Performing Radical Prostatectomy Research Articles

Medical Students Cannot Assess Robotic Surgeons Performing Radical Prostatectomy.

Medical students have previously been shown to be just as effective for video rating as experts. We want to compare medical students to experienced surgeons as video assessors of simulated robot-assisted radical prostatectomy (RARP) performance. Video recordings of three RARP modules on the RobotiX (formerly Simbionix) simulator from a previous study were used. Five novice surgeons, five experienced robotic surgeons, and five experienced robotic surgeons in RARP performed a total of 45 video-recorded procedures. The videos were assessed with the modified Global Evaluative Assessment of Robotic Skills tool as both full-length and an edited edition that only included the first 5 minutes of the procedure. Fifty medical students and two experienced RARP surgeons (ES) performed a total of 680 video ratings of full-length videos and 5-minute videos (2-9 ratings per video). Medical students and ES showed poor agreement for both full-length videos and 5-minute videos (0.29 and -0.13, respectively). Medical students could not discriminate between the skill level of the surgeons in either full-length videos or 5-minute videos ( P = 0.053-0.36 and P = 0.21-0.82), whereas ES could discriminate between novice surgeons and experienced surgeons (full-length, P < 0.001, and 5 minutes, P = 0.007) and intermediate and experienced surgeons (full-length, P = 0.001, and 5 minutes, P = 0.01) in both full-length videos and 5-minute videos. We found that medical students cannot be used to assess RARP because they showed poor agreement with the ES rating for both full-length videos and 5-minute videos. Medical students could not discriminate between surgical skill levels.

Intraoperative technologies to assess margin status during radical prostatectomy - a narrative review.

Positive surgical margin (PSM) is a frequent concern for surgeons performing radical prostatectomy for prostate cancer (PCa). PSM are recognized as risk factors for earlier biochemical recurrence and expose patients to adjuvant or salvage treatments such as external radiotherapy and hormonotherapy. Several strategies have been established to reduce PSM rate, while still allowing safe nerve-sparing surgery. Precise preoperative staging by multiparametric magnetic resonance imaging (mpMRI) and fusion biopsy is recommended to identify suspicious areas of extracapsular extension (ECE) that warrant special attention during dissection. However, even with optimal imaging, ECE can be missed, some cancers are not well defined or visible, and capsular incision during surgery remains an issue. Hence, intraoperative frozen section techniques, such as the neurovascular structure-adjacent frozen section examination (NeuroSAFE) have been developed and lately widely disseminated. The NeuroSAFE technique reduces PSM rate while allowing higher rate of nerve-sparing surgery. However, its use is limited to high volume or expert center because of its high barrier-to-entry in terms of logistics, human resources and expertise, as well as cost. Also, NeuroSAFE is a time-consuming process, even in expert hands. To address these issues, several technologies have been developed for an ex vivo and in vivo use. Ex vivo technology such as fluorescent confocal microscopy and intraoperative PET-CT require the extraction of the specimen for preparation, and digital images acquisition. In vivo technology, such as augmented reality based on mpMRI images and PSMA-fluorescent guided surgery have the advantage to provide an intracorporeal analysis of the completeness of the resection. The current manuscript provides a narrative review of established techniques, and details several new and promising techniques for intraoperative PSM assessment.

Urinary continence following extraperitoneal radical prostatectomy: impact of surgical technique and pelvic fascial spaces reconstruction

Introduction. Urinary incontinence is a common complication of radical prostatectomy. The development of surgical techniques when performing radical prostatectomy that improve the function of urinary continence after surgery is actual.Objective. To compare urinary continence functions in long-term follow-up after open and laparoscopic radical prostatectomy when only posterior or combined (anterior + posterior) reconstruction of the pelvic fascial spaces is performed.Materials &amp; methods. The study included 130 patients aged 63.0 [59.0; 68.0] years with local prostate cancer (сT1a-2сN0-xM0; 1 – 4 ISUP groups), subjected to non-nerve-sparing retropubic radical prostatectomy with posterior reconstruction and non-nerve-sparing extraperitoneal laparoscopic radical prostatectomy with isolated posterior or combined (anterior + posterior) fascial reconstruction of the pelvic fascial spaces. Postoperative continence function was studied at 1, 3, 6, and 12 months following surgery using a standard pad test.Results. The incidence of urinary continence was higher at all follow-up periods during laparoscopic surgery. From the 6-months follow-up, these patients did not have severe urinary incontinence. At the same time, the rate of growth of some patients who began to retain urine did not depend on the method of reconstruction of the pelvic fascial spaces. The use of combined reconstruction of the pelvic fascial spaces at 12-months follow-up showed an advantage in urinary continence over performing only posterior reconstruction. Such patients achieved urinary continence in 90% of cases compared to 80.0% of cases. At the same time, the restoration of urinary continence at all periods of observation had a relatively uniform linear rate of increase in the indicator.Conclusion. Reconstruction of the pelvic fascial spaces during open and laparoscopic radical prostatectomy allows one to achieve satisfactory continuation in the postoperative period. However, higher efficiency is achieved when using a combined reconstruction technique.

Feasibility and safety of dual-console telesurgery with the KangDuo Surgical Robot-1500 System using fifth-generation and wired networks: an animal experiment and sea-spanning clinical study.

To evaluate the feasibility and safety of dual-console telesurgery with the new KangDuo system in an animal experiment and clinical study. Six canine models were performed radical prostatectomy with dual-console KanDuo surgical robot-1500 (KD-SR-1500-RARP). The perioperative outcomes, physical and mental workload of the surgeon were collected. Physical workload was evaluated with surface electromyography. Mental workload was evaluated with NASA-TLX. After conducting animal experiments to verify safety of dual-console KD-SR-1500-RARP, we conducted the clinical trial using 5G and wired networks. In the animal experiment, all surgeries were performed successfully. The operative time was 80.2±32.1 min. The docking time was 2.4±0.5 min. The console time was 49.7±25.3 min. There were no perioperative complications or equipment related adverse events. All dogs can micturate after catheter removal at one week postoperatively. The mental workload was at a low level (a scale ranging from 0 to 60), which scored 15.7±6.9. Among the eight recorded muscles, the fatigue degree of the right radial flexor and left biceps was the highest two (iEMG, resection, 299.8±344 uV, 109.9±16.9 uV; suture, 849.4±1252.5 uV, 423.1±621.3 uV, respectively). In the clinical study, the console time was 136 min. The mean latency time was ≤200 ms. The data pocket loss was <1%. The operation was successfully completed without malfunctions occurring throughout the entire process. Dual-console telesurgery with the KD-SR-1500 system was shown to be feasible and safe in radical prostatectomy using 5G and wired networks.

Robot-Assisted Radical Prostatectomy Performed with the Novel Surgical Robotic Platform Hugo™ RAS: Monocentric First Series of 132 Cases Reporting Surgical, and Early Functional and Oncological Outcomes at a Tertiary Referral Robotic Center.

Robotic-assisted surgery is the gold standard for performing radical prostatectomy (RARP), with new robotic devices such as HugoTM RAS gaining prominence worldwide. We report the surgical, perioperative, and early postoperative outcomes of RARP using HugoTM RAS. Between April 2022 and October 2023, we performed 132 procedures using the Montsouris technique with a four-robotic-arm configuration in patients with biopsy-proven prostate cancer (PCa). We collected intraoperative and perioperative data during hospitalization, along with follow-up data at predefined postoperative intervals of 3 and 6 months. Lymphadenectomy was performed in 25 procedures, with a bilateral nerve-sparing technique in 33 and a monolateral nerve-sparing technique in 33 cases. The mean total surgery time was 242 (±57) min, the mean console time was 124 (±48) min, and the mean docking time was 10 (±2) min. We identified 17 system errors related to robotic arm failures, 9 robotic instrument breakdowns, and 8 significant conflicts between robotic arms. One post-operative complication was classified as Clavien-Dindo 3b. None of the adverse events, whether singular or combined, increased the operative time. Positive margins (pR1) were found in 54 (40.9%) histological specimens, 37 (28.0%) of which were clinically significant. At 3 and 6 months post-surgery, the PSA levels were undetectable in 94.6% and 92.1% of patients, respectively. Social urinary continence was regained in 86% after 6 months. Limitations of our study include its observational monocentric case-series design and the short follow-up data for functional and oncological outcomes. Our initial experience highlights the reliability of the HugoTM RAS system in performing RARP. Additionally, we also list problems and solutions found in our daily work.

Initial experience of laparoendoscopic single-site radical prostatectomy with a novel purpose-built robotic system

ObjectiveThis prospective single-arm clinical trial aimed to evaluated the feasibility and safety of the application of the SHURUI system (Beijing Surgerii Technology Co., Ltd., Beijing, China), a novel purpose-built robotic system, in single-port robotic radical prostatectomy. MethodsSixteen patients diagnosed with prostate cancer were prospectively enrolled in and underwent robotic radical prostatectomy from October 2021 to August 2022 by the SHURUI single-port robotic surgical system. The demographic and baseline data, surgical, oncological, and functional outcomes as well as follow-up data were recorded. ResultsThe mean operative time was 226.3 (standard deviation [SD] 52.0) min, and the mean console time was 183.4 (SD 48.3) min, with the mean estimated blood loss of 116.3 (SD 90.0) mL. The mean length of postoperative hospital stay was 4.50 (SD 0.97) days. Two patients had postoperative complications (Clavien-Dindo Grade II), and both patients improved after conservative treatment. All patients’ postoperative prostate-specific antigen levels decreased to below 0.2 ng/mL 1 month after discharge. The mean prostate-specific antigen level further decreased to a mean of 0.0219 (SD 0.0641) ng/mL 6 months after surgery. Thirty days postoperatively, 12 out of 16 patients reported using no more than one urinary pad per day, and all patients reported satisfactory urinary control without the need for pads 6 months after surgery. ConclusionThe SHURUI system is safe and feasible in performing radical prostatectomy via both transperitoneal and extraperitoneal approaches. Tumor control and urinary continence were satisfying for patients enrolled in. The next phase involves conducting a large-scale, multicenter randomized controlled trial to thoroughly assess the effectiveness and safety of the new technology in a broader population.

Laparoscopic radical prostatectomy with sparing of the proximal prostatic urethra

Introduction. The most common treatment option for prostate cancer is radical prostatectomy, which involves the removal of the prostate itself and the prostatic urethra in a single block, followed by the formation of a vesicourethral anastomosis. This approach is fraught with postoperative complications, such as urinary incontinence and strictures of anastomosis. In this sense, the clinic's staff faced the question of the possibility of a urethral-sparing variant of operative benefit for a certain category of patients.Objective. To assess the possibility of performing radical prostatectomy with sparing of the proximal prostatic urethra in the laparoscopic version, its advantages, and disadvantages.Materials &amp; methods. From 2021 to 2022, 18 successful laparoscopic operations were performed using this technique at the St. Luke Clinical Multidisciplinary Medical Centre. Patients were selected according to the above criteria. In the preoperative period, patients underwent a standard examination in accordance with guidelines, including a blood test for prostate-specific antigen (PSA), ultrasound, magnetic resonance imaging (MRI) with 3D-modelling, data from a multifocal prostate biopsy, the International Prostate Symptom Score (IPSS), the International Index of Erectile Function (IIEF), the Quality of Life (QoL) index due to urinary disorders, assessment by the Partin’s nomogram. Intraoperative ratios, early and late postoperative complications, length of hospital stay, day of catheter removal, and time to complete urethral recovery were evaluated to study the effectiveness of this surgery type. PSA testing, uroflowmetry with post-void residual urine measurement and IPSS questionnaire were carried out one month after surgery.Results. There was an improvement in all measurements one month after surgery: median values of the mean urine flow rate increased by 1.7 ml/s, median values of the max urine flow rate increased by 3.7 ml/s, the IPSS decreased by 12 points.Conclusion. Based on the results of the study, clinical observations, and statistical analysis of the data obtained, it can be concluded that laparoscopic radical prostatectomy with sparing of the proximal prostatic urethra is the preferred surgical option for this pathology, due to its organ-preserving nature.

PD26-09 PRACTICE PATTERNS IN REHABILITATION OF ERECTILE FUNCTION FOLLOWING NERVE-SPARING RADICAL PROSTATECTOMY: RESULTS FROM A GERMAN MULTI-INSTITUTIONAL SURVEY

You have accessJournal of UrologyCME1 Apr 2023PD26-09 PRACTICE PATTERNS IN REHABILITATION OF ERECTILE FUNCTION FOLLOWING NERVE-SPARING RADICAL PROSTATECTOMY: RESULTS FROM A GERMAN MULTI-INSTITUTIONAL SURVEY Andreas Bannowsky, Daniar Osmonov, Sabine Bannowsky, and Stefan Ückert Andreas BannowskyAndreas Bannowsky More articles by this author , Daniar OsmonovDaniar Osmonov More articles by this author , Sabine BannowskySabine Bannowsky More articles by this author , and Stefan ÜckertStefan Ückert More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003304.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Despite objective data regarding rehabilitation of erectile function (EF) after nerve-sparing radical prostatectomy (nsRP) the ″gold-standard″-treatment is still under debate. The aim of this study was to evaluate the distribution of the different treatment options in Germany. METHODS: We performed a questionnaire sent to all urologist (outpatient/general and university hospitals/rehabilitation hospitals) in Germany. The survey consists of different questions, e.g. if and what kind of therapy the urologist choose to support rehabilitation of EF after nsRP. Further questions dealt with the frequency, duration and ″optimal″ start of the chosen therapy. RESULTS: Until today 262 urologists completed and returned the questionnaire. The distribution was: urologists in hospitals n=110, outpatient/ambulatory n=148, with 24% performing surgical treatment, and urologist in rehabilitation hospitals n=4. Overall 50% of the urologists are performing radical prostatectomy on a regular basis. The question about the ″rehabilitation concept″ showed 39 different treatments within this group. To increase EF after nsRP PDE5-inhibitors were mostly administered (88%): 45% ″on demand″ vs. 55% on a daily or regular basis ≥3 times/week. The use of penile injection therapy, MUSE or VCD was 32%, 6% and 30% respectively. In 56% the treatment started within the first weeks after surgery and was performed until the patient regained potency in 46%. Only 14% of the urologists didn′t choose any ″active″ kind of rehabilitation treatment for EF recovery after nsRP. CONCLUSIONS: Lots of different therapeutic concepts are currently performed in Germany to increase EF recovery after nsRP. The use of PDE5-inhibitors is the most chosen treatment option. Despite the published data regarding effectiveness the optimal treatment seems to be still unknown. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e738 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andreas Bannowsky More articles by this author Daniar Osmonov More articles by this author Sabine Bannowsky More articles by this author Stefan Ückert More articles by this author Expand All Advertisement PDF downloadLoading ...

Significance of extraprostatic extension by Grade Groups 1–3 prostatic carcinoma on needle biopsy

It is rare for extraprostatic extension (EPE) on biopsy to be seen with Grade Groups (GG) 1-3 (Gleason scores 3 + 3 = 6; 3 + 4 = 7; 4 + 3 = 7) prostatic adenocarcinoma, and there is no data whether this finding should be a contraindication for performing radical prostatectomy (RP). Thirty eight cases with GG 1-3 prostatic adenocarcinoma as the highest grade in the case with EPE on biopsy were identified from our consultation files. Highly unfavorable findings at RP were those that if they could have been predicted preoperatively, might have factored into the decision of whether to proceed with surgery. For these purposes, highly unfavorable pathology at RP was defined as either the presence of seminal vesicle invasion or lymph node metastases or GG5 (Gleason score 9-10). Among 37 patients with clinical follow-up data, 18 (49%) received radiation and/or hormonal therapy (RT/HT), 13 patients (35%) either underwent (n = 11) or are planning (n = 2) RP, and 6 patients (16%) received either ablation therapy or active surveillance. Based on the 11 RP pathology reports, 8 were GG2, one GG3 with tertiary pattern 5, and two GG3. Ten cases were reported to have EPE and six cases had positive margins. Only one had highly unfavorable pathology with pT3bN1 disease. The only difference between the RP and the RT/HT groups in their pretreatment parameters was the mean age of the RP patients was 61 compared with 69 for the RT/HT men (p = 0.02); the lack of many cases with highly unfavorable pathology at RP cannot be attributable to a selection bias of men with lower volume cancer on biopsy or lower serum prostate-specific antigen levels choosing RP over RT/HT. Despite EPE on biopsy, most men do not have highly unfavorable pathology at RP, and this treatment should remain an option in this setting.

Confirmation of PSMA expression measured on [68Ga]Ga-PSMA PET/CT by immunohistochemistry in prostate adenocarcinoma.

Our aim is to determine the accuracy of [68Ga]Ga-PSMA PET/CT in showing PSMA expression in primary prostate cancer and to investigate the relationship between SUVmax and immunohistochemical PSMA expression, Gleason score, and PSA value. We retrospectively analyzed 66 male patients who were diagnosed with primary prostate adenocarcinoma, underwent pre-treatment [68Ga]Ga-PSMA PET/CT examination for staging, and performed radical prostatectomy between March 2018-August 2020. Immunohistochemical staining was applied to the radical prostatectomy specimens of all patients to detect PSMA expression. The results were evaluated as an immunoreactive score (IRS) and a modified IRS was obtained. Gleason score groups and prostate-specific antigen (PSA) serum values of the patients were obtained from the patient files. The high SUVmax of primary prostate tumors was significantly correlated with a high modified IRS score (score 2; 3), high PSA value, high Gleason score, and metastasis. In correlation analysis, a positive correlation was found between SUVmax and PSA value and modified IRS score (r = 0.69, p = 0.001; r = 0.39, p = 0.001). In addition, there was a statistically significant weak correlation between PSA serum concentration and modified IRS scores (r = 0.267; p = 0.03). In regression analysis, the percentage of positive cells had a statistically significant and increasing effect on SUVmax (p = 0.031; std beta = 0.268; 95% CI = 0.231-4.596). In prostate adenocarcinoma, SUVmax of the primary tumor in [68Ga]Ga-PSMA PET/CT correlates with immunohistochemical PSMA expression. In addition, high SUVmax is associated with markers of poor prognoses, such as high PSMA expression, PSA value, and Gleason score.

A Novel Expert Coaching Model in Urology, Aimed at Accelerating the Learning Curve in Robotic Prostatectomy

The surgical residency model assumes that upon completion, a surgeon is ready to practice and grow independently. However, many surgeons fail to improve after reaching proficiency, which in certain instances has correlated with worse clinical outcomes. Coaching addresses this problem and furthers surgeons' education post-residency. Currently, surgical coaching programs focus on medical students and residents, and have been shown to improve residents' and medical students' technical and non-technical abilities. Coaching programs also increase the accuracy of residents, fellows, and attendings in self-assessing their surgical ability. Despite the potential benefits, coaching remains underutilized and poorly studied. We developed an expert-led, face-to-face, video-based surgical coaching program at a tertiary medical center among specialized attending surgeons. Our goal was to evaluate the feasibility of such a program, measure surgeons' attitudes towards internal peer coaching, determine whether surgeons found the sessions valuable and educational, and to subjectively self-assess changes in operative technique. Surgeons who perform robot-assisted laparoscopic prostatectomies were chosen and grouped by number of cases completed: junior (<100 cases), intermediate (100-500 cases), and senior (>500 cases). Surgeons were scheduled for 3 1-hour coaching sessions 1-2 months apart (February-October 2019), meeting individually with the coach (PS), an expert Urologic Oncologist with thousands of cases of experience performing radical prostatectomy. He received training on coaching methodology prior to beginning the coaching program. Before each session, surgeons selected 1 of their recent intraoperative videos to review. During sessions, the coach led discussion on topics chosen by the surgeon (i.e. neurovascular bundle dissection, apical dissection, bladder neck); together, they developed goals to achieve before the next session. Subsequent sessions included presentation and discussion of a case occurring subsequent to the prior session. Sessions were coded by discussion topics and analyzed based on level of experience. Surgeons completed a survey evaluating the experience. All 6 surgeons completed 3 sessions. Five surgeons completed the survey; most respondents evaluated themselves as having improved in desired areas and feeling more confident performing the discussed steps of the operation. Discussed surgical principles varied by experience group; when subjectively quantifying the difficulty of surgical steps, the more difficult steps were discussed by the higher experience groups compared to the junior surgeons. The senior surgeons also focused more on oncologic potency, continence outcomes, and more theory-driven questions while the junior surgeons tended to focus more on anatomic and technique-based questions such as tissue handling and the use of cautery and clips. Overall, the surgeons thought this program provoked critical discussion and subsequently modified their technique, and "agreed" or "strongly agreed" that they would seek further sessions. Surgical coaching at a large medical center is not only feasible but was rated positively by surgeons across all levels of experience. Coaching led to subjective self-improvement and increased self-confidence among most surgeons. Surgeons also felt that this program offered a safe space to acquire new skills and think critically after finishing residency/fellowship. Themes discussed and takeaways from the sessions varied based on surgeon experience level. While further research is needed to more objectively quantify the impact coaching has on surgeon metrics and patient outcomes, the results of this study supports the initial "proof-of-concept" of peer-based surgical coaching and its potential benefits in accelerating the learning curve for surgeons' post-residency.

The diffusion of robotic surgery: Examining technology use in the English NHS

This paper examines the adoption and diffusion of medical technology as associated with the dramatic recent increase in the surgical use of robots. We consider specifically the sequential adoption and diffusion patterns of three interrelated surgical technologies within a single healthcare system (the English NHS): robotic, laparoscopic and open radical prostatectomy. Robotic and laparoscopic techniques are minimally invasive procedures with similar patient benefits, but the newer robotic technique requires a high initial investment cost to purchase the robot and carries high maintenance costs over time. Using data from a large UK administrative database, Hospital Episodes Statistics, for the period 2000–2018, we analyse 173 hospitals performing radical prostatectomy, the most prevalent and earliest surgical area of adoption of robotic surgery. Our empirical analysis first identifies substitution effects, with robotic surgery replacing the incumbent technology, including the recently diffused laparoscopic technology. We then quantify the spillover of robotic surgery as it diffuses to other surgical specialties. Finally, we perform time-to-event analysis at the hospital level to quantitatively examine the adoption. Results show that a higher number of urologists and a wealthier referral area favor robot adoption.

Preventive intraoperative methods for restoring urine function after laparoscopic and open radical prostatectomy

Purpose of the study. To evaluate the effectiveness of preserving the anatomical structures surrounding the prostate gland for prophylactic intraoperative restoration of urinary retention functions in the postoperative period.&#x0D; Materials and methods. A study was carried out in 86 patients with prostate cancer after performing radical prostatectomy from 2013 to 2021. Men were divided into 4 groups:&#x0D; Group 1 – LRP with preservation of the puboprostatic ligaments, pubo-perineal muscle, pelvic fascia and neurovascular bundles of the penis.&#x0D; Group 2 – LRP with complete preservation of the anatomical structures of the small pelvis without preserving the neurovascular bundles of the penis.&#x0D; Group 3 – ORP with preservation of the puboprostatic ligaments, pubo-perineal muscle, pelvic fascia and neurovascular bundles of the penis.&#x0D; Group 4 – RRP with complete preservation of the anatomical structures of the small pelvis without preserving the neurovascular bundles of the penis.&#x0D; In group 1, in which LRP was performed, 58 patients with prostate cancer T1N0M0 and T2N0M0.&#x0D; In group 2 LRP 12 patients with prostate cancer T1N0M0 and T2N0M0.&#x0D; There were 12 patients with prostate cancer T1N0M0 and T2N0M0 in group 3 with RRP.&#x0D; There are 4 patients with prostate cancer T1N0M0 and T2N0M0 in group 4 with RRP.&#x0D; He diagnosis of prostate cancer in all patients was established on the basis of a histological examination of preparations obtained by performing a transrectal multifaceted biopsy of the prostate gland. The basis for performing a biopsy was an increase in the level of prostate-specific antigen (PSA) in the blood above 4 ng/ml, the presence of pathological nodes according to MRI of the pelvic organs with contrast, as well as suspicious areas of the prostate gland during digital rectal examination. A study was carried out in 86 patients with prostate cancer after performing radical prostatectomy from 2013 to 2021.&#x0D; Research results and their discussion. 12 patients of group 3 underwent open surgery-radical prostatectomy. RRP (12 people) with preservation of the pubo-prostatic ligaments, pubo-perineal muscle, pelvic fascia and neurovascular bundles of the penis.&#x0D; In 4 patients of group 4, RRP with complete preservation of the anatomical structures of the small pelvis without preservation of the neurovascular bundles of the penis.&#x0D; We do not dwell on the method of performing the operation, it is known, all 16 patients underwent lymphadenectomy.&#x0D; The average operation time in the groups LRP 1 group, LRP 2 group did not differ significantly, and amounted to 147,16. And in a comparative analysis in group 3 RR, Group 4 RR there was a difference of 89,29, open operations were performed much faster.&#x0D; In our study, the criterion for urinary retention was the absence of the patient's need to use safety pads. This definition is adhered to by many specialists involved in the surgical treatment of prostate cancer. The use of at least 1 safety pad was equivalent to urinary incontinence. And it was considered a complication after the operations performed. Inourstudy, themeantimetorestoration of the full urinary continence function was the longest where the standard surgical procedure was performed, and the shortest was in the groups where the maximum preservation of the anatomical structures of the periprostatic anatomical zone was performed.&#x0D; Conclusions. 1. The main mechanism for the rapid restoration of urinary retention in patients after radical prostatectomy with prostate cancer is the maximum preservation of the pubo-prostatic ligaments and the pubo-perineal muscle, which makes it possible to fully restore the function of urinary retention within a month. 2. Preservation, only of the neurovascular bundle of the penis, is not enough to restore the function of early urinary retention after surgery.

Cerenkov Luminescence Imaging for Surgical Margins in Radical Prostatectomy: A Surgical Perspective

See the associated article on page [1500][1]. “How can I reduce my positive surgical margin rate?” This is a common refrain from the urologist performing radical prostatectomy (RP) for localized prostate cancer (PC). Avoidance of positive surgical margins (PSMs) during RP is important to reduce

Influence of previous laparo-endoscopic inguinal hernia repair on performing radical prostatectomy: a nationwide survey among urological surgeons.

There is considerable demographic overlap of inguinal hernia patients and prostate cancer patients. Previous laparo-endoscopic inguinal hernia mesh repairs can complicate subsequent radical prostatectomies due to adhesions and distortion of anatomic planes. This study aims to assess the experience of urological surgeons on the safety and feasibility of performing radical prostatectomies after laparo-endoscopic inguinal hernia mesh repair. For this cross-sectional study, an online 24 question survey was developed regarding the experience in performing a radical prostatectomy and pelvic lymph node dissection (PLND) with a prior preperitoneal inguinal hernia mesh repair. Between June 2016 and December 2017, the questionnaire was sent to all 68 urological surgeons performing radical prostatectomy in the Netherlands. The response rate of urological surgeons was 69% (n = 47). The majority (77%) of urological surgeons perform robot-assisted laparoscopic prostatectomies. A previous preperitoneal inguinal hernia repair was reported by 40% of urological surgeons in 10-30% of patients undergoing radical prostatectomy. Radical prostatectomy with prior preperitoneal inguinal hernia mesh repair is considered more difficult by 49%, predominantly because of (occasionally to always) experienced longer operating times (88.4%), increased blood loss (46.5%), difficult dissection of Retzius space (88.4%), nerve-sparing difficulties (32.6%), less adequate PLND (69.8%), and bladder- (16.3%) or peritoneal perforations (27.9%). Additionally, 11.6% had performed mesh explantation, 16.3% had aborted radical prostatectomies, and 35.7% experienced increased inguinal hernia recurrences after radical prostatectomies with prior preperitoneal inguinal hernia mesh repair. More experienced urological surgeons reported an increased difficulty for all outcomes. Laparo-endoscopic inguinal hernia mesh repair has a significant impact on performing a radical prostatectomy and PLND. Surgeons should postpone the inguinal hernia repair of patients in the workup for a radical prostatectomy, with the preferable option of performing the radical prostatectomy and inguinal hernia repair in the same procedure. Alternatively, a Lichtenstein repair can be performed.

MP02-19 SURPASSING RADICAL PROSTATECTOMY LEARNING CURVES: REAL WORLD EVIDENCE FROM THE NEW YORK

INTRODUCTION AND OBJECTIVE:Prior work suggests that <5% of urologists performing radical prostatectomy (RP) in the U.S. have adequate annual surgical volume to achieve expertise with 250 cumulative...

PD05-11 IS LOW VOLUME MAJOR SURGERY SET FOR EXTINCTION? EVIDENCE FROM THE RADICAL PROSTATECTOMY MARKET IN A STATE-WIDE REGISTRY

INTRODUCTION AND OBJECTIVE: Higher surgical volume is associated with improved outcomes leading some to suggest regionalization of care and minimum surgical volume standards. Prior work from 2005 in New York state suggested that 80% of urologists performing radical prostatectomy (RP) were low annual volume surgeons who accounted for over 24% of the total RP surgical volume. We assess the extent to which current market forces have limited low-volume major surgery in New York state through a case study of the radical prostatectomy (RP) market and characterize persistent low-volume surgeons. METHODS: We used the NY Statewide Planning and Research Cooperative System (SPARCS) database to determine surgeons’ annual RP and total surgical volume from 2010 to 2015. We fit a multivariate logistic regression to determine predictors of low volume surgeons (≤10 RP/year) accounting for robotic surgery, other major urologic oncology cases, career stage measured in years from medical school graduation, patient and hospital characteristics. RESULTS: Of 349 urologists who performed 23,568 RP for prostate cancer from 2010-2015, 78% performed a median of ≤10 RP/year but accounted for only 11.4% of the total RP surgical volume. Low-volume surgeons were more likely advanced career stage (16-30, and >30 years from medical school graduation), less likely to be robotic surgeons, rarely performed other major urologic oncology cases, and had low prior year volume (all p≤0.001). Among low-volume surgeons 31% were over 30 years from medical school graduation. Further, 57% of low-volume RP occurred in the New York City metro area and 46% occurred at hospitals in the top quartile of RP volume. CONCLUSIONS: While low-volume RP surgery is not set for complete extinction, its population impact is substantially reduced, now affecting roughly 11% of patients as compared to 24% in 2005. Existing market forces can promote significant consolidation for procedures such as RP and a nearly one third of remaining low-volume urologists performing RP are approaching retirement. Source of Funding: None

Role of surgery in oligometastatic prostate cancer.

Androgen deprivation therapy as single modality therapy was the standard management for oligometastatic prostate cancer (PCa). Current paradigm shifts toward a multimodality therapy approach, targeting all sites of disease, including treatment of the primary in the form of radical prostatectomy or radiation therapy. The objective of this article was to reveiw the literature regarding the role of surgery in oligometastatic PCa. PubMed and MEDLINE electronic databases were queried for English language articles from January 1, 1980 to March 31, 2019. Keywords use included oligometastatic PCa, metastatic prostate cancer (mPCa), radical prostatectomy, and cytoreductive prostatectomy. Preclinical, prospective, and retrospective studies were included. There is no published randomized controlled trials, evaluating the role of surgery in mPCa. Preclinical and retrospective data suggest benefit of primary tumor treatment in mPCa. Current literature supports the concept of cytoreductive surgery as it can prevent late symptomatic local progression, has acceptable complications, and may prolong survival in patients with mPCa. Surgery is a feasible procedure in mPCa which may improve outcome in mPCa. However, there is no Level 1 evidence, yet that support the role of surgery in mPCa. The results from well-organized prospective, randomized controlled trials are awaited before performing radical prostatectomy for mPCa in clinical practice.

Influence of the facility caseload on the subsequent survival of men with localized prostate cancer undergoing radical prostatectomy.

Several studies have investigated the relationship between experience measured by caseload and oncological outcomes, economics, and access to care for prostate cancer care. Oncological outcomes have been limited to biochemical failure after radical prostatectomy. Questions remain regarding the more definitive measures of outcomes and their relationship with caseload. The National Cancer Database was used to investigate the outcomes of radical prostatectomy in the United States. With overall survival (OS) as the primary outcome, the relationship between the facility annual caseload (FAC) for all prostate cancer encounters and the facility annual surgical caseload (FASC) for those requiring radical prostatectomy was examined with a Cox proportional hazards model. Four volume groups were defined by caseload: <50th percentile (volume group 1 [VG1]), 50th to 74th percentiles (volume group 2 [VG2]), 75th to 89th percentiles (volume group 3 [VG3]), and ≥90th percentile (volume group 4 [VG4]). By FAC/FASC, 11%/8%, 17%/18%, 25%/26%, and 47%/49% of patients were treated in VG1 through VG4, respectively. Between 2004 and 2014, 488,389 patients underwent radical prostatectomy. At a median follow-up of 60.75months, the median OS was not reached. There was a significant OS benefit as the caseload increased. For FAC, the adjusted OS difference between VG1 and VG4 at 90th percentile survivorship reached 13.2months (hazard ratio [HR], 1.30; 95% CI, 1.23-1.36; P<.0001). For FASC, this was 11.3months (HR, 1.25; 95% CI, 1.192-1.321; P<.0001). There is a statistically significant OS advantage from performing radical prostatectomy at a facility with a high annual caseload. Caseload measured by all prostate cancer encounters is a better predictor of favorable outcomes than the number of surgeries performed at a facility. An in-depth analysis of 488,389 cases of radical prostatectomyperformed inmore than 1000 facilities over a 10-year period showed bettersurvivalwhen surgery was performed in facilities with more experience and greater caseload. A survival difference of up to 13months was observed when comparing patients treated at less experienced versus more experienced centers. Experienceacross allstages of prostate cancer was a stronger predictor ofsurvivaloutcomethanjust the number of surgeriesperformed.

Spatial distribution of smooth muscle tissue in the male pelvic floor with special reference to the lateral extent of the rectourethralis muscle: Application to prostatectomy and proctectomy.

The anatomy of the rectourethralis muscle is essential for performing radical prostatectomy and proctectomy. The rectourethralis muscle is known to continue to the rectal wall posteriorly and to the membranous urethra anteriorly. However, the lateral extent of the rectourethralis muscle remains unclear. This study aimed to verify the hypothesis that the rectourethralis muscle laterally extends and directly adheres to the levator ani. Eight male cadavers were used for macroscopic dissection, and three male cadavers were used for immunohistological analysis using anti-smooth muscle and anti-skeletal muscle antibodies. The rectourethralis muscle laterally extended smooth muscle fibers both superoposteriorly and inferoanteriorly toward the levator ani. The smooth muscle fibers sandwiched the levator ani superoanteriorly and inferoanteriorly. A few smooth muscle fibers of the rectourethralis muscle inserted into the levator ani. This study clarified the spatial distribution of the rectourethralis muscle and its detailed positional relationship with the levator ani. The findings are valuable especially to urologists and anorectal surgeons for dissecting an optimal layer around the urethra and the rectum, and for avoiding rectal or urethral injuries during surgery. Clin. Anat. 31:1167-1176, 2018. © 2018 Wiley Periodicals, Inc.