Robotic-assisted radical prostatectomy learning curve for experienced laparoscopic surgeons: does it really exist?

Robot-Assisted Radical Prostatectomy (RARP) Trifecta Learning Curve for Surgeons with Previous Experience in Laparoscopy

Background and Objectives: Robot-assisted radical prostatectomy (RARP) is a complex surgery with a steep learning curve (LC). No clear evidence exists for how previous laparoscopic experience affects the RARP LC. We report the LC of three surgeons with vast experience in laparoscopy (more than 400 procedures), analyzing the results of functional and oncological outcomes under the "Trifecta" concept (defined as the achievement of continence, potency, and oncological control free of biochemical recurrence). Materials and Methods: The surgical experience of the three surgeons from September 2021 to December 2022, involving 146 RARP consecutive patients in a single institution center, was evaluated prospectively. Erectile disfunction patients were excluded. ANOVA and chi-square test were used to compare the distribution of variables between the three surgeons. LC analysis was performed using the cumulative sum control chart (CUSUM) technique to achieve trifecta. Results: The median age was 65.42 (±7.34); the clinical stage were T1c (68%) and T2a (32%); the biopsy grades were ISUP 1 (15.9%), ISUP 2 (47.98), and ≥ISUP 3 (35%). The median surgical time was 132.8 (±32.8), and the mean intraoperative bleeding was 186 cc (±115). Complications included the following: Clavien-Dindo I 8/146 (5.47%); II 9/146 (6.16%); and III 3/146 (2.05%). Positive margins were reported in 44/146 (30.13%). The PSA of 145/146 patients (99%) at 6 months was below 0.08. Early continence was achieved in 101/146 (69.17%), 6-month continence 126/146 (86%), early potency 51/146 (34.9%), and 6-month potency 65/146 (44%). Surgeons "a", "b", and "c" performed 50, 47, and 49 cases, respectively. After CUSUM analysis, the "Trifecta" LC peak was achieved at case 19 in surgeon "a", 21 in surgeon "b", and 20 in surgeon "c". Conclusions: RARP LC to accomplish "Trifecta" can be significantly reduced in surgeons with previous experience in laparoscopy and be achieved at around 20 cases.

Challenges and opportunities in prostate cancer surgery in South America: Insights into robot-assisted radical prostatectomies-A perspective

Background and Aims

Prostate cancer imposes a significant health burden, particularly in South America with its high incidence and mortality rates. This article explores the emergence of robot-assisted radical prostatectomy (RARP) as a potential solution in the region.

Methods

This study relies on a comprehensive review of relevant literature. The analysis highlights the advantages of RARP, identifies impediments to its implementation, and proposes strategies to overcome these barriers.

Results

RARP demonstrates notable benefits, including improved functional outcomes, reduced complications, and minimized incisions. However, the integration of RARP in South America is hindered by challenges such as regional disparities, financial limitations, and data gaps. Limited healthcare infrastructure and a scarcity of skilled professionals further compound the issues.

Conclusion

Despite its potential, RARP faces obstacles to widespread adoption in South America. Strategic solutions encompassing technology investment, healthcare infrastructure enhancement, and workforce training are imperative. Overcoming these challenges can establish RARP as a crucial tool in managing prostate cancer in the region, ultimately enhancing patient care and treatment outcomes.

Robotic-assisted versus laparoscopic radical prostatectomy for prostate cancer: the first separate systematic review and meta-analysis of randomised controlled trials and non-randomised studies

BACKGROUND

Due to the lack of sufficient evidence, it is not clear whether robotic-assisted radical prostatectomy (RARP) or laparoscopic radical prostatectomy (LRP) is better for prostate cancer. The authors conducted this study by separately pooling and analysing randomised controlled trials (RCTs) and non-randomised studies to compare the perioperative, functional, and oncologic outcomes between RARP and LRP.

METHODS

A systematic literature search was performed in March 2022 using Cochrane Library, Pubmed, Embase, Medline, Web of Science, and China National Knowledge Infrastructure. Two independent reviewers performed literature screening, data extraction and quality assessment according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. Subgroup analysis and sensitivity analysis were performed.

RESULTS

A total of 46 articles were included, including 4 from 3 RCTs and 42 from non-randomised studies. For RCTs, meta-analysis showed that RARP and LRP were similar in blood loss, catheter indwelling time, overall complication rate, overall positive surgical margin and biochemical recurrence rates, but quantitative synthesis of non-randomised studies showed that RARP was associated with less blood loss [weighted mean difference (WMD)=-71.99, 95% CI -99.37 to -44.61, P <0.001], shorter catheterization duration (WMD=-1.03, 95% CI -1.84 to -0.22, P =0.010), shorter hospital stay (WMD=-0.41, 95% CI -0.68 to -0.13, P =0.004), lower transfusion rate (OR=0.44, 95% CI 0.35-0.56, P <0.001), lower overall complication rate (OR=0.72, 95% CI 0.54-0.96, P =0.020), and lower biochemical recurrence rate (OR=0.78, 95% CI 0.66-0.92, P =0.004), compared with LRP. Both meta-analysis of RCTs and quantitative synthesis of non-randomised studies showed that RARP was associated with improved functional outcomes. From the results of the meta-analysis of RCTs, RARP was higher than LRP in terms of overall continence recovery [odds ratio (OR)=1.60, 95% CI 1.16-2.20, P =0.004), overall erectile function recovery (OR=4.07, 95% CI 2.51-6.60, P <0.001), continence recovery at 1 month (OR=2.14, 95% CI 1.25-3.66, P =0.005), 3 (OR=1.51, 95% CI 1.12-2.02, P =0.006), 6 (OR=2.66, 95% CI 1.31-5.40, P =0.007), and 12 months (OR=3.52, 95% CI 1.36-9.13, P =0.010) postoperatively, and potency recovery at 3 (OR=4.25, 95% CI 1.67-10.82, P =0.002), 6 (OR=3.52, 95% CI 1.31-9.44, P =0.010), and 12 months (OR=3.59, 95% CI 1.78-7.27, P <0.001) postoperatively, which were consistent with the quantitative synthesis of non-randomised studies. When sensitivity analysis was performed, the results remained largely unchanged, but the heterogeneity among studies was greatly reduced.

CONCLUSION

This study suggests that RARP can improve functional outcomes compared with LRP. Meanwhile, RARP has potential advantages in perioperative and oncologic outcomes.

Pentafecta outcomes of robotic laparoscopically assisted radical prostatectomy during the initial experience in a university hospital

Background

Robotic laparoscopically assisted radical prostatectomy (RARP) is an option for the treatment of localized prostate cancer. The objective of the present study was to evaluate the pentafecta outcomes (biochemical recurrence, continence, potency, surgical complications and surgical margins) in patients undergoing RARP during the initial experience in a university hospital.

Methods

This is a retrospective study of patients who had RARP for localized prostate adenocarcinoma at a university hospital from August 2013 to October 2019 to evaluate pentafecta outcomes (biochemical recurrence, continence, potency, surgical complications and surgical margins). Data were collected and stored via Microsoft Office Excel program and analyzed using SPSS Software, version 20.0.

Results

One hundred and sixty-three RARP were performed, the mean age is 64.16 ± 6.54 years, PSA 6.20 (IQR = 4.91–8.95) ng/dl, BMI 27.14 (IQR = 24.22–29.26) kg/m2, D’Amico risk classification was 35 (22.3%) low risk, 81 (51.6%) intermediate risk and 41 (26.1%) high risk. One hundred and fifty-four patients entered the analysis of pentafecta with a rate of 38.3% reaching this outcome. Complications: Twenty-three (14.1%) patients had minor complications (Clavien I and II) and eight patients had major complications (Clavien IIIa, IIIb and IVa). Surgical margins were negative in 69.9% of patients. The biochemical recurrence-free rate was 89.5%. The overall continence rate was 93.5%, and the potency rate was 63.5%. Multivariate analysis showed that T2 patients are 2.7 times more likely to achieve pentafecta outcome than patients ≥ T3 (p < 0.05), while younger age and lower BMI data were found as a protective factor with RR of 0.95 and 0.94, respectively.

Conclusions

Preliminary pentafecta outcome of RARP in this university hospital is promising.

The transferability of laparoscopic and open surgical skills to robotic surgery

BACKGROUND

Within the last decades, robotic surgery has gained popularity. Most robotic surgeons have changed their main surgical activity from open or laparoscopic without prior formal robotic training. With the current practice, it is of great interest to know whether there is a transfer of surgical skills. In visualization, motion scaling, and freedom of motion, robotic surgery resembles open surgery far more than laparoscopic surgery. Therefore, our hypothesis is that open-trained surgeons have more transfer of surgical skills to robotic surgery, compared to surgeons trained in laparoscopy.

METHODS

Thirty-six surgically inexperienced medical students were randomized into three groups for intensive simulation training in an assigned modality: open surgery, laparoscopy, or robot-assisted laparoscopy. The training period was, for all study subjects, followed by performing a robot-assisted bowel anastomosis in a pig model. As surrogate markers of surgical quality, the anastomoses were tested for resistance to pressure, and video recordings of the procedure were evaluated by two blinded expert robotic surgeons, using a global rating scale of robotic operative performance (Global Evaluative Assessment of Robotic Skills (GEARS)).

RESULTS

The mean leak pressure of bowel anastomosis was 36.25 (7.62-64.89) mmHg in the laparoscopic training group and 69.01 (28.02-109.99) mmHg in the open surgery group, and the mean leak pressure for the robotic training group was 108.45 (74.96-141.94) mmHg. The same pattern was found with GEARS as surrogate markers of surgical quality. GEARS score was 15.71 (12.37-19.04) in the laparoscopic training group, 18.14 (14.70-21.58) in the open surgery group, and 22.04 (19.29-24.79) in the robotic training group. In comparison with the laparoscopic training group, the robotic training group had a statistically higher leak pressure (p = 0.0015) and GEARS score (p = 0.0023). No significant difference, for neither leak pressure nor GEARS, between the open and the robotic training group.

CONCLUSION

In our study, training in open surgery was superior to training in laparoscopy when transitioning to robotic surgery in a simulation setting performed by surgically naive study subjects.

Robotic-assisted radical prostatectomy with preceptor's assistance: the training experience and outcomes in South America

Prostate cancer is currently the second leading cause of cancer deaths in Brazilian men. In 2020, sixty-five thousand new prostate cancer cases were expected in Brazil, and almost 30% of these patients are estimated to be from the northeast region. However, from 75 robotic platforms available in the country, only one is accessible in the state of Ceará since 2015. This study reports the intraoperative, functional, and oncological outcomes of patients who underwent radical prostatectomy for prostate cancer performed by robotic surgeons during a training period supervised by a proctor. We also compared these results with the literature reporting the experience of different Brazilian centers. We retrospectively analyzed prospectively collected data of 58 initial cases of robotic-assisted radical prostatectomy at a private Brazilian hospital in Fortaleza, Ceará. The surgeries were performed by two robotic surgeons during the training period under proctor supervision. We reported the epidemiological and intraoperative data, complications, pathological report, functional and oncological outcomes. The median operative time was 180 min. None of the patients needed conversion or blood transfusion. The pathology report described 21.81% of positive surgical margins (16.27% of all pT2 and 45.45% of all pT3 patients). The median follow-up was 40 months. Biochemical recurrence occurred in 21.73%, continence in 92%, and potency in 79.54%. No major complications (Clavien grades III-V) were reported. In our experience, robotic-assisted radical prostatectomy performed by surgeons training with proctor's assistance is feasible and safe. The operative time, complication rates, functional and oncological outcomes were satisfactory and compatible with the literature.

Analysis of Learning Curve in Robot-Assisted Radical Prostatectomy Performed by a Surgeon

This study aimed to report the learning curve in robot-assisted radical prostatectomy (RARP) performed by one surgeon who is experienced in laparoscopic prostatectomies. The records of 145 RARP cases performed between 2015 and 2017 were evaluated retrospectively. Patients were divided into three groups: group 1 comprised the first 49 cases, group 2 comprised 50–88 cases, and the rest of the cases were assigned to group 3. Continence was defined as the necessity to use at least one pad during a day. Additionally, erectile function recovery was defined as having erection sufficient for sexual intercourse regardless of using a phosphodiesterase type 5 inhibitor. Continence and erectile function recovery were assessed during interviews at 3, 6, and 12 months after surgery. First, all procedures were successfully performed without conversions or blood transfusions. The median follow-up period was 22 months. Moreover, the median skin-to-skin operative time (OT) was 220 minutes. The median blood loss was 150 ml, and the mean hospital stay was 8.9 ± 3.87 days. The median prostate volume was 36 cm³. The overall positive surgical margin rate was 13.1%. Overall, 38 (26.2%) postoperative complications were observed, and 17.9% of them were graded as minor. Anastomotic leakage decreased significantly from group 1 to group 3 (26.5% and 7%, respectively). The continence recovery (0-1 pad) rates were 60.6%, 75.7%, and 84.9% at 3, 6, and 12 months after surgery, respectively. Subsequently, the erectile function recovery rates were 50.9% and 65.4% at 6 and 12 months after surgery, respectively. In conclusion, there are several types of learning curves for RARP. First, the shallowest learning curve was observed for the OT. Regarding the analysis of “advanced learning curve,” demonstrating the improvement of OT and blood loss is considered insufficient. Therefore, additional oncological and functional results that require a longer period of investigation are required.

Perioperative outcomes of robotic-assisted laparoscopic radical prostatectomy, laparoscopic radical prostatectomy and open radical prostatectomy: 10 years of cases at Ramathibodi Hospital

Background

This study aims to compare the perioperative and pathological outcomes of open radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP), and robotic-assisted laparoscopic radical prostatectomy (RALRP) at Ramathibodi Hospital within Mahidol University in Thailand.

Methods

From January 2008 to July 2017, 679 RPs were performed. Patients' data were collected retrospectively to evaluate their perioperative and pathological outcomes. This data included the age, body mass index (BMI), serum prostate specific antigen (PSA) level, clinical stage, Gleason score (GS) from biopsy, operative time, estimated blood loss (EBL), perioperative complications, blood transfusion rate, adjacent organ injury rate, length of hospital stay, pathological stage, GS of the biopsy specimen, specimen weight (g), and marginal status of the patients.

Results

Of the 679 RPs performed, 128 (19.28%) were ORPs, 241 (36.30%) were LRPs, and 295 (44.43%) were RALRPs. Patients who underwent a RALRP had a significant advantage in EBL (1,600, 500, and 300 mL for ORPs, LRPs, and RALRPs, respectively), overall complications, and blood transfusion rate. As they are minimally invasive techniques, LRP and RALRP presented an advantage in terms of the length of hospital stay (an average of 9, 6, and 6 days for ORPs, LRPs, and RALRPs, respectively) and adjacent organ injury rate. ORPs also had the shortest operative time (160, 210, and 200 min for ORPs, LRPs, and RALRPs, respectively). However, the specimen weight and marginal status were similar in all of the techniques.

Conclusions

Minimally invasive RP techniques, such as LRPs and RALRPs, appear to be safe, have significantly better perioperative outcomes than ORPs, and have comparable pathological outcomes to those of ORPs.

Analysis of the Learning Curve of Surgeons without Previous Experience in Laparoscopy to Perform Robot-Assisted Radical Prostatectomy

Objective

To assess the learning curve in robot-assisted radical prostatectomy (RARP) performed by surgeons without previous experience in laparoscopic prostatectomy.

Materials and Methods

We analyzed 119 patients submitted to RARP performed by two surgeons without previous experience in laparoscopic prostatectomy, with emphasis on the relevant outcomes such as continence, erectile function, and oncologic control with a minimum follow-up of 24 months. We used Fisher's exact test and the chi-square test to investigate the existence of a relationship between the variables and analysis of variance (ANOVA) to verify possible statistically significant differences between groups, at the 5% level.

Results

The patients' age varied from 41 to 72 years (mean = 61.09), with 68 (57.14%) cases having intermediate or high risk. There was a consistent decline in operative time. Of the 119 patients, 80.67% were continent 6 months after surgery and 89.07% 12 months afterward, while 35.29% were potent 6 months after surgery and 60.50% 12 months following surgery. Twelve months after surgery, the trifecta outcome rate was 51.26% and the pentafecta rate was 31.09%. There was progressive postoperative improvement and maintenance of continence and sexual potency until the last patient was operated in our sample.

Conclusions

Robot-assisted radical prostatectomy does not require previous experience in laparoscopic radical prostatectomy, but the learning curve is not short to achieve the plateau.

Does Previous Laparoscopic Experience Influence Basic Robotic Surgical Skills?

OBJECTIVE

Studies addressing the effect of laparoscopic experience on robotic skills have produced conflicting results. This study aimed to compare simulated robotic surgical tasks using the virtual reality simulator dV-Trainer between laparoscopically experienced surgeons and first-year surgical residents.

DESIGN

A cross-sectional study. Participants completed 4 trials of the following tasks on the dV-Trainer: Peg Board 2, Ring and Rail 1, and Suture Sponge 1. Performance was recorded using a computerized built-in scoring algorithm. Scores and metrics were compared between groups 1 and 2 and between the first and subsequent trials.

SETTING

Hospital de Clínicas, Porto Alegre, Brazil, a tertiary care teaching hospital.

PARTICIPANTS

Twenty laparoscopically experienced surgeons (group 1) and 20 first-year surgical residents (group 2). All participants completed the study.

RESULTS

The overall scores for Peg Board 2 (738.04 ± 267.83 vs 730.39 ± 225.31; p  = 0.57), Ring and Rail 1 (919.03 ± 242.69 vs 965.84 ± 222.96; p  =  0.13), and Suture Sponge 1 (563.62 ± 185.50 vs 560.99 ± 152.71; p = 0.67) did not differ significantly between groups 1 and 2. Group 1 had better results for master workspace range in Peg Board 2 and Ring and Rail 1. Group 2 had higher scores for economy of motion in Peg Board 2 and Ring and Rail 1 and for excessive instrument force in Ring and Rail 1. In both groups, the overall scores in the third and fourth trials were significantly higher than those in the first trial.

CONCLUSIONS

There are no significant differences in the performance of simulated robotic surgical tasks between laparoscopically experienced surgeons and laparoscopically naïve surgical residents. Some slight differences were observed in specific metrics, but these differences were not sufficient to change the final results. We may assume that laparoscopic experience should not be an essential step in the initial learning curve of robotic surgery.

A Safe teaching protocol of LRP (laparoscopic radical prostatectomy)

PURPOSE

The LRP has a steep learning curve to obtain proficiency during which patient safety may be compromised. We present an adapted modular training system which purpose to optimize the learning curve and perform a safe surgery.

MATERIALS AND METHODS

A retrospective analysis of the LRP safe learning protocol applied during a fellowship program over eight years (2008-2015). The surgery was divided in 12 steps and 5 levels of difficulty. A maximum time interval was stipulated in 240 minutes. After an adaptation, the fellows had 120 minutes to perform all the corresponding modules to its accumulated skill. The participants gradually and safely pass through the steps and difficulty levels. Surgeries performed by fellows were analyzed as a single group and compared to a prior series performed by tutor.

RESULTS

In eight years, 250 LRP were performed (25 per apprentice) during fellowship program and 150 procedures after completion. The baseline characteristics were comparable. Most cases operated were of intermediate risk. Mean operative time was longer in the fellow group when compared to the tutor (150 min). Mean estimated blood loss were similar among the groups. Functional and oncological outcomes were better in the Tutor´s group. No conversion to open surgery was performed.

CONCLUSIONS

The LRP safe learning protocol proved to be an effective method to optimize the learning curve and perform safe surgery. However, the tutor's functional and oncological results were better, showing that this is a procedure with a steep learning curve and proficiency demands more than 25 cases.

Prospective evaluation of vesicourethral anastomosis outcomes in robotic radical prostatectomy during early experience in a university hospital

Purpose:

Robotic assisted radical prostatectomy (RARP) presents challenges for the surgeon, especially during the initial learning curve. We aimed to evaluate early and mid-term functional outcomes and complications related to vesicourethral anastomosis (VUA), in patients who underwent RARP, during the initial experience in an academic hospital. We also assessed possible predictors of postoperative incontinence and compared these results with the literature.

Materials and Methods:

We prospectively collected data from consecutive patients that underwent RARP. Patients with at least 6 months of follow-up were included in the analysis for the following outcomes: time to complete VUA, continence and complications related to anastomosis. Nerve-sparing status, age, BMI, EBL, pathological tumor staging, and prostate size were evaluated as possible factors predicting early and midterm continence. Results were compared with current literature.

Results:

Data from 60 patients was assessed. Mean time to complete VUA was 34 minutes, and console time was 247 minutes. Continence in 6 months was 90%. Incidence of urinary leakage was 3.3%, no patients developed bladder neck contracture or postoperative urinary retention. On multivariate analysis, age and pathological staging was associated to 3-month continence status.

Conclusion:

Our data show that, during early experience with RARP in a public university hospital, it is possible to achieve good results regarding continence and other outcomes related to VUA. We also found that age and pathological staging was associated to early continence status.

Prostatectomies for localized prostate cancer: a mixed comparison network and cumulative meta-analysis

No consensus has been attained regarding the utility of open retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALRP) for localized prostate cancer (PCa). We carried out a network meta-analysis and cumulative meta-analysis comparing RRP, LRP and RALRP on peri-operative and functional outcome measures. Electronic databases were searched for either randomized clinical trials or cohort studies comparing RALRP either with LRP or RRP in patients with localized PCa. Outcome measures were as follows: overall, pT2 and pT3-positive surgical margins (PSMs); biochemical recurrence (BCR); complication rates; estimated blood loss; blood transfusion rate; continence and potency rates; duration of catheterization and hospital stay. Publication bias, risk of bias and inconsistency were assessed. Inverse heterogeneity model was used for analysis. A total of 45 studies were included for the final analysis. We observed that RALRP and LRP did not differ significantly from RRP with regard to the following outcomes: overall PSM; pT2 and pT3 PSMs; OT; complication rate; continence and potency rates; total blood loss and hospital stay. Duration of catheterization was significantly shorter in RALRP than LRP and RRP while significant reductions in the need for blood transfusion and BCR were observed for both RALRP and LRP in comparison with RRP. To conclude, similar functional, operative and oncologic outcomes were observed for both RALRP and LRP compared to RRP.