Establishing a successful robotic surgery program and improving operating room efficiency: literature review and our experience report.

The benefits and outcomes of robotic surgery are well established in the literature across multiple specialties. The increasing need for and dissemination of this technology associated with high costs, demand adequate planning during its implementation. Therefore, after years of training several robotic surgeons and establishing multiple robotic programs worldwide, the purpose of this article is to focus on the necessary elements in the initial phase of establishing a robotics program. We summarized in our article crucial factors when implementing a robotic program. Therefore, we explained in detail the critical aspects of the program design, implementation, marketing, research and outcomes, and ultimately improving efficiency. The creation of a robotics planning committee composed of several hospital individuals contributes in different lines of work such as cost evaluation, staff training, and OR modifications. A multidisciplinary approach and a robotic lead surgeon are also recommended to guarantee surgical volume and satisfactory outcomes. Furthermore, market analysis should evaluate the competition with other centres and potential surgical candidates in that area. Data collection should also be considered a vital element of the program organization, which assures quality control and helps to diagnose any program deficiency. We believe that the robotic program should be individualized according to the economy and reality of each centre. The success and duration of a robotic surgery program depend on long-term results. Therefore, careful planning with a robotic committee defining the types of procedures to be performed and appropriate multidisciplinary training to avoid surgery cancelations are crucial factors in establishing a successful program.

The Bohl Spectrum for Linear Nonautonomous Differential Equations.

We develop the Bohl spectrum for nonautonomous linear differential equations on a half line, which is a spectral concept that lies between the Lyapunov and the Sacker-Sell spectra. We prove that the Bohl spectrum is given by the union of finitely many intervals, and we show by means of an explicit example that the Bohl spectrum does not coincide with the Sacker-Sell spectrum in general even for bounded systems. We demonstrate for this example that any higher-order nonlinear perturbation is exponentially stable (which is not evident from the Sacker-Sell spectrum), but we show that in general this is not true. We also analyze in detail situations in which the Bohl spectrum is identical to the Sacker-Sell spectrum.

Overall rate, location, and predictive factors for positive surgical margins after robot-assisted laparoscopic radical prostatectomy for high-risk prostate cancer.

We report the overall rate, locations and predictive factors of positive surgical margins (PSMs) in 271 patients with high-risk prostate cancer. Between April 2008 and October 2011, we prospectively collected data from patients classified as D'Amico high-risk who underwent robot-assisted laparoscopic radical prostatectomy. Overall rate and location of PSMs were reported. Stepwise logistic regression models were fitted to assess predictive factors of PSM. The overall rate of PSMs was 25.1% (68 of 271 patients). Of these PSM, 38.2% (26 of 68) were posterolateral (PL), 26.5% (18 of 68) multifocal, 16.2% (11 of 68) in the apex, 14.7% (10 of 68) in the bladder neck, and 4.4% (3/68) in other locations. The PSM rate of patients with pathological stage pT2 was 8.6% (12 of 140), 26.6% (17 of 64) of pT3a, 53.3% (32/60) of pT3b, and 100% (7 of 7) of pT4. In a logistic regression model including pre-, intra-, and post-operative parameters, body mass index (odds ratio [OR]: 1.09; 95% confidence interval [CI]: 1.01-1.19, P= 0.029), pathological stage (pT3b or higher vs pT2; OR: 5.14; 95% CI: 1.92-13.78; P = 0.001) and percentage of the tumor (OR: 46.71; 95% CI: 6.37-342.57; P< 0.001) were independent predictive factors for PSMs. The most common location of PSMs in patients at high-risk was the PL aspect, which reflects the reported tumor aggressiveness. The only significant predictive factors of PSMs were pathological outcomes, such as percentage of the tumor in the specimen and pathological stage.

Does surgeon subjective nerve sparing score predict recovery time of erectile function following robot-assisted radical prostatectomy?

INTRODUCTION: During robot-assisted radical prostatectomy (RARP), the quality of nerve sparing (NS) was usually classified by laterality of NS (none, unilateral, and bilateral) or degree of NS (none, partial, and full). Recently, side-specific NS have been more frequently performed, but previous NS grading system might not reflect the differential NS in each side. AIM: Herein, we assessed whether a subjective NS score (NSS) incorporating both degree of NS and NS laterality can predict the time to potency recovery following RARP. METHODS: Data were analyzed from 1,898 patients who had left and right neurovascular bundle sparing quality scores and at least one year of follow-up after RARP was performed between January 2008 and October 2011. MAIN OUTCOME MEASURES: Cox proportional hazard method analyses were used to determine predictive factors for early recovery. Multivariate linear regression models were used to assess subjective NSS in an effort to predict time to potency recovery. Subjective NSSs were compared to a model based on the three grades according to laterality and degree. RESULTS: Time to potency recovery showed a statistically significant difference in favor of higher NSS by the Cox proportional hazard regression analysis (NSS 0 vs. NSS 5-6, 7-8, and 9-10; P < 0.01). The regression model indicated that the statistical significance of the subjective NSS covering the differential NS is not different from that of the conventional three-grade scales, while it has a higher R(2). The regression equation with subjective NSS was as follows: Log (Time) = 5.163 - (0.035 × SHIM Score) + 0.028 Age - (0.101 × Subjective NSS). CONCLUSION: The subjective NSS can reflect NS degree for each side based on the visual cues. Regression model can be used to help inform the patient about the time to postoperative potency regain, which is an important patient concern following RARP.

The Tube 3 module designed for practicing vesicourethral anastomosis in a virtual reality robotic simulator: determination of face, content, and construct validity.

OBJECTIVE: To better use virtual reality robotic simulators and offer surgeons more practical exercises, we developed the Tube 3 module for practicing vesicourethral anastomosis (VUA), one of the most complex steps in the robot-assisted radical prostatectomy procedure. Herein, we describe the principle of the Tube 3 module and evaluate its face, content, and construct validity. MATERIALS AND METHODS: Residents and attending surgeons participated in a prospective study approved by the institutional review board. We divided subjects into 2 groups, those with experience and novices. Each subject performed a simulated VUA using the Tube 3 module. A built-in scoring algorithm recorded the data from each performance. After completing the Tube 3 module exercise, each subject answered a questionnaire to provide data to be used for face and content validation. RESULTS: The novice group consisted of 10 residents. The experienced subjects (n = 10) had each previously performed at least 10 robotic surgeries. The experienced group outperformed the novice group in most variables, including task time, total score, total economy of motion, and number of instrument collisions (P <.05). Additionally, 80% of the experienced surgeons agreed that the module reflects the technical skills required to perform VUA and would be a useful training tool. CONCLUSION: We describe the Tube 3 module for practicing VUA, which showed excellent face, content, and construct validity. The task needs to be refined in the future to reflect VUA under real operating conditions, and concurrent and predictive validity studies are currently underway.

Proposal of a method to assess and report the extent of residual neurovascular tissue present in radical prostatectomy specimens.

OBJECTIVE: To propose a method to assess and report the amount of neurovascular tissue present in radical prostatectomy (RP) specimens. PATIENTS AND METHODS: The data of 133 consecutive patients who underwent robot-assisted RP by a single surgeon (V.R.P.) were prospectively collected. Degree of nerve sparing (NS) was graded intraoperatively by the surgeon independently at either side as complete, partial or none. A pathologist who was 'blinded' to the surgeon's classification measured the following parameters at the posterolateral aspect of the apex, base and mid prostate at either side of the RP specimen: length, width and area of neural tissue, number of nerves per high-power field and number of total slides containing neural tissue. Measurements were correlated to the surgeon's intraoperative perception. RESULTS: All measurements correlated significantly with surgeon's intent of NS at all locations (P = 0.001). Among them, the cross-sectional area had the highest correlation coefficient (-0.550 at apex, -0.604 at mid prostate and -0.606 at the base). CONCLUSIONS: The cross-sectional area of nerve tissue showed the highest correlation with surgeon's intent of NS at all locations. Having a standardised method of assessing and reporting residual nerve tissue allows the surgeon to objectively evaluate the quality of nerve preservation and to compare the progress of his NS technique over time.

Retrograde versus antegrade nerve sparing during robot-assisted radical prostatectomy: which is better for achieving early functional recovery?

BACKGROUND: Although the retrograde approach to nerve sparing (NS) aimed at maximizing NS during robot-assisted radical prostatectomy (RARP) has been described, its significant benefits compared to the antegrade approach have not yet been investigated. OBJECTIVE: To evaluate the impact of NS approaches on perioperative, pathologic, and functional outcomes. DESIGN, SETTING, AND PARTICIPANTS: Five hundred one potent (Sexual Health Inventory for Men [SHIM] score >21) men underwent bilateral full NS and were followed up for a minimum of 1 yr. After propensity score matching, 344 patients were selected and were then categorized into two groups. SURGICAL PROCEDURE: RARP with antegrade NS (n=172) or RARP with retrograde NS (n=172). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Functional outcomes were assessed using validated questionnaires. Multivariable logistic regression models were applied. RESULTS AND LIMITATIONS: Positive margin rates were similar (11.1% vs 6.9%; p=0.192), and no correlation with the NS approach was found on regression analysis. At 3, 6, and 9 mo, the potency rate was significantly higher in the retrograde approach (65% vs 80.8% and 72.1% vs 90.1% and 85.3% vs 92.9%, respectively). The multivariable model indicated that the NS approach was an independent predictor for potency recovery at 3, 6, and 9 mo, along with age, gland size, and hyperlipidemia. After adjusting for these predictors, the hazard ratio (HR) for the retrograde relative to the antegrade approach was 2.462 (95% confidence interval [CI], 1.482-4.089; p=0.001) at 3, 4.024 (95% CI, 2.171-7.457; p<0.001) at 6, and 2.145 (95% CI, 1.019-4.514; p=0.044) at 9 mo. Regarding continence, the recovery rates at each time point and the mean time to regaining it were similar, and the method of NS had no effect on multivariable analysis. The absence of randomization is a major limitation of this study. CONCLUSIONS: In patients with normal erectile function who underwent bilateral full NS, a retrograde NS approach facilitated early recovery of potency compared to that with an antegrade NS approach without compromising cancer control.

Cavernosal nerve preservation during robot-assisted radical prostatectomy is a graded rather than an all-or-none phenomenon: objective demonstration by assessment of residual nerve tissue on surgical specimens.

OBJECTIVE: To demonstrate the existence of different degrees of nerve sparing (NS) (graded NS) by comparing the surgeon's intent of NS with the residual nerve tissue on prostatectomy specimens. METHODS: We performed a prospective study of 133 consecutive patients who underwent robot-assisted radical prostatectomy in January and February of 2011. The surgeon graded the amount of NS intraoperatively independently for either side as follows: 1, no NS; 2, <50% NS; 3, 50% NS; 4, 75% NS; and 5, ≥ 95% NS. A pathologist who was unaware of the surgeon's score measured the area of residual nerve tissue on the posterolateral surface of the prostate. RESULTS: A greater NS score correlated significantly with a decreasing area of residual nerve tissue on the prostatectomy specimens (P < .001). Overall, the area of residual nerve tissue on the prostatectomy specimens was significantly different among the NS groups (P < .001). On specific intergroup analysis, significant differences were found in the area of residual nerve tissue on the prostatectomy specimens between the greater NS groups: NS score 3 versus 4, median 13 mm(2) (interquartile range [IQR] 7-23) versus 3 mm(2) (IQR 0-8; P = .01); NS score 4 versus 5, median 3 mm(2) (IQR 0-8) versus 0.5 mm(2) (IQR 0-2; P = .001). CONCLUSION: Subjective NS classification using the surgeon's intraoperative perception correlated significantly with the area of residual nerve tissue on the prostatectomy specimens determined by the pathologist. It is possible to intentionally tailor the amount of NS performed at surgery. This finding demonstrates that NS is a graded rather than an all-or-none phenomenon that can even go beyond the traditional concept of complete, partial, or no NS.

Anatomic grading of nerve sparing during robot-assisted radical prostatectomy.

BACKGROUND: Because of the lack of intraoperative visual cues, the amount of nerve sparing (NS) intended by the surgeon does not always correspond to what is actually performed during surgery. OBJECTIVE: Describe a standardized NS grading system based on intraoperative visual cues. DESIGN, SETTING, AND PARTICIPANTS: A total of 133 consecutive patients who underwent robot-assisted radical prostatectomy (RARP) by a single surgeon were evaluated. The surgeon intraoperatively graded the NS independently for either side as follows: 1=no NS; 2=<50% NS; 3=50% NS; 4=75% NS; 5= ≥ 95% NS. SURGICAL PROCEDURE: RARP; detailed description of a five-point NS grading system. MEASUREMENTS: The area of residual nerve tissue on prostatectomy specimens was compared with the intraoperative NS score (NSS). The rate of positive surgical margins (PSMs) according to the NSS is also reported. RESULTS AND LIMITATIONS: In all, 52.6% of operated sides (140 of 266 sides) had NSS 5, 30.1% (80 of 266) had NSS 4, 2.3% (6 of 266) had NSS 3, 13.2% (35 of 266) had NSS 2, and 1.9% (5 of 266) had NSS 1. The area of residual nerve tissue was significantly different among the different NSSs: median area (interquartile range) for NSS 5: 0.5 (0-2) mm(2); for NSS 4: 3 (0-8) mm(2); for NSS 3: 13 (7-23) mm(2); for NSS 2: 14 (8-24) mm(2); and for NSS 1: 57 (56-165) mm(2) (p<0.001). Overall, 9.02% of the patients (12 of 133 patients) had a PSM, with 8.3% (9 of 108) for pT2 and 12% (3 of 25) for pT3. Side-specific PSMs according to NSS were 3.6% (5 of 140) for NSS 5, 7.5% (6 of 80) for NSS 4, 16.7% (1 of 6) for NSS 3, 5.7% (2 of 35) for NSS 2, and 0% (0 of 5) for NSS 1. A limitation of our study is that the key anatomic landmarks are not recognizable in every case, and this technique might not be easy to perform during the early learning curve. CONCLUSIONS: We believe that the visual cues exposed in this article will help surgeons achieve more consistent NS during RARP.

The role of the prostatic vasculature as a landmark for nerve sparing during robot-assisted radical prostatectomy.

BACKGROUND: Macroscopic landmarks are lacking to identify the cavernosal nerves (CNs) during radical prostatectomy. The prostatic and capsular arteries run along the lateral border of the prostate and could help identify the location of the CNs during robot-assisted radical prostatectomy (RARP). OBJECTIVE: Describe the visual cues that have helped us achieve consistent nerve sparing (NS) during RARP, placing special emphasis on the usefulness of the prostatic vasculature (PV). DESIGN, SETTING, AND PARTICIPANTS: Retrospective video analysis of 133 consecutive patients who underwent RARP in a single institution between January and February 2011. SURGICAL PROCEDURE: NS was performed using a retrograde, antegrade, or combined approach. MEASUREMENTS: A landmark artery (LA) was identified running on the lateral border of the prostate corresponding to either a prostatic or capsular artery. NS was classified as either medial or lateral to the LA. The area of residual nerve tissue on surgical specimens was measured to compare the amount of NS between the groups. RESULTS AND LIMITATIONS: We could identify an LA in 73.3% (195 of 266) of the operated sides. The area of residual nerve tissue was significantly different whether the NS was performed medial (between the LA and the prostate) or lateral to the LA (between the LA and pelvic side wall): median (interquartile range) of 0 (0-3) mm2 versus14 (9-25) mm2; p<0.001, respectively. CONCLUSIONS: The PV is an identifiable landmark during NS. Fine tailoring on the medial border of an LA can consistently result in a complete or almost complete NS, whereas performing the NS on its lateral border results in several degrees of incomplete NS.

Robot-assisted laparoscopic dismembered pyeloplasty for ureteropelvic junction obstruction: a multi-institutional experience.

OBJECTIVE: To report a 6-year multi-institutional experience and outcomes with robot-assisted laparoscopic pyeloplasty (RLP) for the repair of ureteropelvic junction obstruction (UPJO). PATIENTS AND METHODS: Between June 2002 and October 2008, 168 adult patients from 3 institutions underwent RLP for UPJO. A retrospective analysis of prospectively collected data were performed after institutional review board approval. Diagnosis was by intravenous urogram or computed tomography scan and diuretic renogram. All patients underwent RLP through a 4-port laparoscopic technique. Demographic, preoperative, operative, and postoperative endpoints for primary and secondary repair of UPJO were measured. Success was defined as a T½ of <20 minutes on diuretic renogram and symptom resolution. Pain resolution was assessed by subjective patient reports. RESULTS: Of 168 patients, 147 (87.5%) had primary repairs and 21 (12.5%) had secondary repairs. Of the secondary repairs, 57% had a crossing vessel etiology. Mean operative time was 134.9 minutes, estimated blood loss was 49 mL, and length of stay was 1.5 days. Mean follow-up was 39 months. Overall, 97.6% of patients had a successful outcome, with a 6.6% overall complication rate. CONCLUSIONS: To our knowledge, this review represents the largest multi-institutional experience of RLP with intermediate-term follow-up. RLP is a safe, efficacious, and viable option for either primary or secondary repair of UPJO with reproducible outcomes, a high success rate, and a low incidence of complications.

Modified technique of robotic-assisted simple prostatectomy: advantages of a vesico-urethral anastomosis.

OBJECTIVES: To describe a technical modification during robotic-assisted simple prostatectomy (RASP) aiming to decrease perioperative blood loss, shorten the length of hospital stay and eliminate the need of postoperative continuous bladder irrigation. To describe perioperative outcomes, pathological findings and functional outcomes of our single-surgeon series using this technique. METHODS: We analysed six consecutive patients who underwent RASP using our technical modification between February and September 2010. Transrectal ultrasonography (TRUS) guided prostate biopsy was performed in all cases and revealed benign prostatic hyperplasia in two cases and benign prostatic hyperplasia plus chronic prostatitis in four cases. The mean estimated prostate volume in the TRUS was 157 ± 74 (range 90-300) mL and the average preoperative International Prostate Symptom score was 19.8 ± 9.6 (10-32). Two patients were in urinary retention before surgery. Our technique of RASP includes the standard operative steps reported during open and laparoscopic simple prostatectomy; however, with the addition of some technical modifications during the reconstructive part of the procedure. Following the resection of the adenoma, instead of performing the classical 'trigonization' of the bladder neck and closure of the prostatic capsule, we propose three modified surgical steps: plication of the posterior prostatic capsule, a modified van Velthoven continuous vesico-urethral anastomosis and, finally, suture of the anterior prostatic capsule to the anterior bladder wall. RESULTS: The patients' average age was 69 ± 4.9 (63-74) years; the mean estimated blood loss was 208 ± 66 (100-300) mL and the mean operative time was 90 ± 17.6 (75-120) min. All patients were discharged on postoperative day 1 without the need of continuous bladder irrigation at any time after RASP. No blood transfusion or perioperative complications were reported. The mean weight of the surgical specimen was 145 ± 41.6 (84-186) g. Histopathological evaluation revealed benign prostatic hyperplasia plus chronic prostatitis in five patients and prostatic adenocarcinoma (Gleason score 3+3, pT1a) with negative surgical margins in one patient. The mean serum prostate-specific antigen level decreased from 7 ± 2.5 (4.2-11) ng/mL preoperatively to 1.05 ± 0.8 (0.2-2.5) after RASP. Significant improvement from baseline was reported in the average International Prostate Symptom score (average preoperative vs postoperative, 19.8 ± 9.6 vs 5.5 ± 2.5, P= 0.01) and in mean maximum urine flow (average preoperative vs postoperative 7.75 ± 3.3 vs 19 ± 4.5 mL/s, P= 0.019) at 2 months after RASP. All patients were continent (defined as the use of no pads) at 2 months after RASP. CONCLUSIONS: Our modified technique of RASP is a safe and feasible option for treatment of lower urinary tract symptoms caused by large prostatic adenomas. Potential advantages of our technique include reduced blood loss, lower blood transfusion rates and shorter length of hospital stay with no need of postoperative continuous bladder irrigation. Larger series with longer follow-up are necessary to determine long-term outcomes in comparison to open simple prostatectomy or to the standard technique of RASP.

Does the presence of median lobe affect outcomes of robot-assisted laparoscopic radical prostatectomy?

PURPOSE: To determine whether the presence of median lobe (ML) affects perioperative outcomes, positive surgical margin (PSM) rates, and recovery of urinary continence after robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: We analyzed 1693 consecutive patients undergoing RARP performed by a single surgeon. Patients were analyzed in two groups based on the presence or not of a ML identified during RARP. Perioperative outcomes, PSM rates, and recovery of urinary continence were compared between the groups. Continence was assessed using validated questionnaires, and it was defined as the use of "no pads" postoperatively. RESULTS: A ML was identified in 323 (19%) patients. Both groups had similar estimated blood loss, length of hospital stay, pathologic stage, complication rates, anastomotic leakage rates, overall PSM rates, and PSM rate at the bladder neck. The median overall operative time was slightly greater in patients with ML (80 vs 75 min, P<0.001); however, there was no difference in the operative time when stratifying this result by prostate weight. Continence rates were also similar between patients with and without ML at 1 week (27.8% vs 27%, P=0.870), 4 weeks (42.3% vs 48%, P=0.136), 12 weeks (82.5% vs 86.8%, P=0.107), and 24 weeks (91.5% vs 94.1%, P=0.183) after catheter removal. Finally, the median time to recovery of continence was similar between the groups (median: 5 wks, 95% confidence interval [CI]: 4.41-5.59 vs median: 5 wks, CI 4.66-5.34; log rank test, P=0.113). CONCLUSION: The presence of a ML does not affect outcomes of RARP performed by an experienced surgeon.

Critical review of 'pentafecta' outcomes after robot-assisted laparoscopic prostatectomy in high-volume centres.

• Historically, the ideal outcome of radical prostatectomy (RP) has been measured by achievement of the so-called 'trifecta', or the concurrent attainment of continence and potency with no evidence of biochemical recurrence. However, in the PSA era, younger and healthier men are more frequently diagnosed with prostate cancer. Such patients have higher expectations from the advanced minimally invasive surgical technologies. Mere trifecta is no longer an ideal outcome measure to meet the demands of such patients. • Keeping the limitations of trifecta in mind, we have earlier proposed a new method of outcomes analysis, called the 'pentafecta', which adds early complications and positive surgical margins (PSMs) to trifecta. • We performed a Medline search for articles reporting the complications, PSM rates, continence, potency and biochemical recurrence after robot-assisted RP. Related articles were selected and individual outcomes were reviewed.

Positive surgical margins after robotic assisted radical prostatectomy: a multi-institutional study.

PURPOSE: Positive surgical margins are an independent predictive factor for biochemical recurrence after radical prostatectomy. We analyzed the incidence of and associative factors for positive surgical margins in a multi-institutional series of 8,418 robotic assisted radical prostatectomies. MATERIALS AND METHODS: We analyzed the records of 8,418 patients who underwent robotic assisted radical prostatectomy at 7 institutions. Of the patients 323 had missing data on margin status. Positive surgical margins were categorized into 4 groups, including apex, bladder neck, posterolateral and multifocal. The records of 6,169 patients were available for multivariate analysis. The variables entered into the logistic regression models were age, body mass index, preoperative prostate specific antigen, biopsy Gleason score, prostate weight and pathological stage. A second model was built to identify predictive factors for positive surgical margins in the subset of patients with organ confined disease (pT2). RESULTS: The overall positive surgical margin rate was 15.7% (1,272 of 8,095 patients). The positive surgical margin rate for pT2 and pT3 disease was 9.45% and 37.2%, respectively. On multivariate analysis pathological stage (pT2 vs pT3 OR 4.588, p<0.001) and preoperative prostate specific antigen (4 or less vs greater than 10 ng/ml OR 2.918, p<0.001) were the most important independent predictive factors for positive surgical margins after robotic assisted radical prostatectomy. Increasing prostate weight was associated with a lower risk of positive surgical margins after robotic assisted radical prostatectomy (OR 0.984, p<0.001) and a higher body mass index was associated with a higher risk of positive surgical margins (OR 1.032, p<0.001). For organ confined disease preoperative prostate specific antigen was the most important factor that independently correlated with positive surgical margins (4 or less vs greater than 10 ng/ml OR 3.8, p<0.001). CONCLUSIONS: The prostatic apex followed by a posterolateral site was the most common location of positive surgical margins after robotic assisted radical prostatectomy. Factors that correlated with cancer aggressiveness, such as pathological stage and preoperative prostate specific antigen, were the most important factors independently associated with an increased risk of positive surgical margins after robotic assisted radical prostatectomy.

Preliminary analysis of the feasibility and safety of salvage robot-assisted radical prostatectomy after radiation failure: multi-institutional perioperative and short-term functional outcomes.

BACKGROUND AND PURPOSE: Open radical prostatectomy after radiation treatment failure for prostate cancer is associated with significant morbidity. The purpose of the study is to report multi-institutional experiences while performing salvage robot-assisted radical prostatectomy (sRARP). PATIENTS AND METHODS: We retrospectively identified 15 patients with biopsy-proven prostate cancer after definitive radiotherapy who underwent sRARP in three academic institutions over a 20-month period. Continence was defined as the use of 0 pads after surgery. Potency was defined as the ability to achieve erections adequate enough for penetration with or without the use of phosphodiesterase-5 inhibitors. Biochemical recurrence after sRARP was defined as a prostate-specific antigen value of >0.2 ng/mL. RESULTS: Radiation treatment consisted of external-beam radiation therapy (XRT) in five cases, interstitial radioactive 125-iodine brachytherapy (BT) in five cases, proton beam therapy in two cases, and XRT followed by interstitial radioactive 125-iodine BT in three cases. The median operative time, the median estimated blood loss, and the median length of hospital stay were 140.5 min (interquartile range [IQR] 97.5-157 min), 75 mL (IQR 50-100 mL), and 1 day (IQR 1-2 d), respectively. There were no rectal injuries. Two (13.3%) patients had a positive surgical margin. A total of three (20%) patients had postoperative complications. One patient had a deep vein thrombosis (Clavien grade II), one had wound infection (Clavien grade II), and one patient had an anastomotic leak (Clavien gradeId). An anastomotic stricture (Clavien grade IIIa) later developed in this same patient, which was managed by direct visual internal urethrotomy. Of the patients, 71.4% were continent. At a median follow-up of 4.6 months (IQR 3-9.75 mos), four (28.6%) patients presented with biochemical recurrence after sRARP. CONCLUSIONS: The challenge during sRALP is the presence of extensive fibrosis and loss of dissection planes secondary to radiation therapy. It is a technically challenging but feasible procedure. The early complication rates were low, and early continence rates are encouraging.

Incidence of lymphoceles after robot-assisted pelvic lymph node dissection.

OBJECTIVE: • To determine the incidence and predictive factors of lymphocele formation in patients undergoing pelvic lymph node dissection (PLND) during robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: • Between April and December 2008, 76 patients underwent PLND during RARP for ≥cT2c, prostate-specific antigen level ≥10, Gleason score ≥7 prostate cancer. • All patients were prospectively followed up with pelvic computed tomography 6-12 weeks after the procedure. • All patients received s.c. heparin preoperatively and postoperatively. PLND was limited to zones 1 and 2 as defined by Studer. • Plasma-kinetic bipolar forceps were used for haemostasis during PLND. RESULTS: • At a mean follow-up of 10.8 weeks, 51% (39/76) of patients had developed a lymphocele. Of these 39 lymphoceles 32 (82%) were unilateral and seven (18%) were bilateral. • The mean (range) lymphocele size was 4.3 × 3.2 (1.5-12.3) cm; 41% of lymphoceles were <4 cm, 53.9% were 4-10 cm, and 5.1% were >10 cm in diameter. Six of the 39 lymphoceles (15.4%) were clinically symptomatic. The symptoms were as follows: pelvic pressure in five patients, abdominal distension with ileus in three patients, leg pain/weakness in one patient and costovertebral tenderness in one patient. Two lymphoceles required intervention. • On the logistic regression model the presence of nodal metastases, tumour volume in the prostate specimen and extracapsular extension (ECE) were independent risk factors for the development of a lymphocele. • There was no correlation between estimated blood loss, body mass index, pathological Gleason score or number nodes dissected and the presence of lymphocele. CONCLUSIONS: • The incidence of lymphoceles was higher than anticipated given the believed protective effect of the transperitoneal approach against lymphocele formation. • The risk of lymphocele seemed to increase linearly with the presence of more extensive disease, particularly ECE and nodal involvement. • The benefit of PLND during RARP should be weighed against the elevated risk of lymphocele formation and its potential complications.

Pentafecta: a new concept for reporting outcomes of robot-assisted laparoscopic radical prostatectomy.

BACKGROUND: Widespread use of prostate-specific antigen screening has resulted in younger and healthier men being diagnosed with prostate cancer. Their demands and expectations of surgical intervention are much higher and cannot be adequately addressed with the classic trifecta outcome measures. OBJECTIVE: A new and more comprehensive method for reporting outcomes after radical prostatectomy, the pentafecta, is proposed. DESIGN, SETTING, AND PARTICIPANTS: From January 2008 through September 2009, details of 1111 consecutive patients who underwent robot-assisted radical prostatectomy performed by a single surgeon were retrospectively analyzed. Of 626 potent men, 332 who underwent bilateral nerve sparing and who had 1 yr of follow-up were included in the study group. MEASUREMENTS: In addition to the traditional trifecta outcomes, two perioperative variables were included in the pentafecta: no postoperative complications and negative surgical margins. Patients who attained the trifecta and concurrently the two additional outcomes were considered as having achieved the pentafecta. A logistic regression model was created to evaluate independent factors for achieving the pentafecta. RESULTS AND LIMITATIONS: Continence, potency, biochemical recurrence-free survival, and trifecta rates at 12 mo were 96.4%, 89.8%, 96.4%, and 83.1%, respectively. With regard to the perioperative outcomes, 93.4% had no postoperative complication and 90.7% had negative surgical margins. The pentafecta rate at 12 mo was 70.8%. On multivariable analysis, patient age (p=0.001) was confirmed as the only factor independently associated with the pentafecta. CONCLUSIONS: A more comprehensive approach for reporting prostate surgery outcomes, the pentafecta, is being proposed. We believe that pentafecta outcomes more accurately represent patients' expectations after minimally invasive surgery for prostate cancer. This approach may be beneficial and may be used when counseling patients with clinically localized disease.

Influence of modified posterior reconstruction of the rhabdosphincter on early recovery of continence and anastomotic leakage rates after robot-assisted radical prostatectomy.

BACKGROUND: Posterior reconstruction (PR) of the rhabdosphincter has been previously described during retropubic radical prostatectomy, and shorter times to return of urinary continence were reported using this technical modification. This technique has also been applied during robot-assisted radical prostatectomy (RARP); however, contradictory results have been reported. OBJECTIVE: We describe here a modified technique for PR of the rhabdosphincter during RARP and report its impact on early recovery of urinary continence and on cystographic leakage rates. DESIGN, SETTING, AND PARTICIPANTS: We analyzed 803 consecutive patients who underwent RARP by a single surgeon over a 12-mo period: 330 without performing PR and 473 with PR. SURGICAL PROCEDURE: The reconstruction was performed using two 6-in 3-0 Poliglecaprone sutures tied together. The free edge of the remaining Denonvillier's fascia was identified after prostatectomy and approximated to the posterior aspect of the rhabdosphincter and the posterior median raphe using one arm of the continuous suture. The second layer of the reconstruction was then performed with the other arm of the suture, approximating the posterior lip of the bladder neck and vesicoprostatic muscle to the posterior urethral edge. MEASUREMENTS: Continence rates were assessed with a self-administrated, validated questionnaire (Expanded Prostate Cancer Index Composite) at 1, 4, 12, and 24 wk after catheter removal. Continence was defined as the use of "no absorbent pads." Cystogram was performed in all patients on postoperative day 4 or 5 before catheter removal. RESULTS AND LIMITATIONS: There was no significant difference between the groups with respect to patient age, body mass index, prostate-specific antigen levels, prostate weight, American Urological Association symptom score, estimated blood loss, operative time, number of nerve-sparing procedures, and days with catheter. In the PR group, the continence rates at 1, 4, 12, and 24 wk postoperatively were 28.7%, 51.6%, 91.1%, and 97%, respectively; in the non-PR group, the continence rates were 22.7%, 42.7%, 91.8%, and 96.3%, respectively. The modified PR technique resulted in significantly higher continence rates at 1 and 4 wk after catheter removal (p = 0.048 and 0.016, respectively), although the continence rates at 12 and 24 wk were not significantly affected (p = 0.908 and p = 0.741, respectively). The median interval to recovery of continence was also statistically significantly shorter in the PR group (median: 4 wk; 95% confidence interval [CI]: 3.39-4.61) when compared to the non-PR group (median: 6 wk; 95% CI: 5.18-6.82; log-rank test, p=0.037). Finally, the incidence of cystographic leaks was lower in the PR group (0.4% vs 2.1%; p=0.036). Although the patients' baseline characteristics were similar between the groups, the patients were not preoperatively randomized and unknown confounding factors may have influenced the results. CONCLUSIONS: Our modified PR combines the benefits of early recovery of continence reported with the original PR technique with a reinforced watertight closure of the posterior anastomotic wall. Shorter interval to recovery of continence and lower incidence of cystographic leaks were demonstrated with our PR technique when compared to RARP with no reconstruction.