Outcomes of Salvage Robotic-assisted Radical Prostatectomy in the last decade: systematic review and perspectives of referral centers

ABSTRACT Purpose: Salvage robotic-assisted radical prostatectomy (S-RARP) has gained prominence in recent years for treating patients with cancer recurrence following non-surgical treatments of Prostate Cancer. We conducted a systematic literature review to evaluate the role and outcomes of S-RARP over the past decade. Materials and Methods: A systematic review was conducted, encompassing articles published between January 1st, 2013, and June 1st, 2023, on S-RARP outcomes. Articles were screened according to PRISMA guidelines, resulting in 33 selected studies. Data were extracted, including patient demographics, operative times, complications, functional outcomes, and oncological outcomes. Results: Among 1,630 patients from 33 studies, radiotherapy was the most common primary treatment (42%). Operative times ranged from 110 to 303 minutes, with estimated blood loss between 50 to 745 mL. Intraoperative complications occurred in 0 to 9% of cases, while postoperative complications ranged from 0 to 90% (Clavien 1-5). Continence rates varied (from 0 to 100%), and potency rates ranged from 0 to 66.7%. Positive surgical margins were reported up to 65.6%, and biochemical recurrence ranged from 0 to 57%. Conclusion: Salvage robotic-assisted radical prostatectomy in patients with cancer recurrence after previous prostate cancer treatment is safe and feasible. The literature is based on retrospective studies with inherent limitations describing low rates of intraoperative complications and small blood loss. However, potency and continence rates are largely reduced compared to the primary RARP series, despite the type of the primary treatment. Better-designed studies to assess the long-term outcomes and individually specify each primary therapy impact on the salvage treatment are still needed. Future articles should be more specific and provide more details regarding the previous therapies and S-RARP surgical techniques.

Different approaches for bladder neck dissection during robot-assisted radical prostatectomy: the Aalst technique

ABSTRACT Introduction: Bladder neck dissection is one of the most delicate surgical steps of robotic-assisted radical prostatectomy (RARP) [1, 2], and it may affect surgical margins rate and functional outcomes [3, 4]. Given the relationship between outcomes and surgical experience [5-7], it is crucial to implement a step-by-step approach for each surgical step of the procedure, especially in the most challenging part of the intervention. In this video compilation, we described the techniques for bladder neck dissection utilized at OLV Hospital (Aalst, Belgium). Surgical Technique: We illustrated five different techniques for bladder neck dissection during RARP. The anterior technique tackles the bladder neck from above until the urethral catheter is visualized, and then the dissection is completed posteriorly. The lateral and postero-lateral approaches involve the identification of a weakness point at the prostate-vesical junction and aim to develop the posterior plane - virtually until the seminal vesicles - prior to the opening of the urethra anteriorly. Finally, we described our techniques for bladder neck dissection in more challenging cases such as in patients with bulky middle lobes and prior surgery for benign prostatic hyperplasia. All approaches follow anatomic landmarks to minimize positive surgical margins and aim to preserve the bladder neck in order to promote optimal functional recovery. All procedures were performed with DaVinci robotic platforms using a 3-instruments configuration (scissors, fenestrated bipolar, and needle driver). As standard protocol at our Institution, urinary catheter was removed on postoperative day two [8]. Conclusions: Five different approaches for bladder neck dissection during RARP were described in this video compilation. We believe that the technical details provided here might be of help for clinicians who are starting their practice with this surgical intervention.

Da Vinci SP radical prostatectomy: a multicentric collaboration and step-by-step techniques

ABSTRACT Introduction Several techniques of robotic-assisted radical prostatectomy (RARP) using the da Vinci SP (SP) have been described since its clearance by the FDA (Food and Drug Administration) in 2018 ( 1 , 2 ). Even with the expanding literature about this robot, the SP technology has been restricted to a few centers in the US and Asia due to the recent release of this robot in the marked.3 In this scenario, we provided, in this video compilation, a consensus of SP referral centers describing the current approaches and techniques of da Vinci SP Radical prostatectomy (SP-RARP). Surgical Technique We have illustrated five different techniques, including transperitoneal, extraperitoneal, Retzius-sparing, transvesical, and transperineal ( 4 - 6 ). Each surgery demonstrated crucial steps from the trocar placement until anastomosis. All approaches follow anatomic concepts and landmarks to minimize positive surgical margins, optimize oncological outcomes and promote optimal functional recovery. The trocar placement and the use of an assistant port were selected according to the operative technique of each institution. None of these surgeries had intra- or postoperative complications, and the pain management until discharge was controlled without using narcotics. All patients were discharged in less than 16 hours of surgery. Conclusion Robotic-assisted radical prostatectomy performed with the da Vinci SP is feasible and safe with optimal perioperative outcomes. Five different approaches were described in this video compilation, and we believe that the technical details provided by this multicentric collaboration are crucial for centers willing to initiate the SP approach to radical prostatectomy.

Contemporary techniques of da Vinci SP radical prostatectomy: multicentric collaboration and expert opinion

ABSTRACT Background The da Vinci SP robot consists of an innovative single port trocar that houses a flexible camera and three biarticulated arms, which minimizes the number of incisions to assess the surgical site, allowing a less invasive procedure. However, due to its recent release in the market, the current literature reporting SP-RARP is still restricted to a few centers. In this scenario, after performing a literature search with all available techniques of SP-RARP, our objective is to report a multicentric opinion of referral centers on different techniques to approach SP-RARP. Results The SP literature is provided by only a few centers due to the limited number of this new console in the market. Five different approaches are available: transperitoneal, extraperitoneal, Retzius-Sparing, transperineal and transvesical. None of the current studies describe long-term functional or oncological outcomes. However, all approaches had satisfactory operative performance with minimum complication rates. Conclusions Several techniques of SP-RARP have been reported in the literature. We performed a multicentric collaboration describing and illustrating the most challenging steps of this surgery. We believe that the details provided in this article are useful teaching material for new centers willing to adopt the SP technology.

Step-by-step optimisation of robotic-assisted radical prostatectomy using augmented reality

ABSTRACT Introduction: Surgical training will be complemented by digitalisation, as the COVID 19 pandemic continues (1). Proximie is an augmented reality (AR) platform that can display up to 4 native camera views, with live or semi live telementoring. It can optimise ergonomics of the surgeon at the console (2), and robotic instrument orientation. We describe the utilisation of Proximie as a step-by-step guide in a robotic assisted radical prostatectomy (RARP). Surgical Technique: Author V. P. performed a transperitoneal multiport da Vinci Xi RARP with the Proximie platform: a laptop computer, multiple HD webcams, microphones and speakers. Using an HDMI cable to the Intuitive Surgical tower, output display from the console and an additional laparoscopic tower is shown. Each webcam was mounted to the side armrests of the console, directed at the surgeon's hands. An independent 'drop in' laparoscope via an additional 5mm left upper quadrant port was utilised. Observers can visualise the AR platform's recordings on a laptop and/or smartphone. A PTZ (pan-tilt-zoom) camera can capture the operating room, bedside assistant, ports and patient position. Our video demonstrates three of four camera views for posture, forearm, wrist, hand, and finger orientation, relative to the translated robotic steps. A pincer grasp of the endowrist manipulator during anastomosis allows optimal robotic wrist rotation. The second laparoscopic camera view demonstrated intracorporeal angles of robotic arm and bedside assistant's instrument position for critical steps such as nerve sparing and anastomosis (3). The console time was 100 minutes, no intraoperative complications, or delay in image transmission occurred with utilising the platform. Considerations: An AR platform can create deeper learning for RARP in real time or recorded sessions. Two-way verbal and visual communication with ability to annotate on screen, allows long distance mentoring. The platform's utility can be accessed in anywhere, to project surgeons beyond their immediate environment. This allows for democratisation of access to high volume institutions and their evolution of techniques (4), to assist patients globally. Potential developments are artificial intelligence (AI) networks analysing repository of such recorded data, to identify intraoperative hand motion and robotic instrument tracking. AR is a pertinent building block to enhance robotic training, skill dissemination, precision medicine (5) and surgery overall.

International multi-center study on clinical efficiency of robot-assisted laparoscopic partial nephrectomy in the treatment of clinical T2 renal tumors / 中华泌尿外科杂志

Objective To analyze the safety and effectiveness of robot-assisted laparoscopic partial nephrectomy(RLPN) for cT2 renal tumors in international multi-centers.Methods This study was conducted to collect information on surgical procedures performed by RLPN and robot assisted laparoscopic radical nephrectomy (RRN) in nineteen international urological centers from January 2012 to December 2017.RLPN were performed in 159 patients (118 males and 41 females),with the average age of (59.3 ± 13.2) years,body mass index(BMI) of (28.7 ± 5.4)kg/m2,preoperative GFR of (77.3 ± 22.1) ml/min.RRN were performed in 219 patients,with the average age of (62.0 ± 12.9) years,BMI of (28.7 ±6.1) kg/m2,preoperative GFR of (71.4 ± 20.3) ml/min.There was no statistical difference between the two groups in gender and BMI.The age of the patients in RLPN group was younger than that in RRN group,and the preoperative GFR was better.The patient's baseline demographics,perioperative data,tumor pathology,oncologic outcomes,and renal function (GFR) were recorded.Results All 378 cases underwent successful surgery.The operation time of RLPN was 150 min(65-353 min),which was shorter than that of RRN [180 min(85-361 min),P ＜ 0.001].The intra-operative blood loss of RLPN was more than that of RRN [150 ml (40-3 000 ml) vs.100 ml (10-1 100 ml),P ＜ 0.001].The incidence of intra-operative complications were not statistically different between the two groups [5.7％ (9/159) vs.3.2％ (7/219),P =0.240].The incidence of postoperative complications was higher in the RLPN group than that in RRN group [19.5％ (31/159) vs.10.5％ (23/219),P =0.014],but there was no significant difference in the incidence of complications of grade 3 or above [4.4％ (7/159) vs.2.3％ (5/219),P =0.246].The recurrence-free survival rate of RLPN group was higher than that of RRN group [91.4％ (117/128) vs.81.9％ (167/204),P =0.013],and RLPN group was more conducive to renal function protection (P ＜ 0.001).Conclusions RLPN for cT2 tumors can obtain effective tumor control rate and better renal function preservation.It could be an acceptable alternative for surgical management of cT2 tumors.