“Surgery illustrated–Surgical Atlas. Robotic radical cystectomy in the male.”
Buffi, N., A. Mottrie, et al. (2009).
BJU Int 104(5): 726-745.
“Robotic ureteroureterostomy in children with a duplex collecting system.”
Casale, P. and S. Lambert (2009).
Journal of Robotic Surgery: 1-4.
Duplex collecting system pathology can be handled using an ablative procedure or reconstructive procedure even in the light of a poorly functioning moiety. We propose that, when a reconstructive procedure is an option, a robotic ureteroureterostomy is safe and feasible. Fifteen children between the ages of 6 months and 10 years (mean 31.26 months) underwent transperitoneal robotic ureteroureterostomy for duplex collecting system pathology. The surgical procedure included transperitoneal robotic approach. Outcome measures included operative time, length of hospital stay, and resolution of symptoms. Mean operative time was 1.2 h (range 0.75-2.2 h) for the entire procedure, including the cystoscopic evaluation. Length of stay averaged 20.8 h (range 15-26 h). All postoperative imaging demonstrated intact, well-draining collecting systems. The presenting symptomatology resolved in all the patients in whom symptoms were present. Robotic ureteroureterostomy is feasible and safe in the pediatric population and should be considered part of the surgical armamentarium when upper tract preservation seems warranted. © 2009 Springer-Verlag London Ltd.
“Robotic salvage cystectomy in the nonagenarian.”
Eandi, J. A., K. G. Chan, et al. (2009).
Journal of Robotic Surgery: 1-4.
Radical cystectomy with pelvic lymphadenectomy remains the standard treatment for muscle-invasive bladder cancer. However, bladder preservation with radiotherapy, with or without chemotherapy, represents an alternative treatment strategy. In patients that fail this bladder conservation treatment, salvage cystectomy is then indicated to treat persistent or recurrent cancer. We report our experience with robotic-assisted laparoscopic salvage radical cystoprostatectomy with pelvic lymph node dissection in a 91-year-old man. This minimally invasive approach for treatment of persistent bladder cancer refractory to chemoradiation, even in the nonagenarian, is a safe and viable alternative to traditional open surgery. © 2009 Springer-Verlag London Ltd.
“Critical analysis of complications after robotic-assisted radical cystectomy with identification of preoperative and operative risk factors.”
Kauffman, E. C., C. K. Ng, et al. (2009).
BJU Int.
OBJECTIVE To better characterize short- and long-term complications in patients after robotic-assisted radical cystectomy (RRC) using standardized complications-reporting systems, and to identify preoperative and operative risk factors predicting their occurrence. PATIENTS AND METHODS Data were collected for 79 consecutive patients with bladder cancer undergoing RRC with extracorporeal urinary diversion by one surgeon at our institution. Complications occurring </=90 days after RRC were graded according to two standardized reporting methods (Memorial Sloan Kettering Cancer Center and Modified Clavien), and additionally stratified by organ system. Nineteen preoperative and operative variables were tested by univariate analysis for association with the occurrence of one or more postoperative complications. Variables with a significant (P < 0.05) or near-significant (P < 0.20) association on univariate analysis were included in multivariate analysis to identify independent risk factors. RESULTS Patients were of relatively poor health, with 58% having an American Society of Anesthesiology class or Charlson Index score of >/=3. Advanced bladder disease was frequent (41% had pT3/pT4). After RRC, one or more complications occurred within 90 days of surgery for 39/79 (49%) patients. The vast majority of complications were low grade (79%), and mostly infectious (41%) or gastrointestinal (27%). Sixteen high-grade complications occurred in 13/79 (16%) patients. Urinary obstruction, abscess, enteric fistula, gastrointestinal bleeding and thromboembolism constituted most of the high-grade complications, nearly half (seven of 16) of which occurred 31-90 days after RRC. On multivariate analysis, only preoperative renal insufficiency and intraoperative intravenous (i.v.) fluids of >5000 mL were significantly associated with postoperative complications of any grade, with respective odds ratios (ORs) of 4.2 and 4.1. For high-grade complications, significant independent risk factors included an age of >/=65 years, operative blood loss of >/=500 mL and intraoperative i.v. fluids of >5000 mL, with respective ORs of 12.7, 9.7 and 42.1. CONCLUSION Even among relatively sick patients with frequent advanced disease, the vast majority of complications after RRC are low grade. High-grade complications are infrequent and similar in nature to high-grade events after open RC, and a notable proportion may occur at >30 days after RRC underscoring the importance of longer reporting intervals. The surgeon’s ability to limit blood loss and i.v. fluids during RRC may provide effective risk reduction, particularly for high-grade events.
“For: Radical nephrectomy in the setting of metastatic renal cell cancer: proceed judiciously.”
Aron, M. and I. S. Gill (2009).
J Urol 182(3): 832-833.
“Current Role of Robot-Assisted Pyelolithotomy for the Management of Large Renal Calculi: A Contemporary Analysis.”
Badalato, G. M., A. K. Hemal, et al. (2009).
J Endourol.
Abstract Background and Purpose: The scope of robot-assisted surgery continues to expand with the application of these systems to management of large upper-tract urinary stones, with or without concomitant pyeloplasty. The known advantages of the robot-assisted approach, including enhanced optics, dexterity, wristed instrumentation, and ergonomics, can facilitate complex reconstruction of the collecting system, including uteropelvic junction repair. With the favorable outcomes of contemporary robot-assisted pyeloplasty series, robot-assisted applications have been translated to pyelolithotomy with or without concomitant upper-tract reconstruction. The early results of robot-assisted lithotomy reveal the procedure is a safe and efficacious approach for patients with large renal stones; nevertheless, the technique has met limited success in cases of large staghorn calculi. Our purpose was to evaluate the current role of robot-assisted pyelolithotomy for the management of large renal calculi. Conclusion: Given the known advantages of the robotic system in conjunction with its reconstructive capabilities, the applications of robot-assisted pyelolithotomy, although encouraging, warrant further longitudinal, multi-institutional investigation. This technique is in its early stage of implementation and randomized trials that compare robot-assisted outcomes with other minimally invasive techniques are needed to define clinical efficacy as it pertains to subsets of patients with variable stone size, location, and consistency.
“Assessing the Impact of Ischaemia Time During Partial Nephrectomy.”
Becker, F., H. Van Poppel, et al. (2009).
European Urology 56(4): 625-635.
Context: The impact of applying renal ischaemia during nephron-sparing surgery to avoid renal damage in the treated kidney has gained importance in different surgical techniques. Objective: The main objective of the present study is to point out the limit of renal ischaemia times for warm and cold ischaemia approaches. Important results of research on renal ischaemia and different surgical techniques as well as results of clinical studies concerning renal function after renal ischaemia in partial nephrectomy are highlighted. Evidence acquisition: A Medline literature research was performed, combining queries on the keywords nephron-sparing surgery, partial nephrectomy, and ischemia. Links to related articles and cross-reading of citations in related articles were surveyed, as were reviews, letters to editors, and information collected from urologic textbooks. The references formed the basis of this review article, with selection and deletion based on the relevance and importance of the content. In a final step, interactive peer review by the expert panel of coauthors completed the review. Evidence synthesis: Renal ischaemia research showed an increasing renal damage proportional to ischemic time. Current clinical data support safe ischaemia times, within 20 min of warm ischaemia and up to 2 h of cold ischaemia, to minimise renal ischemic damage. To date, no ischaemia dose-response curve or algorithm is available to predict the risk of acute kidney injury and chronic kidney disease in patients undergoing intraoperative ischaemia. In general, there seems to be a higher risk for comorbidity caused by renal damage in patients suffering from kidney tumour. Conclusions: If ischaemia is required, the tumour should be removed within 20 min of warm ischaemia, regardless of surgical approach. Efforts should be made to start immediately with cold ischaemia, if the feasibility within this span of time seems to be jeopardised. Thus, cold ischaemia times up to 2 h can be tolerated by the kidney, depending on the individual method. Nevertheless, cold ischaemia with ice slush should be kept as short as possible-at best within 35 min. In ischemic nephron-sparing surgery, one of the surgeon’s main aims should be to avoid loss of renal function. Only after optimal preoperative appraisal and planning can the best postoperative outcomes for renal function be achieved. © 2009 European Association of Urology.
“Minimally invasive surgery for renal cell carcinoma.”
Ghoneim, I. A. and A. F. Fergany (2009).
Expert Review of Anticancer Therapy 9(7): 989-997.
The oncologic principles of the surgical management of renal cell carcinoma (RCC) have remained essentially the same since first proposed by Robson in 1963. RCC remains a chemo- and radiation-resistant tumor; hence, surgical treatment is still the mainstay of curative therapy. Extirpative management of RCC via open radical nephrectomy (and later open partial nephrectomy) has been the standard of care for decades. With the advent of laparoscopic surgery and its intense application in urology in the early 1990s, a paradigm shift to minimally invasive renal surgery was initiated and has spurred an array of technologies, methods and procedures. Guidelines on the proper selection of patients and treatment modalities have been developed and established, allowing patients to benefit from better oncologic efficacy and reduced morbidity, and requiring urologic surgeons to master minimally invasive procedures alongside the techniques of open surgery. This review focuses on the minimally invasive management of RCC, discussing the advantages and disadvantages of laparoscopy, partial nephrectomy, probe ablation and newer treatment modalities. In order to provide material for this review, a search of the MEDLINE database was performed through January 2009 using the National Center for Biotechnology Information PubMed internet site to review the world literature regarding the minimally invasive treatment of RCC. © 2009 Expert Reviews Ltd.
“Pediatric single-port-access nephrectomy for a multicystic, dysplastic kidney.”
Johnson, K. C., D. Y. Cha, et al. (2009).
Journal of Pediatric Urology 5(5): 402-404.
Major urologic surgery via a single port has emerged as the latest progression in laparoscopy and robotics. While current literature highlights the single-port approach to the surgical treatment of cholecystitis, appendicitis and varicoceles, this technique has never been employed to perform a nephrectomy on a child. We herein report a case of a pediatric patient who underwent nephrectomy via single-port-access.
“Robotic-assisted laparoscopic donor nephrectomy for kidney transplantation. An evaluation of 35 procedures.”
Louis, G., J. Hubert, et al. (2009).
Transplantation rénale à partir de donneurs vivants prélevés sous laparoscopie assistée par robot. À propos d’une série de 35 cas.
Introduction: Renal transplantation with living donor is actually the best technique for renal replacement therapy, particularly with the problem of shortage of organs. Laparoscopic nephrectomy is actually developed because of low surgical mortality and morbidity. Our medical centre uses an original removal method: robot-assisted laparoscopic donor nephrectomy. Methods: We report our 35 first robot-assisted kidney removals at our centre. Results: After a precise preoperative evaluation, all donors choosed robotic-assisted laparoscopic surgery. The mean hospitalitalization duration was 5,5 days. The serum creatinine level reached respectively 107, 104, 91, 71 μmol/l within a period of 1, 2, 3 and 4 years after the operation. None of the recipients required post-transplant dialysis. No vascular complication was listed. The urological complications observed were: six lymphoceles, one ureteral stenosis and one ureteral necrosis. Ten patients (29% of the recipients) showed 16 biopsy-proven episodes of acute rejection. All donors and recipients were alive after a mean graft survival of 3,8 ± 1 years. Thirty-four grafts fared well with an average serum creatinine level respectively of 107, 124, 125 μmol/l at 1, 2, 3 and 4 years after transplantation. Conclusion: Considering the very low morbidity rate and the positive long term results for donors as well as for recipients, robot-assisted donor laparoscopy seems to be a safe and efficient surgical technique. By offering optimal operative conditions to the urological surgeon, it would serve as a favourable alternative to the present kidney graft shortage. © 2009 Association Société de néphrologie.
“Single-setting robotic radical nephrectomy and radical prostatectomy.”
Madi, R. (2009).
Journal of Robotic Surgery: 1-4.
“Combined robotic-assisted laparoscopic partial nephrectomy and radical prostatectomy.”
Patel, M. N., D. Eun, et al. (2009).
JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 13(2): 229-232.
A 59-year-old man with a history of prostate cancer and clear-cell renal-cell carcinoma of the kidney underwent a combined robot-assisted laparoscopic partial nephrectomy and radical prostatectomy. We describe the initial report of a combined robot-assisted operation for both procedures concurrently with a port strategy allowing reuse of ports.
“Current status of robotic assisted pelvic surgery and future developments.”
Ahmed, K., M. S. Khan, et al. (2009).
Int J Surg.
AIMS: The aim of this review is to assess the role of robotics in pelvic surgery in terms of outcomes. We have also highlighted the issues related to training and future development of robotic systems. MATERIALS AND METHODS: We searched MEDLINE, EMBASE and the Cochrane Databases from 1980 to 2009 for systematic reviews of randomised controlled trials, prospective observational studies, retrospective studies and case reports assessing robotic surgery. RESULTS: During the last decade, there has been a tremendous rise in the use of robotic surgical systems for all forms of precision operations including pelvic surgery. The short-term results of robotic pelvic surgery in the fields of urology, colorectal surgery and gynaecology have been shown to be comparable to the laparoscopic and open surgery. Robotic surgery offers an opportunity where many of these obstacles encountered during open and laparoscopic surgery can be overcome. CONCLUSIONS: Robotic surgery is a continually advancing technology, which has opened new horizons for performing pelvic surgery with precision and accuracy. Although its use is rapidly expanding in all surgical disciplines, particularly in pelvic surgery, further comparative studies are needed to provide robust guidance about the most appropriate application of this technology within the surgical armamentarium.
“Editorial Comment.”
Catalona, W. J. (2009).
Urology 74(3): 624-625.
“Stereotactic body radiotherapy: an emerging treatment approach for localized prostate cancer.”
Friedland, J. L., D. E. Freeman, et al. (2009).
Technol Cancer Res Treat 8(5): 387-392.
Here we report results from the first cohort of over 100 patients treated with hypofractionated, stereotactic body radiotherapy (SBRT) for early stage prostate cancer. Between February 2005 and December 2006, 112 patients with localized, biopsy-proven adenocarcinoma of the prostate (clinical stage T1cN0M0 to T2cN0M0) were treated in Naples, FL on a CyberKnife system (Accuray Incorporated, Sunnyvale, CA). Eighty-one patients had a Gleason score of 3+3. Mean initial PSA was 6.0, and mean initial prostate volume was 46.3cc. Implanted gold fiducials were used for image-guided targeting and tracking. Patients received 35-36 Gy administered in 5 consecutive fractions to the prostate and the proximal seminal vesicles, as identified on CT and MRI scans. At a median follow-up of 24 months, the mean PSA value was 0.78 ng/ml. Two patients have developed biopsy-confirmed local relapse; one developed distant metastases. Acute side effects were generally mild and resolved shortly after treatment. A single Grade 3 rectal complication was reported (bleeding). Eighty-two percent of patients who were sexually potent before treatment maintained erectile function post-treatment. Additional follow-up is required to better evaluate potential late toxicity and long-term PSA outcomes.
“Robotic Assisted Laparoscopic Mitrofanoff Appendicovesicostomy: Preliminary Experience in a Pediatric Population.”
Nguyen, H. T., C. C. Passerotti, et al. (2009).
Journal of Urology 182(4 SUPPL.): 1528-1534.
Purpose: Continent urinary diversion has a central role in treating various urinary tract conditions and traditionally has been performed as an open procedure. We report on 10 patients who underwent a robotic assisted laparoscopic Mitrofanoff procedure using the da Vinci® surgical system. Materials and Methods: Patients had bladder dysfunction of various etiologies, including posterior urethral valves and neurogenic bladder. Preoperatively all patients unsuccessfully attempted clean intermittent catheterization via the urethra. Results: Mean operative time was 323 minutes (range 181 to 507). One case was converted to open surgery secondary to an inadequate appendix discovered intraoperatively. Mean estimated blood loss was 48.4 cc (range 5 to 200). Median hospitalization was 5 days. Median followup was 14.2 months. Urinary leakage developed postoperatively in 1 patient, requiring an open revision. Minor incontinence developed in 2 cases, of which 1 was corrected with dextranomer/hyaluronic acid injection and 1 resolved without intervention. Conclusions: The robotic assisted laparoscopic Mitrofanoff procedure is feasible to perform, is associated with satisfactory outcomes and minimal complications, and has the benefits of a minimally invasive approach. © 2009 American Urological Association.
“Zinner’s syndrome: An up-to-date review of the literature based on a clinical case.”
Pereira, B. J., L. Sousa, et al. (2009).
Andrologia 41(5): 322-330.
Summary The authors made an up-to-date review of the literature concerning the management of Zinner’s syndrome and evaluated a young patient with Zinner’s syndrome who had presented with urinary and ejaculatory complaints. Physical examination and transrectal ultra-sonography showed a 7.0 cm right seminal vesicle cyst. Magnetic resonance imaging (MRI) confirmed the diagnosis of Zinner’s syndrome. Oligoasthenoteratozoospermia was present at the two seminal analyses. Symptomatic improvement was achieved with conservative measures. Actually, the patient is still on a follow-up programme. The diagnosis is usually established at the age of increased sexual activity. Patients may be asymptomatic or present pain, irritative urinary or ejaculatory symptoms and infertility. MRI has proved to be the best imaging examination. Treatment should be adapted to symptoms, surveillance being the best option in the absence of clinical manifestations. Surgical approach may be adequate when conservative measures prove ineffective. Zinner’s syndrome should be suspected if a male young patient presents with unilateral renal agenesis and pelvic complaints and has a supraprostatic mass on digital rectal examination. The initial approach should be medical, but invasive procedures may be the only way to solve the patient’s complaints. Nowadays, laparoscopic and robotic techniques must replace the open surgical approach. © 2009 Blackwell Verlag GmbH.
“Delayed Prostate-specific Antigen Recurrence After Radical Prostatectomy: How to Identify and What Are Their Clinical Outcomes?”
Caire, A. A., L. Sun, et al. (2009).
Urology 74(3): 643-647.
Objectives: To identify factors that predict delayed (> 5 years) prostate-specific antigen recurrence (PSAR) after radical prostatectomy (RP) and to analyze the associated clinical outcomes. Methods: A cohort of 4561 men who underwent RP between 1988 and 2008 was retrieved from the Duke University Prostate Center database. Among them, 1207 (26.5%) had PSAR and were included in this study. The cohort was then divided into 2 groups; PSAR before 5 years (early PSAR) and PSAR after 5 years (delayed PSAR), and Kaplan Meier analysis was performed. Univariate and logistic regression analysis was carried out to determine significant predictors of delayed PSAR, using factors such as race, age, body mass index, PSA, surgical margin status, pathologic Gleason sum, pathologic tumor stage, and prostate weight. Results: There was a marginal difference between the early and delayed PSAR groups with regard to metastasis-free survival (P = .062). A significant difference in disease-specific survival was found between the 2 groups (P = .025). Patients with pathologic Gleason sums < 7 were more likely to have delayed PSAR as compared to those with pathologic Gleason sums > 7 (OR = 2.38). Patients with a PSA < 10 ng/mL were more likely to have delayed PSAR in comparison to those with PSA > 20 ng/mL (OR = 2.38). Conclusions: Approximately 90% of PSAR occurred within 5 years after RP. Lower pathologic Gleason sums and lower PSA at diagnosis were associated with delayed PSAR. Patients with delayed PSAR have a disease-specific survival advantage as compared to men with early PSAR. © 2009 Elsevier Inc. All rights reserved.
“A retrospective comparison of anesthetic management of robot-assisted laparoscopic radical prostatectomy versus radical retropubic prostatectomy.”
D’Alonzo, R. C., T. J. Gan, et al. (2009).
Journal of Clinical Anesthesia 21(5): 322-328.
Study Objective: To compare anesthetic management and postoperative outcomes in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALP) and radical retropubic prostatectomy (RRP) with general anesthesia. Design: Retrospective database study of RALP and RRP patients at Duke University Medical Center from 6/2003 to 6/2006. Setting: University teaching hospital. Patients: 541 ASA physical status I, II, and III men, 280 of whom were RRP patients and 256 RALP patients. Measurements: Patient demographics, intraoperative fluids and blood products, hemodynamic parameters, pain scores in the Postanesthesia Care Unit (PACU), intraoperative and postoperative analgesic consumption, need for rescue antiemetics in the PACU, and intraoperative use of vasopressors and antihypertensives, were all recorded. Additional data included postoperative transfusion data; clinical status of the patient’s cancer preoperatively and postoperatively; hematocrit, platelet count, and creatinine levels; and length of hospital stay. Main Results: Estimated blood loss (EBL) was higher for RRP than RALP patients (mean ± SD; 1,087 ± 853 mL vs. 287 ± 317 mL; P < 0.0001). Likewise, 24% of RRP patients received red blood cell (RBC) transfusions intraoperatively, compared with 0.4% RALP patients (P < 0.0001). Intraoperatively, RALP patients received more antihypertensive agents (37% vs. 21%; P < 0.0001), and fewer vasopressors (63% vs. 78%; P < 0.0001) than did RRP patients. The two groups had similar morphine-equivalent opioid use intraoperatively, but in the PACU, RALP patients required fewer morphine equivalents (mean ± SD; 11.4 ± 7.7 mg vs. 14.9 ± 9.8 mg; P < 0.0001). The RALP patients had longer surgical times (mean ± SD; 296 ± 76 vs.193 ± 69 min; P < 0.0001) but shorter PACU stays (mean ± SD; 113 ± 55 min vs. 143 ± 58 min; P < 0.0001) and shorter hospital stays (mean ± SD; 44 ± 77 hrs vs. 56 ± 26 hrs; P = 0.009). Conclusions: Duration of surgery was greater with RALP, but it was associated with less EBL, fewer transfusions of blood products, and shorter PACU and hospital stays. © 2009 Elsevier Inc. All rights reserved.
“The current status of robot-assisted radical prostatectomy.”
Dasgupta, P. and R. S. Kirby (2009).
Asian journal of andrology 11(1): 90-93.
Robot-assisted radical prostatectomy (RARP) is a rapidly evolving technique for the treatment of localized prostate cancer. In the United States, over 65% of radical prostatectomies are robot-assisted, although the acceptance of this technology in Europe and the rest of the world has been somewhat slower. This article reviews the current literature on RARP with regard to oncological, continence and potency outcomes-the so-called ‘trifecta’. Preliminary data appear to show an advantage of RARP over open prostatectomy, with reduced blood loss, decreased pain, early mobilization, shorter hospital stay and lower margin rates. Most studies show good postoperative continence and potency with RARP; however, this needs to be viewed in the context of the paucity of randomized data available in the literature. There is no definitive evidence to show an advantage over standard laparoscopy, but the fact that this technique has reached parity with laparoscopy within 5 years is encouraging. Finally, evolving techniques of single-port robotic prostatectomy, laser-guided robotics, catheter-free prostatectomy and image-guided robotics are discussed.
“Novel treatment methods for localized prostate cancer: Hypofractionated robotic radiation therapy and adjuvant hemotherapy.”
Dawson, N. A. and S. P. Collins (2009).
Expert Review of Anticancer Therapy 9(7): 953-962.
The standard localized therapies for prostate cancer include external-beam radiation therapy, brachytherapy and radical prostatectomy. There are several novel approaches in development aimed at improving local disease control and survival, and reducing post-treatment complications. In low-to-intermediate-risk patients, new radiation approaches are being explored to include hypofractionated robotic radiation therapy. For high-risk patients, the focus is on multimodality approaches, especially the addition of chemotherapy. Recent developments in radiation therapy and adjuvant chemotherapy are the focus of this review. © 2009 Expert Reviews Ltd.
“Comparison of mid-term carcinologic control obtained after open, laparoscopic, and robot-assisted radical prostatectomy for localized prostate cancer.”
Drouin, S. J., C. Vaessen, et al. (2009).
World J Urol 27(5): 599-605.
OBJECTIVE: To determine the cancer control afforded by radical prostatectomy in patients who underwent either an open, laparoscopic, or robotic procedure for localized prostate cancer. METHODS: We collected data on all patients treated between 2000 and 2004. We recorded age, BMI, PSA, Gleason score and 2002 TNM stage, type of surgery, perioperative parameters, postoperative complications, pathological data, recurrence and outcome. RESULTS: Data were analyzed for 239 patients. Overall, the mean follow-up was 49.7 (18-103) months. Surgical procedures were open in 83 patients, laparoscopic in 85, and robot-assisted in 71. The transfusion rate was 5.6% for robotic cases, 5.9% for laparoscopic cases and 9.6% for open prostatectomy (p = 0.03). The positive margin rates in open, laparoscopic, and robotic cases were 18.1, 18.8, and 16.9% (p = 0.52), respectively. Only margin status, PSA level (>10), and Gleason score (>7) were associated with recurrence in univariate analysis (p < 0.05), and only the margin status and the Gleason score were significant in multivariate analysis. The statistical power was 0.7. Overall, the 5-year PSA-free survival rate was 88%. The 5-year PSA-free survival rates for the specific surgical approaches were 87.8% in open cases, 88.1% in laparoscopic cases, and 89.6% in robot-assisted prostatectomies, and there was no statistical difference between the approaches (p = 0.93). CONCLUSION: Although open radical prostatectomy remains the gold standard procedure, we found no differences between these three techniques regarding early oncologic outcomes. These results are still preliminary, however, and further studies of larger populations with a longer follow-up are needed to make any statement regarding surgical strategy.
“A prospective, non-randomized trial comparing robot-assisted laparoscopic and retropubic radical prostatectomy in one European institution.”
Ficarra, V., G. Novara, et al. (2009).
BJU international 104(4): 534-539.
OBJECTIVE: To compare the functional results of two contemporary series of patients with clinically localized prostate cancer treated by robot-assisted laparoscopic prostatectomy (RALP) or retropubic radical prostatectomy (RRP). PATIENTS AND METHODS: This was a non-randomized prospective comparative study of all patients undergoing RALP or RRP for clinically localized prostate cancer at our institution from February 2006 to April 2007. RESULTS: We enrolled 105 patients in the RRP and 103 in the RALP group; the two groups were comparable for all clinical and pathological variables, except median age. For RRP and RALP the respective median operative duration was 135 and 185 min (P < 0.001), the intraoperative blood loss 500 and 300 mL (P < 0.001) and postoperative transfusion rates 14% and 1.9% (P < 0.01). There were complications in 9.7% and 10.4% of the patients (P = 0.854) after RRP and RALP, respectively; the positive surgical margin rates in pT2 cancers were 12.2% and 11.7% (P = 0.70). For urinary continence, 41% of patients having RRP and 68.9% of those having RALP were continent at catheter removal (P < 0.001). The 12-month continence rates were 88% after RRP and 97% after RALP (P = 0.01), with the mean time to continence being 75 and 25 days (P < 0.001), respectively. At the 12-month follow-up, 20 of 41 patients having bilateral nerve-sparing RRP (49%) and 52 of 64 having bilateral nerve-sparing RALP (81%) (P < 0.001) had recovery of erectile function. CONCLUSIONS: RALP offers better results than RRP in terms of urinary continence and erectile function recovery, with similar positive surgical margin rates.
“Anatomic Bladder Neck Preservation During Robotic-Assisted Laparoscopic Radical Prostatectomy: Description of Technique and Outcomes.”
Freire, M. P., A. C. Weinberg, et al. (2009).
Eur Urol.
BACKGROUND: Robotic-assisted laparoscopic radical prostatectomy (RALP) has been rapidly adopted despite a daunting learning curve with bladder neck dissection as a challenging step for newcomers. OBJECTIVE: To describe an anatomic, reproducible technique of bladder neck preservation (BNP) and associated perioperative and long-term outcomes. DESIGN, SETTINGS, AND PARTICIPANTS: From September 2005 to May 2009, data from 619 consecutive RALP were prospectively collected and compared on the basis of bladder neck dissection technique with 348 BNP and 271 standard technique (ST). SURGICAL PROCEDURE: RALP with BNP. MEASUREMENTS: Tumor characteristics, perioperative complications, and post-operative urinary control were evaluated at 4, 12 and 24 months using (1) the Expanded Prostate Cancer Index (EPIC) urinary function scale scored from 0-100; and (2) continence defined as zero pads per day. RESULTS AND LIMITATIONS: Mean age for BNP versus ST was 57.1+/-6.6 yr versus 58.9+/-6.7 yr (p=0.033), while complication rates did not vary significantly by technique. Estimated blood loss was 183.7+/-95.8ml versus 224.6+/-108ml (p=0.938) in men who underwent BNP versus ST. The overall positive margin rate was 12.8%, which did not differ at the prostate base for BNP versus ST (1.4% vs. 2.2%, p=0.547). Mean urinary function scores for BNP versus ST at 4, 12, and 24 mo were 64.6 versus 57.2 (p=0.037), 80.6 versus 79.0 (p=0.495), and 94.1 versus 86.8 (p<0.001). Similarly, BNP versus ST continence rates at 4, 12, and 24 mo were 65.6% versus 26.5% (p<0.001), 86.4% versus 81.4% (p=0.303), and 100% versus 96.1% (p=0.308). CONCLUSIONS: BNP versus ST is associated with quicker recovery of urinary function and similar cancer control.
“Stereotactic body radiotherapy: an emerging treatment approach for localized prostate cancer.”
Friedland, J. L., D. E. Freeman, et al. (2009).
Technol Cancer Res Treat 8(5): 387-392.
Here we report results from the first cohort of over 100 patients treated with hypofractionated, stereotactic body radiotherapy (SBRT) for early stage prostate cancer. Between February 2005 and December 2006, 112 patients with localized, biopsy-proven adenocarcinoma of the prostate (clinical stage T1cN0M0 to T2cN0M0) were treated in Naples, FL on a CyberKnife system (Accuray Incorporated, Sunnyvale, CA). Eighty-one patients had a Gleason score of 3+3. Mean initial PSA was 6.0, and mean initial prostate volume was 46.3cc. Implanted gold fiducials were used for image-guided targeting and tracking. Patients received 35-36 Gy administered in 5 consecutive fractions to the prostate and the proximal seminal vesicles, as identified on CT and MRI scans. At a median follow-up of 24 months, the mean PSA value was 0.78 ng/ml. Two patients have developed biopsy-confirmed local relapse; one developed distant metastases. Acute side effects were generally mild and resolved shortly after treatment. A single Grade 3 rectal complication was reported (bleeding). Eighty-two percent of patients who were sexually potent before treatment maintained erectile function post-treatment. Additional follow-up is required to better evaluate potential late toxicity and long-term PSA outcomes.
“Open retropubic prostatectomy versus robot-assisted laparoscopic prostatectomy: A comparison of length of sick leave.”
Hohwü, L., O. Akre, et al. (2009).
Scandinavian Journal of Urology and Nephrology 43(4): 259-264.
Objective. It remains uncertain whether the increased direct costs of robot-assisted laparoscopic radical prostatectomy (RALP) are outweighed by cost savings due to shorter postoperative hospital care and shorter sick leave. This study compared the length of sick leave after RALP with that after radical retropubic prostatectomy (RRP). Material and methods. In a cohort study, information on length of sick leave was retrieved for 274 working men undergoing radical prostatectomy (127 RALP and 147 RRP). Data on confounders such as physical workload, average salary, body mass index and disease characteristics were collected from the medical records. Cox regression models were used to compare the treatment groups. Results. The median number of days with sick leave was 11 in the RALP group and 49 in the RRP group. After adjustment for confounders, patients in the RALP group were twice as likely to return to work at any time during follow-up (hazard ratio = 2.13, 95% confidence interval 1.62-2.80). High physical workload, low salary and high tumour grade were more common in the RRP group and associated with longer sick leave. Conclusions. Patients in the RALP group had shorter postoperative hospital stay and less need for paid sick leave than patients in the RRP group. These data indicate that RALP shortens the convalescence. Part of this difference may, however, be attributable to different selection of patients and different a priori expectations among patients and their doctors. A prospective randomized study is advocated, although blinding is unfeasible. © 2009 Informa UK Ltd.
“Does robot-assisted laparoscopic radical prostatectomy enable to obtain adequate oncological and functional outcomes during the learning curve? From the Korean experience.”
Ko, Y. H., J. H. Ban, et al. (2009).
Asian Journal of Andrology 11(2): 167-175.
To estimate the short-term results of robot-assisted laparoscopic radical prostatectomy (RALRP) during the learning curve, in terms of surgical, oncological and functional outcomes, we conducted a prospective survey on RALRP. From July 2007, a single surgeon performed 63 robotic prostatectomies using the same operative technique. Perioperative data, including pathological and early functional results of the patient, were collected prospectively and analyzed. Along with the accumulation of the cases, the total operative time, setup time, console time and blood loss were significantly decreased. No major complication was present in any patient. Transfusion was needed in six patients; all of them were within the initial 15 cases. The positive surgical margin rate was 9.8% (5/51) in pT2 disease. The most frequent location of positive margin in this stage was the lateral aspect (60%), but in pT3 disease multiple margins were the most frequent (41.7%). Overall, 53 (84.1%) patients had totally continent status and the median time to continence was 6.56 weeks. Among 17 patients who maintained preoperative sexual activity (Sexual Health Inventory for Men ≥ 17), stage below pT2, followed up for > 6 months with minimally one side of neurovascular bundle preservation procedure, 12 (70.6%) were capable of intercourse postoperatively, and the mean time for sexual intercourse after operation was 5.7 months. In this series, robotic prostatectomy was a feasible and reproducible technique, with a short learning curve and low perioperative complication rate. Even during the initial phase of the learning curve, satisfactory results were obtained with regard to functional and oncological outcome.
“Transperitoneal robotic-assisted laparoscopic prostatectomy after prosthetic mesh herniorrhaphy.”
Lallas, C. D., M. L. Pe, et al. (2009).
JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 13(2): 142-147.
BACKGROUND AND OBJECTIVES: We report our institutional experience performing transperitoneal robotic-assisted laparoscopic prostatectomy (RALP) in patients with prior prosthetic mesh herniorrhaphy to assess the feasibility of this procedure in this patient population. METHODS: From October 2005 to January 2008, transperitoneal robotic-assisted laparoscopic prostatectomies were performed and prospectively recorded. We retrospectively reviewed 309 patients. RESULTS: Twenty-seven patients (8.7%) were found to have a history of prior hernia repair with prosthetic mesh placement. The mean age was 55.7, estimated blood loss (EBL) was 228 mL, operative (console) time was 197 minutes, and length of hospital stay (LOS) was 1.62 days. In contrast, patients undergoing RALP with no history of mesh herniorrhaphy had a mean age of 59.3, EBL of 302 mL, console time of 193 minutes, and LOS of 2.2 days. These differences were not statistically significant. The mesh herniorrhaphy cohort had a lower percentage of organ-confined disease, but no difference was seen in margin status, continence, or potency rates after one year. CONCLUSIONS: Transperitoneal RALP is a feasible option for previously operated on patients with prosthetic mesh herniorrhaphy. Two areas that we identified as critical were the initial step of gaining access for pneumoperitoneum and port placement, and meticulous dissection to expose the mesh, which can be subsequently avoided and left intact. As RALP continues to gain popularity, urologists will continue to exploit the advantages of robotic surgery to perform increasingly challenging cases.
“Robotic-assisted laparoscopic and radical retropubic prostatectomy generate similar positive margin rates in low and intermediate risk patients.”
Laurila, T. A. J., W. Huang, et al. (2009).
Urologic Oncology: Seminars and Original Investigations 27(5): 529-533.
Objective: Robotic-assisted laparoscopic prostatectomy (RALP) is being increasingly utilized. To assess the efficacy of the operation, we compared apical and overall margin status for RALP with radical retropubic prostatectomy (RRP) in a group of contemporary patients. Patients and methods: We retrospectively reviewed 98 consecutive RRPs and then 94 RALPs from a single institution. Groups were analyzed and matched with regard to preoperative prostate-specific antigen (PSA), cancer grade, pathologic stage, and tumor volume. Surgical margins were quantitated. Results: Clinicopathologic parameters were compared and additional high risk patients were observed in the RRP vs. RALP group. To risk-adjust these patient groups, those meeting preoperative high risk criteria were excluded from further positive margin analysis. Postoperatively, the average tumor volume was 13% in both groups. Pathologic stage pT3 was similar between RRP (14%) and RALP (11%). A positive surgical margin (PSM) was found in 12 cases (14%) after RRP and 11 cases (13%) after RALP including apical margins. Positive margins at the apex, non-apex, and both were statistically similar between groups. Conclusions: In this study, no differences were seen between robotic prostatectomy with regard to apical or overall margin status compared with open prostatectomy in lower risk patients. This suggests that despite improved visualization, RALP generates a similar margin status as RRP. © 2009 Elsevier Inc. All rights reserved.
“The advanced learning curve in robotic prostatectomy: a multi-institutional survey.”
Lavery, H. J., D. B. Samadi, et al. (2009).
Journal of Robotic Surgery: 1-5.
Several studies have attempted to define the learning curve associated with robot-assisted laparoscopic prostatectomy (RALP). These studies have focused on the acquisition of skills by novice robotic surgeons. It is unclear, however, if basic proficiency can be equated with satisfactory patient outcomes. We surveyed experienced robotic surgeons with high surgical volume in an attempt to define an “advanced” learning curve, relating to proficiency and outcomes with the robotic procedure. A questionnaire was designed to evaluate the learning curve of the RALP from basic to advanced techniques. High-volume, experienced surgeons were asked to complete this questionnaire on the basis of their personal experience with the RALP procedure. Nine institutions participated in the study accounting for a total case volume of 6,276. Median surgeon experience was 460 cases (range 325-1,500); median total operative and robotic time were 165 and 105 min, respectively. Median time to “basic proficiency” with the robot was 40 cases; proficiency in more challenging cases was approached after a median of 50 cases. Surgical outcomes were deemed satisfactory to the surgeon for continence, potency, and surgical margins after a median of 100, 200, and 300 procedures, respectively. These data confirm previous studies that basic proficiency with the robotic system occurs relatively quickly, after 25-40 cases. Obtaining “satisfactory outcomes” took substantially longer, from 100 to 300 cases. Satisfactory outcomes regarding surgical margins and potency took longer to obtain than continence, likely reflecting the relative complexity of cancer control and nerve-sparing compared with the vesico-urethral anastomosis. © 2009 Springer-Verlag London Ltd.
“CyberknifeTM for the treatment of non-metastatic prostate cancer.”
Lee, S. J., K. Song, et al. (2009).
Korean Journal of Urology 50(8): 744-750.
Purpose: The radiobiology of prostate cancer favors a hypofractionated dose regimen. We report here our experience with the CyberKnifeTM, demonstrating its efficacy, safety, and feasibility as a treatment modality for non-metastatic prostate cancer. Materials and Methods: Between October 2002 and April 2006, 20 patients with biopsy-proven prostate cancer were treated with the CyberKnifeTM. The distribution of clinical risks, as assessed by using D’Amico’s definition for risk grouping, was as follows: low (4), intermediate (5), and high (11). Three patients received 32 Gy, 7 patients received 34 Gy, and 10 patients received 36 Gy. All patients received the radiation doses in 4 fractions. The rectal and bladder toxicities were graded by using the criteria set forth by the Radiation Therapy Oncology Group (RTOG). Results: The mean patient age was 71.4 years (range, 52-79 years), and the mean follow-up period was 35.5 months (range, 8-74 months). There were 2 acute and 1 late grade 2 gastrointestinal toxicities, and 1 acute and 2 late grade 2 urinary toxicities. The 5-year overall survival rate was 100%, respectively. The 5-year biochemical failure-free rate of the low-risk, intermediate-risk, and high-risk patients was 100%, 100%, and 90.9%, respectively. Conclusions: CyberKnifeTM is a safe, well-tolerated, and rather effective treatment for non-metastatic prostate cancer. We obtained a 100% 5-year biochemical failure-free rate in low-risk and intermediate-risk patients. CyberKnifeTM is a viable option for the treatment of non-metastatic prostate cancer. © The Korean Urological Association, 2009.
“Modified transverse plication for bladder neck reconstruction during robotic-assisted laparoscopic prostatectomy: Surgery Illustrated – Focus on Details.”
Lin, V. C., G. Coughlin, et al. (2009).
BJU International 104(6): 878-881.
“Editorial Comment.”
Menon, M. (2009).
Urology 74(3): 616.
“Outcomes after robot-assisted laparoscopic radical prostatectomy.”
Murphy, D. G., B. J. Challacombe, et al. (2009).
Asian journal of andrology 11(1): 94-99.
Robot-assisted laparoscopic radical prostatectomy (RALRP) using the da Vinci surgical system is now in widespread use in many countries where economic conditions allow the installation of this expensive technology. Controversy has surrounded the procedure since it was first performed in 2000, with many critics highlighting the lack of evidence to support its use. However, despite the lack of level I evidence, many large studies of patients have confirmed that the procedure is feasible and safe, with low morbidity. Available longer-term oncological data seem to show that outcomes from the robotic approach at least match those of traditional open radical prostatectomy. Functional outcomes also seem satisfactory, although randomized controlled trials are lacking. This paper reviews the current status of RALRP with respect to perioperative data and complications and oncologic and functional outcomes.
“Combined robotic-assisted laparoscopic partial nephrectomy and radical prostatectomy.”
Patel, M. N., D. Eun, et al. (2009).
JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 13(2): 229-232.
A 59-year-old man with a history of prostate cancer and clear-cell renal-cell carcinoma of the kidney underwent a combined robot-assisted laparoscopic partial nephrectomy and radical prostatectomy. We describe the initial report of a combined robot-assisted operation for both procedures concurrently with a port strategy allowing reuse of ports.
“Robotic vs open prostatectomy in a laparoscopically naive centre: A matched-pair analysis.”
Rocco, B., D. V. Matei, et al. (2009).
BJU International 104(7): 991-995.
Objective: To compare the early oncological, perioperative and functional outcomes of robotic-assisted radical prostatectomy (RARP) vs open retropubic RP (RRP) in a laparoscopically naive centre, as robotic assistance aids the laparoscopically naive surgeon in minimally invasive prostate surgery, by offering magnification and superior dexterity. Patients and Methods: From 1 November 2006 to 31 December 2007, 120 patients had RARP; this group was followed prospectively and evaluated for early oncological, perioperative and functional outcomes (measured at 3, 6 and 12 months after surgery), and compared to a historical control group of consecutive patients who had RRP from 20 May 2004 to 28 February 2007. All patients were operated by the same laparoscopically naive surgeons. The comparison was by matched-pair analysis. Results: The baseline characteristics of the two groups were equivalent, although there was a higher percentage of patients with pT3/pT4 disease in the RRP group. As a proxy for oncological outcome, positive surgical margins were equivalent in the two groups (22% RARP vs 25% RRP, P = 0.77). The overall mean (range) surgical duration was significantly longer in RARP group, at 215 (165-450) min vs 160 (90-240) min in the RRP group (P < 0.001). However, RARP had a statistically significant advantage over RRP for estimated blood loss, of 200 vs 800 mL (P < 0.001), duration of catheterization (6 vs 7 days P < 0.001) and length of stay (3 vs 6 days, P < 0.001) The 3, 6 and 12-month continence rates were 70%, 93% and 97% vs 63%, 83% and 88% after RARP and RRP, respectively (P = 0.15, 0.011 and 0.014). The 3, 6 and 12 month overall potency recovery rate was 31%, 43% and 61% vs 18%, 31% and 41%, after RARP and RRP, respectively (P = 0.006, 0.045 and 0.003). Conclusion: Our initial experience showed the feasibility of RARP in a laparoscopically naive centre. RRP seems to be a faster procedure, whereas RARP provided better Results: in terms of estimated blood loss, hospitalization and functional results. The early oncological outcome seemed to be equivalent in the two groups. © 2009 BJU International.
“Robot assisted radical prostatectomy: Current concepts.”
Sairam, K. and P. Dasgupta (2009).
Minerva Urologica e Nefrologica 61(2): 115-120.
Laparoscopic cholecystectomy has evolved from being a reluctantly accepted novelty to the most widely adopted procedure. It reached a high popularity even before randomized trials could be carried out. Open cholecystectomy was at one time considered the “gold standard”, only to be replaced by laparoscopic cholecystectomy. Today the same is happening with radical prostatectomy. Open radical prostatectomy (ORP) was the reference standard. Afterwards, came laparoscopic radical prostatectomy (LRP), which matched ORP in terms of the trifecta of oncological, continence and sexual function outcomes. Robot-assisted radical prostatectomy (RARP) was the next step in the evolution. Since 2000, it has become very widespread because of private practice promotion among surgeons and marketing hype by the manufacturers. Furthermore, patients ask for this operation. In the last eight years, there has been a rise in conceptual changes, especially in operative techniques, to improve outcomes following RARP. This review will focus on some of the key concepts emerged in the field of robotic surgery, to improve outcomes following RARP. The lack of randomized controlled trials makes it difficult to make true comparisons with ORP, LRP and other methods of treating localized prostate cancer.
“Lymph node dissection during robot-assisted radical prostatectomy: Where do we stand?”
Silberstein, J. L., I. H. Derweesh, et al. (2009).
Prostate Cancer and Prostatic Diseases 12(3): 227-232.
Since the initial report of robot-assisted laparoscopic prostatectomy (RALP) in 2001, the technique has gained rapid acceptance and utilization. When compared with more traditional forms of surgical intervention, there is still much debate with respect to cost, and impact on potency and continence. Less often is the focus on oncologic outcomes. Pelvic lymph node dissection (PLND) at the time of prostatectomy is an important part of the surgical intervention for prostate cancer and is currently underreported during robotic procedures. Herein, we review the current controversies on the value and extent of PLND and the status of emerging data regarding robot-assisted PLND.
“The case for posterior musculofascial plate reconstruction in robotic prostatectomy.”
Stein, R. J. (2009).
Urology 74(3): 489-491.
“Location, Extent and Number of Positive Surgical Margins Do Not Improve Accuracy of Predicting Prostate Cancer Recurrence After Radical Prostatectomy.”
Stephenson, A. J., D. P. Wood, et al. (2009).
Journal of Urology 182(4 SUPPL.): 1357-1363.
Purpose: Positive surgical margins increase the risk of biochemical recurrence after radical prostatectomy by 2 to 4-fold. The risk of biochemical recurrence may be influenced by the anatomical location and extent of positive surgical margins. In a multicenter study we analyzed the predictive usefulness of several subclassifications of positive surgical margins. Materials and Methods: The clinical information and followup data of 7,160 patients treated with radical prostatectomy alone at 1 of 3 institutions between 1995 and 2006 were modeled using Cox proportional hazards regression analysis for biochemical recurrence. Positive surgical margins were analyzed as solitary vs multiple, focal vs extensive and apical location vs other. The usefulness of these subclassifications was assessed by the improvement in predictive accuracy of nomograms containing these parameters compared to one in which the surgical margin was modeled simply as positive vs negative. Results: The 7-year progression-free probability was 60% in patients with positive surgical margins. A positive surgical margin was significantly associated with biochemical recurrence (HR 2.3, p <0.001) after adjusting for age, prostate specific antigen, pathological Gleason score, pathological stage and year of surgery. An increased risk of biochemical recurrence was associated with multiple vs solitary positive surgical margins (adjusted HR 1.4, p = 0.002) and extensive vs focal positive surgical margins (adjusted HR 1.3, p = 0.004) on multivariable analysis. However, neither parameter improved the predictive accuracy of a nomogram compared to one in which surgical margin status was modeled as positive vs negative (concordance index 0.851 vs 0.850 vs 0.850). Conclusions: The number and extent of positive surgical margin significantly influence the risk of biochemical recurrence after radical prostatectomy. However, the empirical prognostic usefulness of subclassifications of positive surgical margins is limited. © 2009 American Urological Association.
“Erectile function recovery rate after radical prostatectomy: A meta-analysis.”
Tal, R., H. H. Alphs, et al. (2009).
Journal of Sexual Medicine 6(9): 2538-2546.
Introduction. Erectile function recovery (EFR) rates after radical prostatectomy (RP) vary greatly based on a number of factors, such as erectile dysfunction (ED) definition, data acquisition means, time-point postsurgery, and population studied. Aim. To conduct a meta-analysis of carefully selected reports from the available literature to define the EFR rate post-RP. Main Outcome Measures. EFR rate after RP. Methods. An EMBASE and MEDLINE search was conducted for the time range 1985-2007. Articles were assessed blindly by strict inclusion criteria: report of EFR data post-RP, study population ≥ 50 patients, ≥ 1 year follow-up, nerve-sparing status declared, no presurgery ED, and no other prostate cancer therapy. Meta-analysis was conducted to determine the EFR rate and relative risks (RR) for dichotomous subgroups. Results. A total of 212 relevant studies were identified; only 22 (10%) met the inclusion criteria and were analyzed (9,965 RPs, EFR data: 4,983 subjects). Mean study population size: 226.5, standard deviation = 384.1 (range: 17-1,834). Overall EFR rate was 58%. Single center series publications (k = 19) reported a higher EFR rate compared with multicenter series publications (k = 3): 60% vs. 33%, RR = 1.82, P = 0.001. Studies reporting ≥ 18-month follow-up (k = 10) reported higher EFR rate vs. studies with <18-month follow-up (k = 12), 60% vs. 56%, RR = 1.07, P = 0.02. Open RP (k = 16) and laparoscopic RP (k = 4) had similar EFR (57% vs. 58%), while robot-assisted RP resulted in a higher EFR rate (k = 2), 73% compared with these other approaches, P = 0.001. Patients <60 years old had a higher EFR rate vs. patients ≥ 60 years, 77% vs. 61%, RR = 1.26, P = 0.001. Conclusions. These data indicate that most of the published literature does not meet strict criteria for reporting post-RP EFR. Single and multiple surgeon series have comparable EFR rates, but single center studies have a higher EFR. Younger men have higher EFR and no significant difference in EFR between ORP and LRP is evident. © 2009 International Society for Sexual Medicine.
“Impact of prostate weight on radical prostatectomy outcomes.”
Tal, R., M. Konichezky, et al. (2009).
Israel Medical Association Journal 11(6): 354-358.
Background: The management of localized prostate cancer in patients with large prostates is controversial. Objectives: To investigate the impact of prostate weight on radical prostatectomy outcomes. Methods: The files of 244 patients who underwent radical prostatectomy were reviewed. Data were collected on patient and tumor characteristics and on oncological, urinary and erectile function outcomes. Results were compared between patients with prostates weighing ≤ 60 g or > 60 g. Results: A prostate weight of > 60 g was documented in 25% of the patients. There was no difference in clinical stage distribution between patients with smaller and patients with larger prostates. Patients with a larger prostate were characterized preoperatively by higher levels of prostatespecific antigen (9.8 vs. 7.3 ng/ml, P = 0.009), lower tumor grade (biopsy Gleason score ≤ 6: 77.6% vs. 90.2% P = 0.04), and a higher incidence of moderate-severe urinary symptoms (69.8 vs. 38.8%, P = 0.0003). Analysis of pathological stage distribution yielded a higher proportion of lower stage disease and a lower incidence of positive margins in the large-prostate group (11.7 vs. 25.8%, P = 0.024). There were no statistically significant between-group differences in the rate of persistent postoperative detectable PSA, biochemical recurrence, urinary incontinence and erectile function. Conclusions: The outcomes of radical prostatectomy in patients with large prostate are favorable in terms of cancer characteristics despite their higher preoperative PSA levels, and comparable to that in patients with small prostate in terms of urinary continence and erectile function. Surgery may be particularly beneficial in patients with preoperative urinary symptoms. Hence, radical prostatectomy should not be discouraged as a treatment for localized prostate cancer in patients with sizeable prostates.
“Anatomic Restoration Technique: A Biomechanics-based Approach for Early Continence Recovery After Minimally Invasive Radical Prostatectomy.”
Tan, G. Y., J. K. Jhaveri, et al. (2009).
Urology 74(3): 492-496.
“Ultrasensitive prostate specific antigen assay following laparoscopic radical prostatectomy–an outcome measure for defining the learning curve.”
Viney, R., L. Gommersall, et al. (2009).
Annals of the Royal College of Surgeons of England 91(5): 399-403.
INTRODUCTION: Radical retropubic prostatectomy (RRP) performed laparoscopically is a popular treatment with curative intent for organ-confined prostate cancer. After surgery, prostate specific antigen (PSA) levels drop to low levels which can be measured with ultrasensitive assays. This has been described in the literature for open RRP but not for laparoscopic RRP. This paper describes PSA changes in the first 300 consecutive patients undergoing non-robotic laparoscopic RRP by a single surgeon. OBJECTIVES: To use ultrasensitive PSA (uPSA) assays to measure a PSA nadir in patients having laparoscopic radical prostatectomy below levels recorded by standard assays. The aim was to use uPSA nadir at 3 months’ post-prostatectomy as an early surrogate end-point of oncological outcome. In so doing, laparoscopic oncological outcomes could then be compared with published results from other open radical prostatectomy series with similar end-points. Furthermore, this end-point could be used in the assessment of the surgeon’s learning curve. PATIENTS AND METHODS: Prospective, comprehensive, demographic, clinical, biochemical and operative data were collected from all patients undergoing non-robotic laparoscopic RRP. We present data from the first 300 consecutive patients undergoing laparoscopic RRP by a single surgeon. uPSA was measured every 3 months post surgery. RESULTS: Median follow-up was 29 months (minimum 3 months). The likelihood of reaching a uPSA of < or = 0.01 ng/ml at 3 months is 73% for the first 100 patients. This is statistically lower when compared with 83% (P < 0.05) for the second 100 patients and 80% for the third 100 patients (P < 0.05). Overall, 84% of patients with pT2 disease and 66% patients with pT3 disease had a uPSA of < or = 0.01 ng/ml at 3 months. Pre-operative PSA, PSA density and Gleason score were not correlated with outcome as determined by a uPSA of < or = 0.01 ng/ml at 3 months. Positive margins correlate with outcome as determined by a uPSA of < or = 0.01 ng/ml at 3 months but operative time and tumour volume do not (P < 0.05). Attempt at nerve sparing had no adverse effect on achieving a uPSA of < or = 0.01 ng/ml at 3 months. CONCLUSIONS: uPSA can be used as an early end-point in the analysis of oncological outcomes after radical prostatectomy. It is one of many measures that can be used in calculating a surgeon’s learning curve for laparoscopic radical prostatectomy and in bench-marking performance. With experience, a surgeon can achieve in excess of an 80% chance of obtaining a uPSA nadir of < or = 0.01 ng/ml at 3 months after laparoscopic RRP for a British population. This is equivalent to most published open series.