Robotic Radical Prostatectomy Research Articles

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.

Phase I Trial of Stereotactic Radiotherapy Prior to Robotic Prostatectomy in High Risk Prostate Cancer

Standard therapies for patients with high risk prostate cancer (HR-CaP) include radiotherapy (RT) with hormonal therapy and radical prostatectomy (RP), usually followed by 6-7 weeks of local RT. Given recent data in the breast and pancreas cancer literature about the feasibility of preoperative stereotactic body RT (SBRT), we developed a prospective phase I trial investigating pre-operative SBRT dose escalation in patients with HR-CaP. Patients were eligible if they had HR-CaP, defined as a Gleason Score (GS) 8-10 on biopsy specimen. Patients received a total of 25 Gy or 30 Gy in 5 daily fractions of SBRT to the prostate and proximal seminal vesicles. Patients underwent robotic RP with pelvic lymph node dissection approximately 5 weeks after completion of RT. Primary outcomes were physician-reported genitourinary (GU) and gastrointestinal (GI) toxicities (CTCAE v4). Secondary outcomes were patient-reported quality of life (QoL) on AUA and EPIC questionnaires and biochemical recurrence (BcR), defined as PSA ≥0.2ng/mL. PSA was monitored every 3-6 months. Three patients received SBRT to 25 Gy in 5 fractions and four patients received 30 Gy in 5 fractions. Median time to RP after SBRT was 35 days (range 31-45). Median follow-up was 18 months. Patient characteristics are summarized in the accompanying table. Each patient experienced at least one Grade 2 GU event; most commonly erectile dysfunction (100%) and urinary incontinence (57%). One patient experienced Grade 3 urinary incontinence, but there were no Grade ≥4 GU toxicities. Two patients experienced GI toxicity which were one Grade 1 and one Grade 2 hemorrhoidal hemorrhage. On QoL surveys, acute GU complaints were common and peaked at 3 months (mean AUA total score 14.2, mean EPIC overall urinary function score 3). Acute bowel complaints were mild and uncommon, with only one patient reporting a score of ≥3 on EPIC overall bowel function score. Two patients experienced BcR; both had GS 4 + 5 with ypN1 disease at the time of RP, while one of the two was ypT3b and the other was ypT3a. Neither had evidence of distant metastasis on CT or bone scans. Both BcR were salvaged with leuprolide and bicalutamide with subsequent decrease in PSA. Pre-operative SBRT followed by RP in HR-CaP is feasible and safe. It is associated with moderate GU toxicity and rare GI toxicity. Phase II trials evaluating this treatment paradigm should exclude patients with GS 5, and those with clinically or radiographically T3b or node positive disease. A prospective trial is ongoing to determine the efficacy of pre-operative SBRT in selected patients with HR-CaP.Abstract 4112; TableCaseAge (y)SBRT Dose (Gy)GS (pre-op)PSA (pre-op)PSA (post-op)Stage (post-op)Surgical MarginsF/U (m)1**62254 + 525.330.59ypT3bN1+34254254 + 47.91<0.02ypT3aN0+26358254 + 48.40<0.02ypT2cN0-10464304 + 48.66<0.02ypT3aN0+24564304 + 45.93<0.02ypT2aN0-17658304 + 45.94<0.02ypT3aN0-187**66304 + 551.703.69ypT3aN1-12**Patient experienced biochemical recurrence Open table in a new tab

Hood Technique for Robotic Radical Prostatectomy—Preserving Periurethral Anatomical Structures in the Space of Retzius and Sparing the Pouch of Douglas, Enabling Early Return of Continence Without Compromising Surgical Margin Rates

BackgroundA common side effect following radical prostatectomy is urinary incontinence. Here, we describe a novel surgical technique to reduce postoperative urinary incontinence and facilitate early return of continence. ObjectiveTo describe the novel “hood technique” for robotic-assisted radical prostatectomy (RARP). Design, setting, and participantsThis is an institutional review board–approved prospective study of 300 patients (median age 64 yr) with localized prostate cancer treated with the RARP hood technique at a major urban hospital between April 2018 and March 2019. The exclusion criteria were as follows: patients with anterior tumor location based on biopsy or multiparametric magnetic resonance imaging. All but one patient participated in follow-up over 12 mo after the procedure. Surgical procedureThe RARP “hood technique” was performed to preserve the detrusor apron, puboprostatic ligament complex, arcus tendineus, endopelvic fascia, and pouch of Douglas. MeasurementsClinical data collected included pre- and intraoperative variables, and postoperative functional and oncological outcomes and complications. Descriptive statistical analysis was performed. Results and limitationsContinence rates at 1, 2, 4, 6 12, 24, and 48 wk after catheter removal were 21%, 36%, 83%, 88%, 91%, 94%, and 95%, respectively. Positive surgical margin rate was 6%. Thirty patients (9.7%) experienced complications after RARP: 17 (5.7%), 11 (3.6%), and one (0.4%) had Clavien-Dindo grade I, II, and III complications, respectively. This study was conducted within a single health system and may not be generalizable. The study lacked randomization and a comparative arm. ConclusionsResults indicate that the hood technique spares musculofascial structures anterior to the urethral sphincter complex with early return of continence after surgery, without compromising positive surgical margin rates. Exclusion of anterior tumor location contributed to a reduction in positive surgical margins. Patient summaryBy better preservation of anatomical structures around the urethra, we were able to achieve early return of urinary continence without a negative impact on complications and cancer outcomes.

Le rôle de l’IDE dans l’éducation thérapeutique avant opération et la mise en place d’un programme de prostatectomie totale robotique en ambulatoire

The purpose of this article is to explain the role of urology nurse in prehabilitation and same-day discharge programs for robotic radical prostatectomy. This article is based on the analysis of the literature and the experience of our center. In order to prepare patients for outpatient surgery, urology nurse plays a key role during prehabilitation journeys. Two weeks before the operation, the healthcare teams (nurses, anesthetists, physiotherapists, etc.) organize workshops to explain to patients the operation course and post-operative care in order to allay any anxieties. Individual and group interviews, in specific workshops (compression stockings, urinary catheter, sexology) are organized in particular with urology nurse to answer all patients' questions. In association with enhanced recovery after surgery pathway, these programs improve the patient experience and satisfaction as well as peri-operative outcomes, and allows the development of an outpatient surgery program which currently represents approximately one third of surgeries. The implementation of perioperative protocols including prehabilitation improves the early results of robotic total prostatectomy, but also the patient experience. The urology nurse has a key role to play during these patient education days and in the preparation, information, support and follow-up of the patient, since the prehabilitation journey until the patient leaves the outpatient clinic.

Deep learning-based computer vision to recognize and classify suturing gestures in robot-assisted surgery

BackgroundOur previous work classified a taxonomy of suturing gestures during a vesicourethral anastomosis of robotic radical prostatectomy in association with tissue tears and patient outcomes. Herein, we train deep learning-based computer vision to automate the identification and classification of suturing gestures for needle driving attempts. MethodsUsing two independent raters, we manually annotated live suturing video clips to label timepoints and gestures. Identification (2,395 videos) and classification (511 videos) datasets were compiled to train computer vision models to produce 2- and 5-class label predictions, respectively. Networks were trained on inputs of raw red/blue/green pixels as well as optical flow for each frame. Each model was trained on 80/20 train/test splits. ResultsIn this study, all models were able to reliably predict either the presence of a gesture (identification, area under the curve: 0.88) as well as the type of gesture (classification, area under the curve: 0.87) at significantly above chance levels. For both gesture identification and classification datasets, we observed no effect of recurrent classification model choice (long short-term memory unit versus convolutional long short-term memory unit) on performance. ConclusionOur results demonstrate computer vision’s ability to recognize features that not only can identify the action of suturing but also distinguish between different classifications of suturing gestures. This demonstrates the potential to utilize deep learning computer vision toward future automation of surgical skill assessment.

Association between PSA density and pathologically significant prostate cancer: The impact of prostate volume.

The early diagnosis of prostate cancer (PCa) is mainly based on prostate-specific antigen (PSA) blood levels and digital rectal examination. However, this approach may result in a high rate of negative biopsies and increased detection of clinically insignificant PCa (CS-PCa). An important prognostic biomarker, PSA density (PSA-D) demonstrated improved performance in PCa detection compared to PSA. The relationship between prostate volume and the prognostic accuracy of PSA-D remains mostly unclear. The aim of our study is to investigate the PSA-D predictive value of CS-PCa detection at different prostate volumes. Using our local radical prostatectomy registry, patients were divided into three prostate size subgroups based on preoperative sonographic prostate volume assessment: less than 50, 50-75, and more than 75 cc. Patients' and PCa characteristics were recorded, including age, body mass index, PSA at diagnosis, prostate volume, PSA-D, D'Amico risk classification, Gleason grade group, and pathological staging following surgery. The study cohort included 364 patients who underwent Robotic Radical prostatectomy for biopsy-proven clinically localized PCa. 221 (61%) and 143 (39%) patients had PSA-D less than 0.15 and PSA-D more than 0.15, respectively. ISUP GG 1-2 PCa (CS-PCa) was observed in 220 patients (60%), while 144 (40%) had ISUP GG 3-5 PCa at final pathology. PSA-D correlated with CS-PCa only in small and medium-size prostates, but not in large glands (p = .03, p = .01, and p = .36, respectively). The highest sensitivity (72.7%) was observed in small prostates, compared to 3.2% in large prostates. The highest specificity (89.4%) was noted in large prostates. Positive predictive value in small and medium-size prostates was similar (~50%), compared to 20% in large glands. The negative predictive value was slightly better for small and medium-size prostates compared with large glands (68.9%, 73.7%, and 53.1%, respectively). An association between PSA-D and harboring CS-PCa was detected only in small and medium-size glands (72.7% and 43%, respectively). PSA-D is associated with CS-PCa detection in radical prostatectomy specimens in small and medium-size prostates. The level of PSA-D is directly associated with the ISUP PCa grade group. Therefore, PSA-D is a beneficial, available, and cost-effective tool during decision-making in patients with small and medium-size prostate when considering treatment for PCa.

SC247 - Risk factors for development a symptomatic lymphocele after lymph node dissection in a radical robotic prostatectomy: experience from a single center

SC247 - Risk factors for development a symptomatic lymphocele after lymph node dissection in a radical robotic prostatectomy: experience from a single center

SC268 - Real-time augmented reality 3D-guided robotic radical prostatectomy: preliminary experience and evaluation of the impact on surgical planning

SC268 - Real-time augmented reality 3D-guided robotic radical prostatectomy: preliminary experience and evaluation of the impact on surgical planning

A Comparative Analysis of Surgical Scar Cosmesis Based on Operative Approach for Radical Prostatectomy.

Objective: Recent developments in minimally invasive approaches to radical prostatectomy (RP) for localized prostate cancer have improved oncological outcomes, but may also affect surgical scar cosmesis, an important component of survivorship and patient quality of life. Our aim was to evaluate surgical scar appearance based on operative approach to RP using a validated tool for evaluating psychosocial impact of scar appearance. Methods: Men between the ages of 45 and 80 were surveyed on an online crowdsourcing platform. Well-healed surgical scars after open, multiport (MP) robotic (transperitoneal and extraperitoneal), and single-port (SP) robotic RP were digitally rendered on stock photos to control for patient appearance. Respondents evaluated images using the SCAR-Q© psychosocial impact domain. Additionally, different RP scars were ranked by appearance and assigned 10-point appearance scores. Results: Two hundred thirty-four surveys were included for analysis (completion rate 84.2%). The median age was 54 (IQR: 49-61) and 35% (85/234) had previous abdominal surgery, of which 45% (38/85) was robotic or laparoscopic. SP scars had better psychosocial impact scores (median 100 out of 100 vs 69 and 58) than MP and open, respectively (both p < 0.001). SP scars were consistently ranked higher by appearance (median rank 1, IQR: 1-1) than MP (2, IQR: 2-3) and open (3, IQR: 3-4) (p < 0.001). SP without assistant port had the highest appearance score (median 9, IQR: 7-9) among all scars (p < 0.001). Conclusion: SP scars scored highest on psychosocial impact and were consistently ranked highest in appearance. These findings may be informative for optimizing both cosmetic appearance and quality of life for patients undergoing RP.

Post-renal Transplant Retzius Sparing Robotic Radical Prostatectomy: Initial Experience and Case Report

Retzius sparing robotic radical prostatectomy is now an accepted alternative to standard RARP. Our paper aims to evaluate the feasibility, complications, and oncological outcomes of the RS-RARP in kidney transplant recipients. We did a retrospective analysis of 3 patients who underwent retzius sparing robotic radical prostatectomy post-renal transplant. Operative, oncological, and functional outcomes are analyzed. A total of 3 patients underwent RS-RARP post-renal transplant. Mean operative time was 143.2 ± 9.06 min, and nerve-sparing was performed on one side in 1 patient. None of the patients had any intraoperative or postoperative events. Final pathological staging was upgraded in all three patients and was pT3aN0Mx. All three patients were fully continent in the immediate postoperative period after catheter removal. All three patients were free of biochemical recurrence with PSA of less than 0.2 in all patients with no need for additional treatment till last follow-up. There was no change in renal function in the immediate postoperative period and 1 month follow-up in any patient. Retzius sparing robotic radical prostatectomy can be performed safely in a post-transplant setting with minimal complications and excellent functional and oncological outcomes.

Real-time Augmented Reality Three-dimensional Guided Robotic Radical Prostatectomy: Preliminary Experience and Evaluation of the Impact on Surgical Planning

BackgroundAugmented reality (AR) is a novel technology adopted in prostatic surgery. ObjectiveTo evaluate the impact of a 3D model with AR (AR-3D model), to guide nerve sparing (NS) during robot-assisted radical prostatectomy (RARP), on surgical planning. Design, Setting, and ParticipantsTwenty-six consecutive patients with diagnosis of prostate cancer (PCa) and multiparametric magnetic resonance imaging (mpMRI) results available were scheduled for AR-3D NS RARP. InterventionSegmentation of mpMRI and creation of 3D virtual models were achieved. To develop AR guidance, the surgical DaVinci video stream was sent to an AR-dedicated personal computer, and the 3D virtual model was superimposed and manipulated in real time on the robotic console. Outcome measurements and statistical analysisThe concordance of localisation of the index lesion between the 3D model and the pathological specimen was evaluated using a prostate map of 32 specific areas. A preliminary surgical plan to determinate the extent of the NS approach was recorded based on mpMRI. The final surgical plan was reassessed during surgery by implementation of the AR-3D model guidance. Results and limitationsThe positive surgical margin (PSM) rate was 15.4% in the overall patient population; three patients (11.5%) had PSMs at the level of the index lesion. AR-3D technology changed the NS surgical plan in 38.5% of men on patient-based and in 34.6% of sides on side-based analysis, resulting in overall appropriateness of 94.4%. The 3D model revealed 70%, 100%, and 92% of sensitivity, specificity, and accuracy, respectively, at the 32-area map analysis. ConclusionsAR-3D guided surgery is useful for improving the real-time identification of the index lesion and allows changing of the NS approach in approximately one out of three cases, with overall appropriateness of 94.4%. Patient summaryAugmented reality three-dimensional guided robot-assisted radical prostatectomy allows identification of the index prostate cancer during surgery, to tailor the surgical dissection to the index lesion and to change the extent of nerve-sparing dissection.

Current evidence between hospital volume and perioperative outcome: Prospective assessment of robotic radical prostatectomy safety profile in a regional center of medium annual caseload.

We aimed to present the safety profile of robotic radical prostatectomy (RARP) performed in a single center of medium surgical volume since its introduction and identify predictors of postoperative complications. We prospectively collected clinical data from 317 consecutive patients undergoing RARP between August 2011 and November 2019 in a medium-volume center. Surgical procedures were performed by a single experienced surgeon. Complications were collected according to the Martin criteria for reporting and the Clavien-Dindo classification for rating. Preoperative, intraoperative, and postoperative data were analyzed and compared with available literature. A total of 102 complications were observed in 96 (30.3%) patients and were minor in 84.4% of cases (Clavien grade 1 and 2). Transfusion rate was 1.3%. Complications of grade 4b or 5 did not occur. The most frequent complications were urinary retention (7.3%) and anastomotic leak (5.9%). At multivariate analysis, the nerve-sparing technique was an independent predictor of complications (odds ratio [OR] 0.55, p=0.02). The study shows that a high safety profile may be achieved in a medium-volume hospital. The nerve-sparing technique was a predictor of complications. Further studies are needed to define the current relationship between surgical volume and perioperative outcome for RARP.

Aches and Pains in a Patient With History of Prostatectomy: Extensive Skeletal Metastasis Picked up by Diffusion-Weighted Magnetic Resonance Imaging

A 64-year-old gentleman presented to the out-patient with complaints of generalized body ache. He had a history of prostate cancer for which robotic radical prostatectomy (RP) was done earlier. The levels of prostate specific antigen (PSA) and alkaline phosphatase (ALP) were significantly elevated. Skeletal radiograph showed only few sclerotic foci. Magnetic resonance imaging whole-body diffusion-weighted image (MRI-WB-DWI) however revealed the presence of diffuse skeletal metastasis. In any elderly male who presents with generalized body pain, eliciting a good history should not be overlooked. With a history of prostate cancer, diffuse metastases should be high in the list of differential diagnosis. Though there are several imaging methods to detect metastases, MRI-WB-DWI is a welcome alternative to the established methods. Patients who undergo RP for prostate cancer should be counselled regarding the importance of follow-up of their PSA levels. J Med Cases. 2020;11(9):275-278 doi: https://doi.org/10.14740/jmc3545

Erectile dysfunction after robotic radical prostatectomy: Real-life impact of vacuum erection device clinic

Introduction: Post-radical prostatectomy erectile dysfunction (post-RPED) is a common and potentially devastating complication. The role of PDE5-inhibitors (PDE5-Is) in post-RPED is controversial and invasive pharmacological treatments are associated with poor long-term compliance. Vacuum erection devices (VEDs) are a non-pharmacological alternative. Little data regarding VED efficacy and associated patient satisfaction in post-RPED exists. This study aimed to investigate the outcomes of VED therapy in a post-robot assisted radical prostatectomy (post-RARP) population. Methods: All men who underwent RARP at a single centre between February 2015 and October 2017 attended a nurse-led holistic-needs-assessment (HNA) appointment at 10 weeks post-RARP. All men identifying ED as a concern at HNA were offered dedicated nurse-led post-RPED clinic and VED clinic appointments. A cross-sectional survey of patient reported outcomes in these men was performed. Results: In total 137/539 (25%) men reported ED as a concern at HNA. All 137 men attended the VED clinic, 124/137 (90%) responded to the survey. Commonest reason for choosing VED therapy was for combined psychological, penetration and lengthening purposes (48%). Median time from RARP to VED clinic and from VED clinic to survey was 122 days (range 56–595) and 462 days (range 66–932) respectively. At survey 88/124(70.9%) reported continued use of VED, 69/88 (78%) of this group perceived VED treatment to be successful. Of those who had stopped using VED, 7/36 (19%) felt it had been successful. Key reasons for discontinuation were either because men felt it ineffective (13/36 (37%)) or disliked the device (10/36 (29%)). Conclusion: VED therapy is an effective treatment for men with post-RARP ED that is well tolerated with good short- to medium-term compliance. Up to two-thirds of men may find overall satisfaction with their post-RPED after VED therapy. Level of Evidence: 3

Comparing open and robotic salvage radical prostatectomy after radiotherapy: predictors and outcomes.

IntroductionIn the present study, we aim to provide more evidence about benefits of salvage radical prostatectomy (SRP). Our main objective is to assess prostatic-specific antigen control and postoperative urinary incontinence in open and robotic approaches as primary outcomes.Materials and methodsAfter the Institutional Review Board approval (IRB00010193), we retrospectively analyzed 76 consecutive patients who underwent open or robot-assisted SRP for locally relapsed prostate cancer between 2004 and 2019 at the Urology Department of Hospital Italiano de Buenos Aires, Argentina. Data were collected from our electronic medical record and prospective database.Postoperative variables, such as urinary incontinence, erectile function preservation, and vesicourethral anastomosis stricture development, were analyzed.ResultsBefore SRP, 59 patients (76.6%) were treated with 3D external beam radiotherapy, 11 (14.3%) with brachytherapy, and 6 (7.8%) with intensity-modulated radiotherapy. Fifty patients underwent open SRP, and 26, robot-assisted SRP. Comparing surgical approaches, the global incontinence rate was 34.2% versus 9.1% in open versus robot-assisted approach, respectively (p: 0.01).Vesicourethral anastomosis stricture occurred in six patients (8.7%), all in the open approach group (p: 0.07). Five patients of 69 (7.2%) preserved erectile function with/without use of phosphodiesterase 5 inhibitors. Two patients in the open approach group needed blood transfusion. Estimated 2-year biochemical recurrence–free survival rate in the open approach group and robot-assisted group was 67% (95% confidence interval: 53.7–80.3) and 60.9% (95% confidence interval: 40.5–81.3), respectively, with no statistical difference (log-rank test p: 0.873).ConclusionsRobot-assisted SRP is a reliable procedure to treat local recurrences after external beam radiotherapy or brachytherapy, reducing the risk of anastomotic strictures and blood loss and improving continence outcomes.

Relationship between robotic-assisted radical prostatectomy and retropubic radical prostatectomy in the learning curve of a single surgeon as a novice in radical prostatectomy: A retrospective cohort study.

We compared the learning curve and pathologic and functional outcomes of retropubic radical prostatectomy (RRP) and robotic-assisted radical prostatectomy (RARP) performed during the same time period by a novice to identify how the two surgical types affect each other. We retrospectively reviewed 480 men who underwent RRP or RARP for prostate cancer between January 2008 and December 2012. Operation time, estimated blood loss (EBL), positive surgical margin (PSM) rate, urinary continence and potency recovery, and complications were compared. Scatter-graphs were drawn using locally weighted scatterplot smoothing (LOWESS). Operation time reached the lowest point in the 90th case in RRP and the 200th case in RARP. EBL showed a similar pattern, reaching the lowest point in the 95th case in RRP and the 230th case in RARP. The lowest points for both operation time and EBL took about 3 years to reach for both surgical types. PSM rate was not significantly different (P=0.807). No pads were required at 6 and 12 months in 55.6% and 66.9% of patients in RRP, respectively, but in 79.6% and 88.4% of patients in RARP. The potency recovery rates were 59.1% in RRP and 70.9% in RARP at 12 months. When RRP and RARP were begun contemporaneously by a novice, they showed similar learning curve patterns. The direct tactile feedback in RRP and the magnified field of view and detailed techniques in RARP help improve surgical skills complementarily to attain proficiency in both surgical types.

Which is the best radiological imaging method for predicting actual prostate weight?

In this study, we compared the weight of the prostate specimen removed after robotic radical prostatectomy with the prostate weight measured pre-operatively by four different imaging modalities. Pre-operative prostate weight before robotic radical prostatectomy was measured by Transabdominal Ultrasonography (TAUS), Transrectal Ultrasonography (TRUS), Abdominal Tomography (CT) and MultiparametricProstate Magnetic Resonance imaging (mpMRI). Of the 170 patients enrolled in the study, the mean age was 65.2±7.08 (46-84) years and mean prostate-specific antigen (PSA) 9.6±7.7 (1.8-50). The mean post-operative actual prostate weight was 63.1±30gr. The mean pre-operative prostate volumes measured by TAUS, TRUS, CT and MPMRI were 64.5±28.5, 49.1±30.6, 54.5±30.5 and 68.7±31.7ml, respectively (p<.001). Post-operative actual prostate weight correlated with prostate weight measured by TAUS, TRUS, CT and mpMRI (r coefficient 0.776, 0.802, 0.768 and 0.825 respectively). The best of these was mpMRI. Although prostate weight measured by different imaging methods has a high correlation to predict actual prostate weight, actual prostate weight is best predicted by measurements with mpMRI. However, errors and deviations that may occur with these imaging methods should be taken into consideration.

A combination of enhanced recovery after surgery and prehabilitation pathways improves perioperative outcomes and costs for robotic radical prostatectomy

An enhanced recovery after surgery (ERAS) pathway has shown benefit in oncologic surgery. However, literature is scarce regarding the impact of this pathway, alone or combined with prehabilitation (PreHab) programs, on outcomes after robot-assisted radical prostatectomy (RARP). Included in this study were 507 consecutive patients undergoing RARP from 2014 to 2019. The primary endpoint was duration of hospital stay. Secondary outcomes included intraoperative blood loss, operative duration, readmission rate, and overall costs. Univariate and multivariate comparisons were performed according to the ERAS and PreHab program status. ERAS patients had shorter hospital stays (P<.001), reduced operative times (P<.001), and decreased blood loss (P<.001) in comparison with non-ERAS patients. Shorter hospital stays were not associated with an increased readmission rate (7.9% [stable over time]; P=.757). Patients from an ERAS-/PreHab- group had a longer hospital stay (4.7days) than those from an ERAS+/PreHab- group (3.5days) and those from an ERAS+/PreHab+ group (1.6days; P<.001). In a multivariate analysis, operative time and perioperative pathway (odds ratio for ERAS, 0.144; P<.001; odds ratio for ERAS and PreHab, 0.025; P<.001) were independently predictive for a prolonged length of stay (P<.001). Costs significantly decreased when ERAS and PreHab pathways were combined. The implementation of ERAS and PreHab programs significantly changes the postoperative course of patients and may synergistically optimize RARP outcomes. The combination of these pathways improves patient recovery and is associated with reduced lengths of stay, blood loss, operative times, and costs without an increase in the postdischarge readmission rate.

PT282 - Risk factors for peri-operative high-grade complications in patients with prostate cancer treated with robotic radical prostatectomy

PT282 - Risk factors for peri-operative high-grade complications in patients with prostate cancer treated with robotic radical prostatectomy

Routine Postoperative Hemoglobin Assessment Poorly PredictsTransfusion Requirement among Patients Undergoing Minimally Invasive Radical Prostatectomy.

An advantage of minimally invasive radical prostatectomy over open surgery is decreased blood loss. At our institution hemoglobin is routinely checked 4 and 14 hours postoperatively. We assessed the relevance of this practice in a contemporary cohort undergoing minimally invasive radical prostatectomy. We retrospectively reviewed data from patients undergoing laparoscopic or robotic radical prostatectomy at our institution between January 2010 and September 2018. We identified 3,631 patients with preoperative and postoperative hemoglobin values, and assessed the role of routine hemoglobin assessment in determining need for transfusion within 30 days. Medicare reimbursement rates for 2019 were used for cost analysis. Of 3,631 patients in our cohort 44 (1.2%) required transfusion. At 4 hours following surgery the median hemoglobin decrease was 8.0% (IQR 4.8 to 11.4) for patients who did not receive transfusion and 12.5% (9.5 to 19.2) for those who received transfusion. At 14 hours the median decrease was 14.2% (IQR 10.0 to 18.4) vs 33.1% (22.6 to 38.6). Routine hemoglobin assessment had no role in the decision to transfuse in 18 patients (41%). No patient was transfused based on 4-hour values alone. Omitting 1 hemoglobin assessment could have resulted in institutional savings of $37,000 during this period. As transfusion following minimally invasive radical prostatectomy is rare, scheduled postoperative hemoglobin assessments in the absence of symptoms are unnecessary to recognize bleeding events. The largest hemoglobin difference between men who did vs did not receive transfusion was seen at 14 hours postoperatively. Thus, this single hemoglobin evaluation is sufficient.