Robotic-assisted radical prostatectomy in young adults: age-stratified oncological and functional outcomes.

There is a scarcity of information on the outcomes of robotic-assisted prostatectomy (RALP) in young men. To compare the age-stratified functional and oncological outcomes of RALP in men aged ≤ 55 years. Among 10,997 patients in our RALP series, 2243 were ≤ 55 years old. These men were divided into 3 age-stratified groups (group 1 ≤ 45 years, group 2 46-50 years, and group 3 51-55 years old). Age-stratified groups were compared for clinical, oncological, and trifecta outcomes. Kaplan-Meier curves and Cox regression models were used to identify survival estimations and their predictors. Overall, 33% and 22% of men had non-organ confined (≥ pT3) and Gleason ≥ 4 + 3 prostate cancer at final pathology, respectively. Younger patients had a higher incidence of low-risk disease and better erectile function at presentation. Organ-confined and Gleason 3 + 3 cancer rates for men ≤ 45 and 51-55 years were 82 vs. 74% and 41 vs. 30%, respectively (p < 0.05). Biochemical recurrence-free survival was similar among age-stratified groups. Bilateral full nerve-sparing (NS) rate was significantly higher in younger patients (74% in group 1 vs. 56% in group 3, p < 0.001). One-year trifecta rates were 79.8%, 71.6%, and 63.9% for increasing age groups, respectively (p < 0.001). Age, comorbidity score, and extent of NS were independent predictors of functional recovery. This study is limited by its retrospective design. At RALP, one-third of patients ≤ 55 years have locally advanced or high-risk prostate cancer. Age ≤ 45 years is associated with higher incidence of favorable tumor characteristics, which gives the surgeon increased ability to perform bilateral full NS, resulting in better functional recovery. In this report, we compared the age-stratified outcomes of RALP in a large series of men ≤ 55 years. We found that younger age was associated with more favorable tumor characteristics and better functional outcomes. We conclude that earlier diagnosis may lead to improved RALP outcomes.

Stratification of Potency Outcomes Following Robot-Assisted Laparoscopic Radical Prostatectomy Based on Age, Preoperative Potency, and Nerve Sparing.

Introduction: To identify factors affecting potency and to predict ideal patient subgroups who will have the highest chance of being potent after robot-assisted laparoscopic prostatectomy (RALP) based on nerve sparing (NS). Materials and Methods: Analysis of 7268 patients who underwent RALP between 2008 and 2018 with a minimum of 12 months of follow-up was performed. The patients were then categorized into four separate neurovascular bundle-sparing groups (NVB 1-4). A Cox regression analysis was used to determine the independent factors predicting potency outcomes. Cumulative incidence functions were used to depict the probability and time to potency between the NS groups stratified by age and preoperative sexual health inventory in men (SHIM). Results: Cox regression analysis of age, preoperative SHIM score, and grades of NS significantly predicted potency outcomes post-RALP. Patients with SHIM score ≥22 had a better chance of potency vs patients with SHIM <17 (odds ratio [OR]: 1.69, confidence interval [CI]: 1.47-1.79). NVB1 had better potency vs NVB4 (OR: 3.1, CI: 2.51-3.83). Patients <55 years with NVB1 and no preoperative erectile dysfunction had the best potency rates of 92.5%. However, we did not see any statistical difference between NVB2 and NVB3 in this group, implying that in patient groups with SHIM ≥22 and age <55, NVB1 provided the best chance of potency recovery. As age increased and preoperative SHIM worsened, the curves corresponding to NVB 2 and 3 showed significant differences, suggesting that NVB 2 and 3 may be predictive in unfavorable age and preoperative SHIM groups, especially NVB 2 > NVB 3. Conclusions: Preoperative SHIM, age, and NS are the most influential factors for potency recovery following RALP. Patients with good baseline sexual function had similar postoperative potency, irrespective of their grades of partial NS. In patients with decreased baseline SHIM and older age, a higher grade of partial NS resulted in a significantly better potency compared with a lower grade of partial nerve spare.

Müllerianosis of the Urinary Bladder: A Rare Condition Which Mimics Neoplasia.

Müllerianosis of the urinary bladder is an extremely rare, benign condition defined by the presence of at least two of the three müllerian-derived components (endosalpinx, endometrium, and endocervix) in the lamina propria and muscularis propria of the urinary bladder. It frequently mimics neoplastic condition, either malignant or benign. Here, we present a case of cystic müllerianosis of urinary bladder, which was clinically thought to be a urinary bladder neoplasm.

A Predictive Preoperative and Postoperative Nomogram for Postoperative Potency Recovery after Robot-Assisted Radical Prostatectomy.

PURPOSE: Prediction of potency recovery following robot-assisted radical prostatectomy (RARP) is useful for better patient counseling and postoperative treatment strategies. In this study we propose a preoperative and postoperative nomogram to predict postoperative potency recovery following RARP. MATERIALS AND METHODS: Patients from development set (6,502) were selected to develop the nomograms, and patients in validation set (2,706) were used for validation. Cox regression models were fitted on the development cohort to predict potency recovery after RARP using as prognostic factors the covariates selected. Two nomograms were drawn using the regression coefficients of the preoperative and postoperative Cox models. RESULTS: The discrimination ability of the preoperative model was evaluated on the development cohort using the receiver operator curves estimated at 3, 6, 12 and 24 months. The AUC at these time points was 0.726, 0.734, 0.754, and 0.778, respectively. The areas under the curve of the postoperative model at 3, 6, 12 and 24 months were 0.746, 0.756 and 0.777, and 0.801, respectively. Preoperative and postoperative predictive models were validated using a separate set of 2,706 patients. The AUCs of the preoperative model at 3, 6, 12 and 24 months were 0.789, 0.772, 0.768, and 0.778, respectively. The ROC curves of the postoperative model at 3, 6, 12 and 24 months with AUCs of 0.807, 0.797, 0.793 and 0.798, respectively. Along with age and preoperative sexual function, nerve-sparing technique determines the potency outcomes justifying better AUC for postoperative model vs the preoperative model. CONCLUSIONS: The above nomograms help us to predict with good accuracy the probability of potency recovery within 3, 6, 12 and 24 months following surgery taking into consideration preoperative and postoperative factors. This is a novel tool for the care giver to predict realistic expectation of potency outcomes to the patients, while preoperative and immediate postoperative counseling.

Stratification of Potency Outcomes Following Robot-Assisted Laparoscopic Radical Prostatectomy Based on Age, Preoperative Potency, and Nerve Sparing.

Introduction: To identify factors affecting potency and to predict ideal patient subgroups who will have the highest chance of being potent after robot-assisted laparoscopic prostatectomy (RALP) based on nerve sparing (NS). Materials and Methods: Analysis of 7268 patients who underwent RALP between 2008 and 2018 with a minimum of 12 months of follow-up was performed. The patients were then categorized into four separate neurovascular bundle-sparing groups (NVB 1-4). A Cox regression analysis was used to determine the independent factors predicting potency outcomes. Cumulative incidence functions were used to depict the probability and time to potency between the NS groups stratified by age and preoperative sexual health inventory in men (SHIM). Results: Cox regression analysis of age, preoperative SHIM score, and grades of NS significantly predicted potency outcomes post-RALP. Patients with SHIM score ≥22 had a better chance of potency vs patients with SHIM <17 (odds ratio [OR]: 1.69, confidence interval [CI]: 1.47-1.79). NVB1 had better potency vs NVB4 (OR: 3.1, CI: 2.51-3.83). Patients <55 years with NVB1 and no preoperative erectile dysfunction had the best potency rates of 92.5%. However, we did not see any statistical difference between NVB2 and NVB3 in this group, implying that in patient groups with SHIM ≥22 and age <55, NVB1 provided the best chance of potency recovery. As age increased and preoperative SHIM worsened, the curves corresponding to NVB 2 and 3 showed significant differences, suggesting that NVB 2 and 3 may be predictive in unfavorable age and preoperative SHIM groups, especially NVB 2 > NVB 3. Conclusions: Preoperative SHIM, age, and NS are the most influential factors for potency recovery following RALP. Patients with good baseline sexual function had similar postoperative potency, irrespective of their grades of partial NS. In patients with decreased baseline SHIM and older age, a higher grade of partial NS resulted in a significantly better potency compared with a lower grade of partial nerve spare.

Robotic renal and adrenal oncologic surgery: A contemporary review.

Robot-assisted surgery has evolved over time. Radical nephrectomy with inferior vena cava thrombectomy is feasible and safe for level I, II and III thrombus in high volume centers. Though it is feasible for level IV thrombus, this procedure needs a multi-departmental co-operation. However, the safety of robot-assisted procedures in this subset is still unknown. Robot-assisted partial nephrectomy has been universally approved and found oncologically safe. Robotic adrenalectomy has been increasingly utilized for select cases, especially in bilateral tumors and for retroperitoneal adrenalectomy.

Single-port technique evolution and current practice in urologic procedures.

Different groups described the single-port surgery since its first report in laparoscopic procedures. However, the acceptance of this technique among urologists, even after the robotic approach, was reduced in the past years. Therefore, to overcome the challenges related to the single-port surgery, a new robotic platform named da Vinci SP was created with exclusive single port technology. We performed a non-systematic literature review regarding the single port technique in urologic surgeries since the first laparoscopic report until the da Vinci SP robotic platform. Three different periods were described (laparoscopy, robotic, and da Vinci SP), and we focused in our experience with this new single port robot. We selected different articles and summarized the information regarding the use of single-site surgery in laparoscopic procedures and the challenges of this approach. We also reported the experience of different groups using the single port robotic technique and some recent reports of the da Vinci SP approach. In our experience with this new console, we described some critical points related to our radical prostatectomy technique and the lessons learned during the introduction of this novel platform. Previous single-site procedures described some common challenges that limited the technique expansion. However, our experience with the da Vinci SP described feasible and safe procedures with acceptable intraoperative outcomes. The introduction of this platform is recent in the market, and the literature still lacks a high level of evidence describing the long-term outcomes of this new technology.

Magnetic resonance imaging-guided prostate biopsy-A review of literature.

OBJECTIVE: Multiparametric magnetic resonance imaging (MP-MRI) helps to identify lesion of prostate with reasonable accuracy. We aim to describe the various uses of MP-MRI for prostate biopsy comparing different techniques of MP-MRI guided biopsy. MATERIALS AND METHODS: A literature search was performed for "multiparametric MRI", "MRI fusion biopsy", "MRI guided biopsy", "prostate biopsy", "MRI cognitive biopsy", "MRI fusion biopsy systems", "prostate biopsy" and "cost analysis". The search operation was performed using the operator "OR" and "AND" with the above key words. All relevant systematic reviews, original articles, case series, and case reports were selected for this review. RESULTS: The sensitivity of MRI targeted biopsy (MRI-TB) is between 91%-93%, and the specificity is between 36%-41% in various studies. It also has a high negative predictive value (NPV) of 89%-92% and a positive predictive value (PPV) of 51%-52%. The yield of MRI fusion biopsy (MRI-FB) is similar, if not superior to MR cognitive biopsy. In-bore MRI-TB had better detection rates compared to MR cognitive biopsy, but were similar to MR fusion biopsy. CONCLUSIONS: The use of MRI guidance in prostate biopsy is inevitable, subject to availability, cost, and experience. Any one of the three modalities (i.e. MRI cognitive, MRI fusion and MRI in-bore approach) can be used. MRI-FB has a fine balance with regards to accuracy, practicality and affordability.

Comparing the Approach to Radical Prostatectomy Using the Multiport da Vinci Xi and da Vinci SP Robots: A Propensity Score Analysis of Perioperative Outcomes.

BACKGROUND: Use of the single-port da Vinci SP robotic platform for various urological procedures has been described by several groups. However, the comparative performance of the SP robot in relation to earlier models such as the da Vinci Xi is still unclear. OBJECTIVE: To compare intraoperative and short-term postoperative outcomes between the da Vinci Xi and SP robots for patients undergoing radical prostatectomy (RP) in a referral center. DESIGN, SETTING, AND PARTICIPANTS: Data were prospectively collected for patients undergoing RP from June 2019 to April 2020 in a single center. The da Vinci SP was used for 71 patients and the da Vinci Xi for 875 patients. After propensity score (PS) matching, two groups of 71 patients were selected for the comparative study. INTERVENTION: RP via a transperitoneal approach using the same technique steps and anatomy access with both robot consoles. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: A PS analysis was performed using the covariates age, body mass index, Charlson comorbidity index, Sexual Health Inventory for Men score, American Urological Association symptom score, prostate size, prostate-specific antigen levels, Gleason score, D'Amico risk group, and degree of nerve-sparing. Intraoperative performance and short-term functional (continence and potency) and oncological outcomes were compared between the groups. RESULTS AND LIMITATIONS: Median follow-up was 4.4 mo (interquartile range [IQR] 1.6-7.2) for the SP group and 3.2 mo (IQR 1.6-4.8) for the Xi group (p = 0.2). The median total operative time and median console time were both significantly higher in the SP group, with median differences of 14 min (95% confidence interval [CI] 9-19) and 5 min (95% CI 0-5), respectively. The proportion of patients with blood loss of >100 ml was significantly lower in the SP group (difference of 27%, 95% CI 12-42%). No intra- or postoperative complications were reported in either group. There were no significant differences in pain scores at 6, 12, and 18 h or in positive surgical margin rates between the groups. The SP group had a significantly higher percentage of extraprostatic extension than the Xi group (difference of 16%, 95% CI 4.6-27%). None of the patients experienced biochemical recurrence during follow-up. The difference in continence rates at 45 d between the SP and Xi groups was 11% (95% CI -5.6% to 28%) and the difference in potency rates at 45 d was -7.3% (95% CI -21% to 6.2%). The short-term follow-up for comparison of functional and oncological outcomes is a limitation. CONCLUSIONS: Despite differences in trocar placement and technology between the two da Vinci consoles, the SP has satisfactory intraoperative performance compared to the Xi. SP surgery can be performed safely and effectively during the initial learning phase. However, longer-term follow-up is needed to provide further evidence on the impact of SP implementation on functional and oncological outcomes. PATIENT SUMMARY: We compared intraoperative and short-term postoperative outcomes for patients who underwent radical prostatectomy using two different robots, the da Vinci Xi and the single-port da Vinci SP. We found that operative time was longer for the Single Port console. Studies with long-term follow-up are needed to compare the functional and oncological outcomes.

COVID-19 model-based practice changes in managing a large prostate cancer practice: following the trends during a month-long ordeal.

Coronavirus (COVID-19) has been a life-changing experience for both individuals and institutions. We describe changes in our practice based on real-time assessment of various national and international trends of COVID-19 and its effectiveness in the management of our resources. Initial risk assessment and peak resource requirement using the COVID-19 Hospital Impact Model for Epidemics (CHIME) and McKinsey models. Strengths, weaknesses, opportunities, and threats (SWOT) analysis of our practice's approach during the pandemic. Based on CHIME the community followed 60% social distancing, the number of expected new patients hospitalized at maximum surge would be 401, with 100 patients requiring ventilator support. In contrast, when the community followed 15% social distancing, the maximum surge of hospitalized new patients would be 1823 and 455 patients would require a ventilator. on April 15, the expected May requirement of ICU beds at peak would be 68, with 61 patients needing ventilators. The estimated surge numbers improved throughout April, and on April 22 the expected ICU bed peak in May would be 11.7, and those requiring ventilator would be 10.5. Simultaneously, within a month, our surgical waitlist grew from 585 to over 723 patients. Our SWOT analysis revealed our internal strengths and inherent weakness, relevant to the pandemic. A graded and a guarded response to this type of situation is crucial in managing patients in a large practice.

Managing Patients with Prostate Cancer During COVID-19 Pandemic: The Experience of a High-Volume Robotic Surgery Center.

Objectives: To report our experience and lessons learned as high-volume center of robotic surgery managing patients with prostate cancer since the beginning of the COVID-19 pandemic in our center. Materials and Methods: We described some critical changes in our routine to minimize the COVID infection among patients and health care workers. From March 1 to May 25, 2020, we described our actions and surgical outcomes of patients treated in our center during the pandemic. Results: Preventing hospital visits, we implemented some modifications in our office routine in terms of patient appointment, follow-up, and management of nonsurgical candidates. In this period, 147 patients underwent robot-assisted radical prostatectomy (RARP) without intraoperative complications. The median operative time and blood loss were 91 minutes (interquartile range [IQR] = 25) and 50 mL (IQR = 50), respectively. The median hospitalization time was 15.8 hours (IQR = 2.5). None of the patients of our study had COVID in the postoperative follow-up, and only two patients were rescheduled due to a positive rapid COVID test 1 day before surgery. The final pathology described 10 patients (6.8%) Grade Group (GrGp) 1, 34 (23.1%) GrGp 2, 31 (21%) GrGp 3, 16 (10.8%) GrGp 4, 37 (25.3%) GrGp 5, and 19 (13%) with deferred Gleason. Two patients, COVID negative, were readmitted due to infected lymphocele managed with antibiotic and Interventional Radiology drainage. Conclusion: Our experience managing patients with prostate cancer during the COVID-19 pandemic showed that changing the office routine, stratifying the patients according to the National Comprehensive Cancer Network (NCCN) risk, and adopting COVID-based criteria to select patients for surgery are necessary actions to maintain the best quality of treatment and minimize the viral infection among our oncological patients. In our routine, the RARP during the COVID pandemic is safe and feasible for patients and health care workers if the necessary precautions described in this article are taken.

Use of transversus abdominis plane block to decrease pain scores and narcotic use following robot-assisted laparoscopic prostatectomy.

The aim of this study was to assess whether transversus abdominis plane (TAP) blocks can be utilized to decrease patient pain scores and narcotic use during the first 24 h following robot-assisted laparoscopic prostatectomy (RALP). 100 patients received a TAP block with a mixture of 1.3% liposomal bupivacaine, 0.5% Marcaine and 0.9% NaCl prior to RALP. This was in addition to an already established pain management regiment, which included preoperative PO acetaminophen (650 mg), celecoxib (200 mg), and tolterodine ER (4 mg). These patients were prospectively followed and then retrospectively compared to a 1:1 propensity matched group of 100 patients that did not receive a TAP but did receive the preoperative PO medications. Pain scores were assessed on a scale from 1-10 in the PACU, as well as the surgical floor at 8, 16, and 24-h post-surgery. Intra-/post-operative narcotic use and time to ambulation following arrival to the surgical floor were also analyzed. Patient receiving TAP blocks had immediate post-op pain scores of 2.23 vs 4.26 for those not receiving TAP blocks (p = 0.000). The pain scores at 8, 16, and 24 h for TAP patients were 2.68, 2.62, and 2.62 as compared to 2.89, 2.87, and 3.36 for non-TAP patients. The difference was statistically significant for immediate and 24-h pain scores (p = 0.000, 0.001, respectively). On average, TAP block patients ambulated faster than non-TAP patients, 2.68 vs 4.91 h (p = 0.000). Intra-operative narcotic use was decreased in the TAP group for each of the opioids that were used: fentanyl 177.5 vs 205mcg (p = 0.001), morphine 5.5 vs 10 mg (p = 0.000), and hydromorphone 0.75 vs 1.75 mg (p = 0.001). Narcotic usage in the PACU was limited to hydromorphone and TAP patients used 0.7 mg compared to 1.36 mg (p = 0.003) for non-TAP patients. Oral oxycodone/acetaminophen (5 mg/325 mg) was used for pain control on the surgical floor and on average TAP patients received less, 2.4 vs 5 tabs (p = 0.000). Average time to perform the TAP block was 3.5 min and total OR time for TAP vs non-TAP patients was 107.41 vs 106.58 min (p = 0.386). TAP blocks as part of a perioperative pain management protocol can be utilized during RALPs to decrease patient pain scores at two different time intervals, immediately post-operative and 24 h after surgery. Patients also ambulate sooner following surgery and require a decreased amount of narcotics during the intra-operative and post-operative periods. TAP blocks are quick, effective, and do not add a significant amount of OR time to RALPs.

The surgical learning curve for salvage robot-assisted radical prostatectomy: a prospective single-surgeon study.

BACKGROUND: The aim of this study was to report the overall results and the learning curve (LC) in salvage robot-assisted radical prostatectomy (sRARP) patients, in terms of morbidity, oncological and functional outcomes in a single surgeon tertiary-referral center. METHODS: One hundred and twenty patients underwent sRARP by a single surgeon (V.P.) from 2008 to 2018. To assess the trends in the learning experience they were sub-divided in 4 groups of 30 consecutive patients based on date of surgery. The Kaplan-Meier method and regression models were used to identify survival estimations and predictors of potency, continence and biochemical failure (BCF) at 12 months. RESULTS: As the learning experience for sRALP increased operative time (OT) was significantly shorter (from 139.5 to 121 minutes) and the amount of nerve-sparing (NS) undertaken increased (from 46% to 80%). While complications rate remained stable, estimated blood loss (EBL) and radiographic anastomotic leaks (RAL) decreased through the groups (from 124 to 69 ml and 40% to 16,7%, respectively). BCF and continence rates at 12 months after sRARP were similar among groups (23-36% and 36,7-50%, respectively) and chance of potency rates tended to increase (from 3.3% to 16-23%) but was not statistically significant. In a multivariate analysis, predictors for BCF were PSM and GS 8-10. Non-radiation primary treatment was the unique predictor of continence at 12 months after sRARP. CONCLUSIONS: Our data may suggest a decreasing trend in terms of OT and EBL through the sRARP learning curve. While morbidity remained stable through the time, RAL trended towards a decline. A higher degree of NS was observed through the groups and there was a slight correlation trend between surgical expertise and potency recovery. PSM and GS 8-10 were predictors of BCF and non-radiation primary treatment predicted a better continence after sRARP.

Evidence-based evolution of our robot-assisted laparoscopic prostatectomy (RALP) technique through 13,000 cases.

Robot-assisted laparoscopic radical prostatectomy (RALP) has become the standard of surgical care in the USA and around the world. Over the past 18 years, we have performed 13,000 radical prostatectomies, and our surgical technique has evolved over time. We discuss this evolution and how it has helped us achieve optimal patient outcomes.

Applications of the da Vinci single port (SP) robotic platform in urology: a systematic literature review.

INTRODUCTION: Robotic surgical technology has evolved to include a new platform specifically designed for the single-port (SP) approach. Benefits of the da Vinci SP are still under investigation. This study aimed to review the urological literature since the first report of the use of the platform. EVIDENCE ACQUISITION: We performed a systematic literature review of PubMed, Medline, and Web of Science databases on June 15, 2020 searching for all available articles of da Vinci SP use from December 2014 (date of the first clinical report of da Vinci SP in the urology) until June 1, 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines. EVIDENCE SYNTHESIS: A total of 43 articles were eligible for inclusion. Ten studies reported different surgeries and techniques on cadavers while the rest described the clinical experience of different groups. We divided our article and tables into preclinical experience with surgery on cadavers, radical prostatectomy (RP) approach, and multiple types of procedures described in the same study. CONCLUSIONS: The application of da Vinci SP in urologic procedures after five years of the first clinical investigation is feasible and safe. Radical prostatectomy is the most common intervention performed with this robot. Some groups described benefits in terms of less postoperative pain and early discharge, especially with the extraperitoneal approach. However, further studies with larger sample sizes and longer follow-up are awaited.

Early outcomes of single-port robot-assisted radical prostatectomy: lessons learned from the learning-curve experience.

OBJECTIVE: To describe the crucial factors related to the implementation of the da Vinci single-port (SP) system (Intuitive Surgical Inc., Sunnyvale, CA, USA), and the early outcomes after the introduction of this robot for robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: We prospectively collected data from 50 consecutive patients with prostate adenocarcinoma who underwent RARP using this robot. The median follow-up was 53 days. We performed a transperitoneal technique. The robotic (multiport) trocar was placed on the supra-umbilical midline 20 cm from the pubis and an assistant trocar placed in the right lower quadrant. We report our initial experience describing the intra- and postoperative outcomes associated with this new robot. Also, we report the early functional and oncological outcomes in the follow-up period considered. Continuous variables were described as medians and interquartile ranges, while categorical variables as frequencies and proportions. RESULTS: The median total operative time was 118 min, median console time was 80 min, and median estimated blood loss was 50 mL. There were no intraoperative complications or blood transfusions. The final pathology reported 18% Grade Group (GrGp)1, 58% GrGp2, 18% GrGp3, 2% GrGp4, and 4% GrGp5. In all, 40 patients (80%) were pT2 and 20% were ≥pT3a. The overall positive surgical margin rate was 14%. In all, 39 patients (78%) achieved full continence at median of 21 days after RARP. The median pain scale (0-10) score at 8, 12 and 16 h after RARP was 2, 2, and 0, respectively. CONCLUSION: The use of the da Vinci SP robot with an additional assistant port for RARP is technically safe and feasible, with acceptable short-term functional and oncological outcomes. However, there is a technical learning curve for this new platform due to the smaller scope of the operative field and the decreased flexibility and strength of the surgical instruments.

Modified Apical Dissection and Lateral Prostatic Fascia Preservation Improves Early Postoperative Functional Recovery in Robotic-assisted Laparoscopic Radical Prostatectomy: Results from a Propensity Score-matched Analysis.

BACKGROUND: Early recovery of continence and potency after robotic-assisted laparoscopic prostatectomy (RALP) still remains a challenge. OBJECTIVE: To assess the effect of our modified apical dissection and lateral prostatic fascia preservation (mod-RALP) technique on early functional outcomes. DESIGN, SETTING, AND PARTICIPANTS: Among 2168 patients who underwent RALP between 2017 and 2019, 104 received a mod-RALP, and for the purposes of this study they were propensity score (PS) matched with a control group of conventional RALP cases based on preoperative and histological characteristics. SURGICAL PROCEDURE: In the mod-RALP technique, significant dissection of the apical complex was avoided with maximized preservation of periurethral tissue around the urethral stump. Nerve sparing was also modified with intrafascial dissection inside of the lateral fascia, leaving the lateral tissue including the neurovascular bundle (NVB) untouched and covered. MEASUREMENTS: The mod-RALP and conventional RALP groups were compared for continence and potency recovery at 1 and 6 wk postoperatively, as well as at 3, 6, and 12 mo. Kaplan-Meier curves and multivariate Cox regression models were used to identify survival estimations and their predictors. RESULTS AND LIMITATIONS: The mod-RALP technique resulted in faster continence (mean 46 vs 70 d) and potency (mean 74 vs 118 d, p < 0.05 for both) recovery. Functional recovery rates at postoperative follow-up were significantly higher in the mod-RALP group at all time points within the first 6 mo following surgery. Multivariate analyses revealed age, baseline functional status, surgical technique, and lymph node dissection as independent predictors of early functional recovery. This study is limited by its retrospective design and small size of the study groups. CONCLUSIONS: Our results with a modified technique intended to better preserve the apical complex and NVBs suggest earlier recovery of urinary continence and sexual function. These results should be tested with future randomized studies. PATIENT SUMMARY: We report a modified approach to apical dissection and lateral prostatic fascia preservation in robotic-assisted laparoscopic prostatectomy that resulted in earlier continence and potency recovery as compared with our conventional technique.

Trends in clinical and oncological outcomes of robot-assisted radical prostatectomy before and after the 2012 US Preventive Services Task Force recommendation against PSA screening: a decade of experience.

OBJECTIVE: To assess the influence of the 2012 US Preventive Services Task Force (USPSTF) recommendation against prostate-specific antigen (PSA)-based screening on oncological and functional outcomes following robot-assisted laparoscopic prostatectomy (RALP). MATERIALS AND METHODS: We retrospectively analysed patients who underwent RALP between 2008 and 2018 with a minimum of 12-month follow-up from a prospectively collected institutional review board-approved database. The impact of the USPSTF recommendation against PSA screening on our surgical outcomes was assessed using a logistic regression model using two groups comprising patients treated before/after the USPSTF statement and indicating time trends for each successive year. RESULTS: The mean preoperative PSA increased from 6.0 to 7.4 ng/mL after the USPSTF recommendation. We detected statistically significant time-trend changes after 2012, including an increase in the positive slope of Gleason ≥3 + 4 or ≥pT3 disease. We detected a fall in bilateral full nerve-sparing and an increase in partial nerve-sparing. The total positive surgical margin (PSM) rate increased after the USPSTF recommendation; however, PSM rates pertinent to each pathological stage did not change significantly after 2012. There was a significant negative trend change in the postoperative 12-month continence and potency rates, indicating a breakpoint in functional outcomes after 2012. We detected a 1.7-fold increase in 12-month biochemical recurrence (BCR) rates. The 12-month BCR, potency and continence rates were maintained in young (<55 years) patients with a Sexual Health Inventory for Men score >22 and low-volume disease. CONCLUSION: Since the USPSTF's recommendation in 2012, we have seen a significant increase in the incidence of high-risk disease that has forced us to modify our approach to the procedure and the grade of nerve-sparing used, leading to a wider resection, in order to reduce PSMs. This has led to a decrease in postoperative functional recovery. Patients with favourable characteristics had good outcomes before and after the USPSTF's recommendation, implying that the quality of surgery did not change over time.

Lessons learned from 12,000 robotic radical prostatectomies: Is the journey as important as the outcome?

Robotic radical prostatectomy (RARP) is a standardized treatment for localized prostate cancer, which provides better functional outcomes and similar oncological outcomes compared to open approaches. Here, we share our experience of 12,000 RARPs by describing the outcomes of the procedure in terms of positive surgical margin (PSM), continence, and potency as well as by presenting our detailed surgical technique with recent modifications. On cancer control, the PSM rates were 5.8% and 26.1% in T2 and T3, respectively. On the premise of not compromising oncologic outcomes, a tailored approach to individual patients is essential. Even if an extracapsular extension is suspected, neurovascular bundle (NVB) tailoring can be applied using an anatomical landmark to preserve maximal nerve tissue with a negative margin. We developed a nomogram as a useful tool for deciding the degree of tailoring. For improvements of functional outcomes, we used athermal retrograde early release with a toggling technique, wherein the nerve dissection from the bottom helps with blood loss and allows for smooth NVB releasing. Additionally, we recently performed a new minimal apical dissection/lateral prostatic fascia preservation technique. As a result, our 1-week continence rate was 37% and the 6-week rate was 77.6%. In addition, the potency rates in our study were 69%, 82%, and 92% at 3 months, 6 months, and 1 year, respectively (preoperative Sexual Health Inventory for Men scores >21 & bilateral full nerve spared).