Robot-assisted Radical Prostatectomy Cases Research Articles

Optimizing Urological Concurrent Robotic Multisite Surgery: Juxtaposing a Single-Center Experience and a Literature Review

Introduction: This article juxtaposes case series with a systematic review to evaluate the feasibility, safety, and clinical outcomes of concurrent robotic multisite urological surgeries, specifically robot-assisted radical prostatectomy (RARP) and robot-assisted partial nephrectomy (RAPN), for synchronous prostate and kidney cancers. Aim: The aims of this study were to evaluate the feasibility, safety, and clinical outcomes of urological concurrent robotic multisite surgeries through a comparison of institutional findings with the existing literature. Materials and Methods: A retrospective analysis was conducted on eight institutional cases of concurrent robotic multisite surgeries performed between 2021 and 2024. The primary outcomes measured were operative time, blood loss, and postoperative complications. A systematic review of the literature was performed, searching PubMed, Embase, and Cochrane Library databases, with the last search conducted on 1 July 2024. Studies were included if they reported on concurrent robotic surgeries corresponding to the procedures performed at the institution, including RARP with RAPN, RARP with robotic transabdominal preperitoneal inguinal hernia repair (RTAPPIHR), and other multisite robotic surgeries. Risk of bias was assessed using the modified Newcastle–Ottawa Scale. Descriptive statistics were used to analyze operative time and blood loss, with confidence intervals (CIs) calculated to assess precision. Categorical variables, including postoperative complications, were summarized using frequencies and percentages. Heterogeneity was assessed using the I2 statistic, with values above 50% indicating substantial heterogeneity. A random effects model was applied when necessary, and sensitivity analyses excluded studies with high risk of bias. Results: We describe a unique docking technique employed in our procedures, which allows for atraumatic transitions between surgeries using the same port sites. Our institutional cases demonstrated the feasibility and safety of concurrent robotic multisite surgery, with a mean operative time of 315 min (95% CI: 290–340) and mean blood loss of 300 mL (95% CI: 250–350). There were no significant intraoperative complications reported. These findings are consistent with the literature, where mean operative times range from 390 to 430 min and blood loss ranges from 200 to 330 mL. Notably, no positive surgical margins or declines in postoperative renal function were observed in our cases. The systematic review included nine retrospective studies involving 40 cases of concurrent RARP and RAPN, as well as eleven studies including 392 cases of RARP combined with RTAPPIHR. The findings from these studies support the feasibility and safety of concurrent surgeries, showing similar rates of operative time, blood loss, and postoperative complications. Conclusions: Concurrent robotic multisite surgeries, such as RARP combined with RAPN or RTAPPIHR, appear to be safe and feasible. Our data suggest these procedures are non-inferior to separate surgeries in terms of safety and complication rates. Potential benefits, including reduced operative times, shorter hospital stays, and more efficient resource use, may translate into cost savings, although no formal cost-effectiveness analysis was conducted. Limitations include the small sample size, retrospective design, and lack of long-term follow-up. Prospective trials are needed to validate these findings and further refine the techniques. Funding: this review did not receive any external funding. Registration: this review was not registered in any public protocol registry due to its comparative retrospective nature.

Effects of modifying hinotori™ surgical robot system on perioperative outcome of robot-assisted radical prostatectomy.

One of the main advantages of the hinotori™ surgical robot system (HSRS) is that it can be easily adjusted. This study aimed to clarify the effects of modifying the HSRS on the perioperative outcomes of robotic-assisted radical prostatectomy (RARP). Overall, 158 cases of RARP using the HSRS were classified into three groups based on the modification to the system: group A (no modification, 70 cases), group B (addition of the ability to switch between two types of scopes and to adjust the arm base tilt back and forth, left and right, 42 cases), and group C (reduction of arm floating sensation, mitigation of emergency stop during arm collision, and addition of clutch function via hand switch in addition to foot pedal, 46 cases). The perioperative outcomes of each group were compared. The median of operation time, cockpit time, and cockpit time excluding the time required for lymph node dissection of group C were 223, 146, and 135 min, respectively, where are significantly shorter than those of group A (308, 228, and 208 min, p < 0.0001, respectively) and group B (319, 241, and 214 min, p < 0.0001, respectively). There was no significant difference in the rate of positive margin rates and the pad-free rate before the first follow-up visit among these three groups. The complication rates in groups A, B, and C were 11.4%, 9.4%, and 8.4% (Clavien-Dindo grades I-II), and 4.3%, 2.4%, and 0% (grade III), respectively. The modifications to the HSRS have enabled smoother surgical procedures for RARP.

Initial surgical performance in robot-assisted radical prostatectomy is associated with clinical outcomes and learning curves.

The association between surgical performance ratings and clinical outcomes in robotic surgery is poorly understood. Additionally, no studies have reported on the relationship between the surgeon's initial case-skill evaluation and the learning curve in robot-assisted surgery. We evaluated whether an objective surgical technique evaluation score for initial robot-assisted radical prostatectomy (RARP) was associated with clinical outcomes and surgeons' learning curves. Six surgeons who were trained in and started to perform RARP at our institution were included. Anonymized, unedited videos of each surgeon's 10th RARP case were evaluated by three reviewers, using modified Objective Structured Assessment of Technical Skill (OSATS) scores. We then divided the surgeons into two groups on the basis of these OSATS scores. We retrospectively compared the clinical outcomes and learning curves of the console time of the two groups for consecutive RARPs, performed from March 2018 to July 2023. We analyzed 258 RARPs (43 cases/surgeon), including 129 cases performed by high-OSATS score surgeons (18.2-19.3 points) and 129 cases performed by low-OSATS score surgeons (11.9-16.0 points). Overall, the high-OSATS score group had significantly shorter operation and console times than the low-OSATS score group did (both P < 0.01) and their patients' rate of continence recovery by 3months post-RARP was significantly higher (P = 0.03). However, complications, blood loss, and positive margins did not differ between the groups (P = 0.08, P = 0.51, and P = 0.90, respectively). The high-OSATS score group had a significantly shorter console time than the low-OSATS score group did after the 11-20 cases. The OSATS score in early RARP cases can predict subsequent surgical outcomes and surgeons' learning curves.

Robotic urologic applications of the hinotori™ Surgical Robot System

ObjectiveTo assess the safety and effectiveness of urological tumor surgeries using the hinotori™ Surgical Robot System (hinotori) in a real-world clinical setting. MethodsAll surgeries including procedures of robot-assisted radical prostatectomy (RARP), robot-assisted partial nephrectomy (RAPN), robot-assisted radical nephrectomy (RARN), robot-assisted nephroureterectomy (RANU), robot-assisted adrenalectomy (RAA), and robot-assisted radical cystectomy with intracorporeal urinary diversion (RARC+ICUD) for urological tumors with hinotori and da Vinci surgical system (da Vinci) from January 2022 through September 2023 were enrolled. We evaluated the safety and effectiveness of surgery using hinotori compared using da Vinci. ResultsRobotic surgeries using hinotori were performed in a total of 91 cases, comprising 42 cases of RARP, 18 cases of RAPN, six cases of RARN, 10 cases of RANU, 13 cases of RAA, and two cases of RARC+ICUD. No major intraoperative complications were observed in any cases using hinotori. No major postoperative complications occurred in any of the cases. No case experienced unrecoverable equipment error during surgery. Meanwhile, robotic surgeries using da Vinci were performed in a total of 277 cases that included 126 cases of RARP, 94 cases of RAPN, 12 cases of RARN, 10 cases of RANU, 20 cases of RAA and 15 cases of RARC+ICUD. Major intraoperative complications occurred two cases. Major postoperative complications occurred in seven cases. Seven cases required transfusion. One case underwent conversion to open surgery. During the study period, no case experienced an unrecoverable equipment error. Surgical outcomes for cases with hinotori were comparable to those with da Vinci. ConclusionsThis study demonstrated that hinotori is a safe and feasible tool for robotic surgeries in the field of urology.

Propensity score matched analysis of functional outcome in five thousand cases of robot-assisted radical prostatectomy versus high-intensity focused ultrasound

BackgroundTo evaluate functional outcome after robot-assisted radical prostatectomy (RARP) and high-intensity focused ultrasound (HIFU) ablation for prostate cancer. MethodsWe retrospectively reviewed 4,983 RARP and 230 HIFU procedures performed at a single tertiary center. A 1:4 ratio propensity score matching (PSM) was performed to achieve baseline equivalence in age, body mass index (BMI), comorbidities, clinical stage, prostate specific antigen (PSA), prostate volume, biopsy grade, and number of positive cores. Functional outcomes based on International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF-5) scores, and incontinence rates were evaluated at 6, 12, and 24 months. Resultstotal of 193 HIFU cases matched to 760 cases of RARP, were included. No differences were observed in perioperative IPSS at all follow-up periods. Despite comparative erectile function at baseline, HIFU showed significantly better erectile function preservation compared to RARP, with mean IIEF-5 scores of 9.5 versus 4.8, 9.5 versus 5.8, and 8.4 versus 6.7 at 6, 12, and 24 months, respectively (all P < 0.001). Pad-free rates at 6 and 12 months were comparable, with over 96% achieving continence at 12 months in both groups, although the rate of ≤1 pad/day at last follow-up was slightly better in HIFU (98.9% vs. 96.7%, P = 0.049). Subgroup analysis on partial (PGA) and whole gland ablation (WGA) showed no differences in IIEF-5 and incontinence but increased voiding difficulty in WGA versus PGA after 12 months of therapy (P < 0.05). Preoperative IIEF-5 ≥17 and HIFU were significant predictors of early erectile function recovery at 6 months (HR 4.4 and 5.0; all P < 0.001). No differences were observed in treatment-free survival between PGA, WGA, and RARP. ConclusionHIFU shows better performance in early recovery and preservation of erectile function after treatment for prostate cancer without increasing the risk of treatment failure. Patients with moderate to severe erectile dysfunction (IIEF-5 <17) prior to surgery should be warned of poor recovery after treatment.

Functional outcomes of robot-assisted radical prostatectomy with preservation of pelvic stabilized structure and early elevated retrograde liberation of neurovascular bundle

Objectives: To examine the functional outcomes of robot-assisted radical prostatectomy (RARP) with preservation of pelvic floor stabilized structure and early elevated retrograde liberation of the neurovascular bundle (PEEL). Methods: This study was a retrospective cohort study. Between June 1, 2022, and March 20, 2023, 27 cases of RARP with PEEL and 153 cases of RARP with preservation of pelvic floor stabilized structure (PPSS) were included in this study. All patients were males, aged (62.5±5.2) years (range: 50 to 73 years). There were 18 cases of ≤T2b stage and 9 cases of T2c stage. After 1∶1 propensity score matching, the postoperative functional outcomes of 27 cases of RARP with PEEL and 27 cases of RARP with PPSS were compared. All surgeries were performed by a single surgeon and included patients were clinically staged as cT1-2N0M0 without preoperative urinary incontinence or erectile dysfunction. In RARP with PEEL, the prostate was cut near the midline at the front when dissecting the neurovascular bundle, dissection was performed between the visceral layer of the pelvic fascia and the prostatic fascia, preserving the parietal layer and the visceral layer of the pelvic fascia, and the neurovascular bundle was retrogradely released from the apex. The cumulative probability curve was plotted using the Kaplan-Meier method and the Log-rank test was used to compare the differences in functional outcomes between the two groups. Univariate and multivariate analysis with the Cox proportional hazards model was used to compare postoperative urinary continence and sexual function. Results: The recovery time of continence and potency was significantly longer in the PPSS group than in the PEEL group (all P<0.05). The continence rate of the PEEL group was significantly higher than that of the PPSS group (92.59% vs. 68.10%, P=0.026) at 3 months after surgery. The potency rate of the PEEL group was also significantly higher than that of the PPSS group (40.70% vs. 15.10%, P=0.037) at 3 months after surgery. In the univariate analysis, compared to the PPSS technique, the PEEL technique was associated with a shorter recovery time of continence (HR=1.94, 95%CI: 1.08 to 3.48, P=0.027) and a shorter recovery time of potency (HR=2.06, 95%CI: 1.03 to 4.13, P=0.042). In the multivariate analysis, the PEEL technique was an independent prognosis factor for postoperative recovery of continence (HR=2.05, 95%CI: 1.01 to 4.17, P=0.047) and potency (HR=3.57, 95%CI: 1.43 to 8.92, P=0.007). All the cases of the PPSS group and the PEEL group were performed successfully with negative surgical margins. Conclusion: Compared with PPSS, PEEL may be more conducive to the recovery of urinary continence and sexual function after RARP.

Inguinal hernia leads to worse immediate urinary continence after robot-assisted radical prostatectomy.

Patients with inguinal hernia (IH) may have voiding dysfunction and weak urethra-stabilizing periurethral fascial tissues, contributing to urinary incontinence. This study aimed to review the association between IH and urinary continence after robotic-assisted radical prostatectomy (RARP). This single-institution retrospective study included 251 consecutive cases of RARP between April 2019 and June 2022. Patients with concurrent IH or a history of adult IH repair were examined. The urine loss rate (ULR), defined as 24-h urine loss volume divided by the total urine volume immediately after urinary catheter removal (i.e., 6 or 7 postoperative days), was compared between the groups with (n = 33) and without IH (n = 214). Possible contributing factors for ULR were assessed, including age, body mass index (BMI), after benign prostatic hyperplasia surgery, prostate weight, and nerve-sparing. ULR was compared intergroup after propensity score matching countering selection biases. Patients with IH were older (71.3 versus. 66.8years, p < 0.01), had lower BMI (22.8 versus. 24.3, p < 0.01), and had higher ULR (14.5% versus. 5.1%, p < 0.01). In a multiple linear regression analysis (adjusted R2 = 0.084), IH (p < 0.01) was an independent contributing factor for ULR besides advancing age (p < 0.03). After propensity score matching adjusted for patient's age and nerve-sparing, patients with IH had higher ULR (14.1% versus. 5.7%, p < 0.03) as well. This study first reported that IH may be one of the risk factors of urinary incontinence after RARP.

LB01 - Propensity score matched analysis of functional outcome in 5000 cases of robot-assisted radical prostatectomy versus high-intensity focused ultrasound

LB01 - Propensity score matched analysis of functional outcome in 5000 cases of robot-assisted radical prostatectomy versus high-intensity focused ultrasound

V10-06 INTRAOPERATIVE USE OF PET/CT SPECIMEN IMAGER TO GUIDE ROBOTIC RADICAL PROSTATECTOMY AND PELVIC LYMPH NODE DISSECTION

You have accessJournal of UrologyCME1 Apr 2023V10-06 INTRAOPERATIVE USE OF PET/CT SPECIMEN IMAGER TO GUIDE ROBOTIC RADICAL PROSTATECTOMY AND PELVIC LYMPH NODE DISSECTION Marco Oderda, Serena Grimaldi, Giorgio Calleris, Daniele D'Agate, Federico Lavagno, Alessandro Marquis, Giancarlo Marra, Desireé Deandreis, and Paolo Gontero Marco OderdaMarco Oderda More articles by this author , Serena GrimaldiSerena Grimaldi More articles by this author , Giorgio CallerisGiorgio Calleris More articles by this author , Daniele D'AgateDaniele D'Agate More articles by this author , Federico LavagnoFederico Lavagno More articles by this author , Alessandro MarquisAlessandro Marquis More articles by this author , Giancarlo MarraGiancarlo Marra More articles by this author , Desireé DeandreisDesireé Deandreis More articles by this author , and Paolo GonteroPaolo Gontero More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003328.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Today, PSMA is the most accurate radiopharmaceutical in PCa and it can be used as a tracer to identify PCa foci in resected specimens. To do so, a small, high-resolution PET/CT-imaging device (XEOS AURA®) was developed, with near five-fold optimization in spatial resolution as opposed to the standard clinical PET/CT devices. Aim of this feasibility study was to test the intraoperative use of this brand-new PET/CT specimen imager to guide robot-assisted radical prostatectomy (RARP) and pelvic lymph node dissection (PLND). METHODS: To date, we performed three cases of RARP and PLND with intraoperative use of XEOS AURA® specimen imager. All patients underwent preoperative staging with MRI and PSMA PET/CT. Surgeries were performed with Da Vinci Xi robot. During trocar placement, an intravenous injection of 68-Ga PSMA, 2 mBq/kg, was performed. Lymph nodes were immediately removed through the 12-mm assistant trocar and inserted into the specimen imager for analysis. After complete excision, the prostate was removed through a short Pfannestiel incision while maintaining CO2 insufflation, and analysed with the specimen imager to check for positive margins (PSM) before doing the urethra-vesical anastomosis. RESULTS: On average, the time required by XEOS AURA® to analyse each specimen was 12 minutes (SD 3). Total and positive nodal yield were 17.3 (5.8) and 0.3 (0.5 SD), respectively. PET/CT specimen imager showed a marked uptake for the only positive node retrieved, and a diffuse, weak uptake in several negative nodes. There was a good correspondence between marked uptake and node positivity, reflecting also preoperative PET/CT findings (Table 1). XEOS AURA® was useful to predict negative surgical margins, although in one locally advanced case this evaluation was uncertain. CONCLUSIONS: The use of PET/CT specimen imager is safe and feasible. The intraoperative knowledge of prostate cancer (PCa) location within lymph nodes or inside the prostate is essential to improve the oncological radicality of the procedure while safely pushing the boundaries of a hyper-conservative surgery. Source of Funding: University of Turin © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e927 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marco Oderda More articles by this author Serena Grimaldi More articles by this author Giorgio Calleris More articles by this author Daniele D'Agate More articles by this author Federico Lavagno More articles by this author Alessandro Marquis More articles by this author Giancarlo Marra More articles by this author Desireé Deandreis More articles by this author Paolo Gontero More articles by this author Expand All Advertisement PDF downloadLoading ...

PD27-08 COMPARISON OF SURGICAL OUTCOMES BETWEEN OUTPATIENT AND INPATIENT ROBOT-ASSISTED RADICAL PROSTATECTOMY: A META-ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023PD27-08 COMPARISON OF SURGICAL OUTCOMES BETWEEN OUTPATIENT AND INPATIENT ROBOT-ASSISTED RADICAL PROSTATECTOMY: A META-ANALYSIS Muhammed A. Moukhtar Hammad, Tuan Nguyen, Ryan W. Dobbs, Huy Gia Vuong, Jacob Basilius, Khoa Quy, Hanh Thi Tuyet Ngo, An Nguyen, Thi Tuyet Mai Tran, Trinh Ngoc Khanh Van, Sohrab Naushad Ali, Ho Yee Tiong, Se Young Choi, Mohammed Shahait, and David I. Lee Muhammed A. Moukhtar HammadMuhammed A. Moukhtar Hammad More articles by this author , Tuan NguyenTuan Nguyen More articles by this author , Ryan W. DobbsRyan W. Dobbs More articles by this author , Huy Gia VuongHuy Gia Vuong More articles by this author , Jacob BasiliusJacob Basilius More articles by this author , Khoa QuyKhoa Quy More articles by this author , Hanh Thi Tuyet NgoHanh Thi Tuyet Ngo More articles by this author , An NguyenAn Nguyen More articles by this author , Thi Tuyet Mai TranThi Tuyet Mai Tran More articles by this author , Trinh Ngoc Khanh VanTrinh Ngoc Khanh Van More articles by this author , Sohrab Naushad AliSohrab Naushad Ali More articles by this author , Ho Yee TiongHo Yee Tiong More articles by this author , Se Young ChoiSe Young Choi More articles by this author , Mohammed ShahaitMohammed Shahait More articles by this author , and David I. LeeDavid I. Lee More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003305.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Several institutions have reported their experience with outpatient robot-assisted radical prostatectomy (O-RARP). However, it is unclear if utilization of this approach represents an improvement over inpatient robot-assisted radical prostatectomy (I-RARP). This meta-analysis sought to compare the surgical outcomes between O-RARP and I-RARP. METHODS: For relevant articles, three electronic databases, including PubMed, Scopus, and Web of Science, were searched from their inception until April 30, 2022. A meta-analysis has been reported in line with PRISMA 2020 and AMSTAR Guidelines. The risk ratio (RR) and weighted mean difference (MD) were applied for the comparison of dichotomous and continuous variables with 95% confidence intervals (CI). RESULTS: Of the 297 retrieved abstracts, 12 underwent full-text review, and 11 studies were included in the final analysis, comprising a total cohort of 2,875 cases of robot-assisted radical prostatectomy (892 O-RARP cases and 1,983 I-RARP cases). Compared to I-RARP, the O-RARP group had lower mean operative time (MD=-9.4 minutes, 95% CI -15.1 to -3.7, 0.001), fewer overall post-operative complications (RR=0.65, 95% CI 0.46 to 0.92, p=0.017), shorter hospital stay (MD=-22.9 hours, 95% CI -26.0 to -19.7, p≤0.001), and lower postoperative opioid requirements (RR=0.45, 95% CI 0.28 to 0.71, p=0.001). There were no significant differences in other outcomes, including: estimated blood loss, postoperative pain score, unscheduled visits after surgery, positive surgical margins, biochemical recurrence, International Prostate Symptom Score (IPSS) after surgery, or three- and six-month continence rates. (Table 1) CONCLUSIONS: This meta-analysis demonstrates that O-RARP is a safe and feasible option for patients undergoing surgery for localized prostate cancer. Further studies are needed to better evaluate optimal patient selection, associated healthcare costs, and patient reported outcomes. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e744 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Muhammed A. Moukhtar Hammad More articles by this author Tuan Nguyen More articles by this author Ryan W. Dobbs More articles by this author Huy Gia Vuong More articles by this author Jacob Basilius More articles by this author Khoa Quy More articles by this author Hanh Thi Tuyet Ngo More articles by this author An Nguyen More articles by this author Thi Tuyet Mai Tran More articles by this author Trinh Ngoc Khanh Van More articles by this author Sohrab Naushad Ali More articles by this author Ho Yee Tiong More articles by this author Se Young Choi More articles by this author Mohammed Shahait More articles by this author David I. Lee More articles by this author Expand All Advertisement PDF downloadLoading ...

MP80-09 MARGIN STATUS AFTER SINGLE-PORT TRANSVESICAL ROBOT-ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyCME1 Apr 2023MP80-09 MARGIN STATUS AFTER SINGLE-PORT TRANSVESICAL ROBOT-ASSISTED RADICAL PROSTATECTOMY Roxana Ramos, Ethan Ferguson, Jaya S Chavali, Albert Geskin, and Jihad Kaouk Roxana RamosRoxana Ramos More articles by this author , Ethan FergusonEthan Ferguson More articles by this author , Jaya S ChavaliJaya S Chavali More articles by this author , Albert GeskinAlbert Geskin More articles by this author , and Jihad KaoukJihad Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003357.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Single-port (SP) transvesical (TV) robot-assisted radical prostatectomy (RARP) is a feasible procedure for patients with clinically localized prostate cancer, without compromise in early oncologic outcomes. Our aim is to better understand the prevalence, characteristics, and clinical impact of positive surgical margins in patients undergoing SP TV RARP. METHODS: A retrospective analysis of the pathology report from the first 132 consecutive SP TV RARP cases was performed in patients with clinically localized prostate cancer, including those with history of hostile abdomen. All cases were done at one center by a single surgeon from November 2020 to August 2022. Biochemical recurrence was considered if two subsequent detectable prostate specific antigens (PSAs) were ≥0.2 ng/ml. Statistical analysis was done using descriptive methods. RESULTS: All cases were completed successfully without extra ports or conversion to open. Positive margins were present in 22 of 132 cases (16.6%), of which 17 (77.2%) were limited (less than 3 mm). One patient from the 22 with positive margins had a biopsy Gleason score of 9 (4+5), the rest were ≤7. Two patients from this subset had a pre-operative PSA >10 ng/ml. After pathological analysis of the specimens, the most frequent location for positive margins was the apex (9 of 22, 40.9%). Specifically 13.6%, 18.1%, and 9% had positive right, left and bilateral apex margins, respectively. Equally frequent was the posterior area of the mid and base levels of the gland (9 of 22, 40.9%). The third most common location was the right base (4 of 22, 18.1%). Despite the fact that 7 patients from the complete cohort (5.3%) had bladder neck invasion, the prevalence of positive margins in this location was 0%. The median follow-up time was 9 months (interquartile range 4-12). Biochemical recurrence was seen in 3 patients of the complete cohort, however none of them had positive margins. CONCLUSIONS: The prevalence of positive margins after SP TV RARP is low and clinically insignificant within a short follow up. The most frequent positive margin locations are the apex and the posterior aspect of the gland, furthermore the majority of margins are limited (<3 mm). Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1155 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Roxana Ramos More articles by this author Ethan Ferguson More articles by this author Jaya S Chavali More articles by this author Albert Geskin More articles by this author Jihad Kaouk More articles by this author Expand All Advertisement PDF downloadLoading ...

Association of Suturing Technical Skill Assessment Scores Between Virtual Reality Simulation and Live Surgery.

Introduction: Robotic surgical performance, in particular suturing, has been linked to postoperative clinical outcomes. Before attempting live surgery, virtual reality (VR) simulators afford opportunities for training surgeons to learn fundamental technical skills. Herein, we evaluate the association of suturing technical skill assessments between VR simulation and live surgery, and functional clinical outcomes. Materials and Methods: Twenty surgeons completed a VR suturing exercise on the Mimic™ Flex VR simulator and the anterior vesicourethral anastomosis during robot-assisted radical prostatectomy (RARP). Three independent and blinded graders provided technical skill scores using a validated assessment tool. Correlations between VR and live scores were assessed by Spearman's correlation coefficients (ρ). In addition, 117 historic RARP cases from participating surgeons were extracted, and the association between VR technical skill scores and urinary continence recovery was assessed by a multilevel mixed-effects model. Results: A total of 20 (6 training and 14 expert) surgeons participated. Statistically significant correlations for scores provided between VR simulation and live surgery were found for overall and needle driving scores (ρ = 0.555, p = 0.011; ρ = 0.570, p = 0.009, respectively). A subanalysis performed on training surgeons found significant correlations for overall scores between VR simulation and live surgery (ρ = 0.828, p = 0.042). Expert cases with high VR needle driving scores had significantly greater continence recovery rates at 24 months after RARP (98.5% vs 84.9%, p = 0.028). Conclusions: Our study found significant correlations in technical scores between VR and live surgery, especially among training surgeons. In addition, we found that VR needle driving scores were associated with continence recovery after RARP. Our data support the association of skill assessments between VR simulation and live surgery and potential implications for clinical outcomes.

Effect of prostate and bony pelvic dimensions measured by preoperative magnetic resonance imaging on robot-assisted radical prostatectomy.

Bone pelvic dimensions and body habitus may have effects on robot-assisted radical prostatectomy (RARP). In this study, we examined the effects of body mass index, bone pelvis measurements and prostate measurements on console time (CT), decrease in postoperative hemogram level (DHL) and surgical margin(SM) in patients who underwent RARP for clinically localized prostate cancer in our institution. The data of transperitoneal RARP cases performed by a single surgeon between November 2016 and August 2020 were analyzed retrospectively. It was included in 125 patients who met the study criteria. Bone and soft tissue measurements were made on magnetic resonance imaging T2-weighted imaging in the mid-sagittal and transvers plane. In multivariate linear regression analyzes, only soft tissue width/transverse diameter of the prostate and CT were found to be correlated (p = 0.026). For the DHL, no pelvic dimension and body habitus had a significant association on multivariate linear regression analysis. In multivariate analyzes, a statistically significant difference was found only between pathological Gleason Score and SM (p = 0.008). Although we found statistically significant associations between prostate diameters and pelvic bone measurements and operative difficulties, we believe that further studies are needed to confirm these results. Such information can help identify patients with challenging anatomy and can be used in robotic surgery training to achieve optimal patient outcomes after RARP.

PD57-07 AUTOMATED PERFORMANCE METRICS THAT ANTICIPATE EARLY AND LATE URINARY CONTINENCE RECOVERY AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy IV (PD57)1 Sep 2021PD57-07 AUTOMATED PERFORMANCE METRICS THAT ANTICIPATE EARLY AND LATE URINARY CONTINENCE RECOVERY AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY Runzhuo Ma, Ryan S. Lee, Sharath S. Reddy, Jessica H. Nguyen, Steven Cen, Katarina Urbanova, Joern H. Witt, Inderbir S. Gill, Christian Wagner, and Andrew J. Hung Runzhuo MaRunzhuo Ma More articles by this author , Ryan S. LeeRyan S. Lee More articles by this author , Sharath S. ReddySharath S. Reddy More articles by this author , Jessica H. NguyenJessica H. Nguyen More articles by this author , Steven CenSteven Cen More articles by this author , Katarina UrbanovaKatarina Urbanova More articles by this author , Joern H. WittJoern H. Witt More articles by this author , Inderbir S. GillInderbir S. Gill More articles by this author , Christian WagnerChristian Wagner More articles by this author , and Andrew J. HungAndrew J. Hung More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002091.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Automated performance metrics (APMs), objective metrics derived from kinematic/system events data and captured by a systems data recorder (Intuitive Surgical) during surgery, are a validated surgical assessment tool. We previously showed APMs from certain steps of robot-assisted radical prostatectomy (RARP) to be predictors of early urinary continence recovery. Having expanded our cohort to include two high-volume centers with longer follow-up, we now explore how APMs may be associated with both early and late urinary continence recovery after RARP. METHODS: Non-teaching RARP cases from 2016-2019 from two centers were included in this study. Non-teaching cases were defined as cases in which an expert surgeon (>100 prior robotic surgery cases) performed all seven major steps, including anterior/posterior bladder neck dissection (BND), left/right neurovascular bundle (NVB) preservation, apical dissection, and posterior/anterior vesicourethral anastomosis. The outcome of interest was 6-month (early) and 12-month (late) continence recovery status. Continence was defined as using 0 or 1 safety pad per day. Decision tree (CART©) was used to predict outcomes. APMs from the seven major steps (38 x 7), 9 patient factors, and 5 treatment factors were utilized in the model. Gini impurity was used as splitting criteria and a 10-fold cross-validation was conducted. Out-of-bag Gini impurity index was used for feature ranking. RESULTS: 110 non-teaching RARP cases from 22 expert surgeons were included in this study. At 6 and 12 months, 59.1% (65/110) and 74.5% (82/110) of cases recovered continence, respectively. In the training phase of the model, the 6- and 12-month continence recovery prediction achieved 71.8% and 65.5% accuracy, respectively; in the testing phase, the accuracies slightly decreased to 67.3% and 61.8%. At both time points, the top 10 features came from APMs; none were patient factors. For 6-month continence status prediction, all top 10 features came from anterior BND. For 12-month continence status prediction, 6/10 came from anterior BND, 3/10 came from left NVB, and 1/10 came from posterior BND. CONCLUSIONS: Surgical performance, as measured by APMs, was the strongest predicter of both early and late continence recovery after RARP. Bladder neck dissection was the most important surgical performance step for early continence recovery in this non-teaching case cohort, while late continence recovery was affected by performance in more varied steps. Source of Funding: This study was funded in part by an Intuitive Surgical Clinical Grant; Intuitive Surgical provided the systems data recorder. Research reported in this publication was also supported in part by the National Institute Of Biomedical Imaging And Bioengineering of the National Institutes of Health under Award Number K23EB026493. © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1012-e1012 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Runzhuo Ma More articles by this author Ryan S. Lee More articles by this author Sharath S. Reddy More articles by this author Jessica H. Nguyen More articles by this author Steven Cen More articles by this author Katarina Urbanova More articles by this author Joern H. Witt More articles by this author Inderbir S. Gill More articles by this author Christian Wagner More articles by this author Andrew J. Hung More articles by this author Expand All Advertisement Loading ...

Incremental modification of robotic prostatectomy technique can lead to aggregated marginal gains to significantly improve functional outcomes without compromising oncological control.

Surgeons should aim for continuous quality improvement. The aim of this study was to evaluate the impact of incremental changes to Robot Assisted Radical Prostatectomy (RARP) technique on intra-operative and early post-operative outcomes. All cases of RARP performed by a single surgeon in a tertiary institution over a 2-year period were included in this evaluation. Routine clinical data were collected. Cases were retrospectively allocated to four groups depending on key technical steps (1 = standard anterior approach; 2 = anterior approach with preservation of endopelvic fascia, puboprostatic fascia and urachus; 3 = posterior approach for nerve spare, with preservation of endopelvic fascia, puboprostatic fascia and urachus; 4 = Retzius-sparing posterior approach). 187 patients were allocated to groups: 1 = 22, 2 = 53, 3 = 90, 4 = 22. There were no significant differences in pre-operative characteristics, except age: 1 = 62.5, 2 = 62, 3 = 62.5, 4 = 58.5 (p = 0.02). Intra-operative differences were found in console time: 1 = 195, 2 = 167, 3 = 195 4 = 136.5min (p < 0.001); and proportion of non-nerve sparing cases: 1 = 36%, 2 = 17%, 3 = 13%, 4 = 0% (p = 0.044). No significant differences were found in lymph node dissections, blood loss or complications. Post-operatively, no differences were found in length of stay, pathological characteristics, margin status, lymph node yield, complications or PSA levels. Significant differences were seen in pad-free continence at 6 weeks: 1 = 23%, 2 = 23%, 3 = 34%, 4 = 73% (p < 0.01); and social continence (using 1 pad) at 6-weeks: 1 = 59%, 2 = 87%, 3 = 81%, 4 = 95% (p = 0.01). Significant differences in pad-free continence persisted at 12months: 1 = 63%, 2 = 81%, 3 = 78%, 4 = 100% (p = 0.019). Our results suggest that aggregated marginal gains from incremental modification of RARP leads to significantly improved continence outcomes without compromising patient safety or oncological control.

Prediction of a positive surgical margin and biochemical recurrence after robot-assisted radical prostatectomy

The positive surgical margin (PSM) and biochemical recurrence (BCR) are two main factors associated with poor oncotherapeutic outcomes after prostatectomy. This is an Asian population study based on a single-surgeon experience to deeply investigate the predictors for PSM and BCR. We retrospectively included 419 robot-assisted radical prostatectomy cases. The number of PSM cases was 126 (30.1%), stratified as 22 (12.2%) in stage T2 and 103 (43.6%) in stage T3. Preoperative prostate-specific antigen (PSA) > 10 ng/mL (p = 0.047; odds ratio [OR] 1.712), intraoperative blood loss > 200 mL (p = 0.006; OR 4.01), and postoperative pT3 stage (p < 0.001; OR 6.901) were three independent predictors for PSM while PSA > 10 ng/mL (p < 0.015; hazard ratio [HR] 1.8), pT3 stage (p = 0.012; HR 2.264), International Society of Urological Pathology (ISUP) grade > 3 (p = 0.02; HR 1.964), and PSM (p = 0.027; HR 1.725) were four significant predictors for BCR in multivariable analysis. PSMs occurred mostly in the posterolateral regions (73.8%) which were associated with nerve-sparing procedures (p = 0.012) while apical PSMs were correlated intraoperative bleeding (p < 0.001). A high ratio of pT3 stage after RARP in our Asian population-based might surpass the influence of PSM on BCR. PSM was less significant than PSA and ISUP grade for predicting PSA recurrence in pT3 disease. Among PSM cases, unifocal and multifocal positive margins had a similar ratio of the BCR rate (p = 0.172) but ISUP grade > 3 (p = 0.002; HR 2.689) was a significant BCR predictor. These results indicate that PSA and pathological status are key factors influencing PSM and BCR.

Are Postoperative Laboratory Studies Following Robotic Assisted Radical Prostatectomy Necessary?

We evaluated the necessity of obtaining routine postoperative laboratory studies, such as complete blood count and basic metabolic panel, after robotic assisted radical prostatectomy. This study is a retrospective review of 200 robotic assisted radical prostatectomy cases performed over a year and a half at our institution. The incidences of laboratory abnormalities were examined along with any clinical intervention. Patient demographics, tumor stage, Gleason score, operative time, estimated blood loss, length of hospital stay, presence of comorbidities and postoperative laboratory studies were extracted from the electronic medical record. The costs of laboratory studies were tabulated to further analyze potential savings to patients. Only 15 (7.5%) patients demonstrated laboratory abnormalities that required medical intervention. Of these 15 patients, all demonstrated hypokalemia that was treated with potassium supplementation. Patients with longer lengths of stay demonstrated higher percentages of medical intervention. The costs of these laboratory studies were calculated at $8,840. Lower blood loss and transfusion rates with the advent of robotic assisted radical prostatectomy along with the results described in this study provide greater evidence that postoperative laboratory studies may be futile. By eliminating these laboratory studies, substantial cost savings are realized if extrapolated across the United States. This study is limited in its evaluation of complications from different types of medical centers, higher risk patients, postoperative laboratory studies impact on symptomatic patients, and absence of emergency room visits or hospital readmissions.

Robotic-assisted radical prostatectomy with preceptor's assistance: the training experience and outcomes in South America.

Prostate cancer is currently the second leading cause of cancer deaths in Brazilian men. In 2020, sixty-five thousand new prostate cancer cases were expected in Brazil, and almost 30% of these patients are estimated to be from the northeast region. However, from 75 robotic platforms available in the country, only one is accessible in the state of Ceará since 2015. This study reports the intraoperative, functional, and oncological outcomes of patients who underwent radical prostatectomy for prostate cancer performed by robotic surgeons during a training period supervised by a proctor. We also compared these results with the literature reporting the experience of different Brazilian centers. We retrospectively analyzed prospectively collected data of 58 initial cases of robotic-assisted radical prostatectomy at a private Brazilian hospital in Fortaleza, Ceará. The surgeries were performed by two robotic surgeons during the training period under proctor supervision. We reported the epidemiological and intraoperative data, complications, pathological report, functional and oncological outcomes. The median operative time was 180min. None of the patients needed conversion or blood transfusion. The pathology report described 21.81% of positive surgical margins (16.27% of all pT2 and 45.45% of all pT3 patients). The median follow-up was 40months. Biochemical recurrence occurred in 21.73%, continence in 92%, and potency in 79.54%. No major complications (Clavien grades III-V) were reported. In our experience, robotic-assisted radical prostatectomy performed by surgeons training with proctor's assistance is feasible and safe. The operative time, complication rates, functional and oncological outcomes were satisfactory and compatible with the literature.

Salvage Versus Primary Robot-assisted Radical Prostatectomy: A Propensity-matched Comparative Effectiveness Study from a High-volume Tertiary Centre

BackgroundSalvage robot-assisted radical prostatectomy (sRARP) is a potential treatment option for locally recurrent prostate cancer (PCa) after nonsurgical primary treatment. There are minimal data comparing outcomes between propensity-matched sRARP and primary robot-assisted radical prostatectomy (RARP). ObjectiveThe primary objective is to compare perioperative, oncological, and functional outcomes of sRARP with primary RARP, and the secondary is to compare outcomes between sRARP after whole and focal gland therapy. Design, setting, and participantsA 1:1 propensity-matched comparison was carried out of 135 sRARP cases with primary RARP cases from a cohort of 3852 consecutive patients from a high-volume tertiary centre. Outcome measurements and statistical analysisPerioperative, oncological, and functional outcomes including complication rates, positive surgical margins, biochemical recurrence (BCR), continence, and erectile dysfunction (ED) were retrospectively collected. Results and limitationsThere were no significant differences in patient characteristics between sRARP and primary RARP groups. In the salvage and primary groups, median (interquartile range) follow-up periods were 521 (304–951) and 638 (394–951) d, grade III–V Clavien-Dindo complication rates were 1.5% and 0% (p = 0.310), BCR rates were 31.9% and 14.1% (p < 0.001) at the last follow-up, pad-free continence rates were 78.8% and 84.3% at 2 yr (p = 0.337), and ED rates were 94.8% and 76.3% (p < 0.001), respectively. Comparing the whole and focal gland groups, BCR rates were 36.7% and 29.1% (p = 0.687) at follow-up, pad-free continence rates were 53.1% and 89.3% at 2 yr (p < 0.001), and ED rates were 98% and 93% (p = 0.214), respectively. ConclusionsSalvage RARP has similar perioperative outcomes to primary RARP with inferior potency rates. Post–focal therapy sRARP has similar recurrence and continence rates to primary RARP. Post–whole gland therapy, complication, and recurrence rates are higher, and there is a higher risk of urinary incontinence. Patient summaryWe report the largest propensity-matched comparison of salvage robot-assisted radical prostatectomy (RARP) after focal and whole gland therapy. Salvage RARP is a feasible procedure for the treatment of locally recurrent prostate cancer in high-volume centres; however, patients should be counselled appropriately as to the different outcomes.

Risk Factors for Recurrence in Patients with Pathological Lymph Node-Positive Prostate Cancer after Extended Lymph Node Dissection in Laparoscopic and Robotic-Assisted Radical Prostatectomy

From April 2007 to April 2018, we performed lymph node dissection in 305 cases of laparoscopic radical prostatectomy and 202 cases of robot-assisted radical prostatectomy at our hospital, and there were 68 cases with positive lymph node metastasis (pN1). Of these 68 cases, we examined retrospectively 62 cases in which extended lymph node dissection (ELND) was performed. The median number of removed lymph nodes was 25 (interquartile range [IQR] ; 18-34) and the median number of metastatic lymph nodes was 1 (IQR ; 1-3). Postoperative prostate-specific antigen (PSA) recurrence was observed in 40 of the 62 patients. The median time to PSA recurrence was 24 months. After univariate analysis, PSA at initial diagnosis (iPSA) of 10 ng/ml or more, pathological Gleason score (pGS) of 8 or more, total number of lymph node metastases of 2 or more, and positive surgical margin (RM＋) were found to be riskfactors of PSA recurrence. In multivariate analysis, iPSA of 10 ng/ml or more, pGS of 8 or more and RM＋ were independent riskfactors of PSA recurrence (p＜0.05). In the cases without riskfactors such as iPSA≥10, pGS≥8, and RM＋, immediate postoperative adjuvant therapy may be avoided even with pN1.