Impact of median lobe anatomy: does its presence affect surgical margin rates during robot-assisted laparoscopic prostatectomy?

Anatomic Factors Associated with Complications After Radical Prostatectomy: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE

The role of anatomical factors in predicting outcomes after radical prostatectomy (RP) remains unclear. This review aims to evaluate the impact of various anatomical factors on the perioperative outcomes of patients undergoing RP for localized prostate cancer (PCa).

METHODS

A comprehensive literature search was conducted through January 2024 using the PubMed/Medline, Embase, and Web of Science databases. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed to identify eligible studies. Data were extracted and pooled for a meta-analysis, with outcomes including operative time, blood loss, transfusion rates, overall complications, and positive surgical margins (PSMs). Heterogeneity was assessed using Cochrane Q test, and subgroup analyses were conducted to explore the influence of surgical approach.

KEY FINDINGS AND LIMITATIONS

A total of 91 studies met our inclusion criteria. Among the anatomical factors, prostate volume (PV), prostate weight, and median lobe (ML) were suitable for the meta-analysis. Larger prostates were associated with increased operative time, blood loss, and complication rates, but with fewer PSMs (all p < 0.05). ML presence was not associated with a higher risk of complications. Heterogeneity was high across studies (Cochrane Q tests <0.05), reflecting inconsistent definitions and methods. In subgroup analyses, the open approach was associated with a longer operative time than robotic surgery for large prostates (p = 0.03) and a lower PSM rate (p < 0.001).

CONCLUSIONS AND CLINICAL IMPLICATIONS

Anatomical factors, particularly PV, play a significant role in RP outcomes. Larger prostates are associated with higher complication rates but fewer PSMs. Further research with standardized outcome measures is necessary to clarify these relationships and guide clinical decision-making.

PATIENT SUMMARY

In this study, we examined how a patient's individual anatomy might affect the results of prostate surgery for cancer. We found that larger prostates tend to lead to longer surgeries and increased blood loss, but these also have a lower risk of leaving cancer cells behind. These findings could help doctors in better planning surgeries and improving patient outcomes.

Technical Tips in Managing Large Median Lobes During Robot-assisted Radical Prostatectomy

Prostate cancer surgeons are commonly faced by a technically challenging situation dealing with prostate cancer having large median lobes. Patients with large median lobes often have larger prostates, which makes it difficult to visualize anatomical planes during robot-assisted radical prostatectomy (RARP). Herein, we described our experience in dealing with large median lobes during RARP. We have focused on technical tips to avoid complications and facilitate a smooth procedure in patients with large median lobes during RARP. A total of 2671 patients who underwent RARP were divided into two groups based on the presence or absence of a protruded median lobe (PML): group A (2411 patients without a PML) and group B (260 patients with a PML). All patients underwent preoperative magnetic resonance imaging and final intraoperative confirmation for the presence of a PML. Pre-, intra-, and postoperative parameters were compared in two groups using the Student t test and two-proportion t test as appropriate. Patients in group B have statistically significantly higher median prostate-specific antigen (PSA; 7.7 vs 5.8 ng/dl), PSA density (0.17 vs 0.09), and International Prostate Symptom Score (19.5 vs 7.2); longer median console time (114 vs 134 min) and surgery time (145 vs 170 min); and higher blood loss (150 vs 175 ml) than those in group A. There were no statistically significant differences in pathological stages (T2, T3; 87%, 13% vs 88%, 12%) and rates of positive surgical margins (7% vs 8.5%) between groups A and B. Single-center and retrospective design was the major limitation of our study. We conclude that understanding the key steps to facilitate bladder neck dissection is vital to avoid serious intraoperative events and to maximize outcomes.

Patient summary

In this report, we looked at our robotic radical prostatectomy cohort with large median lobes. We found that surgery in these patients requires more time and blood loss, but similar cancer control. We conclude that following the key steps are important to avoid complications.

Preoperative characteristics of the P.R.O.S.T.A.T.E. scores: a novel predictive tool for the risk of positive surgical margin after radical prostatectomy

OBJECTIVES

To propose a novel scoring system to predict the risk of positive surgical margin (PSM) after radical prostatectomy (RP) in prostate cancer (PCa) patients.

MATERIALS AND METHODS

Eight reproducible variables available from preoperative characteristics of PCa patients were measured: PSA level (P), ratio of positive biopsy needles (R), obesity (O), scores of Gleason (S), T stage by preoperative MRI scan (T), age (A), tumor volume (T) and experience of the surgeon (E). Of the eight components, seven were scored on a 0-, 1- or 2-point scale, with only the "A" component on a 0- or 1-point scale. The P.R.O.S.T.A.T.E. scores can range from 0 to 15.

RESULTS

A total of 441 patients were included from the Peking University First Hospital between November 2007 and March 2016, among whom 195 patients (44.2%) had a PSM identified by a postoperative pathological examination. The preoperative P.R.O.S.T.A.T.E. scores statistically correlated with the postoperative SM status (p < 0.001) when the 441 consecutive patients were divided into three groups (low-risk group: score of 0-4, moderate-risk group: score of 5-9 and high-risk group: score of 10-15). The risk of PSM after RP in the low-risk, moderate-risk and high-risk groups was 21.1, 40.1 and 87.0%, respectively.

CONCLUSIONS

The novel scoring system of P.R.O.S.T.A.T.E. that we presented was found to predict the risk of PSM after RP. A combination of reproducible, standardized parameters obtained from preoperative characteristics of PCa patients can be used as a tool for predicting PSM, thus assisting in the strategy of performing surgical procedures. More careful manipulation or wider resection may be of utmost importance in the high-risk group.

Urinary Continence after Robot-Assisted Laparoscopic Radical Prostatectomy: The Impact of Intravesical Prostatic Protrusion

PURPOSE

To assess the impact of intravesical prostatic protrusion (IPP) on the outcomes of robot-assisted laparoscopic prostatectomy (RALP).

MATERIALS AND METHODS

The medical records of 1094 men who underwent RALP from January 2007 to March 2013 were analyzed using our database to identify 641 additional men without IPP (non-IPP group). We excluded 259 patients who presented insufficient data and 14 patients who did not have an MRI image. We compared the following parameters: preoperative transrectal ultrasound, prostate specific antigen (PSA), clinicopathologic characteristics, intraoperative characteristics, postoperative oncologic characteristics, minor and major postoperative complications, and continence until postoperative 1 year. IPP grade was stratified by grade into three groups: Grade 1 (IPP≤5 mm), Grade 2 (5 mm<IPP≤10 mm), and Grade 3 (IPP>10 mm).

RESULTS

Of the 821 patients who underwent RALP, 557 (67.8%) experienced continence at postoperative 3 months, 681 (82.9%) at 6 months, and 757 (92.2%) at 12 months. According to IPP grade, there were significant differences in recovering full continence at postoperative 3 months, 6 months, and 12 months (p<0.001). On multivariate analysis, IPP was the most powerful predictor of postoperative continence in patients who underwent RALP (p<0.001). Using a generalized estimating equation model, IPP also was shown to be the most powerful independent variable for postoperative continence in patients who underwent RALP (p<0.001).

CONCLUSION

Patients with low-grade IPP have significantly higher chances of recovering full continence. Therefore, the known IPP grade will be helpful during consultations with patients before RALP.

A novel surgical technique for preserving the bladder neck during robot-assisted laparoscopic radical prostatectomy: preliminary results

PURPOSE

To describe our new surgical technique for preserving the bladder neck during robot-assisted laparoscopic prostatectomy (RALP) and to present the anatomy between the bladder neck and prostate.

METHODS

Between December 2012 and May 2014, 52 RALPs were performed at our institute. Demographic, perioperative, and postoperative data were recorded. Quality of life (QoL) scores were assessed before RALP, after urethral catheter removal, and at the first month after RALP. Fatty connective tissue between bladder neck and prostate was introduced, and circular muscle fibers of the internal sphincter were seen in all patients. Complications were classified according to the Clavien-Dindo classification. Statistical analyses were performed.

RESULTS

Mean follow-up was 9.6±5.2 months; mean age was 61.1±6.5 years. Our novel surgical technique for preserving the bladder neck was performed in 52 patients, and they were continent after catheter removal; mean duration of the catheter was 9.4±1.4 days. There was a significant difference in QoL before RALP and after catheter removal, however, but there was no statistical difference between before and 1 month after RALP (respectively; P<0.001, P=0.5). Furthermore, there was no complication related to the bladder neck such as bladder neck stricture, acute/chronic urinary retention, as well as no Clavien III, IV, and V complications. In addition, conventional laparoscopy and/or open surgery was not needed in any of the RALP cases.

CONCLUSION

Our novel technique provided very early continence at the time of catheter removal after RALP within short-term follow-up. This can help early recovery and develop QoL scores after RALP.

Impact of prostate weight on perioperative outcomes of robot-assisted laparoscopic prostatectomy with a posterior approach to the seminal vesicle

Background

To determine the effect of prostate weight on the preoperative and postoperative outcomes of robotic-assisted laparoscopic radical prostatectomy with a posterior approach to the seminal vesicle.

Methods

This retrospective study examined prospectively collected data on 219 robotic-assisted laparoscopic radical prostatectomies performed from May 2011 to February 2013. Patients were divided into four groups based on pathologic prostate weight: <30 g, 30–49 g, 50–79 g, and ≥80 g. Continence and sexual function were assessed using validated questionnaires.

Results

Of the 219 patients, 19, 143, 51, and 6 had prostates weighing <30 g, 30–49 g, 50–79 g, and ≥80 g, respectively. Significant differences were found between the preoperative Gleason scores, total operative times, and robotic times of the groups. Both estimated blood loss and anastomosis time tended to be greater in the higher prostate weight groups, but the differences were not significant. No significant differences were observed in transfusion rate, length of catheterization, complication incidence, or positive surgical margins. The return of urinary function, as determined by questionnaire scores, was not affected by prostate weight.

Conclusions

Robotic-assisted laparoscopic radical prostatectomy can be performed safely and with similar perioperative outcomes, regardless of prostate weight. Indeed, oncological outcome, urinary continence, and complications were similar across the prostate weight groups, suggesting that robotic-assisted laparoscopic radical prostatectomy with a posterior approach to the seminal vesicle may be performed effectively on men with large prostates, despite greater surgical times.