Robotic Prostatectomy Program Research Articles

Adding a newly trained surgeon into a high-volume robotic prostatectomy group: are outcomes compromised?

This study evaluates whether a new staff surgeon early in the learning curve can be integrated into a high-volume robotic practice with an established robotic team and mentorship without compromising robot-assisted radical prostatectomy (RARP) outcomes of the practice. We analyzed outcomes of 3064 patients who underwent RARP from 2007 to 2012 at a high-volume tertiary center by a robotic practice comprising three experienced robotic surgeons (2846 patients) and a newly hired surgeon (218 patients) immediately out of training (residency and oncology fellowship with 2years of RARP exposure). The new surgeon performed RARP with intraoperative mentorship by the senior surgeons during the first year. Complications, biochemical recurrence (BCR), positive surgical margins rate (PSM), operating time (OR time), estimated blood loss (EBL) for the new and senior surgeons were compared. Multivariable linear, logistic and exact logistic regression adjusting for disease and patient characteristics were performed. On regression analyses, case number was the most significant predictor of decrease in probability of major complications (p=0.025) and BCR (p=0.004) for the new surgeon. Increasing case number was not associated with decrease in minor complications, PSM, OR time, or EBL (p>0.05). Inclusion of the new surgeon's outcomes did not adversely impact outcomes of the practice. In conclusion, a new surgeon joining a high-volume robotic prostatectomy program with an established robotic team and mentorship can progress through the learning curve without compromising overall outcomes of the practice. Our results may be relevant for programs hiring newly trained staff to join an established robotic practice.

Perioperative, oncological, and functional outcomes of the first robotic prostatectomy program in Quebec: Single fellowship-trained surgeon's experience of 250 cases

Robotic-assisted radical prostatectomy (RARP) is being increasingly done in Canada. Despite this, the Canadian literature lacks publications on the oncologic and functional outcomes of RARP. The objective of this study is to report the longest single surgeon experience in the province of Quebec. We collected prospective data from 250 consecutive patients who underwent RARP by a single fellowship trained surgeon (AEH) from October 2006 to October 2012. Mean follow-up was 28 months (range: 1-72). The D'Amico risk stratification distribution was 34% in low-risk, 48% in intermediate-risk and 18% in high-risk groups. The mean operation time (±SD) was 194 ± 60.6 minutes, and estimated blood loss 318 ± 179 mL. The transfusion rate was only 0.4%. All procedures were completed robotically. The mean hospital stay was 1.2 days, and 88% of patients were discharged on postoperative day 1. The mean catheterization time was 7 days (range: 6-13). There were 2% major (Clavien III-IV) and 7.2% minor (Clavien I-II) postoperative complications, and no mortalities. On final pathology, 76% of patients were organ-confined and 70% specimen-confined. Pathological Gleason sum ≥7 accounted for 86%. Return of urinary continence (0-pads) at 3, 6, 12, and 24 months was 73.3%, 83.5%, 92.3%, 96.5%, respectively. Potency rate (successful penetration with or without medication) at 6, 12, and 24 months was 49.3%, 85%, and 95.3%, respectively. Operative time and positive surgical margin (PSM) in organ-con-fined disease (pT2) decreased significantly after 50 cases. Seventeen patients (6.8%) had no undetectable prostate-specific antigen (PSA) at first visit (PSA <0.1 ng/mL). Of remaining 233 patients, biochemical recurrence (PSA >0.2 ng/mL) was 4.7% (11 patients), and another 3.4% (8 patients) received early salvage radiotherapy (rising PSA, but <0.2 ng/mL). No patients with undetectable PSA required salvage treatments within 6 months postoperatively. Our results compare favourably with high-volume RARP programs, despite mainly intermediate- to high-risk disease. Initial learning curve was estimated to be 50 cases. Fellowship training was instrumental in achieving adequate functional and oncological outcomes, while maintaining low complications rate.

Does hospital setting post robotic fellowship training affect outcomes? A multi-institutional comparison of initial outcomes between academic and community settings.

The effect of practice setting on skill development post robotic fellowship training is currently unknown. We sought to compare learning curves between a high-volume academic center and a similar volume community hospital, in the setting of building a new robotic prostatectomy program. In addition, we sought to characterize benchmarks for learning curve development for post-fellowship training in robotic surgery. At two institutions, one academic (AC) and the other in the community (CO), the first 150 patients who underwent robotic laparoscopic prostatectomy over a period of 1year were evaluated. We compared the following outcomes, operative time (OT), estimated blood loss (EBL), and positive surgical margin (PSM) rates, by two surgeons. Both surgeons completed the same surgical robotic fellowship in the same year. Cases were divided by tertile and primary outcomes measures were compared. Demographic data were similar between the two groups. Statistical differences were seen in age, preoperative Sexual Health Inventory for Men score, clinical and pathologic stage, and bladder neck reconstruction rate (p<0.05). Overall, there was no significant difference in OT between AC (174min) and CO (181min) (p=0.1099). Both EBL and PSM were lower in the AC (155 vs. 197ml, p<0.001 and 10 vs. 26%, p<0.05). The difference in OT was significant only in the first tertile of cases (AC 168min vs. CO 193min, p=0.002). However, OT increased by 13min in AC and decreased by 22min in CO, when comparing the first and last tertile. EBL was different between AC (161ml) and CO (212 ml) only in the first tertile of cases (p=0.002). Both AC and CO had increased EBL over the last tertile of cases (16.2 vs. 26.5ml, respectively). These results demonstrate minor differences in outcomes between the two practice settings. Fellowship training in robotic surgery demonstrates a shorter learning curve towards achieving proficiency. Larger and longer term series will be required to assess functional outcomes and time to proficiency.

Establishment of a new robotic prostatectomy program at a tertiary Veteran's Affairs medical center.

The objective of this study is to report the initial results of a newly established robotic prostatectomy (DVP) program at a Veteran's Affairs (VA) medical center. All patients who underwent a radical prostatectomy during the first 18months of our robotic surgical program were included in this study. These patients were compared to a control group that included all patients who underwent an open prostatectomy 18months prior to starting our robotic program. Preoperative, intraoperative and postoperative data was compared between open and robotic prostatectomies. 38 men underwent radical retropubic prostatectomy (RRP) between September 2007 and February 2009. With the introduction of robotic prostatectomy, the total number of prostatectomies increased by 84% to 70 (9 RRP, 61 DVP). Prostate-specific antigen (PSA), Gleason score and clinical stage were similar for both groups. Average estimated blood loss (EBL) was 1205mL for RRP and 126mL for DVP. Mean operative times in minutes were 259 and 254 for RRP and DVP, respectively. Complications included two rectal perforations, a cerebrovascular accident, one death after RRP and one open conversion for failure to progress. Average length of stay was 5.1 for RRP and 1.8days for DVP. Total positive margins were 24% for RRP and 15% for DVP. For T2-specific disease, 16.7% had positive margins after RRP compared to 4.3% after DVP. The establishment of a robotic prostatectomy program at a tertiary VA medical center was achieved in a safe and efficient manner with improvement in EBL and length of stay when compared to our open prostatectomies. Oncologic outcomes were equivalent when compared to other initial DVP programs.

Building a robotic prostatectomy program

Building a robotic prostatectomy program

Residency Training Program Paradigms for Teaching Robotic Surgical Skills to Urology Residents

The advent of laparoscopic and robotic techniques for management of urologic malignancies marked the beginning of an ever-expanding array of minimally invasive options available to cancer patients. With the popularity of these treatment modalities, there is a growing need for trained surgical oncologists who not only have a deep understanding of the disease process and adept surgical skills, but also show technical mastery in operating the equipment used to perform these techniques. Establishing a robotic prostatectomy program is a tremendous undertaking for any institution, as it involves a huge cost, especially in the purchasing and maintenance of the robot. Residency programs often face many challenges when trying to establish a balance between costs associated with robotic surgery and training of the urology residents, while maintaining an acceptable operative time. Herein we describe residency training program paradigms for teaching robotic surgical skills to urology residents. Our proposed paradigm outlines the approach to compensate for the cost involved in robotic training establishment without compromising the quality of education provided. With the potential advantages for both patients and surgeons, we contemplate that robotic-assisted surgery may become an integral component of residency training programs in the future.

Robotic radical prostatectomy in east Asia: development, surgical results and challenges

The shift toward robot-assisted laparoscopic radical prostatectomy has reshaped the surgical approach for localized prostate cancer in America and many parts of Europe. Its impact on Asia, however, has been somewhat delayed and less widespread compared with western countries. We reviewed and surveyed the evolving trends in robotic prostatectomy in east Asia and describe how the influence of cancer demography, financial reimbursement models, refinements in robotic technology and robotic surgical training will alter the future direction of the procedure in this region. There are about 50 systems installed in east Asia. Numerous centers have reported successful implementation of robotic prostatectomy program, with transfusion rate of 7-26.4%. Margin positivity for T2 disease ranges from 9.8 to 24%, whereas continence rates range from 75 to 94% over 3-6 months. Significant increase in number of prostatectomy has been observed in some centers. The outlook for robotic prostatectomy in east Asia remains rosy despite the obstacles in financial reimbursement, patient volume and surgical skill development. Future robotic systems with smaller footprint, leaner instrument arms and lower costs will help to accelerate its integration into more Asian hospitals.

Pathologic analysis of capsular and incisional denudation and positive margin status in the development of a robot-assisted laparoscopic prostatectomy program.

The aim of this study is to explore the use of pathologically confirmed capsular incision and denudation as a measure of adequacy of extirpation following robot-assisted laparoscopic prostatectomy (RALP). All patients who underwent RALP at the George Washington University Medical Center during the first 2years of inception of the robotic prostatectomy program were included. All pathologic specimens were reviewed by a single pathologist. One hundred twenty-eight men who underwent RALP during the first 2years were identified. Sixty-four patients underwent RALP during the first year (group1) and all pathologic specimens were reviewed retrospectively. Sixty-four patients underwent RALP during the second year (group2) after revision of our operative technique and all pathologic specimens were reviewed prospectively. Of patients in group1, 18 (28%) had a positive surgical margin (PSM), and 18 (28%) with negative surgical margins were found to have capsular incision or denudation. In group1, 32 (50%) patients had evidence of iatrogenic capsular violation. Group2 consisted of 13 (20%) patients with a PSM and 9 (14%) margin-negative patients with capsular incision or denudation. Group2 had a total of 22 (34%) patients with evidence of iatrogenic capsular violation. Overall reduction in positive margins was not statistically significant between the groups. Improvement in capsular incision/denudation rate and overall capsular violation between the two groups was statistically significant (P<0.03 and <0.0055). Surgical margin status alone underestimates the overall quality of surgical resection after RALP because not all capsular violations result in a PSM. Surgeon-guided pathologic review in addition to intraoperative experience may improve oncologic success during the RALP learning curve.

Predictive Correlation Between the International Index of Erectile Function (IIEF) and Sexual Health Inventory for Men (SHIM): Implications for Calculating a Derived SHIM for Clinical Use

Validated questionnaires are used to assess postoperative continence, sexual function, and other quality-of-life issues after radical prostatectomy. The International Index of Erectile Function (IIEF) is one such well-tested inventory that is routinely used. However, some centers use the Sexual Health Inventory for Men (SHIM) or the IIEF-6 to record erectile function, and comparison between the three can be difficult. To define if there was a predictive correlation between IIEF (or IIEF-6) and SHIM, and to explore a strategy for the use of an abbreviated and rapid functional assessment of erectile function in patients. Preoperative and postoperative IIEF questionnaires from the robotic prostatectomy program at our institution were included in the study. The total IIEF, IIEF-6, and SHIM scores were calculated and correlations between the three were sought. We also looked at the feasibility of using only two questions from the IIEF with an aim of calculating both the SHIM and IIEF scores. The power to differentiate between patients with SHIM >or=22 from those with SHIM <or=21 for (i) the ratio allowing direct conversion of IIEF (or IIEF-6) to SHIM; and (ii) a two-question-based recalculation of SHIM. Two hundred seventy-five questionnaires were available for review. If the total IIEF score is known, the IIEF-derived SHIM score can be calculated by dividing the total IIEF score by a factor of 2.8 and then rounding off to a whole number. Furthermore, we have shown that an abbreviated questionnaire using Q5 and Q15 of the IIEF can be used to calculate the SHIM scores (two-question-SHIM). We described an easy way to calculate the SHIM score when the IIEF (or IIEF-6) score alone is known. The two-question model can be used for a rapid assessment of the patients' sexual function.

Robotic radical prostatectomy: the Vattikuti Urology Institute training experience

Robotic radical prostatectomy is increasingly becoming a popular surgical treatment modality for men with clinically localized prostate cancer. Establishing a robotic prostatectomy program is a tremendous undertaking for any institution requiring both financial support and a dedicated operating room team. A structured approach to learning robotics is paramount in order to successfully start a program while optimizing the learning curve to master the technique and minimize peri-operative complications. We describe our own experience in establishing a robotics program to accomplish a safe and effective operation. In addition, we describe the steps utilized in order to teach our structured approach to other practitioners and institutions around the world. Robotic surgery can be taught to experienced open, as well as, laparoscopic surgeons, and incorporated into residency and fellowship training using this structured approach to learning.