Outcomes of robot-assisted radical prostatectomy with novel robotic platforms vs da Vinci multiport systems: a systematic review and network meta-analysis.

Robotic-assisted radical prostatectomy (RARP) is widely used as the main surgical approach to treat prostate cancer in the United States. Prostate size is often described as a factor affecting the outcomes of RARP as shown by many studies. However, these studies are limited to a small number of patients. To evaluate the functional and oncologic outcomes of RARP in very large prostate sizes. Three hundred and seventy-five RARP patients were divided into two groups according to prostate size: Group 1 had prostates larger than 150 g and Group 2 smaller than 50 g. Perioperative variables were matched with propensity score matching 1:3 and postoperative variables were analyzed for significant differences in outcomes between groups. Variables analyzed included estimated blood loss (EBL), operative time, catheter time, hospitalization time, postoperative complications, pathological staging, positive surgical margins (PSM) rates, biochemical recurrence (BCR), potency, and continence rates. The two groups exhibited similar preoperative characteristics. Patients with larger prostates (Group 1) were more likely to have higher blood loss (EBL), longer console time, and more days with catheter. However, we could not find significant difference in the overall postoperative complications (Clavien-Dindo). Pathological outcomes were also statistically different as patients with larger prostates had (69.7%) more pT2 disease and (12.1%) lower rates of PSM. Finally, we could not find significant difference in the functional outcomes between the groups. The results demonstrate that prostate size impacts multiple outcomes. Larger prostates had lower-grade disease, reduced EPE and PSM rates, with no significant differences in BCR or functional outcomes. Perioperative differences, such as increased blood loss and console time, were also observed.

Since the introduction of the da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA, USA), the trend of minimally invasive surgery has accelerated. Recently, Intuitive Surgical launched the new da Vinci Xi platform and a prototype of a single-port surgical system. Other platforms from other robotic companies are on the horizon. The multiport surgical robotic ALF-X system (SORAR SpA, Milan, Italy) was initially introduced for gynecological surgery and was recently assessed in a preclinical animal study of robot-assisted partial nephrectomy (RPN) [1,2]. The ALF-X robot consists of a remote-controlled unit with a haptic handle, a three-dimensional high-definition monitor, an infrared eye-tracking system, and four detached robotic arms. The haptic feedback allows the surgeon to feel the force and resistance to the tissue. The surgeon can move the camera by gaze, and the system includes a large set of reusable instruments. Other manufacturers include Medrobotics (Raynham, MA, USA), which received U.S. Food and Drug Administration clearance for the Flex Robotic System in July 2015. The Flex Robotic System provides surgeons with single-site access visualization of hard-to-reach anatomical locations. Titan Medical (Toronto, ON, Canada) is a public company based on Single Port Orifice Robotic Technology. The system utilizes a 25-mm single-access port that contains two articulating instruments and a three-dimensional high-definition camera. The Korean domestic manufacturer Meree Company has developed the REVO I robot system. A clinical trial for the REVO I robot has been planned to supplement the global market. Meanwhile, the Korean national evidence-based health care collaborating agency (NECA) published a preliminary report on the clinical feasibility and cost-effectiveness of robot-assisted radical prostatectomy (RARP) from a total of five high-volume centers to provide fundamental data for instituting the national health policy. Concerning oncological outcomes, there were no significant differences in biochemical recurrence or the positive surgical margin rate. Concerning functional outcomes, RARP revealed the highest continence rate of 88.7% and 95.3% achievement of complete continence at postoperative 3 months and 3 years, respectively. Concerning cost analysis of the robotic system, with a threshold value of 30.5 million Korean won (KRW; 27,000 US dollars [USD]), a cost-effectiveness analysis of purchase among RARP, laparoscopic radical prostatectomy, and open radical prostatectomy (ORP) showed that RARP was not yet cost-effective. RARP could be cost-effective if the expenses could be reduced by 8.3 million KRW (7,400 USD). The effectiveness of the system could not offset the costs, because there was no significant difference in effectiveness among the different procedures, and the robotic cost of RARP was significantly more than that of the other procedures. However, owing to the short term of 1 year of data used for the cost-effectiveness analysis, long-term prospective study is necessary for further high-quality analysis. Recently, high-quality evidence is emerging comparing robotics with its traditional counterparts. In a study of RARP, Wallerstedt et al. [3] performed a prospective comparative trial of ORP versus RARP in a Swedish group of 14 centers including a total of 2,506 patients. The study was conducted prospectively over a 3-year period with patient-reported outcome measurement. The RARP group had less perioperative bleeding and shorter hospital stays. Reoperation during the hospital stay and seeking health care for cardiovascular reasons were more frequent after ORP. Haglind et al. [4] performed a prospective, controlled, nonrandomized trial evaluating urinary incontinence and erectile dysfunction in a total of 14 centers in Sweden including 2,625 patients and concluded that RARP was beneficial in preserving erectile function compared with ORP, with no statistically significant differences in continence or surgical margins. In an analysis of RPN, Choi et al. [5] performed a systematic review and meta-analysis of 23 studies and 2,240 patients. The authors concluded that RPN is more favorable than laparoscopic partial nephrectomy (LPN) in terms of a lower conversion rate to radical nephrectomy, more favorable renal function, a shorter length of hospital stay, and a shorter warm ischemia time. Potretzke and Bhayani [6] wrote an editorial comment on our previous article [5]. The authors mentioned the superior outcomes of RPN and the efficiency of excision and suturing. The true value of RPN is in its feasibility, accessibility, and learning curves, and the procedure competing with RPN now is not LPN, but rather radical nephrectomy, ablation, and observation. There will be more new robotic platforms, and new prospective randomized data will become available. The Korean Journal of Urology hopes to continue to share this knowledge on recent updates in robotic minimally invasive surgery and to enhance future perspectives on robotic minimally invasive surgery.

Objective To explore the influencing factors and correlation of positive surgical margin (PSM) and biochemical recurrence (BCR) in men after robot-assisted radical prostatectomy (RALP). Methods The clinical data of 190 patients with local or locally advanced prostate cancer who underwent RALP by single surgeon in the Department of Urology of Changhai Hospital from January 2016 to September 2017 were collected. Age was (67.5±6.9) years old; median body mass index (BMI), preoperative PSA, prostate weight were 24.2 kg/m2 (16.6-34.2 kg/m2), 15.0 ng/ml (1.41-393.94 ng/ml) and 36.9 g (8.65-207.58 g) respectively. The group of surgical margin was divided into negative surgical margin, apex-only PSM, base-only PSM as well as apex and base PSM. Characteristics between patients stratified by surgical margin or BCR were compared using χ2 test. The influencing factors of PSM were analyzed by logistic regression. Cox regression was used for the analysis of predictive factors of BCR. Log-rank test and Kaplan-Meier curves were used for comparing the BCR rate between the groups of surgical margin. Results Of all the 190 enrolled patients, total PSM rate was 24.7% (47/190), apex-only PSM rate was 13.2 % (25/190), base-only PSM rate was 5.8% (11/190), apex and base PSM rate was 5.8 % (11/190). Multivariate analysis showed the independent predictive factors influencing PSM were preoperative PSA (P=0.048) and pathological stage (P=0.004 ). The median follow-up period was 7.3 months (0.9-26.6 months) and BCR happened in 19.5% (37/190) patients. The rates of BCR were 15.4% (22/143), 16.0% (4/25), 27.3% (3/11) and 72.7% (8/11) in the patients with negative surgical margin, apex-only PSM, base-only PSM and both apex and base PSM respectively. Log-rank test revealed that the rate of BCR in patients with apex and base PSM was higher than that in patients with negative surgical margin (P<0.001) or patients with apex-only PSM(P=0.002). Cox analysis indicated that higher preoperative PSA (P=0.040), higher pathological stage (P=0.041) and higher pathological Gleason score (P=0.004) were the independent predictors of BCR. PSM was not a predictive factor of BCR (P=0.257). Conclusions Preoperative PSA and pathological stage are the influencing factors of PSM. Higher preoperative PSA, higher pathological stage and higher pathological Gleason Score are the predictive factors of BCR. PSM may not be a predictive factor of BCR. The relationship between PSM and BCR needs further study. Key words: Prostatic neoplasms; Radical prostatectomy; Robot; Positive surgical margin; Biochemical recurrence

Systematic Review and Meta-analysis of Studies Reporting Oncologic Outcome After Robot-assisted Radical Prostatectomy

Aim To assess the effects of nerve sparing (NS) on recovery of urinary continence, oncological outcome, and positive surgical margin (PSM) rates in patients undergoing robotic-assisted radical prostatectomy (RARP). Method Retrospective analysis of patients who underwent RARP between January-December 2017 at a single high- volume centre was undertaken. Urinary continence and symptoms according to different NS types (Non-NS, Unilateral, Bilateral) at 2, 6, 12, and 24 months were collated. COX proportional hazards model and Kaplan-Meier were used to correlate NS type with achievement of a dry-state; pad-free state; and oncological outcome defined by biochemical (PSA) recurrence (BCR), over 2 years follow-up. PSM occurrence was compared in non-nerve spared versus nerve spared prostate lobes. Results 241 patients underwent full analysis, Non-NS = 30 (12%), Unilateral = 84 (35%), Bilateral = 127 (53%). Comparing each NS cohort, there was no significant difference in the Mean (±SD) number of pads used per day, or rates-of-dryness at all time points during follow-up. Both COX-regression and Kaplan-Meier analyses found no significant association between any NS-type and biochemical recurrence or final achievement of continence. There was no significant risk association between NS-type and PSM rate, or significant difference in the rate of PSM between lobes that were nerve spared or not. Conclusions The degree of nerve sparing does not appear to enhance post-RARP continence recovery and is not associated with worse oncological outcomes, studied as positive surgical margin rates and biochemical recurrence at all time points up to 2 years of follow-up.

Anterior versus posterior first approach for robot assisted radical prostatectomy-perioperative, functional, and oncological outcomes.

BACKGROUND: Robot-assisted radical prostatectomy (RARP) offers advantages over open and laparoscopic approaches, including superior visualization and enhanced surgeon ergonomics. This study analyzed the short-term outcomes of the first RARP performed at the N.N. Petrov National Medical Research Center of Oncology, comparing them with laparoscopic radical prostatectomy (LRP). AIM: To compare the outcomes of RARP and LRP in patients with clinically localized prostate cancer of low and favorable intermediate risk. MATERIALS AND METHODS: The study included patients who underwent radical prostatectomy (RP) for localized prostate cancer of low and favorable intermediate risk (according to the NCCN classification) between 2022 and 2023. The final cohort consisted of 49 patients who underwent LRP and 58 patients who underwent RARP. RESULTS: There were no significant differences between the groups in the incidence of early postoperative complications. However, positive surgical margins were significantly more frequent in the RARP group (51.7%) than in the LRP group (20.4%). Urethral catheter removal occurred earlier in the LRP group (median: 4 days) than in the RARP group (median: 6 days). At six months postoperatively, erectile function, including with conservative therapy, was preserved in 36.4% of patients after RARP and in 21.4% after LRP (χ2 = 0.202). Severe urinary incontinence was observed in 3.5% of patients in the LRP group and 12.5% in the RARP group (χ2 = 0.249). CONCLUSIONS: The study demonstrated a significantly lower rate of positive surgical margins following LRP compared to RARP. However, it should be noted that the RARP group included patients operated on at the N.N. Petrov National Medical Research Center of Oncology during the initial implementation of this technique, which may have influenced the outcomes. Further studies are required.

A clinical evaluation of robotic-assisted radical prostatectomy (RARP) in located prostate cancer: A systematic review and network meta-analysis

Introduction: We sought to update our experience of oncologic and functional outcomes of robot-assisted radical prostatectomy (RARP) for prostate cancer in patients with history of holmium laser enucleation of the prostate (HoLEP). Patients and Methods: Twenty-seven patients with previous HoLEP who underwent RARP were matched 1:1 with RARP patients with no history of transurethral surgery. Demographic, operative, oncologic, continence, and erectile function outcomes were analyzed. Results: Median time between HoLEP and RARP was 31 months with a mean prostate-specific antigen doubling time of 4.28 ng/mL/year. Operative times were significantly longer with higher bladder neck reconstruction rates and similarly low complication rates. Biochemical recurrence was relatively low (7%) in the HoLEP group, identical to the comparative group. Continence at last follow-up was not statistically significant between groups, although time to continence favored the non-HoLEP cohort. Erectile function recovery was generally poor in the post-HoLEP cohort (11%), although bilateral nerve sparing was rarely performed (11%). Compared with our initial experience, there were significant improvements in time to continence (16 vs 36 weeks). No T2 post-HoLEP RARP since 2010 has had a positive surgical margin. Conclusions: Post-HoLEP prostatectomy remains feasible with similar perioperative and oncologic outcomes compared with matched cohorts. Functional recovery remains slowed yet may continue to improve with technical familiarity.

PurposeDespite the large number of analytical reports regarding the learning curve in the transition from open to robot-assisted radical prostatectomy (RARP), few comparative results with laparoscopic radical prostatectomy (LRP) have been reported. Thus, we evaluated operative and postoperative outcomes in RARP versus 100 simultaneously performed LRPs.Materials and MethodsA single surgeon had performed more than 1,000 laparoscopic operations, including 415 cases of radical nephrectomy, 85 radical cystectomies, 369 radical prostatectomies, and treatment of 212 other urological tumors, since 2009. We evaluated operative (operation time, intraoperative transfusion, complications, hospital stay, margin status, pathological stage, Gleason score) and postoperative (continence and erectile function) parameters in initial cases of RARP without tutoring compared with 100 recently performed LRPs.ResultsMean operation time and length of hospital stay for RARP and LRP were 145.5±43.6 minutes and 118.1±39.1 minutes, and 6.4±0.9 days and 6.6±1.1 days, respectively (p=0.003 and p=0.721). After 17 cases, the mean operation time for RARP was similar to LRP (less than 2 hours). Positive surgical margins in localized cancer were seen in 11.1% and 8.9% of cases in RARP and LRP, respectively (p=0.733). At postoperative 3 months, sexual intercourse was reported in 14.0% and 12.0%, and pad-free continence in 96.0% and 81.0% in patients with RARP and LRP, respectively (p=0.796 and p=0.012).ConclusionsPrevious large-volume experience of LRPs may shorten the learning curve for RARP in terms of oncological outcome. Additionally, previous experience with laparoscopy may improve the functional outcomes of RARP.

75 Background: High-risk prostate cancer (PCa) is associated with greater risk of biochemical recurrence and cancer specific lethality. A multi-modal treatment is required for this group of patients, comprising surgery as part of it. However, the role of surgery as monotherapy is still under investigation. The purpose of this study is to analyze the influence of surgical margins on biochemical recurrence (BCR) among patients with high-risk prostate cancer (PCa) treated with robot assisted radical prostatectomy (RARP) since the start of our robotic program. Methods: We retrospectively analyzed our prospectively collected database of 5695 minimally invasive prostatectomies performed between 2000 and 2015. Clinical, pathological and oncological outcomes were evaluated in patients fulfilling Damico´s high risk characteristics. Primary endpoint was BCR, defined as post-operative PSA ≥ 0,2. Patients with neoadjuvant or adjuvant therapy were excluded. BCR was estimated with Kaplan-Meier curves. Cox proportional hazards regression was used to estimate variables associated with BCR. Results: We identified 199 high-risk PCa patients treated with RARP during the study period. Gleason score ≥ 8, PSA ≥ 20 and clinical stage ≥ T2c were present in 44%, 35% and 11% of the patients, respectively. The rate of positive surgical margins was 25%. With a median follow-up of 23 months (interquartile 12 – 34 months), 31% of the patients had BCR. Five-year BCR-free survival was 34,5%. Gleason score ≥ 8, PSA ≥ 20 and positive surgical margins were not predictors of BCR. A positive correlation of pathological stage ≥ T3 and BCR was found with (HR = 2.9; 95% CI = 1.2-6.9). Conclusions: The 5-years BCR-free survival was poor despite a low rate of positive surgical margins, when compared to historical series. We found that pathological stage ≥ T3 has a significant correlation with the BCR and that negative surgical margins do not assure good prognosis for high-risk patients.

BackgroundObesity (BMI ≥ 35 kg/m2) is a growing global health concern and presents technical challenges during robot-assisted radical prostatectomy (RARP). Despite increasing prevalence, limited data exist on surgical and oncological outcomes of RARP in severely obese patients, especially in the United Kingdom. This study evaluates the safety and efficacy of RARP in this population using a matched-pairs analysis.MethodsWe conducted a retrospective review of 1,273 patients undergoing RARP between January 2018 and June 2021. Forty-three patients with BMI ≥ 35 kg/m2 were matched 1:1 with patients having BMI < 35 kg/m2 based on PSA, Gleason grade, clinical stage, D’Amico risk, and nerve-sparing status. Perioperative outcomes, 1-year continence rates, and biochemical recurrence (BCR) were assessed. Statistical analyses included Wilcoxon rank-sum and logistic regression (P < .05 considered significant).ResultsBoth groups were comparable in PSA, tumor stage, grade, and nerve-sparing, though the higher BMI group was younger (P < .001). No significant differences were observed in console time (P = .20), blood loss (P > .90), complications, or BCR at 1-year follow-up (P > .90). Continence rates at 1 year were equivalent across both cohorts. Multivariable logistic regression identified age (P < .001) and nerve-sparing extent (P = .038) as independent predictors of continence recovery; BMI was not a significant factor.ConclusionsRARP in patients with BMI ≥ 35 kg/m2 is safe and yields similar functional and oncological outcomes compared to non-obese counterparts when performed in experienced centers. High BMI alone should not exclude patients from surgical treatment of localized prostate cancer.

Comparison of surgical approaches to radical prostatectomy in our series beyond oncological and functional outcomes

Does Presence of a Median Lobe Affect Perioperative Complications, Oncological Outcomes and Urinary Continence Following Robotic-assisted Radical Prostatectomy?

Robot-assisted radical prostatectomy (RARP) is a rising minimally invasive treatment of localized prostate cancer (PC). We present our multicenter experience of 1,499 consecutive cases with an analysis of complication rates, oncologic, and functional outcomes. From March 2005 through December 2012, details of 1,499 patients were retrospectively analyzed. Transperitoneal approach using a da-Vinci robotic system was used to perform RARP. Perioperative characteristics and postoperative oncologic and functional outcomes are reported. The mean age was 61.3 years (37-77). Mean PSA level was 8.3 ng/ml. According to D'Amico classification, the percentage of patients with low-, intermediate-, and high-risk disease cases were 65.0, 30.1, and 4.8 %, respectively. Mean operative time was 181.9 min. Mean estimated blood loss was 225.4 cc (30-1,250). Positive surgical margin (PSM) was detected in 212 (14.1 %) patients. PSM rates in pT2, pT3, and pT4 stages were 6.1, 37.1, and 100 %, respectively. The overall complication rate due to modified Clavien classification was 6.1 %. Mean follow-up time was 26.7 months. Continence, potency, and biochemical recurrence rates were 88.7, 58.2, and 2.9 %, respectively. Our analyses including high-volume centers, which is the first largest series in Turkey, show that RARP is a safe procedure, has low PSM rates, high continence, and potency rates for the treatment of localized PC at experienced centers.