Intermediate-term oncological and functional outcomes in prostate cancer patients treated with perineal robot-assisted radical prostatectomy:A single center analysis

Objective:In the last 10 years,robotic platforms allowed to resume of some alternative surgical approaches,including perineal robot-assisted radical prostatectomy(p-RARP).Herein,we present in detail the oncological and functional outcomes of patients who underwent p-RARP with a median follow-up of 30 months.Methods:Patients presenting low-or intermediate-risk prostate cancer and prostate volume up to 60 mL who underwent p-RARP between November 2018 and November 2022 were selected.Baseline,intraoperative,pathological,and postoperative data were collected and then analyzed.Results:Thirty-seven p-RARP cases were included.Such patients presented mean age of 62 years and a mean Charlson comorbidity index of 4.Body mass index of≥25 kg/m^(2)was reported by 24(64.9%)patients,as well as 7(18.9%)patients reported a past surgical history.Mean prostate volume and median prostate-specific antigen were 41 mL and 6.2 ng/mL,respectively.The median operative time was 242 min.The positive surgical margin rate was 45.9%.In terms of postoperative complications,10 patients reported complications with any grade;however,a single case(2.7%)of major(Clavien-Dindo grade≥3)complication was observed.No patient with biochemical recurrence or distant metastasis was reported at 2 years of follow-up.Recovery of continence rates were 67.6%,75.7%,and 92.9%,at 6 months,12 months,and 24 months after surgery,respectively.

The current status of robot-assisted radical prostatectomy

Robot-assisted radical prostatectomy （RARP） is a rapidly evolving technique for the treatment of localized prostate cancer. In the United States, over 65% of radical prostatectomies are robot-assisted, although the acceptance of this technology in Europe and the rest of the world has been somewhat slower. This article reviews the current literature on RARP with regard to oncological, continence and potency outcomes-the so-called ＇trifecta＇. Preliminary data appear to show an advantage of RARP over open prostatectomy, with reduced blood loss, decreased pain, early mobilization, shorter hospital stay and lower margin rates. Most studies show good postoperative continence and potency with RARP; however, this needs to be viewed in the context of the paucity of randomized data available in the literature. There is no definitive evidence to show an advantage over standard laparoscopy, but the fact that this technique has reached parity with laparoscopy within 5 years is encouraging. Finally, evolving techniques of single-port robotic prostatectomy, laser- guided robotics, catheter-free prostatectomy and image-guided robotics are discussed.

Nerve-sparing robot-assisted radical prostatectomy:Current perspectives

Robotic-assisted radical prostatectomy(RARP)is the current standard of care with long term cure in organ-confined disease.The introduction of nerve-sparing(NS)to standard RARP has shown positive results in terms of functional outcomes in addition to the oncological outcomes.This article reviews the current perspectives of NS-RARP in terms of applied anatomy of the prostatic fascial planes,the neurovascular bundle(NVB),various NS techniques and postoperative functional outcomes.A non-systematic review was done using PubMed,Embase and Medline databases to retrieve and analyse articles in English,with following keywords“prostate cancer”,“robotic radical prostatectomy”,“nerve-sparing”.The Delphi method was used with an expert panel of robotic surgeons in urology to analyse the potency outcomes of various published comparative and non-comparative studies.The literature has shown that NS-RARP involves various techniques and approaches while there is a lack of randomized studies to suggest the superiority of one over the other.Variables such as preoperative risk assessments,baseline potency,surgical anatomy of individual patients and surgeons’expertise play a major role in the outcomes.A tailored approach for each patient is required for applying the NS approach during RARP.

Significance of preoperatively observed detrusor overactivity as a predictor of continence status early after robot-assisted radical prostatectomy

Several recent studies have reported the involvement of bladder dysfunction in the delayed recovery of urinary continence following radical prostatectomy （RP）. The objective of this study was to investigate the significance of detrusor overactivity （DO） as a predictor of the early continence status following robot-assisted RP （RARP）. This study included 84 consecutive patients with prostate cancer undergoing RARP. Urodynamic studies, including filling cystometry, pressure flow study, electromyogram of the external urethral sphincter and urethral pressure profile, were performed in these patients before surgery. Urinary continence was defined as the use of either no or one pad per day as a precaution only. DO was preoperatively observed in 30 patients （35.7%）, and 55 （65.5%） and 34 （40.5%） were judged to be incontinent 1 and 3 months after RARP, respectively. At both 1 and 3 months after RARP, the incidences of incontinence in patients with DO were significantly higher than in those without DO. Of several demographic and urodynamic parameters, univariate analyses identified DO and maximal urethral closure pressure （MUCP） as significant predictors of the continence status at both 1 and 3 months after RARP. Furthermore, DO and MUCP appeared to be independently associated with the continence at both I and 3 months after RARP on multivariate analysis. These findings suggest that preoperatively observed DO could be a significant predictor of urinary incontinence early after RARP; therefore, it is recommended to perform urodynamic studies for patients who are scheduled to undergo RARP in order to comprehensively evaluate their preoperative vesicourethral functions.

Cavernous Nerve Graft Reconstruction with a Novel Artificial Conduit during Robot-Assisted Laparoscopic Radical Prostatectomy

The interposition sural nerve graft has been attempted occasionally during radical prostatectomy for the recovery of continence and erectile function;however, nerve autograft may result in adverse events for the patient. Here, we present our initial experiences using NerbridgeTM, a novel conduit for peripheral nerve regeneration, rather than utilizing sural nerve grafting, in robot-assisted laparoscopic radical prostatectomy to overcome autograft problems such as prolongation of operation time and postoperative abnormal sensation. This novel artificial conduit interposition can be technically feasible when combined with robotic surgery, and prospective randomized controlled trials with high patients-numbers and long follow-up periods are warranted.

系统教学模式下无腔镜经验术者实施机器人辅助根治性前列腺切除术的学习曲线分析

目的评估在系统教学模式下无腔镜前列腺切除术经验的术者行机器人辅助根治性前列腺切除术的学习曲线。方法回顾性分析由解放军总医院第三医学中心泌尿外科医学部1名无腔镜经验的术者实施的前120例机器人辅助根治性前列腺切除术患者的资料。术者在术前接受了系统教学指导。本研究按手术实施的先后顺序将患者分为4组,每30例为一组。以手术时间、术中出血量、术后住院天数等作为学习曲线的衡量标准,比较各组间的术后切缘阳性率和并发症发生率以及术后1年的生化复发率和尿控恢复率。结果手术时间90~355 min,平均(186.0±54.7)min;术中出血量50~1000 ml,平均(266.0±186.1)ml;术后住院天数4~21 d,平均(10.0±3.5)d。术后切缘阳性率为27.5%,并发症发生率为20.8%;术后1年生化复发率为15.8%,尿控恢复率为80.8%。随着前30例手术经验的积累,术者到达学习曲线平台期,手术时间、术中出血量、术后住院天数均显著降低(P<0.05);而术者在最后30例渡过了学习平台期,切缘阳性率、并发症发生率、生化复发率和尿控恢复率均显著降低(P<0.05)。结论在系统教学的模式下,无腔镜经验的术者可顺利完成机器人辅助根治性前列腺切除术,并具有明显的学习曲线。术者需要通过90~120例的手术积累以渡过学习曲线的平台期,以获得较满意的肿瘤学和功能学结果。