Evidencia actual en prostatectomía radical robótica en pacientes con cirugía prostática previa / Current evidence in robot-assisted radical prostatectomy with previous prostate surgery

INTRODUCCIÓN: El cáncer de próstata es la segunda causa de muerte en hombres en Chile. La prostatectomía radical robo-asistida (RARP) se ha posicionado progresivamente como el tratamiento de elección en cáncer localizado pero se ha cuestionado tradicionalmente en pacientes con cirugía prostática previa, recomendación que pareciera no tener sustento en evidencia. OBJETIVO: Describir la evidencia actualmente disponible referente a resultados oncológicos y funcionales de prostatectomía radical robo-asistida en pacientes con cirugía prostática previa por hiperplasia prostática. Método: Revisión de la literatura publicada en la base de datos PUBMED entre el 1 de Enero del año 2008 hasta el 31 de Diciembre del año 2017. Se incluyen artículos que reporten resultados de pacientes con RARP tras cirugía prostática previa en cualquier modalidad sin límite de edad. RESULTADOS: Se encontraron un total de 1813 artículos. El total de estudios evaluados fue de 9 que en conjunto suman 297 pacientes. 7 artículos corresponden a series de casos y 2 a cohortes. Existen algunos artículos que informan mayor tiempo quirúrgico, sangrado intraoperatorio y porcentaje de márgenes positivos, sin embargo, el perfil de complicaciones perioperatorias y los resultados funcionales a largo plazo parecen no diferir de forma significativa respecto a los encontrados en pacientes sin cirugía prostática previa.

INTRODUCTION: Prostate cancer is the second leading cause of death in men in Chile. Robo-assisted radical prostatectomy has been progressively positioned as the treatment of choice in localized cancer but has been traditionally questioned in patients with previous prostate surgery, a recommendation that seems to have no support in evidence. OBJECTIVE: To describe the currently available evidence regarding oncological and functional results of robo-assisted radical prostatectomy in patients with previous prostatic surgery for prostatic benign hyperplasia. METHOD: Review of the literature published in the PUBMED database between January 1, 2008 and December 31, 2017. Articles that report results of patients with RARP after previous prostate surgery in any modality are included with no age limit. RESULTS: A total of 1813 articles were found. The total number of studies evaluated was 9, which together total 297 patients. 7 articles correspond to case series and 2 to cohorts. There are some articles that report longer surgical time, intraoperative bleeding and percentage of positive margins, however, the perioperative complications profile and longterm functional results do not seem to differ significantly from those found in patients without previous prostatic surgery

Avaliação prospectiva de curva de aprendizado da prostatectomia radical laparoscópica assistida por robótica / Prospective evaluation of the learning curve for robotic assisted laparoscopic radical prostatectomy

INTRODUÇÃO: O câncer de próstata é responsável por 15% dos casos novos de câncer que acometem os homens e pela 5ª causa de morte. As técnicas minimamente invasivas, sobretudo a cirurgia robótica tornou-se a técnica comumente empregada nos Estados Unidos. Muitos artigos tentam demonstrar a curva de aprendizado necessária para a estabilização dos resultados, mas a implementação de novas tecnologias passa por diversos desafios, além da avaliação de seus resultados e dos custos, o que em países em desenvolvimento pode ter um importante impacto no sistema de saúde. OBJETIVO: Avaliar a curva de aprendizado da prostatectomia radical laparoscópica robótica assistida (PRRA) para o tratamento do câncer de próstata, de acordo com a continência urinária, a potência sexual, o tempo cirúrgico e o controle oncológico. MÉTODOS: Duzentos pacientes com neoplasia de próstata localizada submetidos à PRRA por um único cirurgião foram divididos em quatro grupos de acordo com a sequência das cirurgias. Foram avaliados os dados intra-operatórios, como: tempo cirúrgico, perda sanguínea estimada e as margens cirúrgicas. Também durante o pósoperatório foram avaliadas a potência (IIEF) e a continência (ICIQ). RESULTADOS: Os pacientes apresentaram idade média de 60,6 anos (59,72-61,61), volume prostático ao toque retal de 40 gramas e valor do PSA 6,95 ng/ml (5,79-8,10) semelhantes em todos os grupos (p > 0,05). A biópsia prostática pré-operatória mostrou diferença no escore de Gleason e no tamanho da próstata, sendo que o escore 6 foi menos frequente no grupo 4, representado por 23 pacientes (46%) e no grupo 1, com 39 pacientes (78%) (p < 0,01). Já o tamanho prostático avaliado pelo USTR foi de 39,6 gramas (29,75-48,7) no grupo 4 e 30,5 gramas (23,0-38,15) no grupo 2. A curva de aprendizado estabelecida demonstrou uma diminuição no tempo cirúrgico de 157 minutos (145-170) no grupo 1, para 132 minutos (119-140) no grupo 2 (p < 0,01). A perda sanguínea estimada também se reduziu...

BACKGROUND: Prostate cancer is responsible for 15% of new cases of male cancer and is the fifth leading cause of death. Minimally invasive and mainly, robotic surgery technique became the technique most widely utilized in the United States. Many articles have tried to demonstrate the required learning curve to achieve the plateau. Although, new techniques implementation go through many challenges besides the evaluation of its results, costs also became an issue, which may impact in developing countries health system. OBJECTIVE: We aim to evaluate the learning curve of robot-assisted radical prostatectomy (RARP) for the treatment of prostate cancer, according to continence, potency, surgical time and oncologic control. METHODS: Two hundred patients with localized prostate cancer that underwent RARP by a single surgeon were divided into four groups according to its surgical sequence. Intraoperative data, such as surgical time, estimated blood loss and margins were recorded. Also postoperative functional parameters as continence and potency were gathered using validated questionnaires (ICIQ and IIEF). RESULTS: Patients mean age were 60.6 years (59.72- 61.61), mean prostate volume at digital rectal examination was 40 grams and PSA value 6.95 ng/ml (5.79-8.10) were similar in all groups (p > 0.05). Pre-operative prostate biopsy showed difference in Gleason score and prostate size. Gleason score 6 was less frequent in group 4, 23 patients (46%), than group 1, 39 patients (78%)(p <0.01) and prostate size at TRUS was 39.6 grams (29.75- 48.7) in group 4 and 30.5 grams (23.0- 38.15) in group 2. The established learning curve showed a reduction on surgical time from 157 minutes (145-170) in group 1 to 132 minutes (119-140 min) in group 2 (p < 0.01). The estimated blood loss also decreased almost to half, from 395 ml (250-500) in group 1 to 200 ml (150-250) in group 3 (p < 0.01). Positive margins decreased from 16% to only 8 %, but were statistically similar (p=0.236)....

Technical Aspects of Holmium Laser Enucleation of the Prostate for Benign Prostatic Hyperplasia

Holmium laser enucleation of the prostate (HoLEP) is a minimally invasive procedure and a size-independent treatment for benign prostatic hyperplasia with excellent long-term surgical outcome. HoLEP has become an alternative to conventional transurethral resection of the prostate or open prostatectomy owing to its efficacy and safety. Although HoLEP is known to have a steep learning curve, very few articles have addressed the technical aspects of HoLEP. Herein, we described detailed techniques and tips for HoLEP as performed at Seoul National University Hospital in a step-by-step manner with extensive review of the literature.