Robot-assisted Laparoscopic Radical Prostatectomy Research Articles

Anorectal function and symptoms 6 months after robot-assisted laparoscopic radical prostatectomy: a single-center study.

Robot-assisted laparoscopic radical prostatectomy (RALP) is a common procedure for the treatment of localised prostate cancer. Anorectal symptoms such as fecal incontinence (FI), rectal urgency or disturbed defecation have been reported after the operation. Anorectal function is dependent on the integrity of anal and pelvic nerves and muscles, rectal sensory function as well as rectal reservoir function. The aim of this study was to investigate the potential influence of RALP on anorectal physiological function and bowel symptoms. In this pilot study, 29 patients with localised prostate cancer scheduled for RALP were included. Anorectal physiology was used to measure rectal sensitivity and reservoir function as well as anal sphincter pressures. Bowel symptoms were measured by a bowel function questionnaire and a 2-week bowel function diary. Measurements were done before the operation and repeated at 6 months after the operation. The study observed a significant postoperative increase in rectal sensory threshold for rectal balloon distention, from 20 to 40 mmHg, P < 0.001. This change is indicative of a decrease in rectal sensation after RALP. There were no other statistical significant differences in any of the physiological tests performed. Importantly, there was no change in any of the bowel symptoms after surgery. This study showed that RALP may lead to impaired rectal sensory function. This finding did not, however, seem to have any influence on the patients´ postoperative clinical bowel function.

Identifying risk factors for hypoxemia during emergence from anesthesia in patients undergoing robot-assisted laparoscopic radical prostatectomy.

Robot-assisted laparoscopic radical prostatectomy (RALP) has emerged as an effective treatment for prostate cancer with obvious advantages. This study aims to identify risk factors related to hypoxemia during the emergence from anesthesia in patients undergoing RALP. A cohort of 316 patients undergoing RALP was divided into two groups: the hypoxemia group (N = 134) and the non-hypoxemia group (N = 182), based on their postoperative oxygen fraction. Comprehensive data were collected from the hospital information system, including preoperative baseline parameters, intraoperative data, and postoperative recovery profiles. Risk factors were examined using multiple logistic regression analysis. The study showed that 38.9% of patients had low preoperative partial pressure of oxygen (PaO2) levels. Several clinical parameters showed significant differences between the hypoxemia group and the non-hypoxemia group, including weight (P < 0.0001), BMI (P < 0.0001), diabetes mellitus (P = 0.044), history of emphysema and pulmonary alveoli (P < 0.0001), low preoperative PaO2 (P < 0.0001), preoperative white blood cell count (P = 0.012), preoperative albumin (P = 0.048), intraoperative bleeding (P = 0.043), intraoperative CO2 accumulation (P = 0.001), duration of surgery (P = 0.046), postoperative hemoglobin level (P = 0.002), postoperative hypoxemia (P = 0.002), and early postoperative fever (P = 0.006). Multiple logistic regression analysis revealed BMI (adjusted odds ratio = 0.696, 95% confidence interval 0.612-0.719), low preoperative PaO2 (adjusted odds ratio = 9.119, 95% confidence interval 4.834-17.203), and history of emphysema and pulmonary alveoli (adjusted odds ratio = 2.804, 95% confidence interval 1.432-5.491) as independent factors significantly associated with hypoxemia on emergence from anesthesia in patients undergoing RALP. Our results demonstrate that BMI, lower preoperative PaO2, and a history of emphysema and pulmonary alveolar disease are independent risk factors associated with hypoxemia on emergence from anesthesia in patients undergoing RALP. These findings provide a theoretical framework for surgeons and anesthesiologists to facilitate strategies to mitigate postoperative hypoxemia in this unique patient population.

Comparison of perioperative and functional outcomes of single-incision versus standard multi-incision robot-assisted laparoscopic radical prostatectomy: a prospective, controlled, nonrandomized trial

To compare perioperative and functional outcomes between improved (port-free) single-site robot-assisted laparoscopic radical prostatectomy (pf-ssRARP) and standard multi-port robot-assisted radical prostatectomy (MPRARP). A total of 372 consecutive patients underwent RARAP using the da Vinci Si® robotic surgical system. Group I (n = 210) included patients undergoing pf-ssRARP and Group II (n = 162) included patients undergoing MPRARP. Demographics and perioperative data including postoperative recovery outcomes were recorded and compared between the two groups. Overall mean operative time was significantly shorter with the pf-ssRARP compared to the MPRARP (p < 0.05). The length of hospitalization after the pf-ssRARP was shorter (p < 0.05). In Group I, the positive surgical margin rate was 15.2%; while in Group II, the positive margin rate was 33.3% (p < 0.05). The rate of instant urinary continence was significantly higher in Group I than in Group II (p < 0.05). The percentage of urinary continence was higher in the pf-ssRARP than in the MPRARP, at 6 months post-surgery (p < 0.05) and 9 months post-surgery (p < 0.05). There was no significant difference in the proportion of erectile function in the pf-ssRARP and MPRARP groups at the time of reaching the endpoint of this study (p > 0.05). The two groups were comparable in terms of total hospitalization costs (p < 0.05). The improved (port-free) single-site robot-assisted laparoscopic radical prostatectomy is a practical and easy technique to implement in clinical practice. Extraperitoneal implementation of the modified technique requires only a small incision, no special PORT, no additional auxiliary foramen creation, increased postoperative aesthetics and reduced hospitalization costs, and a high percentage of early postoperative urinary control recovery.

The effect of ultrasound-guided rectus sheath block on postoperative analgesia in robot assisted prostatectomy: A randomized controlled trial.

Postoperative pain continues to represent an important problem even after minimally invasive robotic-assisted laparoscopic radical prostatectomy, which results in discomfort in the postoperative period and sometimes prolongs hospital stays. Regional anesthesia and analgesia techniques are used in addition to systemic analgesics with the multimodal approach in postoperative pain management. Ultrasound-guided fascial plane blocks are becoming increasingly important, especially in minimally invasive surgeries. Another important cause of discomfort is urinary catheter pain. The present randomized controlled study investigated the effect of rectus sheath block on postoperative pain and catheter-related bladder discomfort in robotic prostatectomy operations. This randomized controlled trial was conducted from March to August 2022. Written informed consent was obtained from all participants. Approval for the study was granted by the Clinical Research Ethics Committee. All individuals provided written informed consent, and adults with American Society of Anesthesiologists Physical Condition classification I to III planned for robotic prostatectomy operations under general anesthesia were enrolled. Following computer-assisted randomization, patients were divided into 2 groups, and general anesthesia was induced in all cases. Rectus sheath block was performed under general anesthesia and at the end of the surgery. No fascial plane block was applied to the patients in the non-rectus sheath block (RSB) group.Postoperative pain and urinary catheter pain were assessed using a numerical rating scale. Fentanyl was planned as rescue analgesia in the recovery room. In case of numerical rating scale scores of 4 or more, patients were given 50 µg fentanyl IV, repeated if necessary. The total fentanyl dose administered was recorded in the recovery room. IV morphine patient-controlled analgesia was planned for all patients. All patients' pain (postoperative pain at surgical site and urethral catheter discomfort) scores and total morphine consumption in the recovery unit and during follow-ups on the ward (3, 6, 12, and 24 hours) in the postoperative period were recorded. Sixty-one patients were evaluated. Total tramadol consumption during follow-up on the ward was significantly higher in the non-RSB group. Fentanyl consumption in the postanesthesia care unit was significantly higher in the non-RSB group. Total morphine consumption was significantly lower in the RSB group at 0 to 12 hours and 12 to 24 hours. Total opioid consumption was 8.81 mg in the RSB group and 19.87 mg in the non-RSB group. A statistically significant decrease in urethral catheter pain was noted in the RSB group at all time points. RSB exhibits effective analgesia by significantly reducing postoperative opioid consumption in robotic prostatectomy operations.

Physiotherapy for continence and muscle function in prostatectomy: a randomised controlled trial.

To assess the effectiveness of pre- and postoperative supervised pelvic floor muscle training (PFMT) on the recovery of continence and pelvic floor muscle (PFM) function after robot-assisted laparoscopic radical prostatectomy (RARP). We carried out a single-blind randomised controlled trial involving 54 male patients scheduled to undergo RARP. The intervention group started supervised PFMT 2 months before RARP and continued for 12 months after surgery with a physiotherapist. The control group was given verbal instructions, a brochure about PFMT, and lifestyle advice. The primary outcome was 24-h pad weight (g) at 3 months after RARP. The secondary outcomes were continence status (assessed by pad use), PFM function, and the Expanded Prostate Cancer Index Composite (EPIC) score. Patients who participated in supervised PFMT showed significantly improved postoperative urinary incontinence (UI) compared with the control group (5.0 [0.0-908.0] g vs 21.0 [0.0-750.0] g; effect size: 0.34, P = 0.022) at 3 months after RARP based on 24-h pad weight. A significant improvement was seen in the intervention compared with the control group (65.2% continence [no pad use] vs 31.6% continence, respectively) at 12 months after surgery (effect size: 0.34, P = 0.030). Peak pressure during a maximum voluntary contraction was higher in the intervention group immediately after catheter removal and at 6 months, and a longer duration of sustained contraction was found in the intervention group compared with the control group. We were unable to demonstrate a difference between groups in EPIC scores. Supervised PFMT can improve postoperative UI and PFM function after RARP. Further studies are needed to confirm whether intra-anal pressure reflects PFM function and affects continence status in UI in men who have undergone RARP.

Precise Prediction of Long-Term Urinary Incontinence after Robot-Assisted Laparoscopic Radical Prostatectomy by Readily Accessible “Everyday” Diagnostics during Post-Surgical Hospitalization

Aim and Objectives: We aimed to test the predictive value of readily accessible and easily performed post-surgical “bedside tests” on their validity of long-term urinary incontinence (UI) (≥12 months) in patients following robot-assisted laparoscopic radical prostatectomy (RALP). Material and Methods: Patients undergoing RALP between July 2020 and March 2021 were prospectively included and subdivided into two groups based on their pad usage after 12 months (0 vs. ≥1 pad). After catheter removal, patients performed a 1 h pad test, documented the need for pad change in a micturition protocol and received post-voiding residual urine volume ultrasound. Univariate and multivariable analyses were used to demonstrate the predictive value of easily accessible tests applied after catheter removal for UI following RALP. Results: Of 109 patients, 47 (43%) had to use at least one pad (vs. 62 (57%) zero pads) after 12 months. Univariate testing showed a significant difference in urine loss between both groups evaluated by the 1 h pad test performed within 24 h after catheter removal (70% &lt; 10 mL, vs. 30% ≥ 10 mL, p = 0.004) and in the need for pad change within the first 24 h after catheter removal (14% dry pads vs. 86% wet pads, p = 0.003). In multivariable analyses, the combination of both tests (synoptical incontinence score) could be confirmed as an independent predictor for UI after 12 months (p = 0.011). Conclusions: Readily accessible “everyday” diagnostics (pad test/change of pads after catheter removal) following RALP seem to be associated with a higher rate of long-term UI. This finding is crucial since patients with a potentially higher need for patient education and counselling can be identified using these readily accessible tests. This could lead to a higher patient satisfaction and improved outcomes.

The effects of different positions on lower extremity hemodynamics during robot-assisted laparoscopic radical prostatectomy for prostate cancer

PurposeThis study aimed to investigate the effects of two different positions on lower extremity hemodynamics during robot-assisted laparoscopic radical prostatectomy (RARP) for prostate cancer.MethodsA total of 196 patients who underwent RARP in our hospital from February 2020 to March 2022 were included in this study. Among them, 98 patients who underwent surgery with the Trendelenburg position and split-leg position with calf reverse arch from March 2021 to March 2022 were assigned to the observation group, while 98 patients who underwent surgery with the Trendelenburg position and low lithotomy position from February 2020 to February 2021 were assigned to the control group. Using an ultrasound diagnostic instrument to detect the internal diameter, mean blood flow velocity, and mean blood flow volume of the left deep femoral vein at different times, such as the supine position (T0), after 5 minutes of placing the patient in the leg spilt or low lithotomy position (T1), after 5 minutes of pneumoperitoneum (T2), after 5 minutes of head-down tilt or head-down tilt and calf reverse arch (T3), 1.5 hours after the start of surgery (T4), before the removal of CO2 gas (T5), and before the patient left the operating room (T6). As well as the patency of deep venous blood flow in both lower extremities before leaving the operating room,ResultsAfter establishment of pneumoperitoneum, the internal diameter of the deep femoral vein increased significantly, while the mean blood flow velocity and mean blood flow volume decreased significantly in both groups(T0) (P<0.001). With the prolongation of surgical time, the impact on lower extremity hemodynamics in the observation group was smaller than that in the control group. From T2 to T6, the internal diameter of the femoral vein in the observation group was smaller than that in the control group, while the mean blood flow velocity and mean blood flow volume were increased compared to the control group (P<0.05). Before leaving the operating room, the patency of deep venous blood flow in the observation group was better than that in the control group (P=0.003).ConclusionPlacing patients in the Trendelenburg position and split-leg position with calf reverse arch during RARP for prostate cancer has a smaller impact on lower extremity hemodynamics than the low lithotomy position, and can relatively reduce the risk of postoperative deep vein thrombosis.

Assessment of the accuracy of biparametric MRI/TRUS fusion-guided biopsy for index tumor evaluation using postoperative pathology specimens

BackgroundMultiparametric MRI (mpMRI) is widely used for the diagnosis, surveillance, and staging of prostate cancer. However, it has several limitations, including higher costs, longer examination times, and the use of gadolinium-based contrast agents. This study aimed to investigate the accuracy of preoperatively assessed index tumors (ITs) using biparametric MRI (bpMRI)/transrectal ultrasound (TRUS) fusion biopsy compared with radical prostatectomy (RP) specimens.MethodsWe included 113 patients diagnosed with prostate cancer through bpMRI/TRUS fusion-guided biopsies of lesions with a Prostate Imaging Reporting and Data System (PI-RADS) category ≥ 3. These patients underwent robot-assisted laparoscopic radical prostatectomy (RARP) at our institution between July 2017 and March 2023. We examined the localization of preoperative and postoperative ITs, the highest Gleason score (GS), and tumor diameter in these patients.ResultsThe preoperative cT stage matched the postoperative pT stage in 53 cases (47%), while 31 cases (27%) were upstaged, and 29 cases (26%) were downstaged (Weighted Kappa = 0.21). The preoperative and postoperative IT localizations were consistent in 97 cases (86%). The concordance rate between Gleason groups in targeted biopsies and RP specimens was 51%, with an upgrade in 25 cases (23%) and a downgrade in 27 cases (25%) (Weighted Kappa = 0.42). The maximum diameter of the IT and the maximum cancer core length on biopsy were correlated with the RP tumor's maximum diameter (p < 0.001 for both).ConclusionThe diagnostic accuracy of bpMRI/TRUS fusion biopsy is comparable to mpMRI, suggesting that it can be a cost-effective and time-saving alternative.

Ten-year functional and oncological outcomes of a prospective randomized controlled trial comparing laparoscopic versus robot-assisted radical prostatectomy.

Among prostate cancer (PCa) treatment options, mini-invasive surgical approaches have gained a wide diffusion in the last decades. The aim of this study was to present oncological, functional, and quality of life data after 10 years of follow-up of a prospective randomized controlled trial (RCT) (ISRCTN11552140) comparing robot-assisted radical prostatectomy (RARP) versus laparoscopic radical prostatectomy (LRP) for the treatment of PCa. Patients with localized PCa were randomized to undergo LRP or RARP between January 2010 and January 2011. Functional (continence and potency) and oncological (prostate-specific antigen, biochemical recurrence [BCR] and BCR-free survival [BCRFS]) variables were evaluated. BCRFS curves were estimated by the Kaplan-Meier method and compared using the log-rank test. Machine learning partial least square-discriminant analysis (PLS-DA) was used to identify the variables characterizing more the patients who underwent RARP or LRP. Seventy-five of the originally enrolled 120 patients remained on follow-up for 10 years; 40 (53%) underwent RARP and 35 (47%) LRP. Continence and potency recovery rates did not show significant differences (p = 0.068 and p = 0.56, respectively), despite a Δ12% for continence and Δ8% for potency in favor of the robotic approach. However, the quality of continence (in terms of International Consultation on Incontinence Questionnaire-Short Form [ICIQ-SF] score) and erection (in terms of International Index of Erectile Function-5 [IIEF-5] score) was significantly better after 10 years in the robotic group (p = 0.02 and p < 0.001). PLS-DA revealed that LRP was characterized by the worst functional-related outcomes analyzing the entire follow-up period. Four (10%) and six (17%) patients experienced BCR in RARP and LRP groups, respectively (p = 0.36), with an overall 10-year BCR-free survival of 88% and 78% (p = 0.16). Comparable continence and potency rates were observed between RARP and LRP after a 10-year follow-up. However, the RARP group exhibited superior totally dry rate and erection quality. No difference in terms of oncological outcomes was found.

Assessing Stress Induced by Fluid Shifts and Reduced Cerebral Clearance during Robotic-Assisted Laparoscopic Radical Prostatectomy under Trendelenburg Positioning (UroTreND Study).

In addition to general anesthesia and mechanical ventilation, robotic-assisted laparoscopic radical prostatectomy (RALP) necessitates maintaining a capnoperitoneum and placing the patient in a pronounced downward tilt (Trendelenburg position). While the effects of the resulting fluid shift on the cardiovascular system seem to be modest and well tolerated, the effects on the brain and the blood-brain barrier have not been thoroughly investigated. Previous studies indicated that select patients showed an increase in the optic nerve sheath diameter (ONSD), detected by ultrasound during RALP, which suggests an elevation in intracranial pressure. We hypothesize that the intraoperative fluid shift results in endothelial dysfunction and reduced cerebral clearance, potentially leading to transient neuronal damage. This prospective, monocentric, non-randomized, controlled clinical trial will compare RALP to conventional open radical prostatectomy (control group) in a total of 50 subjects. The primary endpoint will be the perioperative concentration of neurofilament light chain (NfL) in blood using single-molecule array (SiMoA) as a measure for neuronal damage. As secondary endpoints, various other markers for endothelial function, inflammation, and neuronal damage as well as the ONSD will be assessed. Perioperative stress will be evaluated by questionnaires and stress hormone levels in saliva samples. Furthermore, the subjects will participate in functional tests to evaluate neurocognitive function. Each subject will be followed up until discharge. Conclusion: This trial aims to expand current knowledge as well as to develop strategies for improved monitoring and higher safety of patients undergoing RALP. The trial was registered with the German Clinical Trials Register DRKS00031041 on 11 January 2023.

Robot-assisted surgery in urology

Background: In the field of urological surgery, robotic surgery continues to develop and increase. This paper is an overview of the present and future of robotic urological surgery.Current Concepts: Robot-assisted surgery has revolutionized minimally invasive surgery and advanced the technical limitations of laparoscopy. Urologists have always been eager to adopt new technological advances to benefit their patients, and they have also been pioneers in the field of robotic surgery.Discussion and Conclusion: Following the first approval by the Food and Drug Administration in 2000, the da Vinci System (Intuitive Surgical, USA) remained the leading robotic surgical system for over 20 years. In 2000, the first robot-assisted laparoscopic radical prostatectomy was performed in urology. Subsequently, applications of the da Vinci System in urology have grown exponentially, including the kidney, urinary bladder, and reconstructive and functional urological surgeries. To date, urology is driving robotic innovation. The first specialist-engineered system for single-site surgery, the da Vinci SP, was initially approved for use in urological surgery. Due to the advantages of robotic surgery, such as excellent visibility and operability, the demand for robotic surgery in the urology department is continuously increasing. Recently, in addition to the da Vinci System, other robot platforms are being developed and commercialized in many countries. In South Korea, robots such as Revo-I (Meere Company Inc., Korea) and Zamenix (Roen Surgical, Korea) are being released and commercialized. Urologists continue to lead the development of domestic robots and robotic surgery.

Surgical Experience and Results of Retzius Sparing Robotic Assisted Laparoscopic Radical Prostatectomy: First Report in Thailand

Objective: To evaluate the outcomes and safety of the surgical technique Retzius-sparing robot-assisted laparoscopic radical prostatectomy (RS-RALRP), with prostatic cancer; the first report in Thailand. Material and Methods: The authors conducted a retrospective analysis from the medical records of 100 patients who underwent RS-RALRP by a single surgeon; from 1st January 2021 until 31st May 2023, at Rajavithi Hospital. The authors analyzed demographic data, clinical staging, Gleason grade group, operative time, pathologic staging, positive surgical margin rate; postoperative continence recovery and postoperative complications. Results: The median age was 71.34±6.84 years: mean total PSA was 17.16±17.55 ng/ml; with the majority in clinical T1 and T2. The mean operative time was 221.7±51.93 minutes, and the mean estimated blood loss was 312.30±264.55 ml. Of all patients, 88% did not require blood transfusion. The complication rate was 8%. The pathologic stages pT2 and pT3 or greater were 62% and 38%, respectively. Positive surgical margins (PSM) pT2 and pT3 were 14.5% and 63.2%. The postoperative continence recovery after RS-RALRP were 83%, 95%, 97%,100% and 100%: at 1, 3, 6, 9 and 12 months postoperatively, respectively. Conclusion: RS-RALRP has a potential to become the new standard for prostate cancer treatment, with improved early continence and equivalent oncologic efficacy. The limitations of this study are the small number of population, which require prospective multicenter studies.

Intermediate-Term Oncological Outcome Assessment for Robotic Assisted Radical Prostatectomy Comparing Retzius Sparing to Standard Approach in a Randomized Control Cohort.

Retzius sparing prostatectomy was promoted with the early continence result. The long-term oncological outcome is still unknown. In this study, we aimed to compare the Intermediate-term oncologic outcomes of these two approaches in patient's cohort who was treated as part of a randomized controlled trial. A total of 120 patients were previously randomized equally to receive retzius sparing (RS-RARP) versus standard robotic assisted laparoscopic radical prostatectomy (S-RARP) between January 2015 to April 2016. Baseline, surgical, and pathological characteristics as well as oncologic outcomes were assessed. The analysis was done based on the treatment received. Sixty-three patients underwent S-RARP while 57 patients underwent RS-RARP. There was no statistically significant difference in the baseline nor surgical characteristics. The median follow up was 71.24 (IQR 59.75 - 75.75). There were more pathological T3 diseases in RS-RARP. There was no significant difference in the positive margin status nor the biochemical recurrence rate among both groups. After S-RARP and RS-RARP, 6 and 10 patients had biochemical recurrence and the 5-years biochemical recurrence free survival were 91% and 85%, respectively. (p= 0.21) Conclusion: In this cohort, there was no difference in biochemical recurrence in the patients who received either technique. Further mutli-institutional studies with a larger sample size and longer follow up are required.

Epidemiology of and Risk Factors in Postoperative Complications from Robotically Assisted Laparoscopic Radical Prostatectomy in Contemporary National Surgical Quality Improvement Program Data.

Introduction: For localized clinically significant prostate cancer (csPCa), robotically assisted laparoscopic radical prostatectomy (RALP) is the gold standard surgical treatment. Despite low overall complication rate, continued quality assurance (QA) efforts to minimize complications of RALP are important, particularly given movement toward same-day discharge. In 2019, National Surgical Quality Improvement Program (NSQIP) began collecting RALP-specific data. In this study, we assessed pre- and perioperative factors associated with postoperative complications for RALP to further QA efforts. Materials and Methods: Surgical records of csPCa patients who underwent RALP were retrieved from the 2019 to 2021 NSQIP database, including new RALP-specific data. Multivariate logistic regression evaluated the association between risk factors and outcomes specific to RALP and pelvic lymph node dissection (PLND). Input variables included American Society of Anesthesiologists (ASA) class, age, operative time, and body mass index (BMI). Variables from the extended dataset with PLND information included number of nodes evaluated, perioperative antibiotics, postoperative venous thromboembolism (VTE) prophylaxis, history of prior pelvic surgery, and history of prior radiotherapy (RT). Outcomes of interest were any surgical complication, infection, pulmonary embolism, deep venous thrombosis, acute kidney injury, pneumonia, lymphocele, and urinary/anastomotic leak (UAL). Results: A total of 11,811 patients were included with 6.1% experiencing any complication. Prior RT, prior pelvic surgery, older age, higher BMI, lack of perioperative antibiotic therapy, longer operative time, PLND, and number of lymph nodes dissected were associated with higher risk of postoperative complications. Regarding procedure-specific complications, there were increased odds of UAL with prior RT, prior pelvic surgery, longer operative time, and higher BMI. Odds of developing lymphocele increased with prior pelvic surgery, performance of PLND, and increased number of nodes evaluated. Conclusion: In contemporary NSQIP data, RALP is associated with low complication rates; however, these rates have increased compared with historical studies. Attention to and counseling regarding risk factors for peri- and postoperative complications are important to set expectations and minimize risk of unplanned return to a health care setting after discharge.

Impact of the combination of abdominal peripheral nerve block and neuromuscular blockade on the surgical space during robot-assisted laparoscopic surgery: a prospective randomized controlled study.

The impact of the combination of abdominal peripheral nerve block (PNB) and the depth of neuromuscular blockade on the surgical field were assessed. Thirty-eight patients undergoing elective robot-assisted laparoscopic radical prostatectomy (RARP) were randomized into two groups: a PNB group (moderate neuromuscular block [train-of-four 1-3 twitches] with abdominal PNB) and a non-PNB group (deep neuromuscular block [post-tetanic count 0-2 twitches] without abdominal PNB). The primary outcome was the change in the depth of the abdominal cavity relaxation assessed by the change in the distance (Δdistance) between the umbilicus port and peritoneum upon pneumoperitoneal pressure increase from 8 to 12mmHg. The secondary outcomes were the CO2 usage for the pneumoperitoneal pressure increase and the subjective differences in the Surgical Rating Score (SRS) during surgery. The Δdistance and the CO2 usage from 8 to 12mmHg did not differ significantly between the non-PNB and PNB groups (1.34 ± 0.65 vs. 1.28 ± 0.61cm, p = 0.763 and 3.64 ± 1.68 vs. 4.34 ± 1.44 L, p = 0.180, respectively). There was also no significant difference in SRS. Comparisons of the Δdistance values for pressure increases from 6 to 8mmHg, 6 to 10mmHg and 6 to 12mmHg between the non-PNB and PNB groups also showed no between-group differences, despite significant intra-group differences (p < 0.001) by pressure increment. Our findings indicate that moderate neuromuscular block with abdominal PNB maintained an adequate surgical space for RARP, with no significant difference from the space achieved by deep neuromuscular block.

Impact of prostatic shape on the difficulty of robot-assisted laparoscopic radical prostatectomy.

To investigate the impact of prostatic shape observed on preoperative magnetic resonance imaging (MRI) on the difficulty of robot-assisted laparoscopic radical prostatectomy (RALP). We retrospectively reviewed the operative records of 211 patients who underwent RALP. We excluded patients who received neoadjuvant therapy. All surgeries in this study were performed by two surgeons. Each patient clinicopathological and surgical data were reviewed. Prostate sphericity was evaluated by measuring the roundness of the prostate at the largest axial slice by MRI. The console time was adopted as an objective indicator for assessing surgical difficulty. The mean prostate volume was 34 cc (range 14-88) and the mean prostate roundness was 0.55 (range 0.24-0.90). The mean console time was 194 min (range 95-296). To assess the relationship between prostate volume and console time, scatter plot analysis was performed. The prostate volume had a weak positive correlation with the console time (r = .165, p = .016). Similarly, scatter plot analysis between the prostate roundness and console time demonstrated a weak positive correlation (r = .167, p = .015). Next, we performed subgroup analysis of 56 patients with a large prostate volume (≥40 cc), and the positive correlation between the prostate volume and the console time disappeared (r = .142, p = .296). On the other hand, the prostate roundness was more strongly correlated with the console time (r = .439, p = .001). The spherical shape of the prostate is associated with the surgical difficulty of RALP, especially in patients with a large prostate volume.

Feasibility of same-day discharge of robotic-assisted laparoscopic radical prostatectomy with pelvic lymph node dissection.

Prostate cancer is one of the most common oncologic diseases. Outpatient robotic-assisted laparoscopic radical prostatectomy (RALP) has gained popularity due to its ability to minimize patient costs while maintaining low complication rates. Few studies have analyzed the possibility of performing outpatient RALP specifically in patients undergoing concurrent pelvic lymph node dissections (PLND). Using the National Surgical Quality Improvement Program Database (NSQIP), we identified total number of RALP, stratified into inpatient and outpatient groups including those with and without PLND from 2016 to 2021. Baseline characteristics, intraoperative and postoperative complications, and unplanned readmission rates were summarized. Proportions of outpatient procedures were calculated to assess adoption of outpatient protocol. Between 2016 and 2021, a total of 58,527 RALP were performed, 3.7% (2142) outpatient and 96.3% inpatient. Altogether, patients undergoing outpatient RALP without PLND were more likely to have hypertension (52.6% vs. 46.3%, p < 0.01). Patients undergoing outpatient RALP without PLND were more likely to have sepsis or urinary tract infections (3.4% vs. 1.9%, p = 0.04) when compared to outpatient RALP with PLND. Cardiopulmonary, renal, thromboembolic complications, and 30-day events such as unplanned readmission, reoperation rates, and mortality were similar in both groups. However, among multivariate analysis regarding 30-day readmission and complications, there were no significant differences between outpatient RALP with or without PLND. Patients undergoing outpatient RALP without PLND were more likely to have baseline hypertension and higher rates of postoperative infection, when compared to outpatient RALP with PLND. No significant differences were seen regarding 30-day readmission or complications on multivariate analysis.

(012) Incidence of Peyronie’s Disease After Radical Prostatectomy Among Patients Undergoing Penile Rehabilitation Regimen

Abstract Introduction Radical prostatectomy remains one of the gold standard treatments for localized prostate cancer, the most prevalent solid organ cancer in men. Surgical management of prostate cancer has been theorized to increase the risk of developing Peyronie’s Disease (PD). In 2010, Drs. Tal and Mulhall’s team characterized the incidence of PD in a cohort of 1011 men after radical prostatectomy to be 13.7% at 2 years and 15.9% at 3 years of follow-up. These numbers, significantly higher than estimates in the general population, which range from 0.5 to 7.1% (Sharma et al., Sex Med Rev 2020;8:314–23), suggest radical prostatectomy is a risk factor for developing PD. Objective Our aim was to evaluate the incidence of PD among post-prostatectomy patients who undergo a formal multi-modal penile rehabilitation program that includes mechanical and pharmacologic interventions to promote penile smooth muscle activation after surgery. Methods In this retrospective, descriptive study we reviewed the charts of 581 patients who were diagnosed with prostate cancer, treated with robot-assisted laparoscopic radical prostatectomy (RALP), and were engaged in a penile rehabilitation program from January 2016 through January 2019. At our institution, patients scheduled for prostatectomy are referred preoperatively to an academic Men’s Health clinic to start a multi-modal program and follow up regularly for evaluation of sexual health. The program includes daily tadalafil, L-citrulline, and VED use (Table 1). Patients refractory to these therapies had the option to increase tadalafil dosing or undergo further treatment with intracavernosal injections at ~3 months post-op. We excluded patients who had PD pre-operatively or who did not have post-operative follow-up with the providers at this institution. The primary outcome of interest was the incidence of PD among this cohort. Secondary outcome included time to development or diagnosis of PD. Results 581 patients with prostate cancer treated with RALP engaged in penile rehabilitation and were included in this analysis. The median age of men was 62.6 y with additional demographics listed in Table 2. The incidence of PD in this cohort was 2.9% (17 patients) with a median follow-up of 21.4 mo (IQR 2.8 – 55.8 mo). The diagnosis of PD was made at a median of 28.7 mo (IQR 20 – 36 mo) after prostatectomy. The 17 patients with PD had a median follow-up of 38.9 mo (IQR 23.2 – 55.8 mo). Conclusions In this cohort of prostate cancer patients treated with RALP and undergoing a consistent, multi-modal penile rehabilitation program, the incidence of PD was 2.9%, and median time to diagnosis was 28.7 months. This is the first study to assess PD incidence in men who engage in mechanical and pharmacologic penile rehabilitation at time of RALP. Furthermore, diagnosis of PD was made more than two years after surgery; this warrants further evaluation on whether penile rehabilitation prevents PD. This retrospective analysis is a hypothesis-generating study that should inspire further research on the role of regular mechanical stimulation or daily PDE-5 inhibitors in delaying or preventing PD after pelvic surgery. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Endo Scientific.

The efficacy of peritoneal flap fixation on symptomatic lymphocele formation following robotic-assisted laparoscopic radical prostatectomy with pelvic lymph node dissection: a systematic review and meta-analysis.

Pelvic lymphocele is the most common complication after robot-assisted radical prostatectomy (RARP) with pelvic lymph node dissection (PLND), of which symptomatic lymphocele (sLC) ranges up to 10% and is associated with poorer perioperative outcomes. Peritoneal flap fixation (PFF) is a promising intraoperative modification to reduce sLC formation but the clinical evidence failed to reach consistency. Randomized and nonrandomized comparative studies comparing postoperative sLC occurrence with or without PFF after RARP with PLND were identified through a systematic literature search via MEDLINE/PubMed, Embase, Web of Science, and CENTRAL up to July 2023. Outcome data of sLC occurrence (primary) and major perioperative events (secondary) were extracted. Mean difference and risk ratio with 95% CI were synthesized as appropriate for each outcome to determine the cumulative effect size. Five RCTs and five observatory studies involving 3177 patients were finally included in the qualitative and quantitative analysis. PFF implementation significantly reduced the occurrence of sLC (RR 0.35, 95% CI: 0.24-0.50), and the specific lymphocele-related symptoms, without compromised perioperative outcomes including blood loss, operative time, and major nonlymphocele complications. The strength of the evidence was enhanced by the low risk of bias and low inter-study heterogeneity of the eligible RCTs. PFF warrants routine implementation after RARP with PLND to prevent or reduce postoperative sLC formation.

Novel Prostate Biopsy Technique Using Imaging Fusion in a Patient With Absent Rectum

OBJECTIVETo describe a novel technique using pre-operative multi-parametric prostate MRI and intraoperative CT 3D/3D fusion for systematic and targeted prostate biopsy in a patient lacking a rectum. METHODSA 70-year-old male with prior total colectomy for ulcerative colitis was referred for elevated PSA (8.01) with PIRADS 4 lesion on MRI. Under general anesthesia, an ultra-low-dose (ULD) cone beam CT was performed in supine position using a robotic-armed fluoroscopy system (Artis Zeego Care+Clear™, Siemens). 3D/3D auto-registration of the femoral heads and prostate from the MRI and ULD CT was performed. The prostate edges and two areas of concern were marked. Then, reduced-dose fluoroscopy-guided prostate biopsy was performed transperineally using triangulation technique. RESULTS27 prostate biopsy cores were obtained. Grade group 5 (Gleason 4+5=9) prostate cancer was identified in two cores from the targeted lesion and one core from the prostate base. The remaining twenty-four biopsies were negative for malignancy. Surgical time was 81 minutes. PSMA scan demonstrated no metastasis or lymphadenopathy. Robotic-assisted laparoscopic radical prostatectomy was performed without complications. Final pathology demonstrated T3a, grade group 5 prostate adenocarcinoma involving 10% of the prostate volume with negative surgical margins. CONCLUSIONSThis is the initial report of fluoroscopy-guided prostate biopsy using imaging fusion techniques in a patient without a rectum. This technique allowed precise identification of localized, very high-risk prostate cancer with over three times the number of cores, and much lower radiation dose, than typical CT-guided biopsies. Our technique could provide a new paradigm in targeted prostate biopsy.