Propensity-matched analysis comparing the peri- and post-operative outcomes of side-docking versus standard lithotomy docking for robot-assisted radical prostatectomy

Introduction@#Limited access to the perineum and limited operating room space are just some of the limitations of the standard lithotomy docking for robot-assisted radical prostatectomy (RARP-LD). The side-docking technique (RARP-SD) may address these problems.@*Methods@#Thirty cases of robot-assisted radical prostatectomy were matched to 120 cases of RARP-LD cases by propensity scoring using age, body mass index (BMI), clinical T stage, biopsy Gleason score, and ultrasound prostate volume. Operative and docking time, complications were used to compare peri-operative and safety outcomes.@*Results@#Evaluation of 30 RARP-LD and 30 RARP-SD cases was done after propensity matching. Patient age, BMI, clinical T stage, biopsy Gleason score, and prostate volume were similar between the two groups (p>0.050). The mean docking time of RARP-SD is shorter than that of RARP-LD cases (7.56 vs. 4.12, p <0.001), but this did not translate to a shorter operative time. There were less peri-operative complications in the RARP-SD cases.@*Conclusions@#RARP-SD has a docking time and produces less complication than RARP-LD.

A comparison of perioperative outcomes between extraperitoneal robotic single-port and multiport radical prostatectomy with the da Vinci Si Surgical System / 亚洲男科学杂志(英文版)

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.

Robot-assisted laparoscopic radical prostatectomy on a very large prostate gland

@#This is a case of a 74-year-old obese male presented with moderate lower urinary tract symptoms and an elevated prostate specific antigen (PSA) of 48.21ng/ml. Multiparametric MRI of the prostate revealed a markedly enlarged prostate (225grams) with a PIRADS 5 lesion at the left posterior peripheral zone. Prostate biopsy done revealed prostate adenocarcinoma Gleason 7(3+4). Metastatic workup was negative for distant metastasis hence the patient was advised robot-assisted laparoscopic prostatectomy (RALP).Several difficulties were encountered during the surgical technique. The usual posterior approach was not feasible because incising the peritoneum over the rectovesical pouch would not be able to expose the vas deferens and seminal vesicles. An anterior approach was instead done, but this was still difficult due to the lack of space for proper exposure and movement of instruments. The posterior dissection was also challenging; three successive suspension stitches were necessary in order to expose and mobilize the lateral and posterior surface of the prostate. Urethrovesical anastomosis had to be modified by performing a modified posterior repair in order to reduce tension caused by the large gap left by the excised prostate. RALP is a safe and feasible operative technique for very large prostates as long as the difficulties are foreseen and the necessary adjustments are made.Robot-assisted laparoscopic prostatectomy (RALP) has emerged as the preferred option in the treatment of localized prostate cancer. As more cases are being performed, more surgeons are encountering challenging cases, such as those with difficult anatomy, prior abdominal surgery and prior radiation therapy. Large prostate glands increase the technical difficulty of performing robot-assisted laparoscopic prostatectomy.1 Reported is a case of RALP in a patient with prostate size >200. The difficulties and concerns in such situations are also delineated.

Robotic radical prostatectomy experience of a single practitioner at and beyond the learning curve

OBJECTIVE@#To determine the proficiency of a single Urological Oncologist in performing RoboticRadical Prostatectomy (RRP) for localized prostate adenocarcinoma based on the following surgicaland functional outcomes: 1) operative time, 2) estimated blood loss, 3) positive surgical margin rate,4) postoperative complication rate, 5) open conversion rate, and 6) urinary continence rate.@*MATERIALS AND METHODS@#The authors reviewed the records of a single Urological Oncologist fromJanuary 2010 to September 2017 for patients who underwent RRP for prostate adenocarcinoma.Patients were divided into 3 groups: Group 1 consisted of the first 30 cases done by the surgeon,Group 2 consisted of the next set of 30 cases, and Group 3 consisted of his cases done thereafter. Themean operative time, mean estimated blood loss, positive surgical margin rate, site of positive surgicalmargins (apex, midgland, or base), postoperative complication rate, open conversion rate, and urinarycontinence rate at 4, 8, and 12 weeks post-op were compared among the 3 groups.@*RESULTS@#A total of 30 patients were included in Group 1, another 30 were included in Group 2, and 45patients were included in Group 3 for a total of 105. There is significant difference in the meanoperative times among the 3 groups with a Group 1 having a mean operative time of 302.1 minutes,170.3 minutes for Group 2, and 146.7 minutes for Group 3 (p<0.0001.) There is a statisticallysignificant difference in mean estimated blood loss among the 3 groups (706.9 mL, 528.2 mL and386.3 mL, respectively; p<0.0001.) No open conversion was performed in all 105 patients and only3 complications were noted in this study. There was no statistical significance with regards to positivesurgical margin rates among the 3 groups (5.7%, 11.4% and 15.2%, respectively.) with the apex beingthe most common site of positive margin in this study. There is a statistically significant difference in8-week urinary continence rate among the 3 groups (12.4%, 20% and 36.2%, respectively; p=0.005).@*CONCLUSION@#Robotic Radical Prostatectomy is quickly becoming a feasible and safe option in themanagement of localized and locally-advanced prostate cancer in the local setting. The learningcurve of 30 cases, based on the experiences of the Urological Oncologist, is sufficient in establishingproficiency in performing the said procedure.

The Risk Factors of Postoperative Respiratory Insufficiency after Prolonged Robotic Radical Prostatectomy / 대한구급학회지

BACKGROUND: Robotic radical prostatectomy is performed in elderly patients and requires extreme changes in the patient's position and is often associated with a long surgery time. This study reviewed the pulmonary complications occurring after a robotic radical prostatectomy and analyzed the potential risk factors. METHODS: The medical records of all patients who had undergone robotic radical prostatectomy at our institution were reviewed. Among the 80 total patients, 58 were capable of spontaneous respiration at the end of surgery (Group I), whereas 22 patients required assisted ventilation (Group II). A comparison between the two groups was made in terms of the demographic characteristics, coexisting diseases, anesthesia and operation time, amount of intraoperative blood loss and transfused blood products. RESULTS: The mean age of the patients was 67.2 +/- 7.3 years. The mean operation time was 384.1 +/- 203.4 min (range, 195-1,180 min). The anesthesia and operation time, amount of intraoperative blood loss and number of transfused patients were all significantly higher in Group II. Univariate analysis revealed age, body mass index, intraoperative blood loss and transfusion, anesthesia and operation time to be related to postoperative respiratory insufficiency. Multivariate analysis revealed intraoperative transfusion and operation time to be predictive risk factors. CONCLUSIONS: Prolonged laparoscopic surgery in a steep Trendelenburg position has a high likelihood of postoperative respiratory insufficiency, with the intraoperative transfusion and a longer operation time being possible contributing factors.

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.

Comparison of Open and Robotic Surgery in Radical Prostatectomy: A Single Surgeon's Experience / 대한비뇨기과학회지

PURPOSE: To compare the results of open radical prostatectomy(OP) and robotic prostatectomy(RP) for a single surgeon's experience of 219 radical prostatectomy cases. MATERIALS AND METHODS: Between June 2002 and June 2007, 133 patients underwent OP and between July 2005 and June 2007, 86 patients underwent RP. To compare the surgeon's experience-related differences, we divided the OP cases into 73 early cases(OP-I) and 60 late cases(OP-II), and the RP cases into 30 early cases(RP-I) and 56 late cases(RP-II). The clinical characteristics, perioperative results, and early clinical outcomes were evaluated. RESULTS: There were no significant differences in the preoperative characteristics between the four groups. For the RP cases, the mean estimated blood loss was decreased, a normal diet was started earlier, the mean duration of hospital stay and the mean duration of bladder catheterization was shorter than for the OP cases. The frequency of intraoperative complications significantly decreased in the RP-II group as compared to the RP-I group. Although there was no significant statistical difference in the positive surgical margin rates between the four groups, the rates were slightly decreased in the RP-II group. The recovery period of continence was shorter in the RP-II group than in the OP group and for patients 60 years or older, recovery of potency was also better in the RP-II group than the OP group. CONCLUSIONS:Our results suggest that RP at the hands of an experienced surgeon may decrease the positive surgical margin rate to some degree. Additionally, performance of RP may lead to a shorter duration of bladder catheterization and hospital stay and a better recovery of continence and potency than obtainable by OP.

Outcomes of Robotic Prostatectomy for Treating Clinically Advanced Prostate Cancer / 대한비뇨기과학회지

PURPOSE: Robotic prostatectomy(RP) has been widely performed for treating clinically localized prostate cancer(PC), whereas for treating clinically advanced PC, prostatectomy is usually done by open methods. We evaluated the outcomes of RP for treating patients with clinically advanced PC as compared with the outcomes of RP for treating patients with clinically localized PC. MATERIALS AND METHODS: We performed RP in 273 patients with the da Vinci(R) robot system through a transperitoneal approach. Ninety-two patients had clinically advanced PC(Group I) and 181 patients had clinically localized PC(Group II). We compared the perioperative variables and early surgical outcomes between the two groups. RESULTS: The two groups did not show significant differences for their mean age, but the mean preoperative prostate-specific antigen(PSA) levels and biopsy Gleason scores were significantly higher in Group I. There were no significant differences in the mean operation time(Group I: 214.9+/-45.1 min, II: 217.8+/-49.0 min, p=0.709), the estimated blood loss(Group I: 382.8+/-281.5ml, II: 387.5+/-369.5ml, p=0.934), the duration of bladder catheterization (Group I: 12.0+/-2.8 days, II: 12.9+/-4.6 days, p=0.232), the hospital stay(Group I: 5.9+/-3.5 days, II: 5.0+/-2.4 days, p=0.154), and the time to start the postoperative regular diet(Group I: 2.5+/-1.5 days, II: 2.0+/-0.6 days, p=0.089) between the two groups. There was a significant difference in lymph node invasion(p<0.001), but no difference in the positive surgical margin(p= 0.180). Two out of the 4 intraoperative rectal injuries occurred in the clinically advanced PC group, but they were closed primarily without specific problems, except for 1 case. CONCLUSIONS: Our results suggest that RP may be performed safely for patients with clinically advanced PC.

Comparison of Open versus Robotic Radical Prostatectomy in Clinically Advanced Prostate Cancer / 대한비뇨기과학회지

PURPOSE: To evaluate the outcomes of robotic prostatectomy(RP) compared with open radical prostatectomy(OP) in clinically advanced prostate cancer(PC). MATERIALS AND METHODS: Between January 2003 and June 2007 we performed radical prostatectomy in 180 patients with clinically advanced PC (OP, 88; RP, 92). We compared the perioperative parameters and early surgical outcomes between the OP and RP groups in patients with and without neoadjuvant hormonal therapy(NHT). RESULTS: In patients without NHT, there were no significant differences in preoperative characteristics between the OP and RP groups, but in patients with NHT, the RP patients had higher biopsy Gleason scores(GS) and clinical stages. There were no significant differences in lymph node (LN) invasion and extracapsular extension(ECE), but a significant difference existed in the prostatectomy GS between the OP and RP groups, regardless of NHT. The positive surgical margin rates in the RP group were similar to or lower than in the OP groups when stratified by pathologic stages T2 and T3. Irrespective of NHT, in the RP group the mean estimated blood loss was decreased, the mean duration of the hospital stay was less, and the length of bladder catheterization was shorter, but there were no significant differences in the postoperative day the regular diet was started or the frequency of complications. Although there were no significant differences in continence rates between the two groups, all the RP patients had a higher continence rate from 1 month postoperatively, with or without NHT. CONCLUSIONS: Our results suggest that RP may be performed safely and may have results comparable to OP in clinically advanced PC.

Robotic Prostatectomy in a Patient with a Miles' Operation / 대한비뇨기과학회지

Robotic prostatectomy(RP) has recently been added to the treatments for localized prostate cancer and it is increasingly being utilized at many centers. The benefits of minimally invasive surgery, the enhanced functional outcomes and the increased patient demand have led to the popularity of this surgical technique. However, RP has been reported to be technically challenging in patients with a history of prior complex lower abdominal/pelvic surgery, morbid obesity, a large prostate, prior pelvic irradiation, neoadjuvant hormonal therapy or prior prostate surgery. We report here on our experience of robotic prostatectomy (RP) in a prostate cancer patient with a Miles's operation and this pateint had undergone adjuvant chemotherapy and pelvic irradiation for rectal cancer.

Robotic Prostatectomy in a Patient with a Miles' Operation / 대한비뇨기과학회지

Robotic prostatectomy(RP) has recently been added to the treatments for localized prostate cancer and it is increasingly being utilized at many centers. The benefits of minimally invasive surgery, the enhanced functional outcomes and the increased patient demand have led to the popularity of this surgical technique. However, RP has been reported to be technically challenging in patients with a history of prior complex lower abdominal/pelvic surgery, morbid obesity, a large prostate, prior pelvic irradiation, neoadjuvant hormonal therapy or prior prostate surgery. We report here on our experience of robotic prostatectomy (RP) in a prostate cancer patient with a Miles's operation and this pateint had undergone adjuvant chemotherapy and pelvic irradiation for rectal cancer.