic assisted laparoscopic approach is feasible, safe and regarded as a natural continuity of conventional laparoscopy. Previous experience in Robotic assisted laparoscopic prostatectomy (RALP) especially in the posterior dissection technique is recommended.

Robotic cystectomy: surgical technique

OBJECTIVE

• The aim of this report is to describe our surgical technique of robotic assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion in patients with urinary bladder cancer.

PATIENTS AND METHODS

• A total of 45 patients (7 women and 38 men) with high-grade and/or muscle-invasive urothelial cancer of the bladder underwent RARC and intracorporeal urinary diversion at our department. • Orthotopic ileal neobladder was performed in 36 patients and ileal conduit was performed in 9 patients.

RESULT

• Except in two patients that operation was converted to open surgery during the reconstruction of the orthotopic neobladder, the procedure was performed totally intracorporeal. • The operations time, estimated blood loss and length for hospital stay were decreased over the time.

CONCLUSION

• RARC with totally intracorporeal urinary diversion is feasible.

Robot-assisted radical cystectomy with intracorporeal urinary diversion in patients with transitional cell carcinoma of the bladder

BACKGROUND

Robot-assisted radical cystectomy (RARC) may reduce morbidity after cystectomy. Descriptions of the surgical techniques of RARC with intracorporeal orthotopic neobladder or ileal conduit are sparse and oncologic and functional outcome data have not been reported.

OBJECTIVE

We present our technique with RARC and intracorporeal urinary diversion (neobladder or ileal conduit) and present oncologic and functional outcomes, as well as complication rates.

DESIGN, SETTING, AND PARTICIPANTS

Single-hospital institution case-series from 2004 to 2009 including 45 selected patients (38 male, 7 female) with high-grade and/or muscle-invasive urothelial cancer of the bladder.

SURGICAL PROCEDURE

We performed RARC; pelvic lymph node dissection using three different templates; and a totally intracorporeal urinary diversion, either orthotopic neobladder (n=36) or ileal conduit (n=9).

MEASUREMENTS

Perioperative variables, pathology data, early and late complication rates, urinary continence, potency, and cancer-specific survival were evaluated as outcome measures.

RESULTS AND LIMITATIONS

Median patient age, operative time, estimated blood loss, and lymph node yield were 62 yr (range: 37-79), 477 min (range: 325-760), 550 ml (range: 200-2200), and 19 (range: 10-52), respectively. Nine patients were diagnosed with positive lymph nodes. Surgical margins were clear in all but one patient. Early complications occurred in 18 patients (40%). Median postoperative stay was 9 d (range: 4-78), and median postoperative follow-up time was 25 mo. Four patients died due to metastatic disease. The study is limited by a relative small sample size and no comparative group.

CONCLUSIONS

RARC with totally intracorporeal urinary diversion is technically feasible with good intermediate-term oncologic results. This is a nonrandomised study including a limited number of patients with a restricted follow-up time, however, and so precautions must be considered when interpreting the outcomes.

Orgasm-associated urinary incontinence and sexual life after radical prostatectomy

INTRODUCTION

Involuntary release of urine during sexual climax, orgasm-associated urinary incontinence, occurs frequently after radical prostatectomy. We know little about its prevalence and its effect on sexual satisfaction.

AIM

To determine the prevalence of orgasm-associated incontinence after radical prostatectomy and its effect on sexual satisfaction.

METHODS

Consecutive series, follow-up at one point in calendar time of men having undergone radical prostatectomy (open surgery or robot-assisted laparoscopic surgery) at Karolinska University Hospital, Stockholm, Sweden, 2002-2006. Of the 1,411 eligible men, 1,288 (91%) men completed a study-specific questionnaire.

MAIN OUTCOME MEASURE

Prevalence rate of orgasm-associated incontinence.

RESULTS

Of the 1,288 men providing information, 691 were sexually active. Altogether, 268 men reported orgasm-associated urinary incontinence, of whom 230 (86%) were otherwise continent. When comparing them with the 422 not reporting the symptom but being sexually active, we found a prevalence ratio (with 95% confidence interval) of 1.5 (1.2-1.8) for not being able to satisfy the partner, 2.1 (1.1-3.5) for avoiding sexual activity because of fear of failing, 1.5 (1.1-2.1) for low orgasmic satisfaction, and 1.4 (1.2-1.7) for having sexual intercourse infrequently. Prevalence ratios increase in prostate-cancer survivors with a higher frequency of orgasm-associated urinary incontinence.

CONCLUSION

We found orgasm-associated urinary incontinence to occur among a fifth of prostate cancer survivors having undergone radical prostatectomy, most of whom are continent when not engaged in sexual activity. The symptom was associated with several aspects of sexual life.

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.

Erectile function after robotic nerve sparing and semi-sparing of the neurovascular bundles

We set out to present potency results after bilateral, unilateral, and semi-sparing of the neurovascular bundles after robotic prostatectomy. Two hundred and twenty-five consecutive robotic-assisted laparoscopic radical prostatectomies were performed by one surgeon (NPW) from the start of our robotic program in January 2002 until December 2005. Patient demographics, operative, and postoperative data were prospectively entered into a database. We have functional data for 183, 150, and 109 patients followed for 3, 6, and 12 months, respectively. Of 49 preoperatively potent patients 36 (73%, 95% CI 59-85%) had erections sufficient for intercourse at 12 month follow-up. If bilateral nerve sparing was performed, 13 (87%, 95% CI 59-85%) of the patients showed a return of potency sufficient for intercourse. In preoperatively potent patients who did not undergo a traditional nerve sparing due to a high-risk disease, semi-sparing of the neurovascular bundles showed a return of potency in 10 (53%, 95% CI 29-76%). After one-year follow-up, 66 of 71 (93%, 95% CI 84-98%) had no need for protective pads and two (3%) used more than one pad a day. In the first 100 patients there were 24 (24%) positive surgical margins and for the last 125 patients there were 18 (14%). Based on these data, we hypothesize that certain subgroups, e.g., men wanting to preserve their sexual potency but having a tumor that hinders a traditional nerve-sparing approach, may be particularly helped by robot-assisted laparoscopic surgery as compared with other techniques.