Robotic Laparoscopic Radical Prostatectomy Research Articles

Clipless Athermal Suture-ligation of Pedicle and Antegrade Nerve-sparing (CASPAN) technique in Robotic Laparoscopic Radical Prostatectomy (RLRP)

Clipless Athermal Suture-ligation of Pedicle and Antegrade Nerve-sparing (CASPAN) technique in Robotic Laparoscopic Radical Prostatectomy (RLRP)

There Are No Differences in Positive Surgical Margin Rates or Biochemical Failure-Free Survival among Patients Receiving Open, Laparoscopic, or Robotic Radical Prostatectomy: A Nationwide Cohort Study from the National Cancer Database.

Simple SummaryFew studies have evaluated oncologic outcomes in patients with prostate cancer (PC) receiving open, laparoscopic, or robotic radical prostatectomy (RP). To the best of our knowledge, this is the first and largest study to examine PSM and BFS rates in patients with PC undergoing open, laparoscopic, or robotic RP. After adjustment for confounders, no significant differences in PSM or BFS were noted among the patient groups.Purpose: To estimate the rates of positive surgical margin (PSM) and biochemical failure–free survival (BFS) among patients with prostate cancer (PC) receiving open, laparoscopic, or robotic radical prostatectomy (RP). Patients and Methods: The patients were men enrolled in the Taiwan Cancer Registry diagnosed as having PC without distant metastasis who received RP. After adjustment for confounders, logistic regression was used to model the risk of PSM following RP. After adjustment for confounders, Cox proportional regression was used to model the time from the index (i.e., surgical) date to biochemical recurrence. Results: The adjusted odds ratios (95% CIs) of PSM risk after propensity score adjustment for laparoscopic versus open, robotic versus open, and robotic versus laparoscopic RP 95% CIs were 1.25 (0.88 to 1.77; p = 0.2064), 1.16 (0.88 to 1.53; p = 0.2847), and 0.93 (0.70 to 1.24; p = 0.6185), respectively. The corresponding adjusted hazard ratios (95% CIs) of risk of biochemical failure after propensity score adjustment were 1.16 (0.93 to 1.47; p = 0.1940), 1.10 (0.83 to 1.47; p = 0.5085), and 0.95 (0.74 to 1.21; p = 0.6582). Conclusions: No significant differences in PSM or BFS were observed among patients receiving open, laparoscopic, or robotic RP.

Влияние положения Тренделенбурга и пневмоперитонеума на сердечно-сосудистую систему при робот-ассистированной радикальной простатэктомии.

Introduction. Prostate cancer remains one of the most common malignant neoplasms of the genitourinary system. Robot-assisted radical prostatectomy (RARP) is currently considered the most effective option for the treatment of this pathology. Special conditions of this operation, such as long-term stay of the patient in the Trendelenburg position and pneumoperitoneum, affect blood pressure, vascular resistance and inotropic function of the heart. The clinical significance of this effect remains poorly understood. The aim of the study was to systematize new information about hemodynamic disorders in patients with pneumoperitoneum in the Trendelenburg position in RARP. Materials and methods. The search for relevant studies published before may 2019 was conducted in the electronic databases PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Google Scholar using the keywords: «prostatectomy», «robotic surgery», «robotic assisted», «robotic laparoscopic radical prostatectomy», «pneumoperitoneum», «Trendelenburg position», «hemodynamics», «hemodynamic changes», «cardiac function», «cardiovascular function» without restrictions on the publication language. Forty one studies were identified, of which 15 were selected according to pre-defined inclusion criteria. Results. Most studies revealed an increase in arterial and central venous pressure in patients with pneumoperitoneum in the Trendelenburg position. Changes in stroke volume and cardiac output were multidirectional. There was also an increase in pulmonary artery pressure and filling pressure, a decrease in the aortic diameter and an increase in vascular resistance, a deterioration in central hemodynamic parameters, and increased microcirculation. Eleven studies did not show a negative effect of the Trendelenburg position and pneumoperitoneum on the cardiovascular system. The developed changes were easily controlled during anesthesia, and in the postoperative period, the indicators of the cardiovascular system returned to normal. In 4 studies, the negative impact of these factors was noted: the development of mitral valve dysfunction, a significant prolongation of the QT interval and an increase in blood pressure, and hemodynamic instability. Conclusions. The position of the Trendelenburg and pneumoperitoneum and in RARP are accompanied by hemodynamic disorders, most of which are controlled and reversible. Further studies with a longer follow-up period are needed to determine their clinical safety.

Adherence and barriers to penile rehabilitation over 2\u2009years following radical prostatectomy

BackgroundA variety of penile rehabilitation (PR) therapies are available to improve post-prostatectomy erectile dysfunction (ED) with mixed results. It is uncertain how adherent men are to PR therapies. The aim of this study is to determine adherence to and identify barriers to PR treatment.MethodsA longitudinal cross-sectional approach was used in men who underwent radical prostatectomy over 2 years. Men were instructed to take a PDE5 inhibitor (PDE5i) three times per week, and if required, utilize a vacuum constriction device (VCD) daily. Outcomes were measured by multiple validated questionnaires. In addition, penile stretched length, side effects, compliance to PR regimen & barriers to participation were documented.ResultsSeventy-seven patients were enrolled, however only 49 completed evaluation at 3 or more timepoints and were included in analysis. This cohort was an average age of 58.1 years (±7.7), had robotic laparoscopic radical prostatectomy (91.7%), and had bilateral nerve sparing procedures (95.8%). Majority (62.5%) reported normal SHIM pre-operatively, however 79% used PDE5i. Erectile function as measured by IIEF and Erection Hardness Rating were negatively affected post-operatively, with gradual improvement in parameters throughout the 24 month follow up. Of the participants who had normal pre-op SHIM, only 23.1 and 28.6% regained baseline function at 1 and 2 years, respectively. Orgasm was significantly diminished immediately post-operatively, however, at the end of the study period only 37% of men reported diminished climax and no men reported absent orgasm. Adherence to penile rehabilitation therapies declined overtime. Men took oral PDE5i on average 2.3 times weekly at 12 and 24 months (p < 0.001). Men used the VCD 2.3–3.9 days a week, which declined overtime (p = 0.014).ConclusionsImprovement in erectile and orgasm parameters was observed over time, but most men did not return to baseline function. Despite comprehensive instructions and a frequent follow up schedule, PDE5i and VCD adherence was poor. High attrition rates were noted with only 55.8% of men remaining at 12 months and 45% of men completing 24 months. The most common barriers to PR adherence were cost, inconvenience and perceived ineffectiveness.

Curative effects of anatomic reconstruction of periurethral structure in robotic assisted laparoscopic radical prostatectomy

Objective To investigate the outcome of patients underwent anatomic periurethral reconstruction during robotic assisted laparoscopic radical prostatectomy (RARP). Methods During August 2016 to May 2018, anatomic periurethral reconstruction was performed during RARP in 58 consecutive patients. The control group consists of another 50 patients had no anatomic periurethral reconstruction procedure during RARP.Perioperative data of these patients were collected retrospectively, including operation time, anastomosis timeintraoperative blood loss, duration of indwelling catheter, length of hospital stay, complications, postoperative pathology, and continence outcome at 1, 3, 6, 12 months after surgery. Results All cases were successfully performed without conversion to open or laparoscopic surgery. There were no major intraoperative or postoperative complications. Operative time and anastomosis time was (145.3±12.3)mins and (31.6±8.2)mins in reconstruction group comparing to (122.4±11.4)mins and (21.2±4.4) in control group (both P 0.05). Postoperative pathology confirmed 53 T2a-T2b diseases and 5 pT2c diseases in reconstruction group, in comparison with 46 T2a-T2b and 4 pT2c diseases in non-reconstruction group (P>0.05). There were 19 and 15 cases with a final Gleason score of 6, 30 and 27 cases with Gleason 7, 9 and 10 cases with Gleason 8, in reconstruction group and non-reconstruction group respectively(all P>0.05). There was no significant difference between the two groups regarding incidence of positive surgical margins (3 in reconstruction group and 2 in control group, P>0.05). The percentage of patients maintain continence in reconstruction group and non-reconstruction group: at 1 month [84.5%(49/58)and 70.0%(35/50)], at 3 months [89.7%(52/58)and 78.0%(39/50)], at 6 months [91.3%(53/58)and 86.0%(43/50)] and 1 year after surgery [100.0%(58/58)and 96.0%(48/50)]. Reconstruction group showed better continence outcome at 1 and 3 month (P 0.05). Conclusion Anatomic reconstruction of periurethral structure during RARP is safe and feasible with reduced duration of indwelling catheter and better continence outcome. Key words: Robotic assisted laparoscopic surgery; Radical prostatectomy; Incontinence; Enhanced recovery after surgery

A clinical study of lung function protection in patients with robot assisted laparoscopic radical prostatectomy

Objective To evaluate the effect of manipulative pulmonary protective strategy on the pulmonary function of the patients undergoing robotic assisted laparoscopic radical prostatectomy under multiple-mode monitoring. Methods One hundred and twenty patients who underwent robot-assisted laparoscopic radical prostatectomy were divided into 4 groups (30 cases in each group) according to ASA Ⅰ-Ⅲ. Multimodal monitoring + manual relaxation group (group Mm), multimodal monitoring group (group M), conventional anesthesia + manual relaxation group (group m) and conventional anesthesia group (group C). In group Mm and group M, propofol was infused to achieve the BIS value of 45-55, then we monitored the muscle relaxation to conduct closed-loop infusion of cisatracurium. We also monitored and managed liquid input by vigileo. Group M and group C maintained peak airway pressure (≤30 cmH2O) (1 cmH2O=0.098 kPa) and PETCO2 35-40 mmHg (1 mmHg=0.133 kPa). Group Mm and group m received manual lung recruitment maneuver one times every 30 min after establishment of pneumoperitoneum until the end of operation. Blood gas analysis was performed before anesthesia induction (T1), 15 min after intubation (T2), 10 min after pneumoperitoneum (T3), 30 min after pneumoperitoneum (T4), 60 min after Trendelenburg (T5), 10 min after pneumoperitoneum cessation (T6), 5 min after extubation (T7). Airway peak pressure (Ppeak) and airway plateau pressure (Pplat) were recorded. The value of dynamic lung compliance (Cdyn), spiro-index (RI), dying cavity rate (VD/VT), oxygenation index (PaO2/FiO2) and alveolar arterial PO2 difference (A-aDO2) were calculated at different time points. Results Ppeak of group Mm and group m were more stable than Ppeak of group M and group C at T3 and T4 (P<0.05). Pplat of group Mm and group m were more stable than Pplat of group M and group C at T3 and T5 (P<0.05). Oxygenation indexes of group Mm and group m were higher than indexes of group M and group C at T5-T7 (P<0.05). A-aDO2 and RI were lower than group M and group C at T4, T5, T7 (P<0.05). At T4-T6, Cdyn was higher than Cdyn in group M and group C (P<0.05). Conclusions Manipulative pulmonary protective ventilation can improve the pulmonary function in patients undergoing robotic assisted laparoscopic radical prostatectomy under multimode monitoring. Key words: Robot; Therapeutic laparoscopy; Protective lung ventilation; Multi-mode monitoring; Prostate cancer

Clinical characteristics and treatment strategies of prostate mucinous adenocarcinoma: the multi-center summary of 36 cases

Objective To review the clinical characteristics of prostate mucinous adenocarcinoma cases and update literatures , and recommend the corresponding clinical treatment strategy. Methods From October 2010 to March 2018, 36 cases of prostate mucinous adenocarcinoma were involved from 5 urinary centers in China, including 9 cases from Shanghai Changhai Hospital, 4 cases from Wuhan Tongji Hospital, 13 cases from Shanghai Renji Hospitals, 8 cases from the First Affiliated Hospital of Nanjing Medical University, and 2 cases from Sichuan West China Hospitals. The patients′ age were (66.8±7.2) years (53-83 years) and the median PSA was 22.89 ng / ml (2.67-1786 ng / ml). Prostate biopsy confirmed Gleason score 3+ 3 points in 6 cases, 3+ 4 points in 9 cases, 4+ 3 points in 5 cases, 8 points in 11 cases, and 9 to 10 points in 5 cases. According to D′Amico risk stratification, 2 patients were in the low-risk group, 9 in the intermediate-risk group, and 25 in the high-risk group. Eight cases underwent radical retroperitoneal prostatectomy, 13 cases underwent laparoscopic radical prostatectomy, and 12 cases underwent robotic laparoscopic radical prostatectomy. Twenty-three cases underwent pelvic lymphadenectomy, including 12 cases of bilateral obturator lymph node dissection, and 11 cases of bilateral obturator+ intraorbital+ para-vascular para-aortic lymphadenectomy. Results All 36 operations were completed successfully.Twenty-three cases underwent pelvic lymphadenectomy, including 12 of bilateral obturator lymph node dissection, and 11 of bilateral obturator, intraorbital, and para-aortic lymphadenectomy. Pathological examination showed 9 cases of prostate mucinous adenocarcinoma, 26 cases of mucinous adenocarcinoma with acinar adenocarcinoma, and 1 case of mucinous adenocarcinoma with neuroendocrine and immunohistochemical positive of MUC2(+ ). Among 33 cases undergoing radical surgery, the pathological stage of ≤T2b in 12 cases (36.3%), T2c in 7 cases (21.2%), T3a in 7 cases (21.2%), T3b in 6 cases (18.2%), and T4 in 1 case (3.0%). Four cases had positive pelvic lymph nodes and 9 cases had positive margin. The median follow-up period was 26 months (6-48 months). The biochemical recurrence occurred in 6 patients one year after surgery, including 3 cases in the intermediate-risk group and 3 cases in the high-risk group. Six cases with postoperative biochemical recurrence and 19 cases with PSA>0.2 ng/ml after radical or palliative resection underwent adjuvant androgen deprivation therapy(ADT), no postoperative adjuvant radiotherapy or chemotherapy was administered, and 4 cases progressed to castration-resistant prostate cancer. Four cases with CRPC were in the high-risk group and had underwent radical surgery, and the median period progressed to CRPC was 26 months(3-37months)with 2 cases of death. However, there was no significant difference in the rate of biochemical recurrence and the incidence of CRPC in the low-risk group, the intermediate-risk group and the high-risk group. In addition, 2 cases had metastases, with pelvic MRI presenting pelvic multiple nodular mass in one case which was consistent with recurrence and metastasis at the 5th month after radical surgery, and pathological examination presenting the mucinous adenocarcinoma being neurosecretory in another case and mestastasis being detected on glans at the 3rd months after radical surgery. The recovery rate of urinary continience at 6 and 12 months after radical surgery was 86.2%(31/36) and 89.7%(32/36) respectively. Conclusions Prostate mucinous adenocarcinoma is a variant of acinar adenocarcinoma. This study clarifies prostate mucinous adenocarcinoma of Chinese patients with high Gleason scores, advanced pathological stage, variant in prognosis, and prone to recurrence and metastasis. For treatment strategy, the low-risk and intermediate-risk mucinous adenocarcinoma is recommended undergoing radical surgery, and the prognosis maybe good. High-risk mucinous adenocarcinoma could treated with radical surgery or palliative surgery with adjuvant ADT, and most high-risk patients can benefite, with a small number of poor prognosis. Key words: Prostatic neoplasms; Mucinous adenocarcinoma; Biochemical recurrence; Castration-resistant

Improvement of continence with preservation of pelvic stabilized structure in patients undergoing robot-assisted laparoscopic radical prostatectomy

Objective To investigate the effect of pelvic floor stabilized structure preservation (PPSS) during robot-assisted laparoscopic radical prostatectomy (RARP) on postoperative continence recovery. Methods From October 2017 to April 2018, 86 patients with prostatic cancer who underwent traditional RARP and RARP plus PPSS were included. There were 31 patients in non-PPSS group and 55 patients in PPSS group. In non-PPSS group, patients age was (68.48±7.79) years old, BMI was (24.79±3.05) kg/m2, median prostate volume was 63.54 (53.00-99.36)cm3, clinic T-stage T1-T2, T3, T4 accounted for 49.39%, 22.58%, 6.45% and ISUP grade 1, 2, 3, 4, 5 accounted for 22.58%, 22.81%, 12.90%, 12.90%, 19.35% respectively. In PPSS group, patients age was (69.53±6.81) years old, BMI was (23.95±3.03) kg/m2, median prostate volume was 73.39 (54.88-94.23)cm3, clinic T-stage T1-T2, T3, T4 accounted for 72.73%, 7.27%, 3.64% and ISUP grade 1, 2, 3, 4, 5 accounted for 21.82%, 18.18%, 23.64%, 18.18%, 10.91% respectively. The preoperative PSA, BMI, clinical T-stage, ISUP grade, and postoperative hospital days had no significant differences(P>0.05) between the two groups.Both groups were operated via transperitoneal approach. In the non PPSS group, endo-pelvic fascia and pubic prostate ligament was cut, and dorsal vessel complex was ligated. In PPSS group, the partial endo-pelvic fascia was bluntly pushed to the pelvic wall to preserve tendon arch, and pubic prostate ligament also was preserved without suturing and ligating dorsal vascular complex. The catheter was removed 7 d after RARP. The continence recovery were compared between the two groups, including pad number on the day of 1, 7, 14, 30, 90 and ICI-Q-SF scores on the day of 30 and 90 after catheter removal. Results There was no significant difference in pad numbers used between the two groups on the day of 1, 7, 14, 30 after catheter removal. On the 90th day, the proportions of using pad ≥4 in PPSS group were significantly lower than those in non-PPSS group (1.89% vs. 20.69%, P=0.004). No significant difference was found in ICI-Q-SF scores on the 30th and 90th day between the two groups. Univariate analysis showed that PPSS group used less pads than non-PPSS group on the 90th day [OR=0.07(95%CI 0.01-0.65), P=0.019]; T3 patients used more pads than T1-T2 patients [OR=9.19(95%CI 1.32-63.87), P=0.025]. After adjusting for age, ISUP grading, T staging, and PSA, multivariate regression analysis showed that the risk of using pad ≥4 in PPSS group compared with non-PPSS group was 0.46, 0.34, 0.27, 0.25, and 0.03 on the day of 1 , 7, 14 , 30 and 90 after catheter removal, respectively. The PPSS approach didn′t increase the risk of positive surgical margin. Conclusions Preservation of pelvic stabilized structure in RARP is very efficient in term of continence rate after RARP, and it does not increase the risk of positive surgical margin. Key words: Prostatic neoplasms; Robotic assisted laparoscopic radical prostatectomy; Pelvic stabilized structure; Continence

The posterior approach of robot-assisted laparoscopic radical prostatectomy

Objective To explore the feasibility and safety of the posterior approach of robot-assisted laparoscopic radical prostatectomy and to the approach. Methods From November 2001 to April 2017, 32 patients underwent posterior approach of robot-assisted laparoscopic radical prostatectomy. Patients aged 53 to 81 years, with mean of 66.9 years old. Their prostate volumes were 12.0-73.7 ml with an average of 32.9 ml. All patients were diagnosed by prostate biopsy before surgery. The operation time, blood loss and length of hospital stay were recorded. Results All the operations were completed by robotic assisted laparoscopy with no transition to open surgery. The surgery time was 129-210 minutes with an average of 163.6 minutes. The estimated blood loss was 20-200 ml with an average of 59.3 ml. The hospital stay was 8-21 days with an average of 12.8 days. The postoperative hospital stay was 3-13 days with an average of 6.9 days. The time of postoperative catheter removal was 4-14 days with an average of 7.5 days. Postoperative follow-up was 1-6 months. Twenty-four (75%) patients had early recovery of continence, and all (100%) patients regained continence 3-month postoperatively. Conclusion The posterior approach of robotic assisted laparoscopic radical prostatectomy was a safe and effective surgical technique, which was beneficial in early continence recovery. Key words: Prostatic neoplasms; Robotic surgery; Radical prostatectomy; Posterior approach

POD-1.01: Trifecta Outcomes in Preoperatively Potent Men After Nerve Sparing Robotic Laparoscopic Radical Prostatectomy

We evaluated trifecta outcomes (continence, potency and undetectable PSA) for preoperatively continent and potent men following robotic laparoscopic radical prostatectomy (RLRP) with bilateral nerve sparing technique.

Robotic Radical Prostatectomy in Overweight and Obese Patients: Oncological and Validated-Functional Outcomes

To determine the impact of body mass index (BMI) on perioperative functional and oncological outcomes in patients undergoing robotic laparoscopic radical prostatectomy (RLRP) when stratified by BMI. Data were collected prospectively for 945 consecutive patients undergoing RLRP. Patients were evaluated with the UCLA-PCI-SF36v2 validated-quality-of-life questionnaire preoperatively and postoperatively to 24 months. Patients were stratified by BMI as normal weight (BMI < 25 kg/m(2)), overweight (BMI = 25 to < 30 kg/m(2)) and obese (BMI > or = 30 kg/m(2)) for outcomes analysis. Preoperatively, obese men had a significantly greater percentage of medical comorbidities (P < .01) as well as a baseline erectile dysfunction (lower mean baseline Sexual Health Inventory for Men score [P = .01] and UCLA-PCI-SF36v2 sexual function domain scores [P = .01]). Mean operative time was significantly longer in obese patients when compared with normal and overweight men (234 minutes vs 217 minutes vs 214 minutes; P = .0003). Although overall complication rates were comparable between groups, a greater incidence of case abortion caused by pneumoperitoneal pressure with excessive airway pressures was noted in obese men. Urinary continence and potency outcomes were significantly lower for obese men at both 12 and 24 months (all P < .05). In this series, obese men experienced a longer operative time, particularly during the initial robotic experience. As such, surgeons early in their RLRP learning curve should proceed cautiously with surgery in these technically more difficult patients or reserve such cases until the learning curve has been surmounted. These details, including inferior urinary and sexual outcomes, should be discussed with obese patients during preoperative counseling.

Robotic Laparoscopic Radical Prostatectomy for Biopsy Gleason 8 to 10: Prediction of Favorable Pathologic Outcome with Preoperative Parameters

We sought to evaluate the pathologic results and postoperative outcomes for men undergoing robot-assisted laparoscopic radical prostatectomy (RLRP) for biopsy Gleason score (GS) 8 to 10 disease. Stratification of these patients according to preoperative variables was also performed in an attempt to predict organ-confined cancer. A prospective RLRP database identified all patients with preoperative biopsy GS 8 to 10. Variables, including prostate-specific antigen (PSA), percent positive biopsy cores (%PBC), maximal percentage of cancer in biopsy core (%MCB), clinical stage, pathologic stage, pathologic GS, surgical margins status, lymph node status, time to biochemical recurrence, and recurrence rate, were evaluated. Preoperative variables were treated as continuous and categorical using PSA, %PBC and %MCB cutoffs of 10 ng/mL, 50%, and 30%, respectively. Between February 2003 and September 2007, a total of 1225 RLRPs were performed at the University of Chicago Medical Center. Seventy-two (5.9%) patients had preoperative biopsy GS 8 to 10. Two patients received neoadjuvant hormonal therapy and were excluded. Among 70 patients evaluated, 33 (47%) had organconfined (pT(2)N0) disease. Forty (60.6%) patients had pathologic downgrading to GS <or=7. Overall positive surgical margin (PSM) rate was found to be 24.2%. pT(2)- and pT(3)-PSM rate was 6% and 42.3%, respectively. In multivariate logistic regression analysis, PSA <or=10 ng/mL (P = 0.04) and %MCB <or=30% (P = 0.001) were found to be statistically significant predictors of pT(2)N0 disease. Preoperative biopsy GS 8 to 10 predicts a significant likelihood of finding non-organ-confined prostate cancer on the final pathology report. Preoperative PSA <or=10 ng/mL and %MCB <or=30% may be used to predict favorable pathologic outcome for these patients during surgical counseling.

Urinary and Sexual Quality of Life 1 Year Following Robotic Assisted Laparoscopic Radical Prostatectomy

We evaluated urinary and sexual quality of life 1 year following robotic laparoscopic radical prostatectomy and identified preoperative variables predictive of a severe decrease from baseline. Using a prospective robotic laparoscopic radical prostatectomy database we identified patients with greater than 1 year of postoperative followup. The UCLA-PCI SF-36v2 questionnaire was used to evaluate urinary and sexual quality of life before and 1 year after surgery. Severe worsening of the postoperative score was defined as a greater than 1 SD decrease. Demographic and preoperative clinical variables were evaluated along with baseline scores on univariate and multivariate analysis. Between February 2003 and September 2007 a total of 1,225 robotic laparoscopic radical prostatectomies were performed at our center and 361 patients (52%) met inclusion criteria. On multivariate analysis baseline urinary function was the only predictor of significant worsening of urinary function (OR 1.04, p = 0.003). Baseline urinary bother was the only predictor of significant worsening of urinary bother (OR 1.05, p <0.0001). A significant decrease in sexual function was predicted by baseline sexual function (OR 1.03, p = 0.0001), baseline sexual bother (OR 1.03, p = 0.005) and nerve sparing technique (OR 0.31, p = 0.05). Predictors of a significant decrease in sexual bother were also baseline sexual function (OR 1.02, p = 0.0001), baseline sexual bother (OR 1.04, p = 0.0007) and nerve sparing technique (OR 0.38, p = 0.02). ORs indicated that higher baseline scores corresponded to a higher risk of postoperative score worsening. We found that overall better baseline sexual and urinary scores are associated with better postoperative outcomes. However, the risk of a significant decrease in urinary function, urinary bother, sexual function and sexual bother is higher in patients with better baseline scores. Nerve sparing positively affects sexual function and sexual bother.

Robotic versus Standard Laparoscopic Partial/Wedge Nephrectomy: A Comparison of Intraoperative and Perioperative Results from a Single Institution

Laparoscopic partial/wedge nephrectomy, similar to laparoscopic radical prostatectomy, is a technically challenging procedure that is performed by a limited number of expert laparoscopic surgeons. The incorporation of a robotic surgical interface has dramatically increased the use of minimally invasive pelvic surgery such that robotic laparoscopic radical prostatectomy is commonly performed even by laparoscopically naïve surgeons. This analysis compares the outcomes of our initial experience with robot-assisted laparoscopic partial nephrectomy (RLPN) performed by an experienced open surgeon to that of standard laparoscopic partial nephrectomy (LPN) performed by two experienced laparoscopic surgeons. We reviewed the medical records of 11 consecutive patients who underwent 12 standard LPNs (EMM, RVC) (one patient had two unilateral tumors) and 10 consecutive patients (representing the first 11 of such robotic procedures performed at our institution) who underwent 11 RLPNs (one patient had bilateral tumors managed in an asynchronous manner) (DKO). The mean tumor size was 2.3 cm (range 1.7-6.2 cm) for LPN and 3.1 cm (range 2.5-4 cm) for RLPN. The mean total procedure time was 289.5 minutes (range 145-369 min) for LPN and 228.7 minutes (range 98-375 min) for RLPN (P=0.102). The mean estimated blood loss was 198 mL (range 75-500 mL) for LPN v 115 mL (25-300 mL) for RLPN (P=0.169). The mean warm ischemia time was 35.3 minutes (range 15-49 min) in the LPN group and 32.1 minutes (range 30-45 minutes) in the RLPN group (P=0.501). Introducing a robotic interface for laparoscopic partial/wedge resection allowed a fellowship-trained urologic oncologist with limited reconstructive laparoscopic experience to achieve results comparable to those for laparoscopic partial/wedge resection performed by experienced laparoscopic surgeons. In this regard, the learning curve appears truncated, similar to that with robot-assisted laparoscopic prostatectomy.

Effect of Prostate Weight on Operative and Postoperative Outcomes of Robotic-Assisted Laparoscopic Prostatectomy

To determine the effect of prostate weight (PW) on robotic laparoscopic radical prostatectomy (RLRP) outcomes. The effect of PW on surgical and pathologic outcomes has been reviewed in open and laparoscopic prostatectomy series. Little is known about its effects during RLRP. From February 2003 to November 2005, 375 men underwent RLRP. Patients were divided into four groups on the basis of the pathologic PW: group 1, less than 30 g; group 2, 30 g or more to less than 50 g; group 3, 50 g or more to less than 80 g; and group 4, 80 g or larger. The groups were compared prospectively. Continence and sexual function were assessed using validated questionnaires. Of the 375 patients, 20, 201, 123, and 31 had a PW of less than 30 g, 30 g or more to less than 50 g, 50 g or more to less than 80 g, and 80 g or larger, respectively. A significant difference was found in age and prostate-specific antigen values among the four groups (P <0.001). No significant differences in operative time, estimated blood loss, transfusion rate, hospital stay, length of catheterization, and complication incidence were observed among the four groups. The overall rate of positive surgical margins was significantly different among the groups (P = 0.002), demonstrating a trend of increasing positive surgical margins with a lower PW. Within the patients with Stage pT2, a significant increase in positive surgical margins was found with lower PWs (P = 0.026). The objective return of baseline and subjective sexual and urinary function, as determined by questionnaire scores, was not affected by the PW. RLRP can be performed safely and with similar perioperative outcomes in men, regardless of the PW. We found a significant inverse relationship between surgical margin status and PW, specifically in those with Stage pT2 disease.

Minimizing knot tying during reconstructive laparoscopic urology

Objectives Intracorporeal knot tying during urologic reconstructive surgery is one of the most technically challenging skills of laparoscopic surgery. We describe our experience using the Lapra-Ty clip to substitute for knot tying. Methods Our technique for minimizing knot tying entails the use of the Lapra-Ty clip during closure of the collecting system and renal parenchyma for laparoscopic partial nephrectomy, the vesicourethral anastomosis during robotic laparoscopic radical prostatectomy, and the collecting system during laparoscopic pyeloplasty. From October 2002 to July 2005 at our institution, 75 patients underwent laparoscopic partial nephrectomy, 300 underwent robotic laparoscopic radical prostatectomy, and 14 underwent laparoscopic pyeloplasty. We reviewed the charts retrospectively for intraoperative and postoperative parameters related to the use of these clips. Results In the laparoscopic partial nephrectomy group, the mean tumor size, warm ischemia time, and estimated blood loss was 2.53 cm, 30.1 minutes, and 189 mL, respectively. Two postoperative urine leaks (2.7%) developed, and 3 patients experienced postoperative bleeding (4%). In the robotic laparoscopic radical prostatectomy group, the mean operative time was 295 minutes and the mean estimated blood loss was 303.6 mL. Only 3 patients had a urine leak (1%), and 4 patients had bladder neck contracture (1.3%). With regard to the laparoscopic pyeloplasty group, the mean operative time and estimated blood loss was 224 minutes and 36 mL, respectively. No intraoperative complications or urinary leaks occurred. Conclusions Using the Lapra-Ty clip, we have safely and efficiently supplemented knot tying in patients undergoing reconstructive laparoscopic surgery.

Impact of Cautery versus Cautery-Free Preservation of Neurovascular Bundles on Early Return of Potency

To update our short-term potency outcomes from a cautery-free (CFT) versus bipolar cautery technique to preserve the neurovascular bundles (NVB) during robotic laparoscopic radical prostatectomy (RLP). Previously, we reported on 3-month potency outcomes in 23 men, which we now extend to 51 men. All men met three criteria: age <66 years, Sexual Health Inventory in Men (SHIM-5) score of 22 to 25, and either unilateral or bilateral NVB preservation at LRP. Group 1 (N = 51), the study group, had preservation of the NVB with CFT. Group 2 (N = 36) had traditional dissection using bipolar cautery. The average age and preoperative SHIM scores were similar for the two groups. Data were collected prospectively via validated questionnaires. Potency was defined as an erection adequate for vaginal penetration. All men were asked to estimate the fullness of erections compared with baseline (preoperative). The average age and preoperative SHIM scores were similar for both groups. The rate of potency at 3 months was 47% (24/51) in group 1 versus just 8.3% (3/36) in group 2 (P < 0.001). Additionally, only 9 of 25 CFT patients (36%) reported zero fullness compared with 15 of 22 patients (68%) in the bipolar cauterytreated group (P = 0.03). With expanded experience, there was no change in 3-month return of sexual function (47%) compared with our initial publication. This result further supports the importance of avoiding cautery when controlling the vascular pedicle and dissecting the NVB.

Robotic-assisted laparoscopic prostatectomy in overweight and obese patients

Objectives To assess outcomes of robotic laparoscopic radical prostatectomy (RLRP) in overweight and obese patients, defined as those with a body mass index (BMI) of 25 to 30 kg/m 2 and greater than 30 kg/m 2, respectively. Methods This was a nonrandomized study evaluating all of our RLRP patients. Patients were divided into three groups: BMI of 25 kg/m 2 or less (group 1), BMI greater than 25 kg/m 2 and less than 30 kg/m 2 (group 2), and BMI of 30 kg/m 2 or more (group 3). Patients were evaluated prospectively with the validated Rand 36-Item Health Survey (version 2) and with the University of California, Los Angeles Prostate Cancer Index questionnaire. Results Between February 2003 and November 2004, 150 RLRPs were performed at our center. Average follow-up was 8 months. Groups 1, 2, and 3 had 39, 65, and 46 patients, respectively. Average BMIs for all three groups were statistically different ( P <0.01). When compared with group 1, open conversion rates, hospital stay, positive margin, and complication rates were not statistically different for groups 2 or 3. Operative time ( P <0.004) and estimated blood loss ( P <0.03), however, were statistically greater for group 3 compared with group 1. Transfusion rate was highest in group 2 ( P = 0.04 compared with group 1). Prostate weights were also statistically greater in groups 2 ( P = 0.003) and 3 ( P = 0.02) compared with group 1. Overall, BMI did not increase perioperative and postoperative morbidity. Conclusions Robotic laparoscopic radical prostatectomy is safe in overweight and obese patients and might be the surgical management of choice in this subset of patients. Further long-term follow-up with more patients is required to verify this initial observation.

58 Robotic laparoscopic radical prostatectomy for non‐laparoscopic surgeons ‐ what is the learning curve?

Introduction: Laparoscopic radical prostatectomy (LRP) has been shown to have many advantages over open surgery, but has proven difficult for many to become adept at. The use of the Da Vinci® robotic system greatly facilitates the performance of LRP. We set out to analyse how many cases it takes to become proficient at Robotic Assisted Laparoscopic radical Prostatectomy (RALRP).Methods and Methods: Two experienced open surgeons began performing RALRP using the Da Vinci® robotic system in December 2003. Duration of various steps were measured prospectively. Results were grouped sequentially in groups of 10 patients and analysed statistically to determine at what point these results reflected increased operative proficiency. Surgeons results were analysed separately to provide internal validation.Results: One hundred and ten consecutive patients were evaluated. Overall operative times for both surgeons decreased significantly (P &lt; 0.05) over the first 30 cases after which they plateaued at an average of 191 min (36.3% reduction). Actual operative time also decreased significantly (P &lt; 0.01) at or before the 30th case until plateauing at 146 min (39% reduction).Conclusion: RALRP is a procedure that can be mastered much more quickly than standard LRP by experienced open surgeons inexperienced in laparoscopic surgery, with surgical proficiency being attained at/before the 30th case.

Robotic laparoscopic radical prostatectomy: Setup and procedural techniques after 150 cases

Objectives To report our current methods of patient positioning, establishing the pneumoperitoneum, port placement, and helpful maneuvers during the procedure that have been refined over the course of our initial experience with robotic laparoscopic radical prostatectomy (RLRP). RLRP is gaining popularity as a minimally invasive technique for treating patients with organ-confined prostate cancer. Because this is a new procedure, strategies to optimize the surgical technique are constantly evolving. Methods Two genitourinary surgeons experienced in open surgery with no laparoscopic experience began performing RLRP in December 2003 after appropriate training and mentoring. During the course of the ensuing 150 cases, new techniques were developed in an attempt to simplify the operation and improve its outcome. Results We documented and illustrated techniques for patient positioning, safe and rapid placement of the initial camera trocar, use of the third working arm of the da Vinci Surgical System, trocar positioning, and prostatic retraction to assist with posterior dissection. Conclusions We have described setup techniques and principles we developed during our experience with the da Vinci robotic system. These points of technique may be helpful for simplifying a procedure that is still in evolution.