Radical perineal prostatectomy - the contemporary resurgence of a genuinely minimally invasive procedure: Procedure outline. Comparison of the advantages, disadvantages, and outcomes of different surgical techniques of treating organ-confined prostate cancer (PCa). A literature review with special focus on perineal prostatectomy

Comparison of oncological and functional outcomes of perineoscopic radical prostatectomy and robot-assisted radical prostatectomy

The aim of this study is to compare the functional, oncological, and complication outcomes of perineoscopic radical prostatectomy (PeRP) and robot-assisted radical prostatectomy (RARP) operations. Patients who underwent radical prostatectomy (RP) between October 2018 and June 2020 for localized prostate cancer (N0, < T3) were retrospectively screened. After the exclusion criteria, 56 patients who underwent PeRP and 67 patients who underwent RARP remained in the study. Demographic, perioperative, and postoperative data were collected. In functional outcomes, continence and potency status were compared at 1, 3, 6, and 12 months. The mean age of the patients was 61.3 ± 5.9 years in the PeRP group and 62.2 ± 5.7 years in the RARP group. No statistically significant differences were present between preoperative and postoperative values. Among the perioperative findings, the mean operation time was 90.4 ± 11.2 min for the PeRP group and 114.6 ± 14.7 min for the RARP group. The operation time was shorter in the PeRP group. The average hospital stay was 2 ± 0.6 days in the PeRP group and 2.3 ± 0.5 days in the RARP group. It was significantly shorter in the PeRP group. There is no statistically significant difference between the two groups in the oncological and functional results. PeRP is a surgical procedure safe in low-risk patients with medium-risk prostate cancer (PCa) who do not require lymph-node dissection. Moreover, PeRP minimizes the difficulties of perineal surgery.

Comparison of oncological, surgical, and functional outcomes between radical retropubic and radical perineal prostatectomy: A multi-institutional study

Introduction:

To investigate the safety, oncologic, surgical, and functional outcomes of RPP and RRP for localized prostate cancer (Pca), especially focusing on RPP.

Materials and methods:

From March 2005 to January 2021, we retrospectively reviewed the records of 685 patients undergoing RPP ( n = 320) or RRP ( n = 365) for localized Pca. Surgical and functional outcomes, and complications were compared. Oncological outcomes were also compared using Kaplan-Meier survival analysis.

Results:

A higher biochemical recurrence rate were noted in RRP than in RPP group (28.8% vs 21.6%, respectively; p = 0.03). A local recurrence was detected in a few numbers of patients (4.4%) with no statistically significant differences by surgical groups ( p = 0.71). No significant differences were observed in the cancer-specific survival and the overall survival according to the surgical approach. Positive surgical margins were similar in the two techniques. In comparison to RRP, patients undergoing RPP have less postoperative pain, decreased transfusion rate, and less catheterization time. Complete continence was achieved in 96.9% of the RPP group at 18 and 24 months versus 91.8% and 92.3% in the RRP group at 18 and 24 months, respectively ( p = 0.005 and p = 0.01, respectively). At 18 months of follow-up, the nerve-sparing technique was performed equally between the two groups, the mean of erectile function domain improved more in RPP than RRP (12.71 vs 10.42 respectively, p < 0.001). Medical and surgical complication rates were higher for RRP than RPP.

Conclusions:

RPP showed acceptable oncologic outcomes and excellent functional outcomes when compared to RRP.

Transperineal single-port robot-assisted radical prostatectomy with Si da Vinci surgical system: initial experience and description of technique

Background

Single-port robotic-assisted radical laparoscopic prostatectomy has emerged as a novel robotic-assisted radical laparoscopic prostatectomy in recent years, arousing wide attention. However, single-port robotic-assisted radical laparoscopic prostatectomy using Si da Vinci surgical system has been rarely reported, especially via the transperineal approach.

Methods

We retrospectively collected 9 cases of prostate cancer patients who underwent transperineal single-port robot-assisted radical prostatectomy (t-spPARP) using Si da Vinci surgical system in our center from May 2020 to June 2020. The operation time, estimated blood loss (EBL), complications, changes in prostate-specific antigen (PSA) 3 months after surgery, and urinary continence recovery 6 months after surgery were analyzed.

Results

No perioperative complications were recorded. The median [interquartile range (IQR)] operation time was 350 [150] min and the median [IQR] EBL was 300 [100] mL. PSA levels were less than 0.01 ng/mL at 3 months postoperatively in all cases (undetectable in 8 cases). All the 9 patients recovered their urinary continence 6 months after surgery and merely two patients required pads during the day.

Conclusions

t-spRARP was verified as a safe and feasible surgical alternative to treat patients with localized prostate cancer, especially for those whose prostate is small-volume or who had abdominal surgery history.

Robotic radical perineal prostatectomy: tradition and evolution in the robotic era

PURPOSE OF REVIEW

To provide an updated review of robotic radical perineal prostatectomy (r-RPP) with emphasis on the recent advances in terms of surgical technique, outcomes, and new robotic platforms.

RECENT FINDING

The technological innovations in the urological field have been applied to radical prostatectomy with the aim of preserving important anatomical structures and reduce patients' morbidity and mortality. In recent years, robotic surgery contributed to resurge radical perineal prostatectomy. In 2014, the Cleveland Clinic group was the first to demonstrate the utility of a robotic approach in RPP. To date, the majority of the reported studies showed that r-RPP has noninferior perioperative, short-term oncological, and functional outcomes compared with the traditional robot-assisted radical prostatectomy (RARP). Given these benefits, r-RPP is a promising approach in selected patients, such as obese ones. Moreover, robotic perineal pelvic lymph node dissection performed through the same incision of r-RPP and the new Single-Port (SP) Robotic System represent further steps towards the overcoming of some intrinsic limitation of this surgical approach making this technique suitable for a larger number of patients with prostatic cancer.

SUMMARY

Overall, r-RPP represents a reliable and effective novel surgical technique. However, more studies with long-term follow-up are needed to clarify the advantages over RARP.

A Comprehensive Review of Pharmaceutical and Surgical Interventions of Prostate Cancer

As the second most common cause of death amongst men in the United States, prostate cancer is a type of cancer that is known to develop and originate in the prostate gland. The main function of the prostate gland is to produce seminal fluid in which the sperm bathes. The seminal fluids are necessary for allowing the sperm to move easily through the urethra and also allows successful fertilization by providing an alkaline environment for the sperm in the acidic nature of the vagina. The seminal vesicles are two smaller glands that are attached to either side of the prostate gland and in radical prostatectomies, can get removed. In the event that the seminal vesicles are removed during a radical prostatectomy, the individual is unable to produce any seminal fluids and thus, becoming infertile. Prostate cancer is most commonly seen in patients over the age of 66 years, however, in the presence of predisposing risk factors, may occur as early as in the late 40s. Certain risk factors may speed the presentation of prostate cancer in individuals and thus, mandatory screening is recommended around the age of 45. If no risk factors are present, screening is recommended to begin after the age of 50 years. Screening for prostate cancer is focused on looking for prostate-specific antigen (PSA) in a blood test, though this may not be the most reliable method. The method of diagnosis stems from further testing done following an abnormal PSA test. A digital rectal examination and ultrasonography may also be used to assist with the diagnosis of prostate cancer. Though there are several different types of pharmaceutical interventions currently present in the eradication of prostate cancer, with androgen deprivation therapy being the most commonly used, surgical interventions may be utilized to completely resect cancer from an individual. Different radical prostatectomies are used; the appropriate approach utilized is dependent on the extensiveness of cancer and the type of cancer that is present.

Recovery of urinary function after robotic-assisted laparoscopic prostatectomy versus radical perineal prostatectomy for early-stage prostate cancer

INTRODUCTION

Robotic-assisted laparoscopic prostatectomy (RALP) has largely replaced open radical prostatectomy in many centers. Radical perineal prostatectomy (RPP) is another less invasive approach that has not been widely adopted. RPP offers excellent exposure of the urinary sphincter and bladder neck that may provide good urinary function outcomes. We evaluate urinary function after RALP and RPP.

METHODS

Retrospective review of a prospective radical prostatectomy database was performed. Urinary modules from the Expanded Prostate Cancer Index Composite-Urinary Function (EPIC-UF) questionnaire were used to determine urinary symptoms at baseline and at 6, 12, 18, and 24 months after surgery.

RESULTS

753 men underwent RALP (n = 623) or RPP (n = 130). Of these, 558 had complete data and were included in our study (RALP: n = 458, RPP: n = 100). A higher number of patients undergoing RALP than RPP had pelvic lymph node dissection (20.2% vs. 0%, p < 0.0001) and cavernosal neurovascular bundle sparing (79.2% vs. 68.4%, p < 0.0001). 558 patients had complete EPIC-UF data. Overall urinary recovery was greater for RALP than RPP at 6 months (p = 0.028). Urinary incontinence and function were also more improved after RALP compared to RPP at 6 months (p = 0.021, p = 0.006). However, no differences in overall, urinary incontinence, or urinary function scores were seen at 12, 18, or 24 months. There was no difference between groups in urinary bother or irritative/obstructive symptoms at any time point.

CONCLUSIONS

RALP had more rapid recovery of urinary function at 6 months vs. RPP; at 12-24 months, however, RALP and RPP had similar urinary function recovery in all urinary subdomains.

Descriptive Technique and Initial Results for Robotic Radical Perineal Prostatectomy

OBJECTIVE

To minimize technical challenges of radical perineal prostatectomy (RPP), we conceived and applied the robotic approach to this technique in an aim to improve surgical applicability of RPP. Radical prostatectomy via the perineal route, avoiding the intra-abdominal cavity, has been shown to be oncologically safe, with excellent functional outcomes and a short hospital stay. We report our initial results with this novel approach.

MATERIALS AND METHODS

We performed the procedure in 4 patients. With the patient in the exaggerated lithotomy position, following a 3 cm perineal incision, the initial perineal dissection using Belt's approach is performed, followed by single port placement and docking of the robot.

RESULTS

The median age for patients was 64 years (60-69). Two patients had no rectum because of the abdominoperineal resection due to inflammatory bowel diseases. One of the other 2 patients had a surgical history of aborted robotic-assisted laparoscopic radical prostatectomy and 1 patient had no surgical history. There were no perioperative complications and the patients were discharged within 16-48 hours. Urethral catheter was removed within 10 days in 3 patients, and 3 weeks in 1 patient. Two patients were immediately continent when Foley was removed. The final pathology revealed focally positive margin in those 3 patients who had surgical histories and it was margin negative in the patient with native anatomy. All patients had undetectable prostate-specific antigen postoperatively.

CONCLUSION

RPP was successfully completed in 4 cases, applying a single port robotic perineal approach. Initial results are encouraging, with short hospital stay and minimal postoperative pain.

Safety of robotic prostatectomy over time: a national study of in-hospital injury

OBJECTIVE

To assess national trends of iatrogenic complications and associated burden of care among patients undergoing open and minimally invasive prostatectomy using a population-based cohort.

METHODS

Using the nationally representative cohort, we identified patients who were diagnosed with prostate cancer, and underwent prostatectomy during 2001 and 2011. We determined the risk of iatrogenic complication and length of stay (LOS) over time among open and minimally invasive surgery (MIS) patients. Hierarchical multivariable logistic regression was performed to assess the changes over time and elucidate independent predictors of iatrogenic complications.

RESULTS

We identified 556,932 and 219,434 prostate cancer patients undergoing open and minimally invasive prostatectomy. We found that iatrogenic complications for MIS were less frequent in later years (years 09-11 vs. year 01-02 odds ratio (OR), 0.21; 95% confidence intervals (CI), 0.09-0.40). MIS was associated with higher risk of iatrogenic complications in early period (years 01-02 OR, 3.81; 95% CI, 1.72-8.41), but lower risk in late period (years 09-11 OR 0.72 95% CI 0.61-0.86). Patients who experienced iatrogenic complications tended to have longer LOS (Median: Open vs. MIS, 4 days vs. 3 day) than those who didn't (Median: Open vs. MIS, 2 days vs. 1 day), regardless of procedure type.

CONCLUSION

We found that minimally invasive prostatectomy is associated with lower risk of iatrogenic complications when compared with open surgery (OS). However, as "learning curve" is overcome over time, MIS becomes safer than OS. Iatrogenic complications are not benign and seem to be associated with higher burden of inpatient care.

Significance of atypical small acinar proliferation and extensive high-grade prostatic intraepithelial neoplasm in clinical practice

INTRODUCTION

Prostate cancer (PCa) is one of the most commonly diagnosed neoplasms in elderly men. The precancerous lesion of PCa is considered a high-grade prostate intraepithelial neoplasm (HG-PIN), while atypical small acinar proliferation (ASAP) is commonly considered as an under-diagnosed cancer. The aim of the study was to establish the impact of ASAP and extensive HG-PIN on pre-biopsy prostate-specific antigen (PSA) levels and the risk of cancer development in subsequent biopseis.

MATERIAL AND METHODS

The 1,010 men suspected for PCa were included in the study based on elevated PSA, and/or positive rectal examination. Transrectal ultrasound (TRUS) guided 10 core biopsy was performed. In those with extensive HG-PIN or ASAP on the first biopsy, and/or elevated PSA value, a second biopsy was performed.

RESULTS

In the second biopsy, PCa was diagnosed in 6 of 19 patients (31.57%) with extensive HG-PIN, in four of 40 (10%) with BPH, and in 4 of 18 (22.22%) with ASAP. There was a statistically significant difference between the values of PSA in the group of patients with ASAP in comparison to those with benign prostate hyperplasia (BPH) (p = 0.005) as well as in patients with HG-PIN in comparison to BPH (p = 0.02).

CONCLUSIONS

A precancerous lesion diagnosed upon biopsy causes a statistically significant increase in the values of PSA in relation to BPH, as well as in the case of ASAP and extensive HG-PIN. The estimate of risk of PCa diagnosis in patients with ASAP and those with extensive HG-PIN in the first biopsy is comparable, which is why there are no reasons for different treatment of patients with the above-mentioned diagnoses. Both should be subjected to urgent second biopsy in around the 4-6 weeks following the initial biopsy.