Reconstruction of the ligamentous apparatus of the lower pelvis in robot-assisted radical prostatectomy as a stage of the learning curve

Objective of the study. To evaluate results of robot-assisted laparoscopic radical prostatectomy in the framework of a surgeon’s learning curve; to evaluate the effect of reconstruction of the ligamentous apparatus of the lower pelvis on early recovery of urine retention.Materials and methods. 246 patients were divided into 3 groups depending on the surgery date. The analyzed data was accumulated prospectively and retrospectively. Preoperative characteristics (TNM stage, PSA, ISUP), intraoperative characteristics (surgical time, blood loss volume, surgery type and character, type of reconstruction of the ligamentous apparatus of the lower pelvis) and postoperative characteristics (duration of bladder drainage with a urethral catheter, level and time of recovery for urine retention and erectile function) were evaluated. Reconstruction of the ligamentous apparatus of the lower pelvis was performed through reconstruction of the Denonvillier fascia (Rocco stitch), as well as through suturing fibers of the bladder neck with periurethral tissues and residual puboprostatic ligaments for stabilization of the urethrovesical complex.Results. All operations were successfully completed without conversions or transfusions. Median surgical time was 160 minutes (p = 0.0001). Median blood loss was 173.3 cm3 (p = 0.0002). Mean prostatic volume was 36 cm3 (29–47.5 cm3), and overall frequency of positive surgical margin was 12.82 %. Overall frequency of urine retention recovery was 51.6 % after 3 months, 63.7 % after 6 months (p >0.05). In the patient group with reconstruction of the ligamentous apparatus of the lower pelvis, frequency of urine retention recovery was higher than in the group without reconstruction: 64.1 % vs 45.3 % (after 3 months, р = 0.041) and 74.7 % vs 62.3 % (after 6 months, р = 0.034). Conclusion. Surgical time, blood loss were significantly decreased with the number of performed operative interventions. Significant improvement of early urine retention recovery was observed in the patient group with reconstruction of the ligamentous apparatus of the lower pelvis.

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Positive surgical margin rates during the robot-assisted laparoscopic radical prostatectomy learning curve of an experienced laparoscopic surgeon

Canadian Urological Association Journal ◽

10.5489/cuaj.4588 ◽

2017 ◽

Vol 11 (11) ◽

pp. E409-13 ◽

Cited By ~ 2

Author(s):

Anthony F. Adili ◽

Julia Di Giovanni ◽

Emma Kolesar ◽

Nathan C. Wong ◽

Jen Hoogenes ◽

...

Keyword(s):

Radical Prostatectomy ◽

Learning Curve ◽

Surgical Margin ◽

Margin Status ◽

Laparoscopic Radical Prostatectomy ◽

Positive Surgical Margin ◽

Robot Assisted ◽

Estimated Blood Loss ◽

The Mean ◽

The Impact

Introduction: Since its introduction, robot-assisted laparoscopic radical prostatectomy (RARP) has gained widespread popularity, but is associated with a variable learning curve. Herein, we report the positive surgical margin (PSM) rates during the RARP learning curve of a single surgeon with significant previous laparoscopic radical prostatectomy (LRP) experience.Methods: We performed a prospective cohort study of the first 400 men with prostate cancer treated with RARP by a single surgeon (BS) with significant LRP experience. Our primary outcome was the impact of case timing in the learning curve on margin status. Our analysis was conducted by dividing the case numbers into quartiles (Q1‒Q4) and determining if a case falling into an earlier quartile had an impact on margin status relative to the most recent quartile (Q4).Results: The Q1 cases had an odds ratio for margin positivity of 1.74 compared to Q4 (p=0.1). Multivariate logistic regression did not demonstrate case number to be a significant predictor of PSM. The mean Q1 operative time was 207.4 minutes, decreasing to 179.2 by Q4 (p<0.0001). The mean Q1 estimated blood loss was 255.1 ml, decreasing to 213.6 by Q4 (p=0.0064). There was no change in length of hospitalization within the study period.Conclusions: Even when controlling for copredictors, a statistically significant learning curve for PSM rate of a surgeon with significant previous LRP experience was not detected during the first 400 RARP cases. We hypothesize that previous LRP experience may reduce the RARP PSM learning curve.

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The role of bedside assistant during robot assisted radical prostatectomy: Is more experience better? Analysis on perioperative and clinical outcomes

Urologia Journal ◽

10.1177/0391560320951085 ◽

2020 ◽

pp. 039156032095108

Author(s):

Mario Salvatore Mangano ◽

Claudio Lamon ◽

Francesco Beniamin ◽

Alberto De Gobbi ◽

Matteo Ciaccia ◽

...

Keyword(s):

Radical Prostatectomy ◽

Blood Loss ◽

Clinical Outcomes ◽

Operative Time ◽

Surgical Margin ◽

Positive Surgical Margin ◽

Robot Assisted ◽

Estimated Blood Loss ◽

Bedside Assistant ◽

The Impact

Objectives: To analyze the impact of the bedside assistant’s experience during RARP. It is believed that the outcome of robotic surgery during Robot Assisted Radical Prostatectomy (RARP) for prostate cancer depends not only on the console surgeon’s experience. Materials and Methods: All consecutive RARPs from January 2017 to March 2018 were sourced from a prospectively maintained database. All cases were performed by the same surgeon. He was supported by three bedside assistants: one with bedside and console experience, one only with relevant bedside experience, one basically inexperienced. The patient’s parameters analyzed: age, Body Mass Index (BMI), previous abdominal surgery, prostate volume (by TRUS), pre-operative PSA, bioptic grading. Surgical outcomes analyzed included skin-to-skin operative time and estimated blood loss; clinical outcomes included length of hospital stay and time to catheter removal; the oncological outcome was represented by positive surgical margin rate. Results: A total of 116 RARPs were identified: 38 RARPs were performed with the console experienced bedside assistant, 38 with the experienced one, 40 with the novice one. The variables were similar between the three groups. As far as outcomes are concerned, there were no statistically significant differences between the three bedside assistants in terms of operative time, estimated blood loss, length of stay, days of catheterization, positive surgical margin rate.

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Laparoscopic Radical Prostatectomy: The Learning Curve of a Low Volume Surgeon

The Scientific World JOURNAL ◽

10.1155/2013/974276 ◽

2013 ◽

Vol 2013 ◽

pp. 1-5 ◽

Cited By ~ 4

Author(s):

Anuar I. Mitre ◽

Mario F. Chammas ◽

José Eugênio A. Rocha ◽

Ricardo Jordão Duarte ◽

Gustavo Xavier Ebaid ◽

...

Keyword(s):

Radical Prostatectomy ◽

Blood Loss ◽

Learning Curve ◽

Operative Time ◽

Surgical Margin ◽

Positive Surgical Margin ◽

Estimated Blood Loss ◽

Group A ◽

Low Volume ◽

Group B

Objective. Analyze the learning curve for laparoscopic radical prostatectomy in a low volume program.Materials and Methods. A single surgeon operated on 165 patients. Patients were consecutively divided in 3 groups of 55 patients (groups A, B, and C). An enhancement of estimated blood loss, surgery length, and presence of a positive surgical margin were all considered as a function of surgeon’s experience.Results. Operative time was 267 minutes for group A, 230 minutes for group B, and 159 minutes for group C, and the operative time decreased over time, but a significant difference was present only between groups A and C (). Mean estimated blood loss was 328 mL, 254 mL, and 206 mL (). A conversion to open surgery was necessary in 4 patients in group A. Positive surgical margin rates were 29.1%, 21.8%, and 5.5% (). Eight patients in group A, 4 patients in group B, and one in group C had biochemical recurrence.Conclusion. Significantly less intraoperative complications were evident after the first 51 cases. All other parameters (blood loss, operative time, and positive surgical margins) significantly decreased and stabilized after 110 cases. Those outcomes were somehow similar to previous published series by high-volume centers.

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Analysis of Learning Curve in Robot-Assisted Radical Prostatectomy Performed by a Surgeon

Advances in Urology ◽

10.1155/2020/9191830 ◽

2020 ◽

Vol 2020 ◽

pp. 1-7

Author(s):

Roman I. Slusarenco ◽

Konstantin V. Mikheev ◽

Artem O. Prostomolotov ◽

Roman B. Sukhanov ◽

Evgeny A. Bezrukov

Keyword(s):

Radical Prostatectomy ◽

Blood Loss ◽

Learning Curve ◽

Erectile Function ◽

Learning Curves ◽

Positive Surgical Margin ◽

Robot Assisted ◽

Function Recovery ◽

Group 3 ◽

Group 1

This study aimed to report the learning curve in robot-assisted radical prostatectomy (RARP) performed by one surgeon who is experienced in laparoscopic prostatectomies. The records of 145 RARP cases performed between 2015 and 2017 were evaluated retrospectively. Patients were divided into three groups: group 1 comprised the first 49 cases, group 2 comprised 50–88 cases, and the rest of the cases were assigned to group 3. Continence was defined as the necessity to use at least one pad during a day. Additionally, erectile function recovery was defined as having erection sufficient for sexual intercourse regardless of using a phosphodiesterase type 5 inhibitor. Continence and erectile function recovery were assessed during interviews at 3, 6, and 12 months after surgery. First, all procedures were successfully performed without conversions or blood transfusions. The median follow-up period was 22 months. Moreover, the median skin-to-skin operative time (OT) was 220 minutes. The median blood loss was 150 ml, and the mean hospital stay was 8.9 ± 3.87 days. The median prostate volume was 36 cm³. The overall positive surgical margin rate was 13.1%. Overall, 38 (26.2%) postoperative complications were observed, and 17.9% of them were graded as minor. Anastomotic leakage decreased significantly from group 1 to group 3 (26.5% and 7%, respectively). The continence recovery (0-1 pad) rates were 60.6%, 75.7%, and 84.9% at 3, 6, and 12 months after surgery, respectively. Subsequently, the erectile function recovery rates were 50.9% and 65.4% at 6 and 12 months after surgery, respectively. In conclusion, there are several types of learning curves for RARP. First, the shallowest learning curve was observed for the OT. Regarding the analysis of “advanced learning curve,” demonstrating the improvement of OT and blood loss is considered insufficient. Therefore, additional oncological and functional results that require a longer period of investigation are required.

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Prediction of a positive surgical margin and biochemical recurrence after robot-assisted radical prostatectomy

Scientific Reports ◽

10.1038/s41598-021-93860-y ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Ching-Wei Yang ◽

Hsiao-Hsien Wang ◽

Mohamed Fayez Hassouna ◽

Manish Chand ◽

William J. S. Huang ◽

...

Keyword(s):

Radical Prostatectomy ◽

Biochemical Recurrence ◽

Multivariable Analysis ◽

Specific Antigen ◽

Surgical Margin ◽

Asian Population ◽

Nerve Sparing ◽

Positive Surgical Margin ◽

Robot Assisted ◽

Surgeon Experience

AbstractThe positive surgical margin (PSM) and biochemical recurrence (BCR) are two main factors associated with poor oncotherapeutic outcomes after prostatectomy. This is an Asian population study based on a single-surgeon experience to deeply investigate the predictors for PSM and BCR. We retrospectively included 419 robot-assisted radical prostatectomy cases. The number of PSM cases was 126 (30.1%), stratified as 22 (12.2%) in stage T2 and 103 (43.6%) in stage T3. Preoperative prostate-specific antigen (PSA) > 10 ng/mL (p = 0.047; odds ratio [OR] 1.712), intraoperative blood loss > 200 mL (p = 0.006; OR 4.01), and postoperative pT3 stage (p < 0.001; OR 6.901) were three independent predictors for PSM while PSA > 10 ng/mL (p < 0.015; hazard ratio [HR] 1.8), pT3 stage (p = 0.012; HR 2.264), International Society of Urological Pathology (ISUP) grade > 3 (p = 0.02; HR 1.964), and PSM (p = 0.027; HR 1.725) were four significant predictors for BCR in multivariable analysis. PSMs occurred mostly in the posterolateral regions (73.8%) which were associated with nerve-sparing procedures (p = 0.012) while apical PSMs were correlated intraoperative bleeding (p < 0.001). A high ratio of pT3 stage after RARP in our Asian population-based might surpass the influence of PSM on BCR. PSM was less significant than PSA and ISUP grade for predicting PSA recurrence in pT3 disease. Among PSM cases, unifocal and multifocal positive margins had a similar ratio of the BCR rate (p = 0.172) but ISUP grade > 3 (p = 0.002; HR 2.689) was a significant BCR predictor. These results indicate that PSA and pathological status are key factors influencing PSM and BCR.

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Does transition from standard to Retzius-sparing technique in robot-assisted radical prostatectomy affect the functional and oncological outcomes?

Archivio Italiano di Urologia e Andrologia ◽

10.4081/aiua.2021.4.399 ◽

2021 ◽

Vol 93 (4) ◽

pp. 399-403

Author(s):

Hakan Anıl ◽

Kaan Karamık ◽

Ali Yıldız ◽

Murat Savaş

Keyword(s):

Radical Prostatectomy ◽

Learning Curve ◽

Surgical Margin ◽

Nerve Sparing ◽

Robot Assisted ◽

Continence Status ◽

Oncological Results ◽

Group 2 ◽

Group 1

Objective: To appraise the outcomes on the Retzius-sparing robot-assisted radical prostatectomy (Rs-RARP) learning curve of a surgeon with previous experience of anterior (standard) RARP. Materials and methods: The first 50 cases during the Rs-RARP learning curve (group 1) and 50 cases after the second 100 cases with the standard approach (group 2) were comprised in the study. Patients who used zero or one safety pads were considered continent. Erectile function recuperation was characterized as the competence to achieve penetrative intercourse without receiving any medication. All patients were reevaluated at two weeks, first, third, sixth, and 12th months after surgery using IIEF-5, PSA level, and continence status. Results: Immediate continence rates following catheter removal were 32/50 (64%) in Rs-RARP group and 26/50 (52%) in S-RARP group (p = 0.224). The continence recovery rate was 48/50 (96%) in Rs-RARP group and 46/50 (92%) in the S-RARP group at 12 months follow-up (p = 0.400). Total nerve-sparing surgery was enforced in 36/50 (72%) patients for group 1 and 35/50 (70%) patients for group 2. Potency recovery was 27/43 (62.8%) in Rs-RARP and 30/44 (68.2%) for S-RARP at 12 months follow up (p = 0.597). Surgical margin positivity was detected in 6/50 (12%) cases in the Rs-RARP group and in 4/50 (8%) cases in the S-RARP (p = 0.444). Conclusions: Functional and oncological results are not negatively affected in the first 50 cases for a surgeon who is experienced in S-RARP before transition to the Rs-RARP method.

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