Perioperative Complications of Single-Port and Multiport Robotic Radical Prostatectomy: A Single Institutional Comparison Analysis

Background: Following its introduction in 2018, the Single-Port (SP) robotic platform has been increasingly utilized for various approaches of robotic radical prostatectomy (RARP). Despite the demonstrable benefits in enhancing postoperative outcomes, there has been limited evidence on its perioperative morbidity, especially when compared to the gold-standard multiport (MP). This study sought to compare the perioperative morbidity between SP and MP-RARP. Methods: A retrospective review was performed on 911 patients who underwent RARP between January 2015 and May 2023. At our institution, SP-RARP has been performed since October 2018 with Extraperitoneal and Transvesical (TV) techniques. To reduce the risk of selection bias, only MP-RARP cases performed before October 2018 were included. Baseline clinicodemographic and perioperative parameters were collected. Perioperative complications were classified in accordance to the Clavien-Dindo system with postoperative complications and readmission reported within 90 days of surgery. Statistical analysis was performed with R Packages for Statistical Computing with descriptive statistics as presented. Results: Of the 484 SP and 322 MP-RARP cases included in our analysis, one intraoperative complication was reported, which pertained to a small enterotomy during TV SP-RARP. Postoperative complications were identified in 14.5% and 14.6% of SP and MP-RARP cases (p = 0.989), respectively. Major complication represents 4.1% of the SP and 3.4% of MP cohorts. The 90-day rates of hospital readmission following SP and MP-RARP were 5.6% and 4.9%, respectively (p = 0.717). Limitations of this study included the retrospective single surgeon, single institution nature of our series that also included the early learning curve experience associated with the novel SP platform. Conclusion: This comparative study provided evidence highlighting the low rates of perioperative complication and readmission following SP-RARP that were comparable to the Transperitoneal MP approach. The low morbidity associated with SP-RARP supports its wider application as an addition to the contemporary minimally invasive surgical armamentariums for prostate cancer.

Impact of Robotic Technologies on Prostate Cancer Patients' Choice for Radical Treatment

Prostate cancer (PCa) surgery has a strong impact on men's social and sexual lives. For this reason, many patients ask for robotic surgery. To assess the rate of lost patients due to the lack of a robotic platform (RPl) at our center, we retrospectively selected 577 patients who underwent prostate biopsy between 2020 and 2021 who were eligible for radical prostatectomy (RP) (ISUP ≥ 2; age ≤ 70 yr). Patients eligible for surgery who decided to be operated received a phone call interview asking the reason for their choice. Overall, 230 patients (31.7%) underwent laparoscopic-assisted radical prostatectomy (LaRP) at our center, while 494 patients (68.3%) were not treated in our hospital. Finally, 347 patients were included: 87 patients (25.1%) underwent radiotherapy; 59 patients (17%) were already under another urologist's care; 113 patients (32.5%) underwent robotic surgery elsewhere; and 88 patients (25.4%) followed the suggestion of friends or relatives based on their surgical experience. Despite no surgical technique for RP having shown superiority in terms of oncological or functional outcomes, patients eligible for PCa treatment decided to be operated on elsewhere because of the lack of an RPl. Our results show how the presence of an RPl may increase the case volume of RP by 49% at our center.

Effects of Bladder Neck Plication on Climacturia After Robot-Assisted Laparoscopic Prostatectomy

Purpose: The aim of this study is to investigate the effect of bladder neck plication during transperitoneal robot-assisted radical prostatectomy (tRARP) on orgasm-related incontinence (climacturia) and the relationship between International Index of Erectile Function 5 (IIEF-5) scores and climacturia. Materials and Methods: We evaluated 118 patients who underwent nerve-sparing tRARP in our clinic and survived the first postoperative year. Patients were divided into two groups: those who underwent bladder neck plication (Group 1, n = 58) and those who did not (Group 2, n = 60). Our study investigated whether there is a difference between the groups in terms of climacturia or if there is a relationship between IIEF-5 scores and climacturia. Results: Of the patients in Group 1, 10.3% had incontinence and 13.8% had climacturia. Of the patients in Group 2 who did not have bladder neck plication, 10% had incontinence and 15% had climacturia. There was no difference between the groups in terms of climacturia (P > .825). Three patients (5.2%) in Group 1 and four patients (6.6%) in Group 2 requested treatment. There was no statistically significant correlation between IIEF-5 scores and climacturia in both groups (Group 1, P > .208; and Group 2, P > .508). Conclusions: In our study, the frequency of climacturia in patients who underwent bladder neck plication during tRARP was consistent with the literature and did not show a statistically significant difference from patients who did not undergo bladder neck plication. It has been observed that bladder neck plication, which has no effect on long-term continence, does not contribute to prevention of climacturia. No correlation was found between IIEF-5 scores and climacturia.

Prostate Cancer in Renal Transplant Recipients: Results from a Large Contemporary Cohort

Objectives: The aim of this study was to assess the natural history of prostate cancer (PCa) in renal transplant recipients (RTRs) and to clarify the controversy over whether RTRs have a higher risk of PCa and poorer outcomes than non-RTRs, due to factors such as immunosuppression. Patients and Methods: We performed a retrospective multicenter study of RTRs diagnosed with cM0 PCa between 2001 and 2019. Primary outcomes were overall (OS) and cancer-specific survival (CSS). Secondary outcomes included biochemical recurrence and/or progression after active surveillance (AS) and evaluation of variables possibly influencing PCa aggressiveness and outcomes. Management modalities included surgery, radiation, cryotherapy, HIFU, AS, and watchful waiting. Results: We included 166 men from nine institutions. Median age and eGFR at diagnosis were 67 (IQR 60−73) and 45.9 mL/min (IQR 31.5−63.4). ASA score was >2 in 58.4% of cases. Median time from transplant to PCa diagnosis was 117 months (IQR 48−191.5), and median PSA at diagnosis was 6.5 ng/mL (IQR 5.02−10). The biopsy Gleason score was ≥8 in 12.8%; 11.6% and 6.1% patients had suspicion of ≥cT3 > cT2 and cN+ disease. The most frequent management method was radical prostatectomy (65.6%), followed by radiation therapy (16.9%) and AS (10.2%). At a median follow-up of 60.5 months (IQR 31−106) 22.9% of men (n = 38) died, with only n = 4 (2.4%) deaths due to PCa. Local and systemic progression rates were 4.2% and 3.0%. On univariable analysis, no major influence of immunosuppression type was noted, with the exception of a protective effect of antiproliferative agents (HR 0.39, 95% CI 0.16−0.97, p = 0.04) associated with a decreased risk of biochemical recurrence (BCR) or progression after AS. Conclusion: PCa diagnosed in RTRs is mainly of low to intermediate risk and organ-confined at diagnosis, with good cancer control and low PCa death at intermediate follow-up. RTRs have a non-negligible risk of death from causes other than PCa. Aggressive upfront management of the majority of RTRs with PCa may, therefore, be avoided.

Intraoperative 3D-US-mpMRI Elastic Fusion Imaging-Guided Robotic Radical Prostatectomy: A Pilot Study

INTRODUCTION

When performing a nerve-sparing (NS) robotic radical prostatectomy (RARP), cancer location based on multiparametric MRI (mpMRI) is essential, as well as the location of positive biopsy cores outside mpMRI targets. The aim of this pilot study was to assess the feasibility of intraoperative 3D-TRUS-mpMRI elastic fusion imaging to guide RARP and to evaluate its impact on the surgical strategy.

METHODS

We prospectively enrolled 11 patients with organ-confined mpMRI-visible prostate cancer (PCa), histologically confirmed at transperineal fusion biopsy using Koelis Trinity. Before surgery, the 3D model of the prostate generated at biopsy was updated, showing both mpMRI lesions and positive biopsy cores, and was displayed on the Da Vinci robotic console using TilePro™ function.

RESULTS

Intraoperative 3D modeling was feasible in all patients (median of 6 min). The use of 3D models led to a major change in surgical strategy in six cases (54%), allowing bilateral instead of monolateral NS, or monolateral NS instead of non-NS, to be performed. At pathologic examination, no positive surgical margins (PSMs) were reported. Bilateral PCa presence was detected in one (9%), four (36%), and nine (81%) patients after mpMRI, biopsy, and RARP, respectively. Extracapsular extension was found in two patients (18%) even if it was not suspected at MRI.

CONCLUSIONS

Intraoperative 3D-TRUS-mpMRI modeling with Koelis Trinity is feasible and reliable, helping the surgeon to maximize functional outcomes without increasing the risk of positive surgical margins. The location of positive biopsy cores must be registered in 3D models, given the rates of bilateral involvement not seen at mpMRI.

The association of a risk group with positive margin in the intraoperative and final pathology examination after robotic radical prostatectomy

Introduction

The aim of this study was to evaluate the risk of a positive margin in the intraoperative and final pathology depending on the risk group for biochemical recurrence in biopsy specimens after robot-assisted radical prostatectomy (RaRP) with sparing of the neurovascular bundles (NS).

Material and methods

The study was prospective and non-randomised. The intraoperative and final pathology examinations were performed in 65 consecutive patients treated with RaRP between 11.2019–08.2020. In the intraoperative examination, the site of the dissected neurovascular bundles and any suspicious places were examined. Patients were divided into 3 risk groups [according to the European Association of Urology (EAU) biochemical recurrence-risk stratification]. Due to the uncertain prognostic value of microscopic positive margins, 3 groups were identified: R0, Rmicro and R1.

Results

In the intraoperative examination, the distribution of risk groups in R0, Rmicro and R1 groups is similar (p = 0.132). In the postoperative study, the distribution of risk groups in each margin group is different, and is statistically significant (p <0.001). It has been shown that an increase in the risk group is an indicator of the occurrence of a positive margin in the final histopathological result regardless of the inclusion of Rmicro into R1 or into R0 by 2.68 and 6.52 times, respectively.

Conclusions

The preoperative risk group is an important factor for the occurrence of a positive margin, but only in the final examination and not in the intraoperative one. An intraoperative examination of the neurovascular bundles only is pointless and should be extended to the examination of the apex.

Evolution of Salvage Radical Prostatectomy from Open to Robotic and Further to Retzius Sparing Surgery

Salvage radical prostatectomy (sRP) has evolved from open to minimally invasive approaches. sRP can be offered to patients with local recurrence to improve biochemical recurrence (BCR)-free and overall survival. We evaluate oncological outcome and continence after retropubic (RRP), conventional (cRARP), and Retzius-sparing robotic (rsRARP) surgery. Materials/methods: A total of 53 patients undergoing sRP between 2010 and 2020 were included. Follow-up included oncological outcome and continence. Results: sRP was done as RRP (n = 25), cRARP (n = 7), or rsRARP (n = 21). Median blood loss was 900 mL, 500 mL, and 300 mL for RRP, cRARP, and rsRARP, respectively. At 12 months, 5 (20%), 0, and 4 (19%) patients were continent, 9 (36%), 3 (43%), and 7 (33%) had grade 1 incontinence, 5 (20%), 2 (29%), and 3 (14%) had grade 2 incontinence, and 3 (12%), 2 (29%), and 4 (19%) had grade 3 incontinence for RRP, cRARP, or rsRARP, respectively. During a mean follow-up of 52.6 months, 16 (64%), 4 (57%), and 3 (14%) developed BCR in the RRP-, cRARP-, and rsRARP-group, respectively. Conclusions: Over the years, sRP has shifted from open to laparoscopic/robotic surgery. RARP shows good oncological and functional outcome. rsRARP ensures direct vision on the rectum during preparation and can therefore increase safety and surgeon’s confidence, especially in the salvage setting.

Extraperitoneal Single-Port Robot-Assisted Radical Prostatectomy

Robot-assisted radical prostatectomy (RARP) is currently the standard minimally invasive procedure for the surgical management of localized prostate cancer. It has been shown that the minimally invasive robotic approach offers comparable oncologic and functional outcomes with potential advantages, including decreased blood loss, shorter hospital stay, and recovery period when compared with open surgery. Generally, the transperitoneal RARP approach is the most commonly performed among robotic surgeons, owing to its wider space and early adoption. However, similar oncologic outcomes have been reported with the extraperitoneal approach. Owing to its perceived technical difficulty, extraperitoneal RARP is less adopted nowadays. This approach, however, has its merits particularly in cases where intraperitoneal access can be problematic with extensive adhesions from previous surgeries. Also, extraperitoneal approach allows for minimal bowel manipulation, less steep Trendelenburg positioning, and less pneumoperitoneum, which reflect on early recovery of bowel function after RARP. Both transperitoneal and extraperitoneal approaches can be performed using either the conventional multiport robotic system or the more recent single-port (SP) robotic system. With respect to extraperitoneal RARP, there has been an increased adoption of the SP system, with purported advantages such as better cosmesis, less postoperative analgesic and opioid requirements, and shorter duration of hospital stay. Herein, we describe the technical steps relevant to extraperitoneal single-port robot-assisted radical prostatectomy, and elaborate on the clinical outcomes reported in the literature.

Difference in Incontinence Pad Use between Patients after Radical Prostatectomy and Cancer-Free Population with Subgroup Analysis for Open vs. Minimally Invasive Radical Prostatectomy: A Descriptive Analysis of Insurance Claims-Based Data

PURPOSE

to quantify and compare pre- and post-surgical incontinence pad use between men treated with radical prostatectomy (RP) for prostate cancer (PCa) and cancer-free controls, using population-based Austrian insurance claims data.

METHODS

Men who underwent RP for treating PCa between 2013-2015 were identified. Cancer-free men ≥45 years with and without benign prostate hyperplasia (BPH) were used as controls. Longitudinal data on ICD-diagnoses, type of surgery, prescribed incontinence pads, and hospitals' surgery volumes were aggregated between 2011-2018 to capture pre- and up to three years post-RP follow-up. Monthly rates of pad use were calculated and compared between RP types and cancer-free controls.

RESULTS

A total of 6248 RP patients, 7158 cancer-free men with BPH, and 50,257 cancer-free men without BPH were analyzed. Comparing to pre-RP (0.03, 95%CI: 0.02-0.05), RP resulted in significantly higher rates of prescribed pads (at 3 months: 12.61, 95%CI: 11.59-13.65; 12 months: 6.71, 95%CI: 6.10-7.34; 36 months: 4.91, 95%CI: 3.76-4.62). These rates were also higher than those for cancer free controls (with BPH:0.06, 95%CI: 0.04-0.09; without BPH:0.12, 95%CI: 0.10-0.14). The rate of prescribed pads after surgery continued to decline over time and remained higher among men who underwent minimally invasive RP compared to those who underwent an open procedure.

CONCLUSION

Despite progress in surgical techniques, post-RP incontinence remains a prevalent adverse event. The rate of pad usage steadily improved over the first three years post RP. The rate of patients with incontinence needing pads was higher among those who were treated minimally invasive compared to open approach.

A comparison of perioperative outcomes between extraperitoneal robotic single-port and multiport radical prostatectomy with the da Vinci Si Surgical System

To evaluate outcomes between extraperitoneal robotic single-port radical prostatectomy (epR-spRP) and extraperitoneal robotic multiport radical prostatectomy (epR-mpRP) performed with the da Vinci Si Surgical System, comparison was performed between 30 single-port (SP group) and 26 multiport (MP group) cases. Comparisons included operative time, estimated blood loss (EBL), hospital stay, peritoneal violation, pain scores, scar satisfaction, continence, and erectile function. The median operation time and EBL were not different between the two groups. In the SP group, the median operation time of the first 10 patients was obviously longer than that of the latter 20 patients (P < 0.001). The median postoperative hospital stay in the SP group was shorter than that in the MP group (P < 0.001). The rate of peritoneal damage in the SP group was less than that in the MP group (P = 0.017). The pain score and overall need for pain medications in the SP group were lower than those in the MP group (P < 0.001 and P = 0.015, respectively). Patients in the SP group were more satisfied with their scars than those in the MP group 3 months postoperatively (P = 0.007). At 3 months, the cancer control, recovery of erectile function, and urinary continence rates were similar between the two groups. It is safe and feasible to perform epR-spRP using the da Vinci Si surgical system. Therefore, epR-spRP can be a treatment option for localized prostate cancer. Although epR-spRP still has a learning curve, it has advantages for postoperative pain and self-assessed cosmesis. In the absence of the single-port robotic surgery platform, we can still provide minimally invasive surgery for patients.

Latest Comprehensive Medical Resource Consumption in Robot-Assisted versus Laparoscopic and Traditional Open Radical Prostatectomy: A Nationwide Population-Based Cohort Study

BACKGROUND

Few studies have evaluated long-term medical monetary cost in patients with prostate cancer (PC) receiving open radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP), or robot-assisted radical prostatectomy (RARP). To the best of our knowledge, this is the largest and longest follow-up study to examine medical monetary cost in patients with PC undergoing ORP, LRP, or RARP. After adjustment for confounders, the medical monetary cost in the RARP group was the least compared with that in the ORP and LRP groups.

PURPOSE

To estimate long-term medical resource consumption among patients with prostate cancer (PC) receiving open radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP), or robot-assisted radical prostatectomy (RARP).

PATIENTS AND METHODS

Participants were men enrolled in the Taiwan Cancer Registry with localized PC diagnosis who received radical prostatectomy. After adjustment for confounders, a generalized linear mixed model was used to determine significant differences in the number of urology outpatient clinic visits required, proportion of patients being hospitalized for urinary diseases or surgical complications, and medical reimbursement for urinary diseases or surgical complications following ORP, LRP, or RARP in the first, second, and third years. Results: No differences were observed in the median number of urology outpatient clinic visits between the three types of surgical modalities up to the second year after ORP, LRP, and RARP (median: 15, 10, and seven visits, respectively; p < 0.001), but significant differences were observed in the third year. Similarly, with RARP (10.9% versus 18.7% in ORP and 9.8% in LRP; p = 0.0014), the rate of hospitalization for urinary diseases or surgical complications decreased in the third year. Medical reimbursement for urinary diseases or surgical complications reduced after RARP compared with that for ORP and LRP, with approximately 22% reduction in the first year (p = 0.0052) and 20-40% reduction in the third year (p value = 0.0024).

CONCLUSIONS

Medical resource consumption in the RARP group was less compared with those in the ORP and LRP groups.

Effects of 1-Year Hospital Volume on Surgical Margin and Biochemical-Failure-Free Survival in Patients Undergoing Robotic versus Nonrobotic Radical Prostatectomy: A Nationwide Cohort Study from the National Taiwan Cancer Database

Simple Summary

Limited evidence exists regarding the effects of hospital volume (i.e., number of patients with PC receiving robotic RP per year) on the oncologic outcomes of biochemical-failure-free survival (BFS) and positive surgical margin (PSM) between patients with prostate cancer (PC) undergoing robotic or nonrobotic radical prostatectomy (RP). This is the first study to include large sample size, long follow-up time, and consistent covariates of patients with PC receiving different surgical techniques for RP and investigate whether hospital volume affects BFS and PSM. Hospital volume significantly improved BFS and PSM rates in robotic RP, but not in nonrobotic RP. When patients with PC wish to receive robotic RP, we suggest that the surgery be performed in a high-volume hospital (>50 patients/year).

Abstract

Purpose: To examine the effect of hospital volume on positive surgical margin (PSM) and biochemical-failure-free survival (BFS) rates in patients with prostate cancer (PC) undergoing robotic-assisted or nonrobotic-assisted radical prostatectomy (RP). Patients and Methods: The patients were men collected in the National Taiwan Cancer Registry diagnosed as having PC without distant metastasis who received RP from 44 multi-institutes in Taiwan. The logistic regression method was used to analyze the risk from RP to PSM in included patients with hospital volume (i.e., number of patients with PC receiving robotic RP per year), and the Cox proportional hazards method was used to analyze the time from the index date to biochemical recurrence. Results: After propensity score adjustment, compared with hospitals with >100 patients/year, the adjusted odds ratios (aORs; 95% confidence intervals) of PSM in the robotic RP group in hospitals with 1–25, 26–50, and 51–100 patients/year were 2.25 (2.10–3.11), 1.42 (1.25–2.23), and 1.33 (1.13–2.04), respectively (type III p < 0.0001). Sensitivity analysis indicated that the aORs of PSM were 1.29 (1.07–1.81), 1.07 (0.70–1.19), and 0.61 (0.56–0.83), respectively, for patients receiving robotic RP compared with nonrobotic RP within hospitals with 1–25, 26–50, and 51–100 patients/year, respectively. Compared with hospitals with >100 patients/year, the adjusted hazard ratios (aHRs) of biochemical failure in the robotic RP group were 1.40 (1.04–1.67), 1.34 (1.06–1.96), and 1.31 (1.05–2.15) in hospitals with 1–25, 26–50, and 51–100 patients/year, respectively. Conclusions: Hospital volume significantly affected PSM and BFS in robotic RP, but not in nonrobotic RP. When patients with PC want to receive robotic RP, it should be performed in a relatively high-volume hospital (>100 patients/year).

There Are No Differences in Positive Surgical Margin Rates or Biochemical Failure-Free Survival among Patients Receiving Open, Laparoscopic, or Robotic Radical Prostatectomy: A Nationwide Cohort Study from the National Cancer Database

Simple Summary

Few studies have evaluated oncologic outcomes in patients with prostate cancer (PC) receiving open, laparoscopic, or robotic radical prostatectomy (RP). To the best of our knowledge, this is the first and largest study to examine PSM and BFS rates in patients with PC undergoing open, laparoscopic, or robotic RP. After adjustment for confounders, no significant differences in PSM or BFS were noted among the patient groups.

Abstract

Purpose: To estimate the rates of positive surgical margin (PSM) and biochemical failure–free survival (BFS) among patients with prostate cancer (PC) receiving open, laparoscopic, or robotic radical prostatectomy (RP). Patients and Methods: The patients were men enrolled in the Taiwan Cancer Registry diagnosed as having PC without distant metastasis who received RP. After adjustment for confounders, logistic regression was used to model the risk of PSM following RP. After adjustment for confounders, Cox proportional regression was used to model the time from the index (i.e., surgical) date to biochemical recurrence. Results: The adjusted odds ratios (95% CIs) of PSM risk after propensity score adjustment for laparoscopic versus open, robotic versus open, and robotic versus laparoscopic RP 95% CIs were 1.25 (0.88 to 1.77; p = 0.2064), 1.16 (0.88 to 1.53; p = 0.2847), and 0.93 (0.70 to 1.24; p = 0.6185), respectively. The corresponding adjusted hazard ratios (95% CIs) of risk of biochemical failure after propensity score adjustment were 1.16 (0.93 to 1.47; p = 0.1940), 1.10 (0.83 to 1.47; p = 0.5085), and 0.95 (0.74 to 1.21; p = 0.6582). Conclusions: No significant differences in PSM or BFS were observed among patients receiving open, laparoscopic, or robotic RP.

Comparison of suture material for vesico-urethral anastomosis in robotic radical prostatectomy

Introduction

The aim of this study was to compare outcomes after vesicourethral anastomosis (VUA) with barbed suture (BS) and non-barbed monofilament suture (NBS) in robot-assisted laparoscopic radical prostatectomy (RALRP) in a match – pairs design.

Material and methods

Medical recordings of 385 consecutive patients with prostate carcinoma have been evaluated, and 70 patients who have undergone RALRP-BS were compared with 70 patients with RALRP-NBS in a matched – pairs design. Preoperative clinical parameters (age, prostate-specific antigen, clinical stage, Gleason score of the prostate biopsy, and prostate volume) and operative data (operation, docking, console, posterior reconstruction (PR), anastomosis times, duration of catheter, length of hospital stay, estimated blood loss, time to perform the anastomosis and its quality) were evaluated, as well as postoperative parameters (pathological stage, Gleason score, specimen weight, follow-up duration, biochemical recurrence, complication rates, and duration of postoperative analgesic treatment).

Results

No statistically significant difference was found for pre-operative parameters between the two groups. Although, anastomosis time, quality of anastomosis, duration of urethral catheter and total anesthesia time were significantly less in the RALRP-BS group than in the RALRP-NBS group (P <0.01). Other peri- and postoperative parameters were not statistically significant between the two groups. Pathological data and the follow-up period and complication rates were similar between the two groups.

Conclusions

This study showed that, RALRP-BS is a safe, efficient and cost-effective PR and VUA during RALRP than compared with RALRP-NBS. Shorter anastomosis time, operative time and posterior reconstruction time, while it may be equivalent with regard to estimated blood loss (EBL), catheterization time and early continence rates at 4–6 weeks.

Immunomodulation by ketamine as an adjunct to total intravenous anesthesia in patients undergoing minimally invasive radical prostatectomy: A randomized pilot trial

Post-surgery immunomodulation, including reduced natural killer cell cytotoxicity (NKCC), is recognized as a predictor of poor outcomes in patients following cancer surgery. The present study investigated direct immunomodulation via ketamine as an anesthetic adjuvant in patients undergoing cancer surgery. The present non-double blinded randomized trial was conducted at Hirosaki University Hospital with 60 patients who underwent minimally invasive robotic radical prostatectomy to minimize the immunomodulation due to surgical stress. Patients received total intravenous anesthesia using propofol and remifentanil, with ketamine as an anesthetic adjuvant (the ketamine group) or without ketamine (the control group). The primary outcome was the difference in NKCC between these groups. The secondary outcomes were the differences in neutrophil-lymphocyte ratio (NLR) and levels of interleukin (IL)-6, IL-1β, IL-10 and tumor necrosis factor-alpha (TNF-α). NKCC and cytokines were measured before anesthesia (baseline) and at 6 and 24 h after baseline measurements were recorded. NLR was determined on the last day before admission and at 48 h post-baseline. NKCC values were similar in each group at 6 h when compared with respective baseline results (baseline control, 36.9±15.6%; 6 h control, 38.3±13.4%; baseline ketamine, 36.1±17.0%; 6 h ketamine, 36.6±16.4%) but significantly decreased at 24 h (control, 26.5±12.2%; ketamine, 24.1±12.7%; P<0.001). There were no significant differences in NKCC between the ketamine and control groups (P=0.64) at any of the assessed time points. NLR, IL-1β, IL-10 and TNF-α levels were also similar between two groups. In contrast, IL-6 at 24 h was significantly lower in the ketamine group compared with the control group (mean difference, -7.3 pg ml^-1; 95% confidence interval, -14.4 to -0.2; P=0.04). Ketamine as an anesthetic adjuvant did not provide direct immunomodulation in patients who underwent cancer surgery.

Subsphincteric Anastomosis During Laparoscopic Robot-Assisted Radical Prostatectomy and Its Positive Impact on Continence Recovery

Introduction: To assess the interest of a new sphincter preserving anastomosis technique for continence recovery after robot-assisted laparoscopic radical prostatectomy (RALP).

Materials and Methods: We performed a monocentric single-operator study on 187 consecutive RALP. Patients were divided into two groups: Group 1 (standard anastomosis, until December 2017) and Group 2 (subsphincteric anastomosis [SSA], since January 2018). The SSA consisted in respecting the sphincteric sleeve during the anastomosis suturing only the internal layer of the urethra with the bladder and thereby avoiding the loss of sphincteric length induced by the suture. Pre-, intra-, and postoperative data were prospectively collected and compared. Criteria of continence were as follows: no pad use and complete absence of leakage at catheter removal at 1 month and 1 year.

Results: The two groups were comparable in terms of prostate-specific antigen, gland volume, and Gleason score. In Group 2 (SSA), we observed a complete continence recovery in 75.6% at catheter removal (p = 0.0000035), in 82.9% at 1 month (p = 0.000092), and in 97.5% at 1 year (p = 0.028), independently of bladder neck preservation (p = 0.388). There was also a significant difference between the two groups concerning urinary reeducation requirement (p = 0.0006), pad use, and urinary quality of life (p = 0.0000002). No anastomosis complication was reported.

Conclusions: The SSA significantly improved the rates of immediate, early, and 1-year continence recovery after RALP. These results need further study among larger numbers of patients.

Bidirectional Barbed Only vs Poliglecaprone Suture with Rhabdosphincter Reconstruction for Urethrovesical Anastomosis During Robotic Radical Prostatectomy: Does It Make Any Difference?

OBJECTIVES

We investigated the use of bidirectional barbed suture only vs poliglecaprone suture with posterior rhabdosphincter reconstruction for urethrovesical anastomosis (UVA) during robot-assisted radical prostatectomy (RARP) on cystographic leakage, duration of catheterization, and early urinary continence.

MATERIALS AND METHODS

Bidirectional double-armed barbed suture only was used for UVA (n = 50) in Group 1. Two 3/0 poliglecaprone 25 sutures were tied to each other to form a double-armed suture used for UVA with posterior rhabdosphincter reconstruction in Group 2 (n = 50). Groups were similar regarding patient demographics and operative parameters. Groups were compared regarding leakage on cystography, duration of urethral catheterization after RARP, immediate urinary continence (continence at the time of urethral catheter removal), and continence rates at first and third-month follow-up.

RESULTS

Leakage on cystography was detected in 4 (8%) and 10 (20%) of the patients in Group 1 and 2, respectively (p = 0.08). Urinary catheter removal duration was 7.8 and 8.5 days in Group 1 and 2, respectively (p = 0.1). Immediate urinary continence was achieved in 38 (76%) and 20 (40%) of the patients in Group 1 and 2, respectively (p = 0.002). Urinary continence in first-month follow-up was achieved in 46 (92%) and 38 (76%) of the patients in Group 1 and 2, respectively (p = 0.02). Urinary continence in third-month follow-up was achieved in 48 (96%) and 47 (94%) of the patients in Group 1 and 2, respectively (p = 0.64). Mean UVA time was 16.8 and 21.2 minutes, respectively, in Group 1 and 2 (p < 0.001).

CONCLUSIONS

Because of our experience, use of a barbed suture for UVA during RARP seems to lead to better immediate and early (first month) urinary continence rates and a shorter UVA time.

An observational study: Effects of tenting of the abdominal wall on peak airway pressure in robotic radical prostatectomy surgery

Background:

Robotic radical prostatectomy (RRP) is associated with various anesthetic challenges due to pneumoperitoneum and deep Trendelenburg position. Tenting of the abdominal wall done in RRP surgery causes decrease in peak airway pressure leading to better ventilation. Herein, we aimed to describe the effects of tenting of the abdominal wall on peak airway pressure in RRP surgery performed in deep Trendelenburg position.

Methods:

One hundred patients admitted for RRP in Kokilaben Dhirubhai Ambani Hospital of American Society of Anesthesiologists 1 and 2 physical status were included in the study. After undergoing preanesthesia work-up, patients received general anesthesia. Peak airway pressures were recorded after induction of general anesthesia, after insufflation of CO₂, after giving Trendelenburg position, and after tenting of the abdominal wall with robotic arms.

Results:

Mean peak airway pressure recording after induction in supine position was 19.5 ± 2.3 cm of H₂O, after insufflation of CO₂ in supine position was 26.3 ± 2.6 cm of H₂O, after giving steep head low was 34.1 ± 3.4 cm of H₂O, and after tenting of the abdominal wall with robotic arms was 29.5 ± 2.5 cm of H₂O. P value is highly statistically significant (P = 0.001).

Conclusion:

Tenting of the abdominal wall during RRP is beneficial as it decreases peak airway pressure and helps in better ventilation and thus reduces the ill effects of raised peak airway pressure and intra-abdominal pressures.

Feasibility of robotic radical prostatectomy for medication refractory chronic prostatitis/chronic pelvic pain syndrome: Initial results

Four patients diagnosed with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), met criteria for National Institute of Health (NIH) Category III prostatitis, failed multiple medicinal treatments and underwent robotic radical prostatectomy (RRP). Median operative time (range): 157 (127–259) min. Validated functional questionnaires responses and NIH CP symptom index (NIH-CPSI) score were collected for each patient's status at different time points pre- and post-operatively. Median decreases (range) were: International Prostate Symptom Score – 14 (1–19); Sexual Health Inventory for Men – 6 (−14–22); and NIH-CPSI total – 23.5 (13–33). Median length of follow-up (range) was 34 (24–43) months. RRP appears to be an option for carefully selected patients with medication-refractory CP/CPPS who understand that baseline sexual function may not be restored postoperatively.

Does anterior prostatic fat tissue removed during robotic radical prostatectomy contain any lymph nodes?

INTRODUCTION

We investigated whether anterior periprostatic fat (APPF) tissue removed during robotic radical prostatectomy (RARP) contains any lymph nodes (LNs).

MATERIAL AND METHODS

APPF tissues removed during RARP in 129 patients were evaluated histopathologically. Correlation with postoperative pathologic stage was made. Patients with a history of previous prostate or bladder surgery and radiation therapy were excluded.

RESULTS

Mean patient age, serum prostate specific antigen (PSA), prostate weight and body mass index (BMI) were 62.2 ±5.5 (range 45-74), 9.3 ±6.3 ng/dl (range 0.26-30.3), 60.3 ±27.2 grams (range 11.0-180) and 26.6 ±1.9 kg/m(2) (range 20.0-30.3), respectively. Overall, LNs in APPF tissues were detected in 14 (10.9%) patients with a mean LN yield of 1.1 ±0.7 LNs (range, 1-3). Among those found, no metastatic LN was detected. Of the patients with pT2a (n = 22), pT2b (n = 15), pT2c (n = 62) and pT3a (n = 21) disease, LNs in APPF tissues were detected in 1 (4.6%), 1 (6.7%), 11 (17.7%) and 1 (4.8%) patient in each group, respectively. Among the patients, LNs in APPF tissues were detected in 0 (0%), 5 (35.7%), 8 (57.1%) and 1 (7.1%) patients of underweight, optimal weight, overweight and obese patients due to body mass index, respectively.

CONCLUSIONS

In our series, LNs were detected in around 10% of the patients. Therefore, this fat should, not be pushed back during RARP but should be removed and sent for pathologic evaluation. Although no metastatic LN was detected in our series, the presence of metastatic LNs might have an impact on the oncologic outcomes of the patients and warrants further research.

Erectile dysfunction in robotic radical prostatectomy: Outcomes and management

Robot-assisted laparoscopic prostatectomy (RALP) has emerged as the most common treatment for localized prostate cancer. With improved surgical precision, RALP has produced hope of improved potency rates, especially with the advent of nerve-sparing and other modified techniques. However, erectile dysfunction (ED) remains a significant problem for many men regardless of surgical technique. To identify the functional outcomes of robotic versus open and laparoscopic techniques, new robotic surgical techniques and current treatment options of ED following RALP. A Medline search was performed in March 2014 to identify studies comparing RALP with open retropubic radical prostatectomy (RRP) and laparoscopic radical prostatectomy, modified RALP techniques and treatment options and management for ED following radical prostatectomy. RALP demonstrates adequate potency rates without compromising oncologic benefit, with observed benefit for potency rates compared with RRP. Additionally, specific surgical technical modifications appear to provide benefit over traditional RALP. Phosphodiesterase-5 inhibitors (PDE5I) demonstrate benefit for ED treatment compared with placebo. However, long-term benefit is often lost after use. Other therapies have been less extensively studied. Additionally, correct patient identification is important for greatest clinical benefit. RALP appears to provide beneficial potency rates compared with RRP; however, these effects are most pronounced at high-volume centers with experienced surgeons. No optimal rehabilitation program with PDE5Is has been identified based on current data. Additionally, vacuum erection devices, intracavernosal injections and other techniques have not been well validated for post RALP ED treatment.

Impact of surgical case order on perioperative outcomes for robotic-assisted radical prostatectomy

OBJECTIVES

Since its introduction, there have been many refinements in the technique and implementation of robotic-assisted radical prostatectomy (RARP). However, it is unclear whether operative outcomes are influenced by surgical case order. We evaluated the effect of case order on perioperative outcomes for RARP within a large health maintenance organization.

MATERIALS AND METHODS

We conducted a retrospective review of RARP cases performed at our institution from September 2008 to December 2010 using a single robotic platform. Case order was determined from surgical schedules each day and surgeries were grouped into 1(st), 2(nd) and 3(rd) round cases. Fourth round cases (n = 1) were excluded from analysis. We compared clinicopathological variables including operative time, estimated blood loss (EBL), surgical margin rates and complication rates between groups.

RESULTS

Of the 1018 RARP cases in this cohort, 476 (47%) were performed as 1(st) round cases, 398 (39%) 2(nd) round cases and 144 (14%) 3(rd) round cases by a total of 18 surgeons. Mean operative time was shorter as cases were performed later in the day (213 min vs. 209 min vs. 180 min, P < 0.0001) and similarly, EBL also decreased with surgical order (136 mL vs. 134 mL vs. 103 mL, P = 0.01). Transfusion rates, surgical margin rates and complication rates did not significantly differ between groups. Patients undergoing RARP later in the day were much more likely to have a hospital stay of 2 or more days than earlier cases (10% vs. 11% vs. 32%, P = 0.01).

CONCLUSIONS

Surgical case order may influence perioperative outcomes for RARP with decreased operative times and increased length of hospital stay associated with later cases. These findings indicate that select perioperative factors may improve with ascending case order as the surgical team "warms up" during the day. In addition, 3(rd) round cases can increase hospital costs associated with increased lengths of hospital stay. Knowledge of these differences may assist in surgical planning to improve outcomes and limit costs.

Impact of posterior urethral plate repair on continence following robot-assisted laparoscopic radical prostatectomy

PURPOSE

The objective of this study is to evaluate the continence rate following reconstruction of the posterior urethral plate in robot-assisted laparoscopic radical prostatectomy (RLRP).

MATERIALS AND METHODS

A retrospective analysis of 50 men with clinically localized prostate cancer who underwent RLRP was carried out. Twenty-five patients underwent RLRP using the reconstruction of the posterior aspect of the rhabdosphincter (Rocco repair). Results of 25 consecutive patients who underwent RLRP prior to the implementation of the Rocco repair were used as the control. Continence was assessed at 7, 30, 90, and 180 days following foley catheter removal using the EPIC questionnaire as well as a follow-up interview with the surgeon.

RESULTS

There was no statistically significant difference between the two groups in any of the patient demographics. At 7 days, the Rocco experimental group had a continence rate of 19% vs. 38.1% in the non-Rocco control group (p = 0.306). At 30 days, the continence rate in the Rocco group was 76.2% vs. 71.4% in the non-Rocco group (p = 1). At 90 days, the values were 88% vs. 80% (p = 0.718), respectively. At 180 days, the pad-free rate was 96% in both groups.

CONCLUSION

Rocco repair offers no significant advantage in the time to recovery of continence following RLRP when continence is defined as the use of zero pads per day. On the other hand, Rocco repair was associated with increased incidence of urinary retention requiring prolonged foley catheter placement.

Robotic radical prostatectomy: operative technique, outcomes, and learning curve

OBJECTIVE

To report the operative technique, oncologic and therapeutic outcomes, and learning curve from our initial series of over 140 patients treated by robotic radical prostatectomy.

METHODS

Between January 2003 and May 2005, 143 patients with clinically localized prostate cancer underwent a robotic radical prostatectomy. Prospective data collection included patient age, body mass index (BMI), clinical T stage, biopsy Gleason score, and prostate-specific antigen (PSA). Operative outcome measures included operative time, estimated blood loss (EBL), and complications. Post-operative outcomes were length of hospital stay, catheter duration, pathology, margin status, biochemical recurrence, and return of continence.

RESULTS

Mean operative time was 241 minutes with an EBL of 274 mL. Five patients (3%) required conversion to open surgery. The average hospitalization was 1.8 days, and Foley catheters were removed after 8.9 days. Twenty-four of 141 men (17%) had a positive surgical margin, with a decrease from 23% in the first half of our experience to 11% in the latter half. Patients with an extracapsular extension had a significantly higher positive surgical margin rate than did those with organ-confined disease (47% vs 15%). Over 40% of the positive margins were located posteriorly. At a mean follow-up of 11 months, 96% of patients had a PSA <0.2 ng/mL. The median time to complete continence was 3.5 months, and over 95% of patients were fully continent at 1 year.

CONCLUSION

Robotic radical prostatectomy is an effective treatment modality for clinically localized prostate cancer. Although a learning curve needs to be overcome, patients experienced benefits in convalescence with early oncologic and functional outcomes comparable to those of the open approach. Longer-term results are needed; however, patient outcomes in our series are encouraging.