Stratification of Potency Outcomes Following Robot-Assisted Laparoscopic Radical Prostatectomy Based on Age, Preoperative Potency, and Nerve Sparing

Peritoneal Flap Following Lymph Node Dissection in Robotic Radical Prostatectomy: A Novel "Bunching" Technique

BACKGROUND

Pelvic lymph node dissection (PLND) is recommended while performing robot-assisted radical prostatectomy (RARP) for patients with localized intermediate or high-risk prostate cancer. However, symptomatic lymphoceles can occur after surgery, adding significant morbidity to patients. Our objective is to describe a novel Peritoneal Bladder Flap Bunching technique (PBFB) to reduce the risk of clinically significant lymphoceles in patients undergoing RARP and PLND.

METHODS

We evaluated 2267 patients who underwent RARP with PLND, dividing them into two groups: Group 1, comprising 567 patients who had the peritoneal flap (PBFB), and Group 2, comprising 1700 patients without the flap; propensity score matching carried out at a 1:3 ratio. Variables analyzed included estimated blood loss (EBL), operative time, postoperative complications, lymphocele formation, and the development of symptomatic lymphocele.

RESULTS

The two groups exhibited similar preoperative characteristics after matching. There was no statistically significant difference in the occurrence of lymphoceles between the flap group and the non-flap group, with rates of 24% and 20.9%, respectively (p = 0.14). However, none of the patients in the flap group (0%) developed symptomatic lymphoceles, whereas 2.2% of patients in the non-flap group experienced symptomatic lymphoceles (p = 0.01).

CONCLUSION

We have demonstrated a modified technique for a peritoneal flap (PBFB) with the initial elimination of postoperative symptomatic lymphoceles and promising short-term outcomes.

Epidemiology of and Risk Factors in Postoperative Complications from Robotically Assisted Laparoscopic Radical Prostatectomy in Contemporary National Surgical Quality Improvement Program Data

Introduction: For localized clinically significant prostate cancer (csPCa), robotically assisted laparoscopic radical prostatectomy (RALP) is the gold standard surgical treatment. Despite low overall complication rate, continued quality assurance (QA) efforts to minimize complications of RALP are important, particularly given movement toward same-day discharge. In 2019, National Surgical Quality Improvement Program (NSQIP) began collecting RALP-specific data. In this study, we assessed pre- and perioperative factors associated with postoperative complications for RALP to further QA efforts. Materials and Methods: Surgical records of csPCa patients who underwent RALP were retrieved from the 2019 to 2021 NSQIP database, including new RALP-specific data. Multivariate logistic regression evaluated the association between risk factors and outcomes specific to RALP and pelvic lymph node dissection (PLND). Input variables included American Society of Anesthesiologists (ASA) class, age, operative time, and body mass index (BMI). Variables from the extended dataset with PLND information included number of nodes evaluated, perioperative antibiotics, postoperative venous thromboembolism (VTE) prophylaxis, history of prior pelvic surgery, and history of prior radiotherapy (RT). Outcomes of interest were any surgical complication, infection, pulmonary embolism, deep venous thrombosis, acute kidney injury, pneumonia, lymphocele, and urinary/anastomotic leak (UAL). Results: A total of 11,811 patients were included with 6.1% experiencing any complication. Prior RT, prior pelvic surgery, older age, higher BMI, lack of perioperative antibiotic therapy, longer operative time, PLND, and number of lymph nodes dissected were associated with higher risk of postoperative complications. Regarding procedure-specific complications, there were increased odds of UAL with prior RT, prior pelvic surgery, longer operative time, and higher BMI. Odds of developing lymphocele increased with prior pelvic surgery, performance of PLND, and increased number of nodes evaluated. Conclusion: In contemporary NSQIP data, RALP is associated with low complication rates; however, these rates have increased compared with historical studies. Attention to and counseling regarding risk factors for peri- and postoperative complications are important to set expectations and minimize risk of unplanned return to a health care setting after discharge.

Impact of Prostate Size on the Functional and Oncological Outcomes of Robot-assisted Radical Prostatectomy

BACKGROUND AND OBJECTIVE

Robot-assisted radical prostatectomy (RARP) is the main surgical approach for treatment of prostate cancer in the USA. Prostate size is always depicted as a factor affecting the outcomes of RARP as shown by many studies, but these studies are limited to a small number of patients. Our aim was to evaluate functional and oncologic outcomes of RARP across varying prostate size measured as prostate specimen weight.

METHODS

A cohort of 14 481 patients who underwent RARP in a single center was divided into four groups according to prostate specimen weight: group 1, <50 g; group 2, 50-100 g; group 3, 100-150 g; and group 4, >150 g. Perioperative and postoperative variables and pathological and functional outcomes were compared among the four groups. Cumulative incidence functions were plotted to visualize the distribution of event-time variables among the groups, and differences were evaluated using the log-rank test.

KEY FINDINGS AND LIMITATIONS

Patients with larger prostates (groups 3 and 4) were more likely to have higher prostate-specific antigen (PSA), lower biopsy grade group, and worse baseline urinary and sexual characteristics. Group 4 had lower rates of full nerve-sparing surgery (13.7% vs 38.3%) and lymph node dissection (51.3% vs 71.4%), more pT2 disease (69.8% vs 60.3%), less pT3 disease (30.2% vs 39.7%), and lower rates of positive surgical margins (12.8% vs 19.3%) and biochemical recurrence (5.9% vs 7.5%) than group 1. Finally, we observed differences in functional outcomes among the groups for greater prostate size, and patients in group 4 had worse rates of urinary continence (77.8% vs 89.5%) and recovery of sexual function (70.0% vs 84.1%) than group 1. Our study is limited by its retrospective design.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The results demonstrate that in this large cohort of patients, greater prostate size affects multiple outcomes, including the rate of nerve-sparing surgery, potency and continence recovery, and oncological and pathological outcomes. These data will be valuable when counseling patients regarding possible RARP outcomes and the timeline for recovery.

PATIENT SUMMARY

Our study shows that prostate size can affect the outcomes of robot-assisted removal of the prostate for patients with prostate cancer. Larger prostate size can be associated with worse functional outcomes after surgery.

Outcomes of salvage robot-assisted radical prostatectomy in patients who had primary focal versus whole-gland ablation: a multicentric study

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.

Functional outcome after radical prostatectomy in 1313 patients: A single-center study

OBJECTIVES

To assess the impact of urinary continence and erectile function on the quality of life in men undergoing radical prostatectomy (RP) for prostate cancer (PC), we analyzed the preoperative and 1-year postoperative outcomes of five functional domains and their influencing factors.

PATIENTS AND METHODS

In this prospective study, all patients undergoing open or robot-assisted RP between Febuary 2017 and March 2020 in a single academic center were included. Patient-reported outcomes were assessed pre- and 12 months postoperatively using the Expanded Prostate Index Composite (EPIC-26) survey, evaluating continence, irritative/obstructive micturition, gastrointestinal symptoms, sexuality, and overall vitality. We examined the impact of RP on sexual function and urinary continence using multivariable logistic regression models, accounting for patient and tumor characteristics.

RESULTS

Overall, 1313 consecutive patients gave consent for study participation and completed both surveys. The median age was 66 years (IQR: 60-70). The majority of patients (n = 601, 46%) had an intermediate risk PC. Robotic RP was performed in 71.6% and nerve-sparing technique in 81% of the cases. The median pre- versus postoperative scores were the following: urinary continence 100 (IQR: 91.8-100) versus 85.5 (64.8-100), irritative micturition 87.5 (IQR: 75-100) versus 93.8 (IQR: 87.5-100), gastrointestinal symptoms the same with 100 (IQR: 95.8-100), vitality 95 (IQR: 80-100) versus 90 (IQR: 75-100), and erectile function 65.3 (IQR: 38.8-87.5) versus 22.2 (IQR: 12.5-48.7), respectively. Age (p < 0.001), risk classification (p = 0.002), and nerve-sparing surgery (p = 0.016) were associated with good sexual function (EPIC-26 score ≥60), while only age (p = 0.001) was statistically significantly associated with good urinary continence (EPIC-26 score ≥80).

CONCLUSION

Non-modifiable factors such as age and PC risk classification impact urinary continence and sexual function after RP. Nevertheless, urologic surgeons should further focus on improving nerve-sparing techniques, the only modifiable variable, to reduce the surgery's negative impact on urinary continence and sexual function.

Simultaneous hernia repair following robotic-assisted radical prostatectomy is safe with low rates of mesh-related complications

Robotic-assisted radical prostatectomy (RARP) is the gold-standard treatment for localized prostate cancer in the USA. However, performing RARP along with a concomitant hernia repair with mesh is debatable because of the lack of well-designed studies on this subject. Some argue that this procedure may result in mesh infections and increased complications due to possible contact of mesh and urine. This study reports our experience with simultaneous hernia repair with mesh placement in patients who underwent radical prostatectomy. We compared 244 patients (from August 2008 to August 2021) who underwent RARP with concomitant hernia repair (inguinal, umbilical, and ventral) and mesh placement with 244 patients from 6275 RARPs operated on the same period without hernia repair. We performed a propensity score matching analysis using preoperative covariates and compared the perioperative outcomes, and complications in 90 days after surgery. Median follow-up was 36.6 months for the control and hernia groups respectively (p = 0.81). Eighty-three patients had unilateral inguinal hernia repair, 22 had a bilateral inguinal hernia repair, 95 had a ventral hernia repair, and 44 had an umbilical hernia repair. The median operative time was 112 min for the control group and 160 min for hernia groups (p < 0.001). We did not find statistically significant differences in minor complications (Clavien ≤ 2). Although the postoperative readmissions in 90-days were higher in the hernia group (18 vs. 7, p = 0.038), none was associated with mesh complications. Limitation includes the retrospective design of the study. Robotic-assisted radical prostatectomy with simultaneous hernia repair and mesh placement is safe and does not increase complications related to the mesh. In our experience, hernia repair increases the operative time, usually due to initial peritoneal flap dissection and final suturing. Therefore, we believe that hernia repair with mesh during RARP is safe and spares patients the additional impacts of an additional surgical procedure.

Comparison between intra- and postoperative outcomes of the da Vinci SP and da Vinci Xi robotic platforms in patients undergoing radical prostatectomy

The new SP robot incorporates a single trocar that houses a flexible camera and three bi-articulated arms, which minimize the number of incisions needed to assess the surgical site, allowing for a less invasive procedure. To compare the postoperative pain scale and outcomes in patients with similar demographic characteristics undergoing robotic-assisted radical prostatectomy (RARP) with SP and Xi robots, One-hundred consecutive patients undergoing RARP with the SP robot were matched, using a propensity score (PS), with 100 patients from a cohort of 1757 who were operated on with the da Vinci Xi from June 2019 to January 2021. We described and compared the perioperative pain scores and outcomes of both groups. The SP group had less blood loss (50 cc vs. 62.5 cc, P < 0.001) and longer operative time (114 min. vs. 94 min, P < 0.001). The only period we could show a difference in postoperative pain scores was 6 h after surgery, with a small advantage for the SP (2 vs. 2.5, P < 0.001). Both groups had satisfactory postoperative continence recovery, 91% vs. 90% for the SP and Xi, respectively. The groups had a mean follow-up of 24.5 and 22 months for SP and Xi, respectively. The tumor stage and percentage of positive surgical margins were similar between groups (15% vs. 15%, P = 1). Patients undergoing RARP with the SP had longer operative times with less blood loss than the Xi. However, despite the lower number of abdominal incisions on the SP, the groups had similar intraoperative performance, and we were unable to demonstrate clinically significant differences in postoperative pain scores between the groups 6, 12, and 18 h after surgery.

Feasibility, Safety, and Functional Outcomes of Pelvic Hypothermia Induced Using a Rectal Cooling Device During Robot-assisted Radical Prostatectomy: A Phase I/II Trial

Introduction: Radical prostatectomy (RP) is one of the standard treatments for localized prostate cancer. However, in terms of functional outcomes, there are aspects that still need improvements. We designed this prospective phase I/II clinical trial to assess the safety, clinical feasibility, and functional outcomes of hypothermic robot-assisted RP (RARP). Material and Methods: Twenty patients with preoperative total 5-item International Index of Erectile Function scores ≥12 points, scheduled for RARP, were enrolled in the study. Pelvic hypothermia was induced using an endorectal cooling device (BelloCool System). The primary outcome was the completion rate of the planned hypothermic RARP. Secondary outcomes included the drop in neurovascular bundle (NVB) temperature, adverse (including device-related) events, continence, and potency recoveries, and postoperative quality of life. Contemporaneous patients (propensity score-matched for baseline characteristics) who satisfied the inclusion criteria were included in the control group. Results: The completion rate of the planned hypothermic surgery was 100%. The nadir NVB temperature was 24.9 [22.4, 28.2]°C, which was 10.2 [7.0, 13.1]°C lower than the nadir core body temperature. There was no device-related adverse event, and bowel function was well preserved for the whole follow-up period. At 12 months postoperatively, potency and continence recovery rates were higher in the hypothermic group than in the control group (40% vs 15%, p = 0.027 and 95% vs 80%, p = 0.167, respectively). The Kaplan-Meier curve showed faster recovery rate of potency in the hypothermic group (hazard ratios = 3.46, log-rank p < 0.01). Conclusions: Hypothermic RARP using the BelloCool™ endorectal cooling system is safe and feasible. A large-population-based randomized controlled trial is needed to confirm the potential for a benefit in continence and potency recovery.