The effect of the presence of a median lobe on the outcomes of robot-assisted laparoscopic radical prostatectomy

Aim: To report the effect of the presence of a median lobe on perioperative outcomes, positive surgical margin (PSM) rates and short-term urinary continence outcomes after robotassisted laparoscopic radical prostatectomy (RARP). Patients and Methods: We analyzed data from 1,693 consecutive patients who underwent RARP by a single surgeon for treatment of clinically localized prostate cancer. Patients were categorized into two groups based on the presence or absence of a median lobe identified during RARP. Outcomes analyzed included operative time, estimated blood loss (EBL), nervesparing procedure, overall complication rates, length of hospital stay, days with catheter, presence of anastomotic leakage on cystogram, number of bladder neck reconstruction procedures, tumor volume, pathological stage, PSM rates, pathological Gleason score and continence rates. Continence was defined as the use of \u2018no pads\u2019 based on the patient responses to the Expanded Prostate Cancer Index Composite questions at 1, 4, 6, 12 and 24 weeks after catheter removal. Results: Median lobe was intraoperatively identified in 323 (19%) patients. Patients with a median lobe were slightly older (median 63 vs. 60 years, p<0.001), had higher PSA levels (median 5.7 vs. 4.7 ng/ml, p<0.001) and higher AUA-SS before RARP (10 vs. 6, p<0.001). The number of bladder neck reconstruction procedures (93.5% vs. 65.7%, p<0.001) and the median prostate weight (64 vs. 46 g, p<0.001) were also higher. Both groups had equivalent EBL, length of hospital stay, days with catheter, pathological stage, pathological Gleason score, nerve-sparing procedures, complication rates, anastomotic leakage rates, mean tumor volume, PSM rates and PSM rate at the bladder neck. The median OR time was slightly greater in patients with median lobe (80 vs. 75 minutes, p<0.001). There was no difference in the operative time between the two groups when stratifying this result by prostate weight. Continence rates were also equivalent between patients with and without a median lobe at 1 week (27.8% vs. 27%, p=0.870), 4 weeks (42.3% vs. 48%, p=0.136), 6 weeks (64.1% vs. 69.5%, p=0.126), 12 weeks (82.5% vs. 86.8%, p=0.107) and 24 weeks (91.5% vs. 94.1%, p=0.183). Finally, the median time to recovery of continence was similar between the groups based on the Kaplan\u2013Meier curves (median: 5 weeks, 95% CI=4.41-5.59 vs. median: 5 weeks, 95% CI=4.66-5.34; log rank test, p=0.113). Conclusion: The presence of a median lobe does not affect perioperative outcomes, PSM rates and early continence outcomes in patients undergoing RARP performed by an experienced surgeon. There was a slight increase in the operative time in patients with a median lobe which was, however, related to the larger prostate size in this group

Does prostate weight affect perioperative outcomes, positive surgical margin rates and functional outcomes after robot-assisted radical prostatectomy performed by an experienced surgeon?

Aim: To determine whether prostate weight has an impact on pathological, perioperative and early functional outcomes after robot-assisted laparoscopic radical prostatectomy (RARP). Patients and Methods:We analyzed 1,831 consecutive patients who underwent RARP by a single surgeon. Patients were stratified into three groups on the basis of pathological prostate weight: group 1: <30 g, group 2: 30 to 49.9 g, group 3: 50 to 69.9 g and group 4: >70 g. Continence was defined as the use of \u2018no pads\u2019. Potency was defined as the ability to achieve and maintain adequate erections for penetration more than 50% of the time with or without the use of PDE-5 inhibitors. Only patients with preoperative SHIM score >21 and who underwent bilateral nerve-sparing procedure were included in the study. Groups were compared using one-way ANOVA on ranks test and the Dunn\u2019s method for multiple comparisons when statistically significant differences were found. Results: Patients with a larger prostate (group 4) were older (median age 65 years), had higher pre-treatment PSA (median 5.8 ng/ml), higher AUA-SS (median 9), longer operative time (median 80 min) and higher estimated blood loss (median 100 cc) (p<0.001 for all variables). There was no association between prostate size and body mass index, biopsy Gleason score, clinical stage, catheterization time, pathological stage, hospital stay, anastomotic leak rates, specimen Gleason score and continence rates (at one, three and six months). Overall positive surgical margin rates were lower in patients with prostate size larger than 70 g when compared to the other groups (14.4% vs. 12.5% vs. 10.2% vs. 7.2%, respectively, p<0.001). There was a trend towards lower potency rates in patients with prostates larger than 70 g at four weeks (45.4% vs. 35% vs. 32% vs. 25%, p=0.065) and three months (72% vs. 75% vs. 75.2% vs. 65%, p=0.07) after RARP, although the potency rates were similar among the groups at six months after surgery. Conclusion: RARP performed by an experienced surgeon in patients with an enlarged prostate is feasible, with slightly higher operative time and estimated blood loss and without any impact on early continence rates. There was a trend towards lower early potency rates in patients with larger prostates, which can probably be explained by the greater age of these patients. Pathologically larger prostates were associated with lower overall PSM rates even though the pathological stage and specimen Gleason score were similar in the groups

Salvage robot-assisted radical prostatectomy : single surgeon experience

Aim: The objective of this study is to report the perioperative, functional and oncologic outcomes of salvage robot-assisted radical prostatectomy (sRARP). Patients and Methods: We identified 19 patients who underwent sRARP with bilateral limited pelvic lymph node dissection by a single surgeon between July 2002 and October 2010. RT consisted of XRT in nine cases, brachytherapy in seven cases, brachytherapy plus XRT in two cases and proton beam therapy in one case. Biochemical failure was defined as a PSA of >2.0 ng/ml over the absolute nadir. Continence was defined as the use of \u2018no pads\u2019 after surgery and potency was defined as the ability to achieve and maintain adequate erection for penetration, with or without PDE-5 inhibitors. Biochemical recurrence (BCR) was defined as a PSA of >0.2 ng/ml after sRARP. Results: The median (IQR) age, BMI, SHIM score and AUA score were 66 (range: 60-70.5) years, 30 (range: 37-32.5) kg/m2, 5 (range: 4- 15), and 12 (range: 7.5-13), respectively. The median PSA nadir after RT and the median PSA before surgery were 4.3 (range: 3.4-4.9) and 1.2 (range: 0.75-1.2) ng/ml, respectively. Six patients were placed on ADT. The median OR time and blood loss were 92.5 (range: 90-107.5) min and 100 (range: 100-100) ml, respectively. A partial nerve-sparing surgery was performed in five (26.3%) patients, while all other patients underwent non nerve-sparing surgery. On histopathological evaluation, five patients (26.3%) had pT2 disease, eight (42.1%) had pT3a, while five (26.3%) had pT3b. Due to intense scarring, it was not feasible to accurately stage one prostate. Three patients (15.8%) had a positive surgical margin. The median Gleason score, prostate weight and tumor volume were 8 (range: 7-8), 34 (range: 25-43) g and 25% (range: 16-32%), respectively. The median length of hospital stay and days on catheter were 1 (range: 1-2) day and 8 (range: 7-11) days, respectively. Two (10.5%) patients had three complications (15.8%). Two patients had anastomosis leak (1d), both treated by extended Foley\u2019s catheterization. One of these developed an anastomotic stricture (Clavien 3a) at six months and was treated by direct internal urethrotomy. There were no rectal injuries or bladder neck contractures. Fifteen patients had at least six months of follow-up, of whom twelve (80%) were continent. The median time to achieve continence was 5.5 (range: 2.6-9) months. Only two patients who had partial nerve-sparing surgery had six months of follow-up, and none of them were potent. On a median followup of 24 (range: 6-45) months, 4 patients (21%) had BCR. Conclusion: sRALP is a technically challenging but feasible procedure. The challenge lies in extensive fibrosis and loss of dissection planes, secondary to radiation therapy. This is the largest published single surgeon series and it shows encouraging perioperative, continence and oncologic outcomes