Abaza, R., P. P. Dangle, et al. (2012). “Quality of Lymphadenectomy is Equivalent With Robotic and Open Cystectomy Using an Extended Template.” Journal of Urology.
PURPOSE: Extended lymph node dissection for bladder cancer provides better staging, cancerous node removal and potentially survival. Minimally invasive techniques have been criticized about the ability to adequately perform extended lymph node dissection. We compared the extended lymph node dissection quality of robotic and open cystectomy by assessing node yield and positivity. MATERIALS AND METHODS: We compared extended lymph node dissection in 120 open and 35 robotic cystectomy cases. Extended lymph node dissection included skeletonization of structures in each nodal group below the aortic bifurcation (common iliac, external iliac, obturator, hypogastric and presacral nodes). Nodes were processed identically but submitted as 1 or 2 packets for robotic cases and as 10 or more packets for open surgery cases. RESULTS: The mean +/- SD node count in the open group was 36.9 +/- 14.8 (range 11 to 87) and in the robotic group the mean yield was 37.5 +/- 13.2 (range 18 to 64). Only 12 of 120 open (10%) and 2 of 35 robotic (6%) cases had fewer than 20 nodes. A total of 36 open (30%) and 12 robotic (34%) cases were node positive. Open extended lymph node dissection identified 80% and 90% confidence of accurate staging as pN0 when obtaining 23 and 27 nodes, respectively. A node count of 23 or 27 was achieved in 87% and 77% of open cases, and in 91% and 83% of robotic cases, respectively. Of patients with open surgery 36% received neoadjuvant chemotherapy compared to 31% of those with robotic surgery. CONCLUSIONS: No difference was identified in the lymph node yield or the positive node rate when comparing open and robotic extended lymph node dissection. Local recurrence and survival data are needed to confirm whether the 2 techniques are oncologically equivalent.
Niegisch, G., P. Albers, et al. (2012). “Robot-assisted radical cystectomy – Do we actually need a robot?” Roboterassistierte radikale Zystektomie – Brauchen wir den Roboter tatsächlich?: 1-5.
Compared to radical prostatectomy robotic surgery is far from becoming the standard of care for radical cystectomy. Concerns about perioperative and oncological safety as well as patient’s benefit from this procedure may be a reason. In current publications no differences of perioperative morbidity and mortality were observed between patients undergoing open or robot-assisted radical cystectomy. Interestingly, older patients or patients with impaired health status might even profit from this technique. Though long-term data are missing, oncological results of robot-assisted radical cystectomy are encouraging. Extended lymphadenectomy is possible and positive margins are not seen more frequently. Concerning functional results (continence, potency) only little information is evaluable. In summary, operative and oncological outcomes do not seem to be impaired by robot assistance in radical cystectomy. However, whether patients or patient subgroups truly benefit from robot-assisted cystectomy needs to be elucidated in the future. © 2012 Springer-Verlag.
Poch, M. A., A. Stegemann, et al. (2012). “Does Body Mass Index Impact the Performance of Robot-Assisted Intracorporeal Ileal Conduit?” Journal of Endourology.
Introduction: Body mass index (BMI) has been shown to influence perioperative outcomes for patients undergoing open radical cystectomy and urinary diversion. However, the impact of BMI on robot-assisted intracorporeal ileal conduit has not been studied. Patients: All patients undergoing robot-assisted radical cystectomy (RARC) with ileal conduit at our institution were offered intracorporeal ileal conduit beginning May 2009. Fifty-six consecutive patients underwent robot-assisted radical cystectomy with intracorporeal ileal conduit from May of 2009 to July 2010. Methods: Patients were categorized into 3 groups based on BMI: normal (BMI<25 kg/m2), overweight (BMI=25-29 kg/m2) and obese (BMI>/=30 kg/m2). The effect of BMI on intraoperative and postoperative outcomes was assessed by retrospective review of a comprehensive RARC quality assurance database. Results: Median age at cystectomy was 72 (range, 42-87) and 75% of patients were male. Median follow -up for the entire cohort was 5 months (range 12 days-16 months). Median BMI was 27 kg/m2 (range 19-47) and 75% of patients were overweight or obese. Age, ASA score, and overall operative time were not significantly different among the normal, overweight and obese patients. Median urinary diversion times were 95, 151 and 124 minutes for normal, overweight and obese patients, respectively (p = 0.13). Conclusions: Robot-assisted intracorporeal ileal conduit can be safely performed in all body mass indices. Further studies are needed to assess long term conduit function and stomal complications.
Broul, M., J. Schraml, et al. (2011). “Kidney tumour resection using the da Vinci S HD system. our initial experience.” Resekce tumorů ledvin pomocí systému da Vinci S HD. naše první zkušenosti 20(3): 86-88.
The paper evaluates our initial experience with robotic kidney surgery, particularly that with kidney tumour resection. At our centre, the da Vinci S HD robotic system by Intuitive Surgical is used. The first surgery was performed on 19th August, 2008, and by 1st May, 2011 a total of 67 kidney surgeries have been carried out, out of which 42 were surgeries for kidney tumour. The paper evaluates the total surgery time, intraoperative as well as postoperative complications, histological outcomes and length of hospital stay.
Castillo, O. A., A. Rodríguez-Carlin, et al. (2012). “Robotic partial nephrectomy: An initial experience in 25 consecutive cases.” Nefrectomía parcial robótica: experiencia inicial en 25 casos consecutivos 36(1): 15-20.
Objective: To report our initial experience with robotic partial nephrectomy (RPN) in a series of 25 consecutively-operated patients. Material and methods: A series of 25 consecutive patients who underwent RPN from April 2010 to February 2011 were studied. We used the da Vinci S HD robotic system with transperitoneal approach. Total renal hilum control was used 22 cases and 3 patients underwent selective renal parenchymal compression with an ad-hoc device. Results: Mean age was 55.8 years (26-77) with a male/female ratio of 2:1. Mean operative time was 117.6 minutes (54-205) and the warm ischemia time was 20.2 minutes (9-34). Mean estimated blood loss was 440 ml (20-2000) and the mean tumor size was 3.25 cm (1-5.3). Five patients (20%) had complications, the most frequent being intraoperative bleeding (Clavien II). There was no conversion to open or laparoscopic surgery. Mean hospital stay was 3.5 days (1-7). The pathological study revealed renal cell carcinoma in 19 cases and benign lesions in 6 patients. There were no positive surgical margins and no mortality. Conclusions: Our preliminary results show that RPN is a feasible surgical approach in small-sized renal tumors. © 2011 AEU. Published by Elsevier España, S.L. All rights reserved.
de Gorski, A. and C. E. Iselin (2011). “[Robotic partial nephrectomy: development and advantages].” Développement de la néphrectomie partielle robotisée: avantages. 7(320): 2410-2413.
Surgery is the first line of treatment of renal cell carcinoma. For small tumours confined to the kidney (< or = 4 cm), partial tumour resection has logically become the standard treatment. When technically feasible, partial nephrectomy may be applied to treat tumors less than 7 cm, according to 2010 recommendations of the European Association of Urology. In addition, nephron-sparing surgery has proven to positively impact on quality of life. Robotic-assisted laparoscopy partial kidney resection has recently emerged. Its indications are as yet undergoing validation, while open surgery still remains the gold standard. For the patients, the consequences of this minimally invasive evolution are evident: The comfort and postoperative recovery are respectively greater and faster compared to conventional open surgery.
Ficarra, V., S. Bhayani, et al. (2012). “Predictors of warm ischemia time and perioperative complications in a multicenter, international series of robotassisted partial nephrectomy.” Journal of Endourology 26(2): 99.
Hung, A. J., C. K. Ng, et al. (2012). “Validation of a novel robotic-assisted partial nephrectomy surgical training model.” BJU International.
Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? One area of particular growth for robotic surgery has been partial nephrectomy. Despite a perceived notion that robotic-assisted partial nephrectomy is more easily adaptable compared to laparoscopic partial nephrectomy, there is nonetheless an associated learning curve. Validated training models with a corresponding assessment method for robotic-assisted partial nephrectomy were previously unavailable. We have designed and validated a RAPN surgical model appropriate for resident and fellow training. OBJECTIVE: * To evaluate the face, content and construct validities of a novel ex vivo surgical training model for robotic-assisted partial nephrectomy (RAPN). METHODS: * We prospectively identified participants as novice (not completed any robotic console cases), intermediate (at least one robotic console case but <100 cases), and expert (>/=100 robotic console cases). Each participant performed a partial nephrectomy using the da Vinci Si Surgical System on an ex vivo porcine kidney with an embedded Styrofoam ball that mimics a renal tumour. Subjects completed a post-study questionnaire assessing training model realism and utility. Participants were anonymously judged by three expert reviewers using a validated laparoscopic assessment tool. Performance between groups was compared using the tukey-kramer test. RESULTS: * The 46 participants recruited for this study included 24 novices, nine intermediates, and 13 experts. Overall, expert surgeons rated the training model as ‘very realistic’ (median visual analogue score 7/10) (face validity). Experts also rated the model as an ‘extremely useful’ training tool for residents (median 9/10) and fellows (9/10) (content validity), although less so for experienced robotic surgeons (5/10). Experts outscored novices on overall performance (P= 0.0002) as well as individual metrics, including ‘depth perception,”bimanual dexterity,”efficiency,”tissue handling,”autonomy,”precision,’ and ‘instrument and camera awareness’ (P < 0.05) (construct validity). Experts similarly outperformed intermediates in most metrics (P < 0.05). CONCLUSION: * Our novel ex vivo RAPN surgical model has demonstrated face, content and construct validity. Future development of this model should include simulation of haemostasis management and renal reconstruction.
Papalia, R., G. Simone, et al. (2012). “Laparoscopic and Robotic Partial Nephrectomy With Controlled Hypotensive Anesthesia to Avoid Hilar Clamping: Feasibility, Safety and Perioperative Functional Outcomes.” Journal of Urology.
PURPOSE: We evaluated the feasibility and safety of laparoscopic and robotic assisted partial nephrectomy with controlled hypotensive anesthesia to avoid hilar clamping and eliminate renal ischemia. MATERIALS AND METHODS: A total of 60 patients with renal tumors who were candidates for nephron sparing surgery and had no contraindication to hypotensive anesthesia underwent partial nephrectomy without hilar clamping and with controlled hypotension during tumor excision. A total of 40 laparoscopic partial nephrectomies and 20 robotic assisted partial nephrectomies were done. All patients who were candidates for laparoscopic or robotic assisted partial nephrectomy regardless of tumor site, size or growth pattern were included in study. The surgical field was assessed for bleeding and visibility using a numerical rating scale. RESULTS: Median tumor size was 3.6 cm (range 1.8 to 10), median operative time was 2 hours (range 1 to 3.5), median blood loss was 200 ml (range 30 to 700 ml) and median hospital stay was 3 days (range 3 to 8). All margins were negative. The median duration of controlled hypotension with a median mean arterial pressure of 65 mm Hg (range 55 to 70) was 14 minutes (range 7 to 16). No patient required intraoperative transfusion but 4 (6.6%) required transfusion postoperatively. Complications developed postoperatively in 3 patients, ie port site bleeding, hemorrhage and hematoma, respectively. Median preoperative and postoperative serum creatinine was 0.9 and 1.10 mg/dl, respectively. The median preoperative and postoperative estimated glomerular filtration rate was 87.20 and 75.60 ml/minute/1.73 m(2), respectively. CONCLUSIONS: Controlled hypotension allowed laparoscopic and robotic assisted partial nephrectomy to be done without renal hilar clamping. All procedures were completed safely and perioperative outcomes are encouraging.
Pratt, P., E. Mayer, et al. (2012). “An effective visualisation and registration system for image-guided robotic partial nephrectomy.” Journal of Robotic Surgery: 1-9.
Robotic partial nephrectomy is presently the fastest-growing robotic surgical procedure, and in comparison to traditional techniques it offers reduced tissue trauma and likelihood of post-operative infection, while hastening recovery time and improving cosmesis. It is also an ideal candidate for image guidance technology since soft tissue deformation, while still present, is localised and less problematic compared to other surgical procedures. This work describes the implementation and ongoing development of an effective image guidance system that aims to address some of the remaining challenges in this area. Specific innovations include the introduction of an intuitive, partially automated registration interface, and the use of a hardware platform that makes sophisticated augmented reality overlays practical in real time. Results and examples of image augmentation are presented from both retrospective and live cases. Quantitative analysis of registration error verifies that the proposed registration technique is appropriate for the chosen image guidance targets. © 2012 Springer-Verlag London Ltd.
Shiroki, R., T. Maruyama, et al. (2011). “[Robot-assisted laparoscopic partial nephrectomy using daVinci S-surgical system for localized renal tumor: report of initial five cases].” Nihon Hinyokika Gakkai Zasshi 102(5): 679-685.
OBJECTIVES: For the management of patients with small renal tumor, laparoscopic partial nephrectomy (LPN) provides similar oncological control as radical nephrectomy (RN) and is superior to RN with respect to preserving renal function and preventing chronic kidney disease (CKD). The challenge of LPN is to resect a tumor in a bloodless field within a limited warm ischemia time (WIT) , followed by hemostatic renorrhaphy under restricted movement of laparoscopic forceps. Therefore, LPN still remains challenging to even experienced laparoscopic surgeon. DaVinci device improved the movability of forceps in LPN and provided three-dimensional visualization. We evaluated outcome and safety of our first series of robot-assisted laparoscopic partial nephrectomy (RALPN) for localized kidney tumor. There was no previous report of RALPN undertaken in our country. PATIENTS AND METHODS: Since August 2010, our team carried out RALPN for a total of five cases of renal tumor. There were four males and one female with an age range of 41 to 65 years-old. Size of tumor ranged from 15 to 28 mm, located in exophytic region, and four cases in right side and one in left. RALPN was undertaken by single surgeon through transperitoneal approach in two cases and retroperitoneal in tree. RESULTS: RALPN was completed in all patients without conversion to open or hand-assisted surgery. The median operative time and the estimated blood loss were 189 minutes, ranged from 150 to 264, and 29 ml, from 10 to 50, respectively. The median volume of removed tumor and the length of WIT were 7 g, ranged from 4 to 13 g, and 18 minutes, from 13 to 26 minutes, respectively. No complications or reoperations were associated during or post our RALPN cases. Pathological examination of removed tumor showed renal cell carcinoma with negative surgical margin in all cases. CONCLUSIONS: Introduction of daVinci device to LPN made this procedure, RALPN, a secured and promising one, which leading to shorten the WIT and to achieve satisfied renorrhaphy. Even for the complex and technically challenging renal tumors, robotic assistance is expected to provide patients the benefit of minimally invasive surgery with safety and satisfactory renal function.
Sivaraman, A., R. J. Leveillee, et al. (2012). “Robot-assisted laparoscopic dismembered pyeloplasty for ureteropelvic junction obstruction: A multi-institutional experience.” Urology 79(2): 351-355.
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 T 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. © 2012 Elsevier Inc. All Rights Reserved.
White, M. A., G. P. Haber, et al. (2012). “Commentary on “Outcomes of robotic partial nephrectomy for renal masses with nephrometry score of ≥7.”.” Urologic Oncology: Seminars and Original Investigations 30(1): 115-116.
Berglund, R. K. (2011). “Editorial comment.” Urology 78(5): 984.
Eden, C. G., E. Zacharakis, et al. (2012). “Incidence of lymphoceles after robot-assisted pelvic lymph node dissection.” BJU International 109(5): E14.
Janetschek, G. (2012). “Editorial Comment on END-2011-0214-CRT.R3 Laparoscopic RPLND: Is it safe, does it harm, what does the robot add?” Journal of Endourology.
EDITORIAL COMMENT on END-2011-0214-CRT.R3 Laparoscopic RPLND: Is it safe, does it harm, what does the robot add? G. Janetschek, Medical University Salzburg, Dept. of Urology.
Yu, H. Y., N. D. Hevelone, et al. (2012). “Use, Costs and Comparative Effectiveness of Robotic Assisted, Laparoscopic and Open Urological Surgery.” Journal of Urology.
PURPOSE: Although robotic assisted laparoscopic surgery has been aggressively marketed and rapidly adopted, there are few comparative effectiveness studies that support its purported advantages compared to open and laparoscopic surgery. We used a population based approach to assess use, costs and outcomes of robotic assisted laparoscopic surgery vs laparoscopic surgery and open surgery for common robotic assisted urological procedures. MATERIALS AND METHODS: From the Nationwide Inpatient Sample we identified the most common urological robotic assisted laparoscopic surgery procedures during the last quarter of 2008 as radical prostatectomy, nephrectomy, partial nephrectomy and pyeloplasty. Robotic assisted laparoscopic surgery, laparoscopic surgery and open surgery use, costs and inpatient outcomes were compared using propensity score methods. RESULTS: Robotic assisted laparoscopic surgery was performed for 52.7% of radical prostatectomies, 27.3% of pyeloplasties, 11.5% of partial nephrectomies and 2.3% of nephrectomies. For radical prostatectomy robotic assisted laparoscopic surgery was more prevalent than open surgery among white patients in high volume, urban hospitals (all p </=0.015). Geographic variations were found in the use of robotic assisted laparoscopic surgery vs open surgery. Robotic assisted laparoscopic surgery and laparoscopic surgery vs open surgery were associated with shorter length of stay for all procedures, with robotic assisted laparoscopic surgery being the shortest for radical prostatectomy and partial nephrectomy (all p <0.001). For most procedures robotic assisted laparoscopic surgery and laparoscopic surgery vs open surgery resulted in fewer deaths, complications, transfusions and more routine discharges. However, robotic assisted laparoscopic surgery was more costly than laparoscopic surgery and open surgery for most procedures. CONCLUSIONS: While robotic assisted and laparoscopic surgery are associated with fewer deaths, complications, transfusions and shorter length of hospital stay compared to open surgery, robotic assisted laparoscopic surgery is more costly than laparoscopic and open surgery. Additional studies are needed to better delineate the comparative and cost-effectiveness of robotic assisted laparoscopic surgery relative to laparoscopic surgery and open surgery.
Decastro, G. J., G. Jayram, et al. (2012). “Functional Outcomes in African-Americans Following Robotic-Assisted Radical Prostatectomy (RARP).” Journal of Endourology.
Background and Purpose: Previous studies have demonstrated differences in surgical outcomes following radical prostatectomy based on ethnicity. We compared sexual and urinary outcomes in African American (AA) patients 6 and 12 months following robotic-assisted radical prostatectomy (RARP) to non-AA patients. Patients and Methods: We reviewed our RARP database at our institution for patients with at least 12 months of follow-up. Erectile function was defined using the UCLA Prostate Cancer Index as erections “firm enough for masturbation and foreplay” or “firm enough for intercourse,” while urinary continence was defined as being “pad-free.” Only patients who were potent and pad-free preoperatively were included in the analysis. Multivariate logistic regression was used to compare post-operative potency and urinary pad-free status between AA and non-AA patients while controlling for pertinent demographic, clinical, and pathologic variables. Results: 140 AA patients and 576 non-AA patients were included in the urinary continence analysis, compared to 105 AAs and 500 non-AA patients included in the analysis of sexual function. At 12 months post-operatively a smaller proportion of AA patients were potent compared to non-AA patients (60% vs. 76.4%, p=0.001). Similarly, we found a lower incidence of pad-free status for AA patients at 12 months post-operatively (55.7% vs. 69.8%, p=0.039). Similar functional results were found at 6 months postoperatively for both analysis groups. Conclusion: AA men appear to have worse urinary and sexual outcomes at 12 months following RARP compared to non-AA patients. At 6 months, there is no statistically significant difference. Further, longer-term studies are needed to validate these results.
Fareed, K., O. M. Zaytoun, et al. (2012). “Robotic single port suprapubic transvesical enucleation of the prostate (R-STEP): initial experience.” BJU International.
Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Single port transvesical enucleation of the prostate (STEP) performed through a solitary suprapubic incision using a single access port inserted directly into the bladder has been demonstrated to be technically feasible but still challenging.3. Despite being feasible and providing adequate relief of bladder outlet obstruction, robotic STEP carries a high risk of complications. Further evolution of the technique is likely to be strictly dependent on the development of instrumentation. OBJECTIVE: * To report our initial experience with a novel robot assisted single port procedure for the management of benign prostatic hyperplasia (BPH). METHODS: * Between March 2009 and July 2010, nine patients with symptomatic BPH were scheduled for robotic single port suprapubic transvesical enucleation of the prostate (R-STEP). * Prior to intervention, all were submitted to preoperative transrectal ultrasound of the prostate and uroflowmetry. * The surgical procedure included an initial transurethral incision of the prostatic apex. With the patient in the supine position, an approximate 3 cm lower midline incision was made. A cystotomy was created and a GelPort(R) laparoscopic system positioned in the bladder. The da Vinci S robotic operating system was docked through the GelPort(R) platform and enucleation was performed. * Perioperative outcomes and short-term postoperative functional outcomes were assessed. Intra-operative and postoperative complications, graded according to the Dindo-Clavien system, were recorded. RESULTS: * One patient was excluded from the analysis as the procedure was aborted and converted to open simple prostatectomy. * Median operative time was 3.9 h. Median visual analogue pain scale on discharge was 2. Estimated blood loss was 425 mL. Two patients required intra-operative blood transfusion. * Postoperatively, two patients developed clot retention and required evacuation and fulguration (grade IIIb), one of them had a deep vein thrombosis (grade II) and a urinary tract infection (grade II). One patient was admitted to the intensive care unit after a myocardial infarction (grade IVa). All patients were discharged after a median of 4.5 days. * There was almost three and four times postoperative improvement in both median maximum flow (Qmax) and average flow (Qave) rates, respectively. CONCLUSION: * The first series of R-STEP is reported herein. Despite being feasible and providing adequate relief of bladder outlet obstruction, the procedure carries a high risk of complications. Further evolution of the technique is likely to be strictly dependent on the development of instrumentation. Thus, its role in the surgical armamentarium of BPH remains to be determined.
Gianino, M. M., M. Galzerano, et al. (2012). “Costs in surgical techniques for radical prostatectomy: A review of the current state.” Urologia Internationalis 88(1): 1-5.
Introduction: We carried out a mini-review of the literature in order to obtain a snapshot of the present state of the art of surgical techniques costs available for radical prostatectomy. Materials and Methods: We developed a MEDLINE search strategy and one economist assessed the included studies using the NHS EED guidelines for reviewers. Results: When observing costs by the author, it is possible to trace up a trend line of increasing costs which starts off with RPP, passes through RRP and LRP and ends up with robot-assisted radical prostatectomy. Two studies do not agree with this. One author claims that LRP is less costly than radical retropubic prostatectomy whereas another one agrees on radical perineal prostatectomy and radical retropubic prostatectomy but does not on RAP, which he claims to be less costly. Conclusions: The data shown in our study outline a situation by which the observed studies highlight: different costs of the techniques and incapability to achieve a conclusion about the technique with less average costs. These results can be considered in an explorative way and cannot be generalized. They maintain a strictly approximate value in local realities having only an informative purpose. Copyright © 2010 S. Karger AG, Basel.
Grimm, P., I. Billiet, et al. (2012). “Comparative analysis of prostate-specific antigen free survival outcomes for patients with low, intermediate and high risk prostate cancer treatment by radical therapy. Results from the Prostate Cancer Results Study Group.” BJU International 109 Suppl 1: 22-29.
What’s known on the subject? and What does the study add? Very few comparative studies to date evaluate the results of treatment options for prostate cancer using the most sensitive measurement tools. PSA has been identified as the most sensitive tool for measuring treatment effectiveness. To date, comprehensive unbiased reviews of all the current literature are limited for prostate cancer. This is the first large scale comprehensive review of the literature comparing risk stratified patients by treatment option and with long-term follow-up. The results of the studies are weighted, respecting the impact of larger studies on overall results. The study identified a lack of uniformity in reporting results amongst institutions and centres. A large number of studies have been conducted on the primary therapy of prostate cancer but very few randomized controlled trials have been conducted. The comparison of outcomes from individual studies involving surgery (radical prostatectomy or robotic radical prostatectomy), external beam radiation (EBRT) (conformal, intensity modulated radiotherapy, protons), brachytherapy, cryotherapy or high intensity focused ultrasound remains problematic due to the non-uniformity of reporting results and the use of varied disease outcome endpoints. Technical advances in these treatments have also made long-term comparisons difficult. The Prostate Cancer Results Study Group was formed to evaluate the comparative effectiveness of prostate cancer treatments. This international group conducted a comprehensive literature review to identify all studies involving treatment of localized prostate cancer published during 2000-2010. Over 18,000 papers were identified and a further selection was made based on the following key criteria: minimum/median follow-up of 5 years; stratification into low-, intermediate- and high-risk groups; clinical and pathological staging; accepted standard definitions for prostate-specific antigen failure; minimum patient number of 100 in each risk group (50 for high-risk group). A statistical analysis (standard deviational ellipse) of the study outcomes suggested that, in terms of biochemical-free progression, brachytherapy provides superior outcome in patients with low-risk disease. For intermediate-risk disease, the combination of EBRT and brachytherapy appears equivalent to brachytherapy alone. For high-risk patients, combination therapies involving EBRT and brachytherapy plus or minus androgen deprivation therapy appear superior to more localized treatments such as seed implant alone, surgery alone or EBRT. It is anticipated that the study will assist physicians and patients in selecting treatment for men with newly diagnosed prostate cancer.
Hutchinson, R. C., D. D. Thiel, et al. (2012). “The Effect of Robot-Assisted Laparoscopic Prostatectomy on Nocturia.” Journal of Endourology.
Introduction: Investigators have previously reported that men undergoing radical retropubic prostatectomy (RRP) for prostate cancer (PCa) can experience significant changes in nocturia following surgery. We examined the effect of robotic-assisted laparoscopic prostatectomy (RALP) on nocturia symptoms in PCa men from baseline to one year follow-up. Methods: Between August 2006 and August 2010, 116 patients undergoing RALP for clinically localized prostate cancer had baseline and 1 year Expanded Prostate Cancer Index Composite (EPIC) questionnaire data obtained. Patients were divided into three groups with respect to nocturia: N1 (0 or 1 episode per night), N2 (2 episodes per night), and N3 (3 or more episodes per night). Results: N1 (63 patients) had stable or worsened nocturia with 78% of patients retaining their N1 status, 21% progressed to N2 status and 2% progressed to N3. N2 (29 patients) were 52% N1, 34% N2 and 14% N3 after surgery. The N3 (24 patients) had 29% improved to N1, 38% improved to N2 and 33% remained N3. EPIC urinary function and incontinence subscale scores were 92.3 and 91.3 pre-intervention and 85.2 and 76.6, (p = <0.001 for both) respectively at follow up. The combination of improved obstructive symptomatology and continence after RALP resulted in no net change in urinary bother. Conclusions: RALP is associated with improved symptomatology in patients with the greatest level of pre-interventional nocturia. Patients with minimal preoperative nocturia may experience worsening of nocturia. There does not appear to be a difference between RRP and RALP with regards to post-operative nocturia.
Kheterpal, E., A. Bhandari, et al. (2012). “Commentary on “Management of rectal injury during robotic radical prostatectomy.”.” Urologic Oncology: Seminars and Original Investigations 30(1): 113.
Kowalczyk, K. J., H. Yu, et al. (2012). “Outcomes assessment in men undergoing open retropubic radical prostatectomy, laparoscopic radical prostatectomy, and robotic-assisted radical prostatectomy.” World Journal of Urology 30(1): 85-89.
Objectives: To review the various methods of outcomes assessment used for effectiveness studies comparing retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP), and robotic-assisted laparoscopic prostatectomy (RALP). Methods: A review of the peer reviewed literature was performed for reported series of RRP, LRP, and RALP using Pubmed and MEDLINE with emphasis on comparing perioperative, functional, and oncologic outcomes. Common methods used for outcomes assessment were categorized and compared, highlighting the pros and cons of each approach. Results: The majority of the literature comparing RRP, LRP, and RALP comes in the form of observational data or administrative data from secondary datasets. While randomized controlled trials are ideal for outcomes assessment, only one such study was identified and was limited. Non-randomized observational studies contribute to the majority of data, however are limited due to retrospective study design, lack of consistent endpoints, and limited application to the general community. Administrative data provide accurate assessment of operative outcomes in both academic and community settings, however has limited ability to convey accurate functional outcomes. Conclusions: Non-randomized observational studies and secondary data are useful resources for assessment of outcomes; however, limitations exist for both. Neither is without flaws, and conclusions drawn from either should be viewed with caution. Until standardized prospective comparative analyses of RRP, LRP, and RALP are established, comparative outcomes data will remain imperfect. Urologic researchers must strive to provide the best available outcomes data through accurate prospective data collection and consistent outcomes reporting. © 2011 Springer-Verlag.
Louie-Johnsun, M., R. Ouyang, et al. (2012). “Laparoscopic radical prostatectomy: Introduction of training during our first 50 cases.” ANZ Journal of Surgery.
Background: The study aims to assess the initial experience of laparoscopic radical prostatectomy (LRP) in a regional centre in Australia which includes Fellowship training during our first 50 cases. Methods: Data were collected prospectively from our first 50 consecutive patients who underwent LRP for localized prostate cancer between September 2009 and October 2010. All cases were performed or supervised by the primary surgeon. Patient details, operative details, complications, early oncological and functional outcomes were analysed. Results: The median age was 65 (45-76) years and median preoperative prostate-specific antigen was 7.5 (2.5-23) ng/mL, with palpable disease present in 48%. Using D’Amico’s risk stratification, 14%, 74% and 12% were in low, intermediate and high-risk categories, respectively. Forty percent of cases were training cases with a median of 5 (2-8) of 10 operative steps performed by the Fellow. There was one open conversion and no rectal injuries. Mean operative time was 288 (175-440)min and with blood transfusion rate of 6%. Mean length of stay was 2.5 (1-6)days. Positive surgical margin rates for pT2 and pT3 disease were 14% and 52%, respectively, although for the last 25 cases they were 7% and 30%, respectively. Continence rate was 86% at 6months, and 45% and 33% of preoperatively potent patients were potent after bilateral and unilateral nerve preservation at 6months. Conclusion: LRP has been safely introduced in a regional centre with establishment of a Fellowship training programme, with early results comparable with other open, laparoscopic and robotic series. © 2012 The Authors. ANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons.
Murphy, D. G. (2012). “A new standard for radical prostatectomy in Ireland?” Irish Journal of Medical Science: 1-2.
Mustafa, M. O. and L. L. Pisters (2011). “Salvage therapies for radiorecurrent prostate cancer.” Radiorekürren prostat kanseri için salvage terapiler 37(4): 350-356.
Locally recurrent prostate cancer after radiation therapy, also known as radiorecurrent prostate cancer, has an unfavorable prognosis. Two-thirds of patients with radiorecurrent prostate cancer have an advanced pathological disease status by the time they undergo salvage therapy. Several salvage therapies for radiorecurrent prostate cancer are available. Salvage radical prostatectomy (SRP) and salvage cryoablation are the most feasible and effective therapies for radiorecurrent prostate cancer. Although SRP is technically more difficult and has a higher complication rate than do other salvage therapies, the procedure provides a long-term survival benefit. Preliminary studies of salvage robot-assisted radical prostatectomy (SRARP) suggest that SRARP may be similar to or at least as effective as SRP. The intermediate oncological efficacy and morbidity of salvage cryoablation are similar to those of SRP. Prognostic factors for successful salvage therapy include serum prostate-specific antigen level ≤10 ng/mL, Gleason score ≤8, and a clinical disease stage T1c or T2. Assessing the comparative oncological efficacy and complications of the available salvage therapies for radiorecurrent prostate cancer requires strict guidelines, including universal patient selection criteria and an intergrade definition of biochemical failure. © 2011 by Turkish Association of Urology.
Schmitges, J., M. Sun, et al. (2012). “Blood transfusions in radical prostatectomy: A contemporary population-based analysis.” Urology 79(2): 332-338.
Objective: To examine the homologous blood transfusion (HBT), autologous blood transfusion (ABT) and intraoperative blood conservation technique (IOBCT) rates and trends at open (ORP) and minimally invasive radical prostatectomy (MIRP). Methods: The Nationwide Inpatient Sample was queried. Multivariable logistic regression models focused on all three transfusion types. Covariables consisted of procedure specific annual hospital caseload (AHC), year of surgery, age, Charlson Comorbidity Index, and region. Results: Overall, 119,966 patients underwent radical prostatectomy between 1998 and 2007. The HBT, ABT, and IOBCT rates were 6.2%, 6.0%, and 1.2%, respectively. HBT rates ranged from 5.1-5.1% between 1998 and 2007 (P =.49) vs 9.4-2.7% (P <.001) for ABT vs 1.9-0.9% (P =.003) for IOBCT in the same time period, respectively. In multivariable analyses, ORP patients treated at intermediate (odds ratio [OR] 1.48, P =.003) and low (OR 2.73, P <.001) AHC institutions were more likely to receive an HBT than ORP patients treated at high AHC institutions. Conversely, MIRP patients treated at high (OR 0.46, P =.040), intermediate (OR 0.27, P =.001), and low (OR 0.59, P =.015) AHC institutions were less likely to receive an HBT than ORP patients treated at high AHC institutions. Conclusion: Our results indicate that the overall transfusion rate at radical prostatectomy decreased within the last decade because of a substantial decline in ABT use. Moreover, MIRP protects from HBT, even when performed at low AHC Centers. © 2012 Elsevier Inc. All Rights Reserved.
Schroeck, F. R., T. L. Krupski, et al. (2012). “Pretreatment Expectations of Patients Undergoing Robotic Assisted Laparoscopic or Open Retropubic Radical Prostatectomy.” Journal of Urology.
Purpose: We previously found that patients undergoing robotic assisted laparoscopic radical prostatectomy vs radical retropubic prostatectomy had a higher likelihood of not being satisfied, independent of side effect profile. We hypothesized that differential preoperative expectations might contribute to this finding. In the current study we compared expectations of patients undergoing robotic assisted laparoscopic radical prostatectomy vs radical retropubic prostatectomy. Materials and Methods: A questionnaire on expectations regarding recovery was administered to 171 patients electing to undergo robotic assisted laparoscopic radical prostatectomy or radical retropubic prostatectomy from 2008 to 2010. We prospectively collected data on patient expectations before surgery. Differences between patients undergoing robotic assisted laparoscopic radical prostatectomy vs radical retropubic prostatectomy were assessed with adjusted proportional odds models. Results: Patients who underwent robotic assisted laparoscopic radical prostatectomy (97) did not differ significantly from those treated with radical retropubic prostatectomy (74) in age, race, income, time between survey and surgery, and prostate specific antigen (p ≥0.4). Patients who underwent radical retropubic prostatectomy had significantly higher clinical stage and Gleason grade disease (p ≤0.007). After adjusting for socioeconomic factors, clinical stage and grade on multivariate analysis, patients who underwent robotic assisted laparoscopic radical prostatectomy expected a significantly shorter length of stay (OR 0.07, p <0.001) and earlier return to physical activity (OR 0.36, p = 0.005). The choice of robotic assisted laparoscopic radical prostatectomy (OR 0.41, p = 0.012), younger age (OR 0.49, p = 0.001) and higher preoperative International Index of Erectile Function-5-item version score (OR 0.60, p = 0.017) were independently associated with the expectation of earlier return of erections but not of continence on multivariate analysis. Conclusions: The body of evidence surrounding robotic assisted laparoscopic radical prostatectomy supports shorter hospitalization but there is no conclusive evidence that the robotic approach results in earlier return to physical activity or improved disease specific outcomes. Nonetheless we found that patients who underwent robotic assisted laparoscopic radical prostatectomy had higher expectations regarding these outcomes, particularly that of erectile function recovery, than did their radical retropubic prostatectomy counterparts. © 2012 American Urological Association Education and Research, Inc.
Seftel, A. D. (2012). “Re: technique of traction-free nerve-sparing robotic prostatectomy: delicate tissue handling by real-time penile oxygen monitoring.” Journal of Urology 187(3): 993.
Shah, T. T., S. Undre, et al. (2012). “Effect of a suspension suture in addition to a total anatomical reconstruction in robot assisted laparoscopic prostatectomy: Does it help early continence?” British Journal of Medical and Surgical Urology.
Introduction: Continence post robotic assisted laparoscopic radical prostatectomy (RALP) is approximately 90% and many reconstructive techniques have been described to improve early continence. We assessed whether a peri-urethral suspension stitch in addition to a total anatomical repair (TAR) improved early continence. Materials and methods: We describe our procedure and assessed 68 consecutive RALP’s over a two-year period. Complete data were collected on continence rates and incontinence modular questionnaire (ICIQ) scores in 55 patients. Results: In the “no suspension stitch” (NoSS) group continence rates at 2 weeks, 6 weeks and 3 months were 11%, 48% and 81% respectively whilst in the “suspension stitch” (SS) group continence rates were 11%, 46% and 75% respectively (lowest p-value = 0.26 seen at 2 weeks). Average ICIQ scores in the NoSS group were 9.8, 6.6 and 4.3 and in the SS group were 9.4, 6.4 and 4.8 at each time frame (lowest p-value = 0.63 at 6 weeks). Conclusions: No significant difference in continence or ICIQ scores was seen between the two groups. Overall our continence rates were comparable to the published literature. The addition of a suspension stitch did not add any further benefit in improving early continence when performing a total anatomical reconstruction. © 2012 British Association of Urological Surgeons.
Shin, Y. S., A. R. Doo, et al. (2012). “Floating Hem-o-Lok Clips in the Bladder without Stone Formation after Robot-Assisted Laparoscopic Radical Prostatectomy.” Korean J Urol 53(1): 60-62.
Hem-o-Lok clips (Weck Surgical Instruments, Teleflex Medical, Durham, NC, USA) are widely used in robot-assisted laparoscopic radical prostatectomy because of their easy application and secure clamping. To date, there have been some reports of intravesical migration of these clips causing urethral erosion, bladder neck contractures, and subsequent calculus formation. We report the first case of bladder migration of Hem-o-Lok clips without stone formation after robot-assisted laparoscopic radical prostatectomy. The Hem-o-Lok clips were found during urethral dilation with a guide wire for bladder neck contracture under cystourethroscopy. The Hem-o-Lok clips were floating in the bladder without stone formation and were removed by a cystoscopic procedure.
Stolzenburg, J. U. and H. Qazi (2012). “Re: stepwise approach for nerve sparing without countertraction during robot-assisted radical prostatectomy: technique and outcomes.” European Urology 61(3): 621.
Sutherland, D. E., B. Linder, et al. (2012). “Commentary on “Posterior rhabdosphincter reconstruction during robotic assisted radical prostatectomy: Results from a phase II randomized clinical trial.”.” Urologic Oncology: Seminars and Original Investigations 30(1): 114-115.
Talug, C., D. Y. Josephson, et al. (2012). “Controlling the dorsal venous complex during robotic prostatectomy.” Can J Urol 19(1): 6147-6154.
INTRODUCTION: The objective of our study was to determine whether dorsal venous complex (DVC) control technique influences positive apical margins following robotic assisted laparoscopic radical prostatectomy (RALRP). MATERIALS AND METHODS: One thousand fifty-eight patients who underwent RALRP at City of Hope from June 2007 to October 2009 were assessed. Endoscopic stapling and suture ligature of the DVC were compared. Positive apical margins were identified and compared based on DVC-control technique. Recurrence probability was estimated using the Kaplan-Meier method, and logistic regression analysis was used to predict the odds of positive apical margins. RESULTS: Of 1058 patients, 633 (60%) underwent endoscopic stapling, and 425 (40%) had suture ligature. The groups had similar baseline characteristics including age and body mass index. We observed a statistically different PSA (5.4 ng/mL versus 5.2 ng/mL, p = 0.03) and operative time (2.8 hours versus 2.7 hours, p = 0.02) between stapling and suture groups, but the actual difference was small. Operative time, Gleason score, pathologic stage, and overall positive margin rates were not significantly different between groups. Positive apical margins were observed in 39 (6%) and 27 (6%) patients in the staple and suture groups, respectively. Multivariate analysis showed that the positive apical margin rate was greater in patients with higher pathologic stage and final pathological Gleason score. CONCLUSIONS: During RALRP, there is no difference in positive apical margin rate when the DVC is controlled using either endoscopic stapling or suture ligature. However, patients with a higher pathologic stage and final pathologic Gleason score are at higher risk for positive apical surgical margins.
Trinh, Q. D., M. Sun, et al. (2012). “Reply From the Authors re: Quoc-Dien Trinh, Jesse Sammon, Maxine Sun, et al. Perioperative Outcomes of Robot-Assisted Radical Prostatectomy Compared With Open Radical Prostatectomy: Results From the Nationwide Inpatient Sample. Eur Urol. In press. DOI:10.1016/j.eururo.2011.12.027 Robotic Prostatectomy: Men Versus Machines-The Machines Are Already Here.” European Urology.
Villamil, W., N. Billordo Peres, et al. (2012). “Incidence and location of positive surgical margins following open, pure laparoscopic, and robotic-assisted radical prostatectomy and its relation with neurovascular preservation: a single-institution experience.” Journal of Robotic Surgery: 1-7.
To evaluate whether robotic-assisted radical prostatectomy (dvRP) provides adequate local control of the disease, incidence of positive surgical margins (PSMs) obtained with dvRP was compared with that of laparoscopic radical prostatectomy (LRP) and with that of open radical retropubic prostatectomy (RRP) performed in a single institution by the same surgeons. We also studied whether neurovascular bundle preservation modified PSM rates. The records were retrospectively reviewed from electronic medical data, and three groups of 100 patients were organized. Group 1 included 100 patients who underwent RRP prior to the incorporation of minimally invasive techniques. Group 2 included the first 100 patients who underwent LRP, and group 3 was made up of the first 100 patients who underwent dvRP. All surgical specimens were analyzed by the same pathologist. We used the technique described by Patel et al. for dvRP. LRP was performed using a five-trocar extraperitoneal approach as previously published by the authors. RRP was performed using retrograde dissection as described by Walsh et al. The final decision of preserving neurovascular bundles was made during surgery. Using D’Amico’s risk classification, the dvRP group had a lower percentage of patients with low risk (dvRP versus LRP p = 0.017; dvRP versus RRP p = 0.0108). No statistically significant differences were found within high- and intermediate-risk groups. A higher percentage of patients with pT3 disease was found in the dvRP group compared with the RRP group (p = 0.0408). There were no statistically significant differences regarding PSMs among groups (RRP: 25, LRP: 14, dvRP: 18), although when we compared the total number of PSMs we found that the dvRP group had 18 PSMs versus 21 and 50 PSMs for LRP and RRP, respectively. All three groups had more PSMs located posterolaterally. There was a higher percentage of nerve-sparing procedures in the dvRP group (dvRP: 91 patients, LRP: 47 patients, RRP: 5 patients) (p < 0.0001). No statistically significant differences were found in the PSM rates between the three techniques analyzed. The number of nerve-sparing procedures in the dvRP group was statistically higher. However, this preservation did not modify PSM rates. © 2012 Springer-Verlag London Ltd.
Vora, A., S. Mittal, et al. (2012). “Robotic Simple Prostatectomy: Multi-Institutional Outcomes for Glands Larger than 100 gm.” Journal of Endourology.
Objective: To present our experience with robotic-assisted simple prostatectomy in patients with large gland adenoma (>100gm) that would not be amenable to transurethral treaments. Materials and Methods: From August 2009 to May 2011, 13 robotic simple suprapubic prostatectomies were performed in patients with symptomatic large gland (>100gm) prostatomegaly on transrectal ultrasonography (mean 163 cc). Essential aspects of our technique include a transverse cystotomy just proximal to the prostatovesical junction and use of robotic tenotomy grasper to aid in adenoma dissection. Results: Mean operative time was 179 minutes (range 90 to 270) and mean estimated blood loss was 219 ml (range 50 to 500). Mean hospital stay was 2.7 days (range 1 to 8) and the mean urethral catheterization time was 8.8 days (range 5 to 14). None of patients required blood transfusion. One patient had an intraoperative urinary leak after bladder closure which was managed with prolonged urethral catheterization (14 days). Histopathological analysis confirmed benign prostatic hyperplasia in all patients and mean specimen weight on pathological examination was 127 gm (range 100 to 165). Mean follow-up duration was 7.2 months with all patients having a minimum of 4 month follow-up. Significant improvements were noted in the IPSS (preoperative vs postoperative 18.1 vs 5.3, p < 0.001) and the maximum urine flow rate (preoperative vs postoperative 4.3 vs 19.1 cc per minute, p < 0.001). Conclusions: Minimally-invasive robotic simple prostatectomy is techincally feasible in patients with large volume (> 100gm) BPH and is associated with significant improvements in obstructive urinary symptoms. Surgeons with robotic expertise may consider utilizing this approach for treatment of their patients with large volume BPH .
Wang, R., D. P. Wood Jr, et al. (2012). “Risk factors and quality of life for post-prostatectomy vesicourethral anastomotic stenoses.” Urology 79(2): 449-457.
Objective: To evaluate the difference in vesicourethral anastomotic stenosis (VUAS) rates after open radical retropubic prostatectomy (RRP) vs robot-assisted radical prostatectomy (RARP), and to analyze associated factors and effect on quality of life. Methods: From 2001 to 2009, a total of 1038 patients underwent RARP and 707 patients underwent open RRP. Perioperative factors and Expanded Prostate Cancer Index Composite (EPIC) quality of life scores were compared between patients who did and did not develop a VUAS. Independent significant predictors of VUAS development were identified using multivariable modeling. Results: The incidence of VUAS in open RRP cases was higher (53/707, 7.5%) than for RARP (22/1038, 2.1%) (P <.0001). Intervention consisted of dilation in 34 of 75 cases (45.3%), internal urethrotomy in 8 of 75 (10.7%), and multiple procedures in 30 of 75 (40%). Open technique (P <.0001, odds ratio [OR] = 3.0, 95% confidence interval [CI] = 1.8-5.2), prostate-specific antigen (PSA) recurrence (P =.02, OR = 2.2, 95% CI = 1.2-4.1), postoperative hematuria (P =.02, OR = 3.7, 95% CI = 1.2-11.3), urinary leak (P =.002, OR = 6.0, 95% CI = 1.9-19.2), and urinary retention (P =.004, OR = 3.5, 95% CI = 1.5-8.7) were significant independent predictors of VUAS development. EPIC incontinence scores were similar between VUAS and non-VUAS patients, whereas irritative voiding scores were worse initially with VUAS but became similar by 12 months. Conclusion: There is a higher rate of VUAS after open RRP vs RARP. Most cases of VUAS require endoscopic intervention. Predictors include open surgery, PSA recurrence, and postoperative hematuria, urinary leak, and retention. There is no diminution of quality of life scores at 12 months. © 2012 Elsevier Inc. All Rights Reserved.
You, Y. C., T. H. Kim, et al. (2012). “Effect of Bladder Neck Preservation and Posterior Urethral Reconstruction during Robot-Assisted Laparoscopic Radical Prostatectomy for Urinary Continence.” Korean J Urol 53(1): 29-33.
PURPOSE: To report our results on urinary continence after bladder neck preservation (BNP) and posterior urethral reconstruction (PUR) during robot-assisted laparoscopic radical prostatectomy (RALP). MATERIALS AND METHODS: Data from 107 patients who underwent RALP were compared on the basis of whether the patients underwent BNP and PUR, BNP only, or the standard technique (ST). In group A (n=31 patients), ST was performed by using Ven velthoven continuous suturing for urethrovesical anastomosis. In group B (n=28 patients), ST with only PUR was performed. In group C (n=48 patients), both the BNP and PUR techniques were used. “Recovery of continence” was defined as the use of 1 pad (50 ml) or less within 24 hours. RESULTS: The three groups were comparable in terms of patient demographics. The mean operative time and the mean blood loss decreased significantly from group A to group C (p=0.021 for mean operative time and p=0.004 for the mean blood loss). Mean catheterization time was 8.9, 7.8, and 7.1 days in each group (p=0.047). Early return of urinary continence at 3 months was observed in group B (89.2%) and group C (90.6%) compared with group A (71%). However, continence at 6 months was comparable in the 3 groups (87.5% in group A, 92.8% in group B, and 92.3% in group C). Rates of positive surgical margins decreased from 30.2% in group A to 20% in group B and 12% in group C. CONCLUSIONS: BNP and PUR during RALP showed a favorable impact on the early postoperative recovery of continence while not affecting positive surgical margins.