Nerve-sparing robotic prostatectomy in preoperatively high-risk patients is safe and efficacious.

OBJECTIVE: Given the higher likelihood of extraprostatic extension in high-risk patients, many urologists will sacrifice the neurovascular bundles in such patients in an attempt to decrease the risk of positive surgical margins. In contrast, we frequently perform nerve-sparing in high-risk patients. We analyzed our outcomes in patients with preoperatively high-risk prostate cancer according to the D'Amico risk group classification, and stratified by nerve-sparing status. MATERIALS AND METHODS: An institutional database of 1,503 robotic-assisted laparoscopic prostatectomies (RALP) was queried for patients presenting with PSA > 20 ng/ml, Gleason 8 or higher on biopsy, or clinical stage T2c or higher. Interfascial nerve-sparing was performed whenever oncologically feasible. Validated questionnaires were used to assess baseline and postoperative functional outcomes. RESULTS: Adequate follow-up was available in 123 high-risk patients. Mean serum PSA was 10.8. Bilateral, unilateral, and non-nerve-sparing was performed on 58%, 15%, and 27%, respectively. On final histopathology, 42% were organ confined; 55 patients had extraprostatic extension, and 35 had seminal vesicle invasion. Positive surgical margins occurred in 31%: 15% focal and 16% extensive. Favorable pathologic outcomes (organ-confined and negative surgical margins) were observed in 40%. Biochemical recurrence occurred in 20%. Nerve-sparing was associated with more favorable pathologic features, possibly due to selection bias. When controlling for adverse pathologic features, nerve-sparing was not associated with higher rates of positive surgical margins or biochemical recurrence. At a median follow-up of 13 months, 78% were continent and 56% were potent. The "trifecta" of continence, potency, and freedom from recurrence was achieved in 28 patients (23%). CONCLUSIONS: Nerve-sparing robotic-assisted laparoscopic prostatectomy can be safely performed in patients with preoperatively high risk prostate cancer. Histopathologic and short-term oncologic outcomes at 13-month median follow-up are comparable to those in open surgical series from similar cohorts.

Does size matter? The significance of prostate size on pathologic and functional outcomes in patients undergoing robotic prostatectomy.

BACKGROUND: We examined the effect of prostate weight on perioperative data, and the pathological and functional outcomes of robotic-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS: Data were available from 716 consecutive patients before, during and after undergoing RALP at one institution. Prostate size was arbitrarily stratified by recorded prostate weight into <50, 50-80 and >80 g, corresponding to small, moderate and large glands, respectively. Perioperative data and the histopathological and functional outcomes were compared across these groups by both univariable and multivariable-adjusted analyses. RESULTS: Increased prostate size was associated with increased age, preoperative prostate-specific antigen levels, body mass index, operative duration, blood loss, lower biopsy and pathological Gleason scores, and lower pathological staging (P < 0.05). The incidence of extensive positive surgical margins was 14.8%, 9.7%, and 5.3% in small, moderate and large prostates, respectively (P < 0.001). However, after multivariable adjustment, only Gleason score and pathological stage were significantly associated with the incidence of positive margins (P < 0.05); prostate weight was not significantly associated. Overall, 78% and 92% of patients were potent and continent at 12 months, respectively, which was not affected by prostate size. CONCLUSION: Patients with larger prostates had favourable pathological outcomes after RALP. When controlling for pathological stage, prostate size was not associated with margin positivity. Functionally, neither continence nor potency at 12 months was affected by prostate size.

Improvements in robot-assisted prostatectomy: the effect of surgeon experience and technical changes on oncologic and functional outcomes.

PURPOSE: To assess the effect of surgeon experience and technical modifications on functional and oncologic outcomes after robot-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS: Data were available for 1181 of 1420 consecutive patients undergoing RALP by a single surgeon (DBS). Three techniques were evaluated. The "initial" technique included incision of the lateral endopelvic fascia, suture ligation of the dorsal venous complex (DVC), and anterior tennis-racquet bladder neck reconstruction (n = 590 procedures). The "intermediate" technique included a modified "curtain" nerve-sparing technique and incision of the DVC without previous ligation (n = 170). The "current" technique uses a posterior tennis-racquet bladder neck reconstruction (n = 421). Outcomes included continence and potency recovery and the presence of pT(2) surgical margins assessed in continuous fashion. Validated questionnaires were used to assess baseline and postoperative functional outcomes. RESULTS: Continence rates improved between techniques at all evaluated time points, with 1-year continence rates of 88%, 93%, and 96% in the initial, intermediate, and current technique groups, respectively (Ptrend <0.001). One-year potency rates, however, remained similar among the groups, with rates of 77%, 84%, and 79%, respectively (P = 0.58). pT(2) margin rates decreased continuously during the initial technique period, followed by a transient worsening of margin rates during the intermediate time period and a subsequent decrease during the period when the current technique was used. CONCLUSIONS: Increased experience with robot-assisted prostatectomy resulted in improvements in oncologic and functional outcomes. Modifications to robot-assisted prostatectomy techniques may aid in this improvement but are also associated with transient worsening of outcomes during the learning curve of the new technique.

Intraoperative management of robotic-assisted versus open radical prostatectomy.

BACKGROUND AND OBJECTIVES: Minimally invasive surgery has been shown to decrease postoperative morbidity and length of stay for several laparoscopic procedures. We sought to retrospectively compare intraoperative surgical and anesthetic parameters, post-anesthetic care unit (PACU) length of stay, and hospital length of stay of patients who underwent robotic-assisted laparoscopic radical prostatectomy (RAP) versus open radical retropubic prostatectomy (ORP). METHODS: A retrospective investigation was performed using a urologic surgery database and an anesthesia electronic medical record. We queried information regarding 106 ORP patients from 2002 through 2007 and 575 RAP patients from 2007 through 2008. RESULTS: Patients in the RAP group compared with ORP patients had reductions in surgical time, anesthesia time, estimated blood loss, crystalloid administration, and PACU and hospital length of stays. Compared with ORP procedures, intraoperative respiratory rates, peak inspiratory pressures, and arterial pressures in RAP procedures were higher; tidal volumes and heart rates were decreased; but end-tidal carbon dioxide concentrations were not different. In the RAP group, intraoperative complications included severe bradycardia, corneal abrasions, and 2 patients required reintubation. Surgically, no rectal perforations were noted, and no operative mortalities occurred. CONCLUSIONS: Our data demonstrate the safety and efficacy of RAP due to a combination of surgical and anesthetic factors.

What PCPs and geriatricians need to know about robotic prostatectomy and organ-confined prostate cancer.

Prostate cancer is the most common visceral neoplasm diagnosed in the United States and has gained significant public awareness over the past 20 years as a result of the serum prostate-specific antigen (PSA) screening test. Though there is potentially wide variability in presentation, most patients are diagnosed with organ-confined disease. Treatments for localized prostate cancer include surgery, radiation, and active surveillance. One of the newer surgical modalities is robotic-assisted laparoscopic prostatectomy, which has shown promise in improving cancer control and reducing the morbidity commonly associated with open radical prostatectomy. This article will discuss screening and treatment options for localized prostate cancer, with special focus on robotic prostatectomy and its advantages.

Robot-assisted laparoscopic radical prostatectomy: technique and outcomes of 700 cases.

BACKGROUND: Robotic prostatectomy techniques are evolving rapidly as the procedure gains popularity and continues to be compared to the gold standard of open retropubic radical prostatectomy. Our objective is to report the operative technique and outcomes of 700 consecutive robotic radical prostatectomies performed by a single surgeon at Mount Sinai Medical Center between May 2007 and October 2008. Data was prospectively collected in an Internal Review Board (IRB)-approved database. SURGICAL PROCEDURE: Key aspects of our technique include 1) dissection of the bladder neck first; 2) minimal to no use of cautery from posterior bladder neck dissection onward; 3) leaving endopelvic fascia intact until after neurovascular bundles dissected; 4) preservation of a wide margin of endopelvic fascia; 5) posterior dissection and nerve-sparing in a medial to lateral direction; 6) cold transection of the dorsal venous complex without prior ligation; and 7) posterior bladder neck reconstruction. RESULTS: Mean OR time from skin incision to skin closure was 124 minutes [48-266]; mean robotic time was 88 minutes [36-190]. Mean EBL was 69.3ml [5-400]. Mean and median length of stay was 1 day. Overall complication rate was 3.3% with no mortalities and no conversions to open or laparoscopic approaches. The overall positive margin rate (PMR) was 11.9%. PMR was 1.4% for pT2a, 0% for pT2b, 8.3% for pT2c, 39.7% for pT3a, and 56.7% for pT3b. Biochemical recurrence rate at one year was 1.7%. Continence rate by 12 months was 94%. Potency rate by 12 months was 83%. CONCLUSIONS: Both perioperative and postoperative outcomes of our series of robotic prostatectomies performed by a single surgeon at Mount Sinai Medical Center demonstrate the superb outcomes that can be achieved through this modality of treatment.