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.

Outcomes after robot-assisted laparoscopic radical prostatectomy

Robot-assisted laparoscopic radical prostatectomy （RALRP） using the da Vinci surgical system is now in widespread use in many countries where economic conditions allow the installation of this expensive technology. Controversy has surrounded the procedure since it was first performed in 2000, with many critics highlighting the lack of evidence to support its use. However, despite the lack of level I evidence, many large studies of patients have confirmed that the procedure is feasible and safe, with low morbidity. Available longer-term oncological data seem to show that outcomes from the robotic approach at least match those of traditional open radical prostatectomy. Functional outcomes also seem satisfactory, although randomized controlled trials are lacking. This paper reviews the current status of RALRP with respect to perioperative data and complications and oncologic and functional outcomes.

The surgical learning curve for robotic-assisted laparoscopic radical prostatectomy： experience of a single surgeon with 500 cases in Taiwan, China

To analyze the learning curve for cancer control from an initial 250 cases （Group I） and subsequent 250 cases （Group II） of robotic-assisted laparoscopic radical prostatectomy （RALP） performed by a single surgeon. Five hundred consecutive patients with clinically localized prostate cancer received RALP and were evaluated. Surgical parameters and perioperative complications were compared between the groups, Positive surgical margin （PSM） and biochemical recurrence （BCR） were assessed as cancer control outcomes. Patients in Group II had significantly more advanced prostate cancer than those in Group I （22.2% vs 14.2%, respectively, with Gleason score 8-10, P = 0.033; 12.8% vs 5.6%, respectively, with clinical stage T3, P = 0.017）. The incidence of PSM in pT3 was decreased significantly from 49% in Group I to 32.6% in Group Ih A meaningful trend was noted for a decreasing PSM rate with each consecutive group of 50 cases, including pT3 and high-risk patients. Neurovascular bundle （NVB） preservation was significantly influenced by the PSM in high-risk patients （84.1% in the preservation group vs 43.9% in the nonpreservation group）. The 3-year, 5-year, and 7-year BCR-free survival rates were 79.2%, 75.3%, and 70.2%, respectively. In conclusion, the incidence of PSM in pT3 was decreased significantly after 250 cases. There was a trend in the surgical learning curve for decreasing PSM with each group of 50 cases. NVB preservation during RALP for the high-risk group is not suggested due to increasing PSM.

Single-port transperitoneal robotic-assisted laparoscopic radical prostatectomy (spRALP): Initial experience

Objective:To assess the feasibility of single-port transperitoneal robotic-assisted laparoscopic radical prostatectomy(spRALP)and discuss its surgical technique.Methods:A 60-year-old male was admitted with an elevated prostate-specific antigen(PSA)level of 13.89 ng/mL and confirmed with prostate cancer on biopsy showing three of 22 positive cores with a Gleason score of 3þ4=7.Multiparametric magnetic resonance(MR)and bone scintigraphy showed organ-confined disease.spRALP was performed using da Vinci Si HD surgical system,with access of a quadri-channel laparoscopic port placed supraumbilically.Two drainage tubes were placed before wound closure.The surgical procedure was largely in consistence with a conventional robotic-assisted laparoscopic radical prostatectomy.Results:The surgery was successfully carried out with a duration of 152 min and an estimated blood loss of 100 mL.The patient was discharged on postoperative Day 4 after removal of both pelvic drainage tubes.Foley catheter was removed on postoperative Day 14.No major complications were encountered.Postoperative pathology showed a Gleason score of 3þ4=7 with no extraprostatic extension and negative surgical margins.Conclusion:Single-port robotic prostatectomy is feasible using the currently available robotic instruments in most Chinese robotic urological centers.Meticulous preoperative planning and careful patient selection are mandatory.Further studies concerning perioperative complications and pentafecta outcome compared with the conventional multi-port robotic prostatectomy is required.

Open and robotic radical prostatectomy

Open retropubic radical prostatectomy has been the“gold standard”treatment for locally confined prostate cancer(PCa)but in recent years minimal invasive techniques as laparoscopy and robot-assisted prostatectomy have become widely available.The trifecta of the surgical treatment of PCa is cancer control,the preservation of continence,and erectile potency.Over the years the complication rates of radical prostatectomy have become very limited with improved cancer control and better functional results.We review the indications and the surgical technique of radical prostatectomy,be it open or laparoscopic,eventually robot-assisted as well as the pre-and postoperative measures and the surgery-related consequences.

Effect of puboprostatic ligament preservation during robotic-assisted laparoscopic radical prostatectomy on early continence:Randomized controlled trial

Objective:To prove the effectiveness of puboprostatic ligament-preserving robotic-assisted laparoscopic radical(RARP)on enhancing early continence.Methods:Ninety-two patients with localized adenocarcinoma of the prostate scheduled for RARP from April 2018 to January 2019 were prospectively single-blinded and randomized into two groups,standard RARP(Group A)and puboprostatic ligament-sparing RARP(Group B).The outcomes were continent status at Foley catheter removal and 3 months after surgery using the score from the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form(ICIQ-UI SF),pad usage,pathological margin status,blood loss,operative time,and complications.Results:Ninety-six patients were randomized(46 patients in each group),with a mean±SD age of 67.30±6.07 years.There were no differences in baseline characteristics.At 3 months after surgery,ICIQ-UI SF score(mean±SD)in Group A was significantly higher than Group B(8.74±4.28 vs.6.93±3.96,p=0.038)but no difference at Foley catheter removal.Group A also had a significant higher score for interference with daily life(median[interquartile range,IQR]:4[1,5]vs.2[0,4];p=0.041)and higher pad use(median[IQR]:2[0,3]vs.1[1,2];p=0.041)at 3 months.One case in Group A had complete or severe incontinence(>5 pads/day)at 3 months.Groups A and B did not exhibit significant difference in margin status(p=0.828).There were no differences in operative time,blood loss,drain output or complications.Conclusions:Use of puboprostatic ligament-sparing RARP could be a method to accelerate early continence without affecting the final oncological outcome.

Sustainable functional urethral reconstruction:Maximizing early continence recovery in robotic-assisted radical prostatectomy

Objective:To evaluate the safety profile and short-term functional outcome of sustainable functional urethral reconstruction(SFUR)in robotic-assisted radical prostatectomy(RARP).Methods:One hundred and sixty-two consecutive prostate cancer patients who underwent RARP were retrospectively analyzed,in which 53 had undergone SFUR while the other 109 had undergone conventional RARP procedures.Immediate,2-week,1-month and 3-month continence recovery and other perioperative data were compared to evaluate short-term surgical and functional outcome.Results:The median age was 68 and 67 years in the experimental group and control group,respectively(pZ0.206),with a median prostate-specific antigen(PSA)of 13.6 ng/mL(interquartile range[IQR],8.46e27.32 ng/mL)in the experimental group and 13.84 ng/mL(IQR,9.12e26.80 ng/mL)in control group(pZ0.846).Immediate,2-week,1-month and 3-month continence recovery rates between the groups were 34.0%vs.3.7%,50.9%vs.14.7%,62.3%vs.27.5%,and 79.2%vs.63.3%(all p<0.05).The morphological changes made by the new reconstruction technique were maintained on magnetic resonance imaging(MRI)3 months postoperatively.Nerve-sparing procedures and adoption of the new reconstruction technique were significantly relevant to continence recovery on logistics regression model(p<0.001).Conclusions:SFUR is a safe and easy-to-handle modification that may contribute to early continence return for RARP.Long-term follow-up and prospective studies are required to further evaluate its value in postoperative quality-of-life improvement.

Robotic assisted laparoscopic simple suprapubic prostatectomy--The Smith Institute for Urology experience with an evolving technique

Objective:Despite a multitude of minimally invasive surgical options available for benign prostatic enlargement,open simple prostatectomy(OSP)remains the standard for large prostates(typically greater than 100 g).OSP,however,is associated with significant morbidity.Recently,a few reports touting robotic application to simple prostatectomy have been published.Herein,we reviewed our series of robotic assisted laparoscopic simple suprapubic prostatectomy(RALSSP)and detailed modifications in our technique as our experience increased.Methods:All RALSSP cases performed between January 2013 and January 2014 were reviewed for demographics,pre-operative features,and perioperative outcomes.All parameters were tabulated and mean values were calculated.Student’s t-test was utilized with p<0.05 deemed significant.Details regarding surgical technique were reviewed and highlighted.Results:Fifteen patients underwent RALSSP during this period.Mean age of these men was 68.7 years.Mean body mass index(BMI)was 28.5 kg/m^2.American Society of Anesthesiologists(ASA)score was on average 2.6.Average International Prostate Symptom Score(IPSS)was 16.2 with the majority of men experiencing some adverse clinical sequela of such benign prostatic hyperplasia(BPH).For those patients not in retention,preoperative post-void residual(PVR)was 428 mL.All patients underwent successful RALSSP without need for conversion or need for blood transfusion.Mean estimated blood loss(EBL)was 290 mL.Five patients underwent other concurrent procedures(e.g.,cystolithotomy).Mean length of hospital stay(LOS)was 2.4 days and only five patients required continuous bladder irrigation(CBI)postoperatively.Postoperative PVR improved to a mean of 33 mL and IPSS improved to 4.5(p<0.001).No major complications were identified.Adaptation of low transverse cystotomy,utilization of a robotic tenaculum in the#3 arm with its control by a surgeon on a second console,and the utilization of mucosal advancement have all subjectively aided in performance of RALSSP and perioperative outcomes.Conclusion:RALSSP allows for feasible performance of prostate adenoma enucleation with low risk of blood transfusion,short LOS,and significant improvement in IPSS and PVR;all while maintaining a minimally invasive approach.The use of a robotic tenaculum controlled by the secondary console and the mucosal advancement facilitate excellent outcomes and may play a role in minimizing hematuria and need for CBI.

Experience of one single surgeon with the first 500 robot-assisted laparoscopic prostatectomy cases in China's Mainland

Objectives: To summarize the experience of the first 500 robot-assisted laparoscopicradical prostatectomy (RALP) cases by one surgeon and analyze the influencing factorsof functional and oncological outcomes.Methods: Between April 2012 and October 2017, 500 patients who underwent RALP wereincluded and divided sequentially into five equal groups. Patients’ preoperative, perioperativeand postoperative outcomes were analyzed and evaluated, and the Kruskal-Wallis test wasused to analyze and compare the effect of surgeon experience by case.Results: There is a statistically significant reduction in operative time, intraoperative estimatedblood loss and postoperative hospital stay time (all p<0.001) with the increased experience.The results show that experience was the most important influencing factor in bothoperative time and blood loss. Pelvic lymph node dissection (PLND) might increase the operativetime. The total positive surgical margin (PSM) rate was 21.8%. The PSM rate in pT3 tumorswas significantly higher than that in pT2 tumors (12.0% vs. 37.1%, p<0.001). The 5-yearbiochemical recurrence (BCR)-free rate was 70.8%. The results of Cox regression showed thatpreoperative prostate-specific antigen (PSA), postoperative Gleason score (GS), and pathologicT stage were independent risk factors for BCR.Conclusion: After approximately 200 cases, the surgeon reached a plateau for RALP, but theoutcomes could still improve after more cases. The surgeon’s experience was the most importantinfluencing factor for both operative time and blood loss. PSM rate was mainly determinedby tumor stage rather than by operation experience.

Initial experience of laparoendoscopic single-site radical prostatectomy with a novel purpose-built robotic system

Objective This prospective single-arm clinical trial aimed to evaluated the feasibility and safety of the application of the SHURUI system(Beijing Surgerii Technology Co.,Ltd.,Beijing,China),a novel purpose-built robotic system,in single-port robotic radical prostatectomy.Methods Sixteen patients diagnosed with prostate cancer were prospectively enrolled in and underwent robotic radical prostatectomy from October 2021 to August 2022 by the SHURUI single-port robotic surgical system.The demographic and baseline data,surgical,oncological,and functional outcomes as well as follow-up data were recorded.Results The mean operative time was 226.3(standard deviation[SD]52.0)min,and the mean console time was 183.4(SD 48.3)min,with the mean estimated blood loss of 116.3(SD 90.0)mL.The mean length of postoperative hospital stay was 4.50(SD 0.97)days.Two patients had postoperative complications(Clavien-Dindo Grade II),and both patients improved after conservative treatment.All patients’postoperative prostate-specific antigen levels decreased to below 0.2 ng/mL 1 month after discharge.The mean prostate-specific antigen level further decreased to a mean of 0.0219(SD 0.0641)ng/mL 6 months after surgery.Thirty days postoperatively,12 out of 16 patients reported using no more than one urinary pad per day,and all patients reported satisfactory urinary control without the need for pads 6 months after surgery.Conclusion The SHURUI system is safe and feasible in performing radical prostatectomy via both transperitoneal and extraperitoneal approaches.Tumor control and urinary continence were satisfying for patients enrolled in.The next phase involves conducting a large-scale,multicenter randomized controlled trial to thoroughly assess the effectiveness and safety of the new technology in a broader population.

Biochemical recurrence of pathological T2+localized prostate cancer after robotic-assisted radical prostatectomy:A 10-year surveillance

BACKGROUND pT2+prostate cancer(PCa),a term first used in 2004,refers to organ-confined PCa characterized by a positive surgical margin(PSM)without extracapsular extension.Patients with a PSM are vulnerable to biochemical recurrence(BCR)following radical prostatectomy(RP);however,whether adjuvant radiotherapy(aRT)is imperative to PSM after RP remains controversial.This study had the longest follow-up on pT2+PCa after robotic-assisted RP since 2004.Moreover,we discussed our viewpoints on pT2+PCa based on real-world experiences.AIM To conclude a 10-year surveillance on pT2+PCa and compare our results with those of the published literature.METHODS Forty-eight patients who underwent robotic-assisted RP between 2008 and 2011 were enrolled.Two serial tests of prostate specific antigen(PSA)≥0.2 ng/mL were defined as BCR.Various designed factors were analyzed using statistical tools for BCR risk.SAS 9.4 was applied and significance was defined as P<0.05.Univariate,multivariate,linear regression,and receiver operating characteristic(ROC)curve analyses were performed for statistical analyses.RESULTS With a median follow-up period of 9 years,25(52%)patients had BCR(BCR group),and the remaining 23(48%)patients did not(non-BCR group).The median time for BCR test was 4 years from the first postoperative PSA nadir.Preoperative PSA was significantly different between the BCR and non-BCR groups(P<0.001),and ROC curve analysis of preoperative PSA suggested a cutoff value of 19.09 ng/mL(sensitivity,0.600;specificity:0.739).The linear regression analysis showed no correlation between time to BCR and preoperative PSA(Pearson’s correlation,0.13;adjusted R2=0.026).CONCLUSION Robotic-assisted RP in pT2+PCa of worse conditions can provide better BCR-free survival.A surgical technique limiting the PSM in favorable situations is warranted to lower the pT2+PCa BCR rate.Preoperative PSA cut-off value of 19.09 ng/mL is a predictive factor for BCR.Based on our experiences and review of the literature,we do not recommend routine aRT for pT2+PCa.

Robotic assisted radical prostatectomy accelerates postoperative stress recovery: Final results of a contemporary prospective study assessing pathophysiology of cortisol peri-operative kinetics in prostate cancer surgery

Objective:To investigate the effects of prostate cancer(PCa)surgery on the stress system and to identify potential independent factors associating with stress recovery.Methods:The design of the study was prospective and PCa surgery included robot assisted radical prostatectomy(RARP)or retropubic radical prostatectomy(RRP).Between February 2013 to December 2014,315 consecutive patients were evaluated.The effects of PCa surgery on the stress system were measured by cortisol serum levels before and after surgery on postoperative day(POD)0,1,3,5 and 45.Cortisol variations in the population and subpopulation(RARP vs.RRP)of patients were investigated by statistical methods.Factors associating with stress recovery were assessed by simple linear regression(SLR)and multiple linear regression(MLR)analysis.Results:RARP was performed in 75.9%of cases.In the patient population,there were wide serum cortisol perioperative variations.PCa surgery triggered the stress system which immediately(POD 0)responded by cortisol overproduction which induced the negative feedback mechanism that started on POD 1,continued on POD 3,was still ongoing on POD 5 and completely settled on POD 45(stress recovery).In the subpopulation of patients,significantly lower cortisol serum levels were detected on POD 3e5 in RARP cases inwhomcortisol levels were close to preoperative levels(stress recovery)on POD 5.Independent predictive factors of serum cortisol on POD 5(stress recovery)were preoperative cortisol(p Z 0.02),cortisol levels on POD 3(p<0.0001)and RARP(p Z 0.03)in which the association was negative(stress recovery faster than RRP).Conclusion:Our study shows that PCa surgery immediately(POD 0)triggers the stress system which respond by overproduction of cortisol which induces the negative feedback mechanism that starts on POD 1,is still ongoing on POD 5,but is completely settled on POD 45.Moreover,after surgical trauma,our study gives evidence that the RARP procedure associates with stress recovery faster than RRP.Further confirmatory studies are required.

Robotic surgery in giant multilocular cystadenoma of the prostate:A rare case report

BACKGROUND Giant multilocular cystadenoma(GMC)of the prostate gland is a very rare benign tumor.Although the benign nature has been known,complete surgical excision is the major treatment consensus because of its high recurrence rate.We report a rare case of GMC with accompanying lower urinary tract symptoms and repeated urine retention initially thought to be symptoms of benign prostatic hyperplasia,which was treated with robot-assisted laparoscopic radical prostatectomy.CASE SUMMARY A 65-year-old man presented with a 2-year history of lower urinary tract symptoms that had deteriorated gradually within the previous six months,even though he had received treatment with a selective alpha-blocking agent.He had undergone two transurethral resections of the prostate(TURP)at a local hospital during a 4-mo interval because initial ultrasound imaging and prostatic core needle biopsy showed benign prostate hyperplasia.Upon the third recurrence,the patient underwent TURP with a green-light laser at our institution.The diagnosis was a tumor composed of variously sized dilated glandular and cystic structures lined by blended prostatic type epithelia positive for prostate-specific antigen;the final diagnosis was giant multilocular cystadenoma.Magnetic resonance imaging showed a large multilocular retrovesical mass 8.0 cm×7.3 cm×6.4 cm,with heterogeneous enhancement.A coexisting malignant part could not be excluded.Considering the high recurrence rate,risk of coexisting malignancy,and possible sequelae of open surgery for radical excision,the patient decided to undergo robot-assisted radical prostatectomy,with good outcomes at the 2-year follow-up.CONCLUSION Robot-assisted surgery for the treatment of prostate GMC provides another choice for simultaneous attention to disease-control and postoperative quality of life.

Extraperitoneal robot-assisted radical prostatectomy: Comparison with transperitoneal technique

AIM: To determine peri-operative, oncological, functional and safety profiles of extraperitoneal robot-assisted radical prostatectomy(e RARP) vs transperitoneal robot-assisted radical prostatectomy(t RARP) in a single centre.METHODS: A total of 120 consecutive patients underwent 50 e RARP and 70 e RARP operations respectively by the same surgical team. Peri-operative and post-operative outcomes including blood loss, hospitalization, complications(Clavien grade), positive surgical margin(PSM) rates, continence and erectile function were compared. The performance of e RARP required several technical modifications. These included developmentof Retzius' space by balloon insufflation, laparoscopic dissection of lateral extensions of this area; caudal port positioning; cranial digital stripping of peritoneum for sucker port and lodging the bagged prostate specimen adjacent to the lateral assistant port to permit space for urethro-vesical anastomosis.RESULTS: Robotic console times were shorter with e RARP vs t RARP(145.1 min vs 198.3 min, P < 0.0001). There were no significant differences in blood loss, PSM rates(e RARP 17.7% vs t RARP 22%) or complications(e RARP 8.5% vs t RARP 8%). A drain was used in all patients after t RARP and in 25/70 e RARP cases. Length of hospital stay was shorter after e RARP(mean 1.94 d vs 3.6 d, P < 0.0002). There were no differences between techniques in continence or potency at 6 mo. e RARP required several technical modifications: development of Retzius' space by balloon insufflation, laparoscopic dissection of lateral extensions of this area; caudal port positioning; and lodging the bagged prostate specimen adjacent to the lateral assistant port to permit space for urethro-vesical anastomosis.CONCLUSION: e RARP demonstrated advantages in surgical times, hospital stay and equivalence in PSM rates, complications and functional outcomes. e RARP is a useful alternative to t RARP especially in patients with adhesions, pre-existing inguinal hernias, or those unable to withstand steep Trendelenburg position.

Biochemical outcomes after robot-assisted radical prostatectomy in patients with follow-up more than 5-years

In this study, we assessed biochemical outcomes after robot-assisted radical prostatectomy （RARP）. Between July 2005 and November 2007, one hundred and seventy-six consecutive patients treated by RARP without neoadjuvant treatment were included in this study. All procedures were performed by a single surgeon and the median follow-up period was 60 months （interquartile range （IQR）： 59-69）. The median prostate specific antigen was 7.50 ng ml-1 （IQR： 5.14-11.45） and 39.2% of the patients were classified as intermediate risk and 15.3% were classified as high risk; on final pathological examination, 35.2% of the patients had non-organ confined disease and 37.5% and 14.2% had Gleason scores of 7 and 8-10, respectively. The biochemical recurrence （BCR）-free survival rates at 3 and 5 years were 85.6% and 81.2%, respectively. The 5-year BCR-free survival rates stratified by pathologic Gleason scores were 93.1% in Gleason scores of 6 or less, 74.5% in a Gleason score of 7, and 58.1% in Gleason scores of 8 or greater, respectively （P〈0.001）. When stratified by pathologic stage, the BCR-free survival rates were 89.8% in pT2 patients, 66.2% in pT3a patients, and 39.3% in pT3b patients at 5 years following RARP, respectively （P〈0.001）. Preoperative prostate-specific antigen （PSA）, pathologic stage, postoperative Gleason score and surgical margin status were independently associated with BCR in multivariate analysis. In this study, we report biochemical outcomes after RARP with the longest follow-up periods to date in Asian men. We found that robotic surgery provided satisfactory biochemical outcomes, and that RARP is a safe and effective procedure in terms of oncologic outcomes.

Extended lymph node dissection in robot-assisted radical prostatectomy： lymph node yield and distribution of metastases

In this study, we reported our experience performing robotic extended lymph node dissection （eLND） in patients with prostate cancer. A total of 147 patients with intermediate and high-risk prostate cancer who underwent robotic eLND from May 2008 to December 2011 were included in this analysis. The dissection template extended to the ureter crossing the iliac vessels. We assessed lymph node yield, lymph node positivity, and perioperative outcomes. Lymph node positivity was also evaluated according to the number of lymph nodes （LNs） removed （〈22 vs 〉22）. The median number of LNs removed was 22 （11-51）, and 97 positive LNs were found in 24 patients （16.3%）. While the obturator fossa was the most common site for LN metastases （42.3%, 41/97）, the internal iliac area was the most common area for a single positive LN packet （20.8%, 5/24）. Eight patients （33.3%, 8/24） had positive LNs at the common iliac area. The incidence of positive LNs did not differ according to the number of LNs removed. Complications associated with eLND occurred in 21 patients （14.3%） and symptomatic lymphocele was found in five patients （3.4%）. In conclusion, robotic eLND can be performed with minimal morbidity. Furthermore, LN yield and the node positive rate achieved using this robotic technique are comparable to those of open series. In addition, the extent of dissection is more important than the absolute number of LNs removed in eLND, and the robotic technique is not a prohibitive factor for performing eLND.

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.

Three-dimensional automatic artificial intelligence driven augmented-reality selective biopsy during nerve-sparing robot-assisted radical prostatectomy:A feasibility and accuracy study

Objective:To evaluate the accuracy of our new three-dimensional(3D)automatic augmented reality(AAR)system guided by artificial intelligence in the identification of tumour’s location at the level of the preserved neurovascular bundle(NVB)at the end of the extirpative phase of nerve-sparing robot-assisted radical prostatectomy.Methods:In this prospective study,we enrolled patients with prostate cancer(clinical stages cT1ce3,cN0,and cM0)with a positive index lesion at target biopsy,suspicious for capsular contact or extracapsular extension at preoperative multiparametric magnetic resonance imaging.Patients underwent robot-assisted radical prostatectomy at San Luigi Gonzaga Hospital(Orbassano,Turin,Italy),from December 2020 to December 2021.At the end of extirpative phase,thanks to our new AAR artificial intelligence driven system,the virtual prostate 3D model allowed to identify the tumour’s location at the level of the preserved NVB and to perform a selective excisional biopsy,sparing the remaining portion of the bundle.Perioperative and postoperative data were evaluated,especially focusing on the positive surgical margin(PSM)rates,potency,continence recovery,and biochemical recurrence.Results:Thirty-four patients were enrolled.In 15(44.1%)cases,the target lesion was in contact with the prostatic capsule at multiparametric magnetic resonance imaging(Wheeler grade L2)while in 19(55.9%)cases extracapsular extension was detected(Wheeler grade L3).3D AAR guided biopsies were negative in all pathological tumour stage 2(pT2)patients while they revealed the presence of cancer in 14 cases in the pT3 cohort(14/16;87.5%).PSM rates were 0%and 7.1%in the pathological stages pT2 and pT3(<3 mm,Gleason score 3),respectively.Conclusion:With the proposed 3D AAR system,it is possible to correctly identify the lesion’s location on the NVB in 87.5%of pT3 patients and perform a 3D-guided tailored nerve-sparing even in locally advanced diseases,without compromising the oncological safety in terms of PSM rates.

Barbed polyglyconate vs monocryl suture in vesico-urethral anastomosis during robot-assisted radical prostatectomy

AIM: To compare outcomes using barbed polyglyconate(V-Loc 180) vs monofilament monocryl suture in forming vesico-urethral anastomosis(VUA) during robot assisted radical prostatectomy.METHODS: Review of prospectively collected robot assisted radical prostatectomy data between July 2011 and September 2012. VUA technique: VUA was performed using 2 cm × 15 cm 2/0 V-Loc 180 continuous sutures or 3/0 monofilament monocryl sutures. Anastomotic integrity was tested intra-operatively with a water leak test. All patients had a post-operative cystogram at day 7 to 10.RESULTS: There were 189 patients in the study with 113 in the V-Loc group and 76 in the monocryl group. Demographics were similar for both groups P > 0.05). The median operative time for V-Loc group was 130 min and monocryl group was 145 min, which was statistically significant(P < 0.001). The median blood loss for both groups was 200 m L with no significant difference(P = 0.260). The pathology results of the 2 groups were similar(P = 0.537). Four patients in the V-Loc group and two patients in the monocryl group had radiological urinary leak. This was not statistically significant(P = 1.00) and all patients improved with conservative management. The continence rates were comparable for both groups.CONCLUSION: V-Loc suture significantly reduced operative time facilitating ease of VUA formation. Overall functional outcome and urinary morbidity were not significantly different from the monofilament group.

The Impact of Multidisciplinary Care in a Large Volume Robot-Assisted Radical Prostatectomy Program: A Paradoxical Stage Migration toward More Aggressive Disease

Introduction: With the widespread use of robot-assisted radical prostatectomy (RARP), a stage migration to less aggressive prostate cancer (CaP) may be expected in pathological specimens due to over-treatment of low risk disease. It is unclear whether implementation of a multidisciplinary clinic (MDC) model would offset this phenomenon. We sought to analyze our database for possible stage migration in prostatectomy specimens in the setting of MDC. Methods: A total of 262 patients who underwent open prostatectomy (OP) from 2004 to 2006 and 757 patients who underwent RARP from 2007 to 2011 were identified from our prospective database. The implementation of MDC occurred concurrently at the time of RARP initiation. Demographic data, pathology, positive margin rates along with standard CaP reporting data were recorded. The two groups were compared with regards to percentage of cases stratified by Gleason grade. Results: The number of CaP cases managed at our institution increased considerably after the introduction of robotics and MDC. There was a significant decrease in the patients with Gleason 6 CaP undergoing RARP as compared with OP (p = 0.001). Additionally, RARP was performed on a significantly greater percentage of Gleason 7 disease (p < 0.001). When comparing pathological stage, there was a significant increase in the incidence of pT3 disease following RARP (p < 0.0001). Conclusions: The introduction of a MDC and minimally invasive radical prostatectomy did not result in an increased application of surgery for the treatment of low risk prostate cancer. This highlights the importance of MDC in a large volume RARP program.