Operative Details and Oncological and Functional Outcome of Robotic-Assisted Laparoscopic Radical Prostatectomy: 400 Cases with a Minimum of 12 Months Follow-up

doi:10.1016/j.eururo.2008.12.035

European Urology

Volume 55, Issue 6, June 2009, Pages 1358-1367

https://doi.org/10.1016/j.eururo.2008.12.035 Get rights and content

Abstract

Background

Robotic-assisted laparoscopic radical prostatectomy (RALP) using the da Vinci^® surgical system (Intuitive Surgical, Sunnyvale, CA) is increasingly used for the management of localised prostate cancer.

Objective

We report the operative details and short-term oncological and functional outcome of the first 400 RALPs performed at our unit.

Design, setting and participants

From December 2003 to August 2006, 400 consecutive patients underwent RALP at our institution. A prospective database was established to record the relevant details of all RALP cases.

Surgical procedure

A six port transperitoneal approach using a 4-arm da Vinci^® system was used to perform RALP. This database was reviewed to establish the operative details and oncological and functional outcome of all patients with a minimum of 12 months follow-up.

Measurements

Perioperative characteristics and outcomes are reported. Functional outcome was assessed using continence and erectile function questionnaires. Biochemical recurrence (prostate-specific antigen (PSA) ≥0.2 ng/mL) is used as a surrogate for cancer control.

Results and limitations

The mean age ± standard deviation (SD) was 60.2 ± 6 years. Median PSA level was 7.0 (interquartile range (IQR) 5.3–9.6) ng/mL. The mean operating time ± SD was 186 ± 49 mins. The complication rate was 15.75% comprising Clavien grade I-II and Clavien grade III complications in 10.5% and 5.25% of patients respectively.

The overall positive surgical margin rate was 19.2% with T2 and T3 positive margin rates of 9.6% and 42.3% respectively. The biochemical recurrence-free survival was 86.6% at a median follow-up of 22 (IQR = 15–30) months. At 12 months follow-up, 91.4% of patients were pad-free or used a security liner. Of those men previously potent (defined as Sexual Health Inventory for Men [SHIM] score ≥21) who underwent nerve-sparing RALP, 62% were potent at 12 months.

Conclusions

The safety and feasibility of RALP has already been established. Our initial experience with this procedure shows promising short-term outcomes.

Introduction

Tens of thousands of patients with localised prostate cancer have now undergone robotic-assisted laparoscopic radical prostatectomy (RALP) using the da Vinci^® surgical system (Intuitive Surgical, Sunnyvale, CA). The feasibility and safety of this procedure have been well established since its introduction in 2000, and reports from high-volume centres suggest excellent short and medium-term functional and oncological outcomes for patients undergoing this procedure [1], [2].

We installed the first da Vinci^® surgical system in Australia in 2003, and to date have performed over 800 RALPs. Four hundred of our patients have completed a minimum of one year follow-up. Our technique has evolved over five years as our experience has developed. We report and demonstrate our technique as it currently stands. The peri-operative characteristics and short-term functional and oncological outcomes for this cohort are also reported.

Section snippets

Patient selection & preparation

Following a period of training which included visits to experienced centres and da Vinci^® dry and cadaveric laboratory training, two experienced open surgeons with no previous laparoscopic experience started our RALP programme in December 2003. A mentor was present for the first few cases. All patients with primary localised prostate cancer considered suitable for open radical prostatectomy were offered RALP.

Patient positioning and port placement

The patient is placed in low lithotomy position and secured to the table taking care to

Perioperative parameters

From December 2003 to August 2006, 400 consecutive patients underwent RALP at our institution. Patient characteristics and peri-operative parameters are summarized in Table 1. The mean total operative time dropped below 200 min after 50 cases and dropped to a series mean of 186 min soon after (Fig. 11). Thirty-eight patients underwent pelvic lymph node dissection.

In total, 63 patients had complications (15.75%). Of these, 42 (10.5% of series) had Clavien grade I/II complications not requiring any

Discussion

The penetration of RALP into the radical prostatectomy market in the past five years has been remarkable. Though there is no level I evidence to support its use over conventional laparoscopic radical prostatectomy (LRP) or open radical prostatectomy, reports from centres of excellence suggest RALP is a low morbidity procedure producing PSM rates of 9.3–20.9% and potency and continence rates of 70–80% and 90.2–95% respectively [1], [2], [5], [6]. Whilst debate continues about the evidence-base

Conclusions

The safety and feasibility of RALP has already been established. This paper adds to the evidence of good short-term oncological outcomes for patients undergoing RALP for localised prostate cancer. The technique of RALP continues to evolve which may lead to further improvements in oncological and functional outcomes.

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Is early continence recovery related to the length of spared urethra? A prospective multicenter study comparing preoperative MRI and histologic specimen measurements after robotic radical prostatectomy
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Urinary incontinence (UI) is a common complication after radical prostatectomy, significantly affecting patients' quality of life. This study aimed to correlate the length of preserved urethra in robotic radical prostatectomy (RALP) patients with short-term urinary continence rates within 90 days post-surgery.
A prospective multicentric study enrolled 190 prostate adenocarcinoma patients undergoing RALP. Using preoperative magnetic resonance imaging (mpMRI), urethral length was measured from the external urethral sphincter to the bladder neck. After surgery, histological measurements of the removed urethra were compared to the preoperative mpMRI data. Patients were categorized into two groups at the three-month follow-up based on urinary continence assessed through Urodynamic Study (UDS): Group A (94 patients without UI) and Group B (96 patients with UI).
Results revealed a significant difference in mean UI recovery time (Group A: 12.35 days, SD: 3.09 vs. Group B: 93.86 days, SD: 34.8, p < 0.0001). A ROC curve identified a 16.5% cut-off value (p < 0.000, sensitivity 87.5%, specificity 91.8%). Both groups showed a significant negative correlation between preserved urethral percentage and UI recovery time (Group A: r −0.655, p < 0.0001; Group B: r −0.340, p: 0.017). Group A had an average of 21.52% preserved urethra, while Group B had 13.86% (p < 0.0001). At one-year follow-up, 93.2% overall patients reported urinary continence without pads.
This study emphasizes the positive correlation between preserved urethra percentage in RALP and early urinary continence recovery, highlighting its surgical significance.
Incidence of Rectal Injury After Radical Prostatectomy: A Systematic Review and Meta-analysis
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Rectal injury (RI) is a dreaded complication after radical prostatectomy (RP), increasing the risk of early postoperative complications, such as bleeding and severe infection/sepsis, and late sequelae, such as a rectourethral fistula (RUF). Considering its traditionally low incidence, uncertainty remains as to predisposing risk factors and management.
To examine the incidence of RI after RP in contemporary series and to propose a pragmatic algorithm for its management.
A systematic literature search was performed using the Medline and Scopus databases. Studies reporting data on RI incidence were selected. Subgroup analyses were conducted to assess the differential incidence by age, surgical approach, salvage RP after radiation therapy, and previous benign prostatic hyperplasia (BPH)-related surgery.
Eighty-eight, mostly retrospective noncomparative, studies were selected. The meta-analysis obtained a pooled RI incidence of 0.58% (95% confidence interval [CI] 0.46–0.73) in contemporary series with significant across-study heterogeneity (I² = 100%, p < 0.00001). The highest RI incidence was found in patients undergoing open RP (1.25%; 95% CI 0.66–2.38) and laparoscopic RP (1.25%; 95% CI 0.75–2.08) followed by perineal RP (0.19%; 95% CI 0–276.95) and robotic RP (0.08%; 95% CI 0.02–0.31). Age ≥60 yr (0.56%; 95% CI 0.37–06) and salvage RP after radiation therapy (6.01%; 95% CI 3.99–9.05), but not previous BPH-related surgery (4.08%, 95% CI 0.92–18.20), were also associated with an increased RI incidence. Intraoperative versus postoperative RI detection was associated with a significantly decreased risk of severe postoperative complications (such as sepsis and bleeding) and subsequent formation of a RUF.
RI is a rare, but potentially devastating, complication following RP. RI incidence was higher in patients ≥60 yr of age, and in those who underwent open/laparoscopic approach or salvage RP after radiation therapy. Intraoperative RI detection and repair apparently constitute the single most critical step to significantly decrease the risk of major postoperative complications and subsequent RUF formation. Conversely, intraoperatively undetected RI can lead more often to severe infective complications and RUF, the management of which remains poorly standardised and requires complex procedures.
Accidental rectum tear is a rare, but potentially devastating, complication in men undergoing prostate removal for cancer. It occurs more often in patients aged 60 yr or older as well as in those who underwent prostate removal via an open/laparoscopic approach and/or prostate removal after radiation therapy for recurrent disease. Prompt identification and repair of this condition during the initial operation are the key to reduce further complications such as the formation of an abnormal opening between the rectum and the urinary tract.
Rectal Perforation During Pelvic Surgery
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Citation Excerpt :
Historical series reported an incidence of RIs during RP that ranges from 0.5% to 9%; in this setting, RI occurrence is seemingly higher during the transperineal access [4,5]. When considering open retropubic, laparoscopic, and robotic RP, the incidence of rectal perforation across a single series is summarized in Table 1 [6–20]. It has been argued that the incidence of RIs is unreported in the most recent literature likely due to a lower occurrence [3].
Rectal perforations during pelvic surgery are rare but serious complications. The occurrence of rectal involvement is generally lower than that of the involvement of other portions of the bowel. The urologic field is responsible for the majority of iatrogenic rectal injuries from pelvic surgery; general and gynecologic surgeries are prone to the occurrence as well, the latter especially in the case of rectal shaving for deep infiltrating endometriosis. Attention should be posed to the prevention of rectal injuries, especially in case of challenging or salvage procedures; some tricks may be recommended to avoid thermal and mechanical damages and to realize a safe dissection. Intraoperative detection of rectal injuries is of paramount importance; once confirmed, immediate management with the closure of the defect is recommended. In general, rectal injuries diagnosed after surgery are liable to significantly worse outcomes than those detected and managed intraoperatively.
Rectal perforation is a rare but possible complication of pelvic surgeries. The more challenging the procedure (ie, surgery for locally advanced tumors or after radiation therapy), the higher the risk of rectal lesion. Intraoperative management of the injury should be attempted, with direct repair of the defect with or without fecal diversion.
The Management of Intra-abdominal Complications Following Peritoneal Flap Vaginoplasty
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To describe the authors’ experience diagnosing and managing intra-abdominal complications following robotic peritoneal flap vaginoplasty. The peritoneal flap vaginoplasty is a technique used to achieve consistent vaginal depth regardless of available natal tissue. Intra-abdominal complications following robotic peritoneal flap creation are rare but prompt diagnosis and management is critical to preventing patient harm. Given the infancy of the technique there is limited data on associated complications and their management.
Retrospective chart review identified patients undergoing robotically assisted peritoneal flap vaginoplasty by the senior authors between 2017 and 2020 who subsequently developed intra-abdominal complications requiring readmission and/or return to the operating room. Patient charts were analyzed for preoperative demographics, medical comorbidities, intraoperative details, postoperative complication presentation, diagnosis, management, and long-term outcomes.
Out of 274 patients undergoing peritoneal flap vaginoplasty during the study period, six patients were identified who developed intra-abdominal complications (2.2%). One patient developed a postoperative hematoma requiring return to the operating room for diagnostic laparoscopy and hematoma evacuation. Two patients developed intraabdominal abscesses requiring diagnostic laparoscopy and abscess drainage. One patient developed recurrent episodes of small bowel obstructions that resolved with bowel rest. Two patients developed incarcerated internal hernias requiring diagnostic laparoscopy and internal hernia reduction. In one case, the hernia occurred at the peritoneal flap closure site, and in the other case the hernia occurred at the peritoneal flap donor site.
Intra-abdominal complications following robot assisted peritoneal flap vaginoplasty are rare. In addition to hematoma and abscess, small bowel incarceration and internal hernias are potential complications of peritoneal flap vaginoplasty that require prompt attention.
Intraoperative Adverse Incident Classification (EAUiaiC) by the European Association of Urology ad hoc Complications Guidelines Panel[Formula presented]
2020, European Urology
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The success of this system is linked to its logical design and reproducibility. The Clavien-Dindo system (CDS) has previously been applied in urological surgery [6–12]. Various authors have reported limitations when using the CDS to grade intraoperative AIs [7,11–13] as it was originally designed to report postoperative complications.
A surgical adverse incident (AI) is defined as any deviation from the normal operative course. Current complication-grading systems mostly focus on postoperative events.
To propose an intraoperative AI classification (EAUiaiC) to facilitate reporting.
The classification was developed using a modified Delphi process in which experts answered two rounds of survey questionnaires organised by the European Association of Urology ad hoc Complications Guidelines Panel. Experts evaluated AI terminology using a 5-point Likert scale for clarity, exhaustiveness, hierarchical order, mutual exclusivity, clinical utility, and quality improvement.
We considered ≥70% agreement for inclusion or exclusion. The resultant EAUiaiC was evaluated using ten sample clinical scenarios. Numerical and graphical statistical techniques were used to report the results.
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We propose a novel intraoperative AI classification (EAUiaiC) for use for urological procedures. Both the initial assessment of feasibility and the subsequent assessment of reliability suggest that it is a simple and effective tool for classifying intraoperative complications.
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To compare pre- and post-radical prostatectomy (RP) responses in the urinary incontinence domain of Expanded Prostate Cancer Index Composite-26 (EPIC-26) in cohorts from the USA, Norway and Spain.
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Compared to the European men, the American patients were younger, healthier and more presented with lower risk tumors. Before RP no inter-country differences emerged the prevalence of urinary incontinence (6%). One-year post-treatment urinary incontinence was described by 30% of the American and 41% of the European patients, occasional dribbling being the most frequent type of urinary leakage. In the multivariate analysis the risk of “not retaining total control” increased almost 3-fold in European compared to American patients, with age and co-morbidity being additional independent risk factor.
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Surgery in MotionOperative Details and Oncological and Functional Outcome of Robotic-Assisted Laparoscopic Radical Prostatectomy: 400 Cases with a Minimum of 12 Months Follow-up☆

Abstract

Background

Objective

Design, setting and participants

Surgical procedure

Measurements

Results and limitations

Conclusions

Introduction

Section snippets

Patient selection & preparation

Patient positioning and port placement

Perioperative parameters

Discussion

Conclusions

Urology

Eur Urol

Eur Urol

Urology

J Urol

Eur Urol

Eur Urol

Evolution of robotic radical prostatectomy: assessment after 2766 procedures

Cancer

Surgery in Motion
Operative Details and Oncological and Functional Outcome of Robotic-Assisted Laparoscopic Radical Prostatectomy: 400 Cases with a Minimum of 12 Months Follow-up☆