Supporting evidence for robotic urological surgery

Factors Associated with the Adoption of Minimally Invasive Radical Prostatectomy in the United States

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.

With the current patterns of adoption and use of robotic surgery and improvement in the overall survival of patients with prostate cancer, it is important to evaluate the immediate and long-term cost implications of treatments for patients with prostate cancer. To compare health care costs and use 1 year after open radical prostatectomy (ORP) vs robotic-assisted radical prostatectomy (RARP). This retrospective cohort study used a US commercial claims database from January 1, 2013, to December 31, 2018. A total of 11 457 men aged 18 to 64 years who underwent inpatient radical prostatectomy for prostate cancer and were continuously enrolled with medical and prescription drug coverage from 180 days before to 365 days after inpatient prostatectomy were identified. An inverse probability of treatment weighting analysis was performed to examine the differences in costs and use of health care services by surgical modality. Data analysis was conducted from September 2019 to July 2020. Type of surgical procedure: ORP vs RARP. Three outcomes within 1 year after the inpatient prostatectomy were investigated: (1) total health care costs, including reimbursement paid by insurers and out of pocket by patients; (2) health care use, including inpatient readmission, emergency department, hospital outpatient, and office visits; and (3) estimated days missed from work due to health care use. Of the 11 457 patients who underwent inpatient prostatectomy, 1604 (14.0%) had ORP and 9853 (86.0%) had RARP and most patients (8467 [73.9%]) were aged 55 to 64 years. Compared with patients who underwent ORP, those who received RARP had a higher cost at the index hospitalization (mean difference, $2367; 95% CI, $1821-$2914; P < .001), but similar total cumulative costs were observed within 180 days (mean difference, $397; 95% CI, -$582 to $1375; P = .43) and 1 year after discharge (-$383; 95% CI, -$1802 to $1037; P = .60). One-year postdischarge health care use was significantly lower in the RARP compared with ORP group for mean numbers of emergency department visits (-0.09 visits; 95% CI, -0.11 to -0.07 visits; P < .001) and hospital outpatient visits (-1.5 visits; -1.63 to -1.36 visits; P < .001). The reduction in use of health care services among patients who underwent RARP translated into additional savings of $2929 (95% CI, $1600-$4257; P < .001) and approximately 1.69 fewer days (95% CI, 1.49-1.89 days; P < .001) missed from work for health care visits. Total cumulative cost in this study was similar between ORP and RARP 1 year post discharge; this finding suggests that lower postdischarge health care use after RARP may offset the higher costs during the index hospitalization.

Objective: To examine characteristics of robot-assisted (RARP) and open radical prostatectomy (ORP) patients. Patients and Methods: We relied on the Surveillance, Epidemiology, and End Results-Medicare-linked database and focused on prostate cancer patients between 2008 and 2009. In multivariable logistic regression analyses, we predicted RARP. Results: Of 5,915 patients, 3,476 (58.8%) underwent RARP and 2,439 (41.2%) ORP. Patients within intermediate (OR 1.4, p = 0.01) or highest (OR 1.5, p = 0.02) education strata and those treated by surgeons with a high volume (OR 2.2, p < 0.001) were more likely to undergo RARP. Conversely, those residing in rural areas (OR 0.7, p = 0.005) and those with clinical stage T2 or higher (OR 0.7, p = 0.006) were less likely to undergo RARP. Additionally, patients from the Southwest were less likely to undergo RARP (OR 0.4, p < 0.001), but those from the Northern Plains were more likely to undergo RARP (OR 1.4, p = 0.02) than their counterparts from the East. Finally, RARP patients were neither younger nor healthier than ORP patients. Conclusions: Several patient characteristics such as education, region of residence and population density affect the likelihood of RARP vs. ORP treatment. Similarly, clinical stage and surgeon characteristics also affect the assignment to one or other treatment modality.

Introduction. The learning curve (LC) of radical prostatectomy (RP) is an actual problem in contemporary urology.Objective. To assess the LC of retropubic (rpRP), perineal (plRP), laparoscopic (LRP), and robot-assisted radical prostatectomy (RARP).Materials and methods. The study included 400 patients with localized or locally advanced prostate cancer (T1cT3bN0M0) who underwent rpRP, plRP, LRP or RARP performed by a single surgeon. Exclusion criteria: refusal of surgical treatment, metastatic prostate cancer, primary multiple cancer, neoadjuvant hormonal, radiation or chemotherapy.Results. Progressive improvement of metric indicators was noted in all groups as the surgical technique was mastered. Maximum rates of reaching the plateau of satisfactory functional and early oncological results were demonstrated in the RARP group after 25 – 50 procedures. In terms of the duration of the surgery, the LRP group showed the longest mastering period of 75 – 100 cases. Regression of blood loss volume requires 50 – 75 procedures in the rpRP and LRP groups, and 25 – 50 approaches in the rpRP and RARP groups. RARP demonstrates advantages in the context of minimization of catheterization time and inpatient period (25 – 50 cases). rpRP is not only associated with a maximum amount (n = 30) and frequency (21,0%) of complications, but also with a relatively long period of reaching a plateau of 50 – 75 cases. The stabilization of functional results is proceeding at the maximum pace in the RARP group at 25 – 50 procedures, in the other groups at 50 – 75 cases. Oncological safety (positive surgical margin) in the LRP, rpRP and RARP groups is achievable after 25 – 50 cases, in the rpRP group at 50 – 75 cases.Conclusion. The period of RP mastering depends on surgical approaches. RARP demonstrates the shortest LC duration.

Orgasmic Dysfunction After Robot-assisted Versus Open Radical Prostatectomy

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

We studied perioperative outcomes, postoperative complications, and survival rates for open radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP) and robot-assisted radical prostatectomy (RARP). Taiwan’s entire 2018–2021 National Health Insurance Research Database (NHIRD) was linked with the cancer registration file to conduct a retrospective cohort study. A total of 4883 patients with localized (or locally advanced) prostate cancer (PCa) who underwent ORP, RARP, or LRP from 2018 to 2021 were analyzed. Differences in patient characteristics and perioperative outcomes were assessed before and after inverse probability of treatment weighting (IPTW). RARP accounted for 91.3% of the surgeries, followed by LRP (4.7%) and ORP (4.3%). ORP and LRP were associated with higher blood transfusion rates, longer hospital stays, and ICU admissions compared with RARP. Post-IPTW, RARP exhibited significantly lower rates of perioperative complications and postoperative readmissions compared with ORP and LRP. The postoperative risk profile for RARP was lower compared with those for ORP and LRP.

To determine the effects of laparoscopic radical prostatectomy (LRP), or robot-assisted radical prostatectomy (RARP) compared with open radical prostatectomy (ORP) in men with localized prostate cancer. We performed a comprehensive search using multiple databases (CENTRAL, MEDLINE, EMBASE) and abstract proceedings, with no restrictions on the language of publication or publication status, up until 9 June 2017. We included all randomized or pseudo-randomized controlled trials that directly compared LRP and RARP with ORP. Two review authors independently examined full-text reports, identified relevant studies, assessed the eligibility of studies for inclusion, extracted data and assessed risk of bias. We performed statistical analyses using a random-effects model and assessed the quality of the evidence according to Grading of Recommendations Assessment, Development and Evaluation (GRADE). The primary outcomes were prostate cancer-specific survival, urinary quality of life and sexual quality of life. Secondary outcomes were biochemical recurrence-free survival, overall survival, overall surgical complications, serious postoperative surgical complications, postoperative pain, hospital stay and blood transfusions. We included two unique studies in a total of 446 randomized participants with clinically localized prostate cancer. All available outcome data were short-term (up to 3 months). We found no study that addressed the outcome of prostate cancer-specific survival. Based on one trial, RARP probably results in little to no difference in urinary quality of life (mean difference [MD] -1.30, 95% confidence interval [CI] -4.65 to 2.05; moderate quality of evidence) and sexual quality of life (MD 3.90, 95% CI: -1.84 to 9.64; moderate quality of evidence). No study addressed the outcomes of biochemical recurrence-free survival or overall survival. Based on one trial, RARP may result in little to no difference in overall surgical complications (risk ratio [RR] 0.41, 95% CI: 0.16-1.04; low quality of evidence) or serious postoperative complications (RR 0.16, 95% CI: 0.02-1.32; low quality of evidence). Based on two studies, LRP or RARP may result in a small, possibly unimportant improvement in postoperative pain at 1 day (MD -1.05, 95% CI: -1.42 to -0.68; low quality of evidence) and up to 1 week (MD -0.78, 95% CI: -1.40 to -0.17; low quality of evidence). Based on one study, RARP probably results in little to no difference in postoperative pain at 12 weeks (MD 0.01, 95% CI: -0.32 to 0.34; moderate quality of evidence). Based on one study, RARP probably reduces the length of hospital stay (MD -1.72, 95% CI: -2.19 to -1.25; moderate quality of evidence). Based on two studies, LRP or RARP may reduce the frequency of blood transfusions (RR 0.24, 95% CI: 0.12-0.46; low quality of evidence). Assuming a baseline risk for a blood transfusion to be 8.9%, LRP or RARP would result in 68 fewer blood transfusions per 1,000 men (95% CI: 78-48 fewer). There is no evidence to inform the comparative effectiveness of LRP or RARP compared with ORP for oncological outcomes. Urinary and sexual quality of life appear similar. Overall and serious postoperative complication rates appear similar. The difference in postoperative pain may be minimal. Men undergoing LRP or RARP may have a shorter hospital stay and receive fewer blood transfusions.

Risk and Prevention of Acute Urinary Retention After Robotic Prostatectomy

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

The impact of robot-assisted radical prostatectomy on the use and extent of pelvic lymph node dissection in the “post-dissemination” period

Superior Quality of Life and Improved Surgical Margins Are Achievable with Robotic Radical Prostatectomy After a Long Learning Curve: A Prospective Single-surgeon Study of 1552 Consecutive Cases

Vesicourethral Anastomotic Stenosis After Open or Robot-assisted Laparoscopic Retropubic Prostatectomy—Results from the Laparoscopic Prostatectomy Robot Open Trial

Objectives: Robotic-assisted radical prostatectomy (RARP) has been shown to reduce blood loss, peri-operative complications and length of stay when compared to open radical prostatectomy (ORP). We sought to determine whether the reported benefits of RARP over ORP translate to obese patients. Patients and Methods: We utilized the 2009-2010 Nationwide Inpatient Sample to identify all obese men with prostate cancer who underwent ORP and RARP. Our primary outcome was the presence of a peri-operative adverse event (i.e. blood transfusion, complication, prolonged length of stay). We fit multivariable logistic regression models to examine whether RARP in obese patients was independently associated with decreased odds of all three outcomes. Results: We identified 9,108 obese patients who underwent radical prostatectomy. On multivariable analysis, the use of RARP in the obese population was not independently associated with decreased odds of developing a peri-operative complication (OR = 0.81, CI: 0.58-1.13, p = 0.209). RARP was, however, associated with decreased odds of blood transfusion (OR = 0.17, CI: 0.10-0.30, p < 0.001) and prolonged length of stay (OR = 0.28, CI: 0.20-0.40, p < 0.001). Conclusion: Our findings suggest that in obese patients, the use of RARP may reduce length of stay and blood transfusions compared to ORP. Both approaches, however, are associated with similar odds of developing a complication.