Technique of Robotic Prostatectomy and outcomes

V O L U M E 6 8 . N . 5 . O T T O B R E 2 0 1 3

Vol. 68 - No. 5 MINERVA CHIRURGICA 499

treatment modality, and may be the pre-ferred option based on individual patient’s cancer risk, age and comorbidities.5 It offers excellent cancer control with disease spe-cific survival rates of 93% to 95% after 15 years of follow-up.6

Early on RP was not considered the first-line of localized PC management due to the dreaded complications of incontinence and erectile dysfunction. A better under-standing of the pelvic anatomy as well as important advances in surgical technique over a century after the first radical perine-al prostatectomy was performed by Young in 1904 7 have led to its current widespread acceptance. The retropubic approach for RP which allowed access to pelvic lymph nodes for tumor staging was described by Millin in 1947.8 Later, anatomical stud-ies in 1980’s led to the development of modified radical retropubic prostatectomy which integrated better understanding of DVC(Dorsal Venous Complex),9 neu-rovascular bundles (NVBs) 10 and urinary sphincter.11 The incorporation of these new anatomical findings to surgical tech-

Center for Prostate Cancer Lefrak Center of Robotic Surgery

Department of Urology Weill Cornell Medical College

New York Presbyterian Hospital New York, NY, USA

MINERVA CHIR 2013;68:499-512

A. ALI, D. P. NGUYEN, A. TEWARI

Robot assisted laparoscopic prostatectomy in 2013

Robot assisted laparoscopic prostatectomy has surpassed open radical prostatectomy as the most common surgical approach for radical prostatectomy in the United States. In this article we briefly describe the evolution of this minimally invasive technique. The cur-rent diagnostic approaches of multiparamet-ric magnetic resonance imaging and fusion biopsy used in preoperative workup of the patients are discussed, followed by a descrip-tion of risk stratified athermal nerve sparing approach with total anatomical reconstruc-tion. Finally we present a critical appraisal of the published oncological, continence and potency outcomes.Key words: Prostatectomy - Robotics - Prostatic neoplasms.

Prostate cancer (PC) is the most common non-cutaneous malignancy among men

in Western countries. An estimated 30,000 will die of the disease in the United States and 70,000 in Europe in 2013.1, 2 Widespread use of prostate specific antigen (PSA) as a biomarker for prediction of PC has led to a dramatic shift towards early detection of organ-confined disease in a younger patient population.3, 4 For those patients with clini-cally organ-confined disease, radical pros-tatectomy (RP) remains a commonly used

Corresponding author: Dr. A. Tewari, MD, M. Ch, Center for Prostate Cancer, Weill Cornell Medical College and New York Presbyterian Hospital, Lefrak Center of Robotic Sur-gery, NYPH, Weill Cornell Medical College, New York Pres-byterian Hospital, 525 East 68th Street, Starr 900, New York, NY 10021, USA. E-mail: [email protected]

Anno: 2013Mese: OctoberVolume: 68No: 5Rivista: MINERVA CHIRURGICACod Rivista: MINERVA CHIR

Lavoro: titolo breve: ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY IN 2013primo autore: ALIpagine: 499-512

500 MINERVA CHIRURGICA October 2013

ALI ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY IN 2013

nique decreased intraoperative blood loss, preserved potency and decreased urinary incontinence.12, 13 The first laparoscopic RP was performed in 1991 by Schuessler.14 Over the next decade, advancement in op-tics, digital imaging and software led to further refinement of laparoscopic tech-nique.15, 16 The next major advancement was with the development of da Vinci Surgical system (Intuitive Surgical®, Moun-tain View, California). The first robot as-sisted laparoscopic prostatectomy (RALP) using this robotic interface was performed in May 2000 by Binder and Kramer.17 The first generation da Vinci ® Surgical system had three robotic arms, two for instruments and one for endoscope. Using this master-slave surgical system, surgeons were able to view the surgical field three dimension-ally in 10X magnification using stereo-en-doscope lens and camera. Moreover, sur-gical instrument tips had a 360° range of movement. In the United States, RALP was pioneered and established as treatment for patients with PC at Vattikuti Urology Insti-tute.18, 19 By 2008, more than 60% of radical prostatectomies in the USA were RALP.20

We herein review the current surgical management of PC with emphasis on RALP. We offer a detailed description of our RALP technique including individualized NS and the addition of dynamic detrusor cuff trigo-noplasty. Finally, complications, outcomes and economics of RALP are discussed.

Indications for RALP

A complete medical history and physical examination including DRE along with se-rum PSA are done as part of PC screening. In case of an elevated serum PSA level, a transrectal ultrasound (TRUS) guided pros-tate needle biopsy can be done to exclude or confirm PC. Indications for RALP are identical to those for open RP and include patients with biopsy proven, clinically lo-calized PC without clinical or radiographic evidence of metastasis who have consented to the procedure. Patients with severe cardi-opulmonary disease unable to tolerate gen-

eral anesthesia and those with uncorrected bleeding diatheses are not candidates for RALP

Preoperative workup: current approaches

Two MRI-based imaging techniques are used in our institution in order to optimize surgical planning and tune the procedure to each individual patient’s unique require-ment based on preoperative disease char-acteristics.

Targeted fusion biopsy

In place of standard TRUS guided bi-opsy fusion biopsy may be done. Three techniques of fusion have been described: Cognitive fusion, In-Bore MRI-MRI Fusion and MRI-TRUS Fusion. Cognitive fusion simply requires the TRUS operator to tar-get areas where previously reviewed MRI demonstrated significant lesions. This tech-nique however quick and easy is subject to human error. In-Bore MRI-MRI fusion is performed within the MRI tube. It fuses a previous MRI with a synchronous MRI for biopsy needle localization. This technique requires two MRI sessions and is thus time consuming and more expensive. Finally, MRI-TRUS fusion is done in two steps: first a multiparametric endorectal MRI is done; the studies are then loaded onto a software on which the radiologist marks the pros-tate gland and the regions of interest for biopsy in different slices and views of the MRI, known as segmentation (Figure 1). This information is then loaded on to a de-vice which then fuses the segmented MRI with real-time ultrasound to create a three-dimensional real-time reconstruction of the prostate on which the aiming and tracking of biopsy site is done (Figure 2). This tech-nique can be done in an outpatient setting under local anesthesia within a few min-utes. Currently five devices approved by the Food and Drug Administration (FDA) are available for MRI-TRUS fusion biopsy. For instance, the Artemis device (Eigen, Grass


ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY IN 2013 ALI

Figure 2.—MRI-TRUS Fusion with planned targets. MRI on the top left quadrant with the planned target. Bottom right quadrant showing 3D view of the region of interest with planned target site.

Figure 1.—From top left clockwise. A) Axial T2 weighted 3T MRI with endorectal coil showing two regions of interests (Red high suspicion, Green Low suspicion); B) coronal section interpolated image based on the axial section; C) it shows a 3D rendering of the prostate after segmentation in light brown color, regions of interests in red and green; D) axial diffusion weighted imaging showing the marked regions (Red region of interest has an ADC value of 784).

A B

C D



magnet. To obtain sub millimeter-resolu-tion which are necessary for local staging, T2 weighted images acquired should have thickness of 3 mm with a 14 cm field of view.22 PC foci commonly demonstrate de-creased signal intensity relative to the high-signal intensity normal peripheral zone on T2 weighted images.23 For the detection of PC the sensitivity of MRI ranges from 60 to 96%, but has poor specificity.24 However, to detect EPE or seminal vesicle (SV) inva-sion the sensitivity and specificity of MRI is 73% to 80% and 97-100% respectively (Fig-ure 3).25 DW-MRI allows the mapping of diffusion of water molecules within tissue. Apparent diffusion coefficient (ADC) is helpful in differentiating between low, in-termediate and high risk Gleason scores.26 DW-MRI along with T2 weighted imaging has 89% sensitivity and 91% specificity for detection of PC.27 DCE-MRI assesses the micro vascular changes such as blood flow, density and capillary perfusion for detec-tion of malignant PC lesions. This is done by dynamically running a T1-weighted se-quence after intravenous administration of gadolinium chelate. MRSI assess the relative citrate and choline concentrations which are overlaid on T2 images. The addi-tion of these functional scans significantly improves detection of peripheral zone le-sions when compared to T2WI alone.28, 29 Barentsz et al. described a standardized interpretation and reporting guidelines for

Valley, California, USA) has a mechanical arm and is capable of tracking and record-ing biopsy locations with three dimensional ultrasound and fusion of real-time ultra-sound with MRI.

An initial study using the Artemis at UCLA in 171 patients who underwent prostate biopsies using the Artemis plat-form investigated 106 patients under active surveillance for confirmed PC and 65 pa-tients with increasing PSA, prior negative conventional biopsy.21 PC was detected in 53% of all men. MR-TRUS fusion biopsy based targeted cores had higher yield of 21% as compared to 7% for systemic bi-opsy cores. Moreover, a higher number of Gleason 7 cores (36% vs. 24%) were de-tected.

Multiparametric endorectal MRI

The use of MRI for the diagnosis and staging of PC has increased over the past 5 years. The ideal 3T (Tesla) mp-eMRI comprises of T1 and T2 weighted im-ages (T2WI) for demonstrating high sig-nal blood product and demonstrating the anatomy, respectively, as well as functional imaging which includes diffusion weighted (DW) imaging, dynamic contrast enhanced (DCE) imaging and magnetic resonance spectroscopic imaging (MRSI) with the use of pelvic phased-array coil along with an endorectal coil on a high field-strength

Figure 3.—3T MP-MRI and histopathology of a patient with extra prostatic extension who received grade 4 nerve spar-ing and had negative surgical margins. A) T2W axial view showing a hypointense lesion in the left peripheral zone marked by arrows; B) corresponding DWI ADC map showing restricted diffusion with an ADC value of 435 marked by red outline; C) Corresponding T2W coronal view showing the same lesion marked by arrows in the left peripheral zoneextending from apex to base.

A B C



Surgical procedure

The transperitoneal anterior approach for RALP is as here described.

Dropping the blaDDer

Once intra-abdominal access is gained a careful inspection is carried out, urachus and medial umbilical ligaments are identi-fied and adhesions are lysed if present. A wide inverted U-shaped incision is made starting lateral to the left medial umbili-cal ligament and extending anteromedially dividing the urachus in the midline to the right medial umbilical ligament using mo-nopolar cautery. This U-shaped incision is then extended bilaterally to the vas deferens (VD).

The retropubic space is then developed by blunt dissection within the space of Retzius. This exposes pubis, endopelvic fas-cia, bladder, puboprostatic ligaments and prostate. Athermal dissection is then carried out within the periprostatic space between the endopelvic fascia and lateral prostatic fascia (LPF). During development of the ret-ropubic space and incision of the endopel-vic fascia, we proceed distally and medially. Meticulous dissection is performed to mini-mize disruption of the puboprostatic liga-ments and arcus tendineus until the urethra is exposed and there is a clear space for the placement of the dorsal venous stitch. The arcus tendineus and puboprostatic liga-ments are used later in the anterior recon-struction.

blaDDer neck Dissection

Using a 30° downward angle lens for visu-alization, the prostate is held on either side using blunt robotic instruments and pulled proximally until there is a sudden feeling of “giving way” at the junction with collapsed bladder. This technique enables relatively easy identification of the prostatovesical junction (PVJ) and this techniques is known as “bimanual bladder neck pinch”.32 Once the PVJ is identified, the bladder neck is in-cised in the midline using Maryland bipolar

mp-eMRI known as PI-RADS(Prostate Im-aging Reporting and Data System) which could lead to broader and more reliable adoption of mp-eMRI.30

At our institution 3T mp-eMRI findings are used to improve surgical management and optimize the functional outcomes in individual patients based on their own unique disease and anatomical characteris-tics. The information retrieved from 3T mp-eMRI helps in making informed decisions during surgery for achieving negative sur-gical margins and preserving periprostatic tissue and nerves which control continence and sexual functions.31

RALP: Surgical technique

Positioning

Once the patient has been put under general anesthesia, he is placed in steep trendelenburg position with arms tucked and padded on the side and legs securely abducted on a split leg table. The stomach and bladder are decompressed by place-ment of orogastric tube and urethral cath-eter under aseptic precautions.

Port placement

A pneumoperitoneum is created by in-sufflation using a Veress needle inserted infraumbilically. Once adequate insufflation is done, a 12 mm trocar is placed supraum-bilically or at umbilicus for the placement of stereoscopic-endoscope. A total of five trocars, three for robotic arms and two for assistants are placed. Two 8mm pararectal trocars are placed on the right and left side for second and third robotic arms. Another 8 mm trocar is placed in the left lumbar re-gion for the second and third robotic arms. Additionally, two trocars of 12 mm and 5 mm for assistant ports are placed on the patient’s right side. Once the placement of trocars is done, the da Vinci robot is moved into position between the patient’s legs and the arms of the robot are brought above the patient and docked.



dict ipsilateral EPE. This preoperative deci-sion making model incorporates serum PSA level, clinical stage, biopsy Gleason score and MRI findings and strives to achieve the competing goals of cancer clearance and preservation of continence and potency by varying degress of preservation of the nerve fibers in different fascial planes (Fig-ure 4).31 These degrees of preservation are described as follows:

— Grade 1 NS: The Denonvilliers’ fas-cia and the LPF are incised just outside the prostatic capsule to preserve the neural hammock. We also describe this as medial venous plane for complete hammock pres-ervation. This is the greatest degree of NS possible, and we perform this procedure for patients with no-to-minimal risk of EPE.

— Grade 2 NS: The Denonvilliers’ fascia (leaving deeper layers on the rectum) and LPF are incised just outside the layer of veins of the prostate capsule. This allows the pres-ervation of most large neural trunks and gan-glia and is used for patients at low risk of EPE.

— Grade 3 NS (partial/incremental): In-cision is made through the outer compart-ment of the LPF (leaving some yellow adi-pose and neural tissue on the specimen), excising all layers of Denonvilliers’ fascia. This is performed for patients with moder-ate risk of EPE because some of the medial trunks are sacrificed, whereas the lateral trunks are preserved.

forceps and hot shears. Dissection is carried out until the Foley catheter is identified, the tip is identified and the catheter is grasped by the left-side assistant with firm anterior traction. The dissection then proceeds later-ally. With traction on the shaft of the cath-eter, the exact location for the posterior inci-sion becomes visible and the mucosa of the posterior bladder neck is now incised pre-cisely. After dissection through the mucosa, the retrotrigonal fibromuscular layer is iden-tified.33 Dissection then proceeds athermally to preserve the neural hammock surround-ing the prostate and the trigonal nerves until the shiny white surface of the VD is seen.

athermal Dissection of sV anD VD

The SV and VD are identified and dis-sected athermally, the ends are clipped and cut. The cut ends are then lifted by the fourth arm of the robot to develop a plane between the SV and the surrounding fascia, arteries entering into the SV are identified. These are cut using clips and sharp dissec-tion. Every attempt is made to preserve the NVB which are present lateral to the SV. Both the SV and VD are then pulled up-ward. In patients who are appropriate can-didates for nerve sparing, an intracompart-mental SV dissection is performed.34

risk stratifieD graDes of ns

Nerve sparing has been found to be in-dependently associated with post-operative recovery of erectile function.35 Different variations of NS technique have been de-scribed in the literature. Use of cautery-free NS which significantly improved return of sexual function was reported by Ahlering et al.36 The “Veil of Aphrodite” technique in which dissection of the prostatic fasica is carried to the prostatic surface, and peripro-static tissue is released in a relatively avas-cular plane was described by Menon et al.37 A clipless antegrade nerve sparing tech-nique was described by Chien et al.38

Our risk stratified approach to athermal, traction free NS during RALP is based on the patient’s preoperative findings which pre-

Figure 4.—Risk stratification algorithm for nerve sparing. PSA levels in nanograms per milliliter. Risk grade 1: All criteria should be met; Risk grade 2-4 any two criteria or magnetic resonance imaging findings. If MRI findings are not available, only clinical criteria are used.EPE: extra prostatic extension; eMRI: endorectal mag-netic resonance imaging; PSA: prostate specific antigen.



additional 1-2 mm of ventral membranous urethral length prior to transection of the urethra posteriorly, it is swept away from the apex. Once transected the foley catheter is seen and then the transection of the ure-thra is completed circumferentially via the retroapical approach.42 The DVC is ligated using CT-1 needle and 0-polyglactin suture. Once the prostate is free, lymph node dis-section is done and the specimen is bagged (Figure 5).

Dynamic Detrusor cuff trigonoplasty

The anterior bladder is held using the 4th arm of the robot and the bladder open-ing, mucosa and uretric orifices are iden-tified. The posterior extent of the bladder opening is closed using a “tennis racquet” stich with a 4-0 Biosin suture. The mucosa is then everted using the same suture and the posterior gap is covered using a flap of detrusor muscle and approximated in the midline using a 3-0 V-Lock suture to sup-port the bladder neck creating a detrusor cuff. This posterior reinforcement is based on the principles of Pagano (Figure 6).43

posterior reconstruction

Using a few shallow bites from the pos-terior aspect of the Denonviller’s fascia, the

— Grade 4 NS (non-NS): These patients have high risk of EPE and are not candi-dates for NS. In such cases, we perform a wide excision of the LPF and Denonvilliers’ fascia containing most of the peri-prostatic neurovascular tissue. In selected patients, we attempt nerve advancement of the iden-tifiable ends of the NVB.

These planes are developed athermally by sharp and blunt dissection, proceeding distally toward the apex and laterally on both sides. At the lateral attachments, the perforating arteries enter into the prostatic capsule. They are sharply cut after being secured by clips and the plane is created between the capsule and the medial aspect of the pedicular vessels.39-41

circumapical Dissection of the urethra

As the prostatic apex is a frequent site of positive surgical margin (PSM), extra care has to be taken during apical dissection. Once the prostate is mobilized, it is lifted anteriorly and a plane is developed along the posterior surface of the prostate. At this time the a few layers of Denonvillers fascia and the rectourethralis muscle covers the posterior prostatic apex. Once the prostate is lifted anteriorly, blunt dissection is carried out to develop a distinct plane between the prostatic apex and the urethra. To gain an

Figure 5.—Circum-apical dissection. A) Shows the posterior aspect of the prostate gland and a good length of mem-branous urethra is clearly visible; C) Shows the Foley catheter tip being pulled from the transected urethra posteriorly.P: prostate; U: membranous urethra

A B



Postoperative management

A suprapubic catheter, bulb drain, and occasionally a Foley catheter are left in place. Parentral narcotics are used for post-operative pain management. Early ambula-tion is encouraged to prevent deep venous thrombosis. The patient is started on a clear liquid diet and advanced as tolerated. Once the patient has been taught catheter care, is ambulatory and tolerating oral pain medica-tion, he is discharged. Patient returns one week after surgery for catheter removal. Pa-tients then begin Kegel exercises.

Complications

Perioperative complication rate after RALP ranged from 2.5 to 26% of all cases and include was follows.47

Hemorrhage

Most studies show that for laparoscopic RP and RALP blood loss is about 50-200 mL during the procedure and blood transfusion rates of 2% or less have been reported.48 This limited blood loss is due to the tam-ponade effect of the pneumoperitoneum and possibly due to improved visualization.

suture is then passed through the retrotrigo-nal layer and cinched down. The shallow bites are taken to avoid injury to the under-lying nervous tissue.

anastomosis anD anterior repair

Using a V-lock suture, a two layer anas-tomosis is completed by synchronized pull and push technique to cinche the retrotrigo-nal layer close to rectourethralis.44 A secure water tight anastomosis is created by mu-cosa-mucosal, tension-free approximation and avoidance of neurovascular bundles. The previously preserved arcus tendinius are sutured to the detrusor muscle using a single-knotted suture for the anterior recon-struction.45 This helps in positioning and stabilizing the vesico-urethral junction.

supra pubic catheter placement

The bladder is filled with 180mL of water and a suprapubic catheter is then inserted into. The placement of a supra pubic cath-eter helps in elevation of the bladder to its normal preoperative position and also serves as a urinary diversion route in cas-es which a catheter is not used.46 Finally, reperitonization is done to restore preop-erative anatomy (Figure 7).

Figure 6.—Dynamic detrusor cuff trigonoplasty. A) The posterior flap of detrusor is clearly seen. A running suture is passed to approximate the flaps medially; B) the posterior detrusor flap is approximated using a running suture cuffing the bladder neck.

A B



tion. Large prostates or median lobes and history of prostatitis are known risk factors for ureteral injury.52

Anastomotic stricture

The incidence of anastomotic stricture following RALP ranges from less than 2% to 14.0% and depends on the surgical tech-nique.53, 54 Its occurrence depends mainly on the surgical technique and surgeon experience. Other risk factors include pa-tient age, obesity, smoking, diabetes melli-tus, hypertension, coronary artery disease, postoperative bleeding and previous his-tory of transurethral resection of the pros-tate.55 For patients who develop a postop-erative anastomotic stricture, the treatment options include transurethral anastomotic dilation or incision and intermittent self-dilation.

Outcomes

Oncological outcomes

surgical margins

In a meta-analysis with data abstracted from 400 original research articles repre-senting 167 184 open RP, 57 303 laparo-

Excessive bleeding is most often due to in-jury to the DVC. Rarely the superior epi-gastric artery can be injured during trocar insertion. During the procedure increasing the pneumoperitoneum pressure can help in controlling minor bleeding.

Rectal injury

Intraoperative rectal injury occurs in 0.7% to 2.4% cases undergoing RALP and can be usually managed successfully without open conversion.49, 50 Large prostates, inflamma-tion and scarred tissue between the anterior rectal wall and the Denonvillier’s fascia are the major causes of rectal injuries. These injuries may occur during dissection of the posterior prostate plane or the SV, and some cases may occur at the prostatic apex when dissecting the neurovascular bundles or during separation of prostatic apex.

Ureter injury

Ureteral injuries occur in lower than 0.5% of all cases. Most of cases are detected postoperatively because of urinary leakage intra- or retroperitoneally.51 Urinary leak-age can be easily diagnosed by contrast-enhanced computed tomography. Ureteral injuries usually happen during extended lymphadenectomy or bladder neck dissec-

Figure 7.—Suprapubic catheter placement. A) Supra pubic catheter is inserted through the anterior abdominal wall and the bladder is held in position for receiving the supra pubic catheter; B) Supra pubic catheter inserted into the bladder.A: anterior abdominal wall; PB: pubic bone; SPC: suprapubic catheter; B: bladder.

A B



of >0.2 ng/mL.57 The European Association of Urology defines it as PSA values >0.2 ng/mL, confirmed by two consecutive measure-ments.58 BCR is positively associated with the PSM, tumor stage and Gleason score. PSA elevations developed within the first 2 years following surgery are more often associated with distant recurrences. Master-son et al., in a retrospective review of 357 open RP patients and 669 RALP patients who underwent surgery between 1999 and 2010 were compared for biochemical recur-rence-free survival rates according to surgi-cal approach, no differences were seen at 24 or 60 months postoperatively between open RP patients (87% and 71%, respec-tively) and RALP patients (87% and 73%, respectively)[59]. Similarly, Magheli et al., evaluated 522 patients undergoing RALP with open RP patients; short-term follow-up yielded BCR rates of 93% for open and 94% for RALP.60

scopic RP, and 62 389 RALP patients (total: 286 876), RALP was found at least equiva-lent to open RP or laparoscopic RP in terms of margin rates. The overall PSM rates were 24.2% for open RP patients and 16.2% for RALP patients; pT2 PSM rates were 16.6% for open RP patients and 10.7% for RALP patients; pT3 PSM rates were 42.6% for open RP, 39.7% for laparoscopic RP, and 37.2% for RALP (Table I).

Intraoperative real time transrectal ultra-sound (US) and surgical loupes are new technical adjuncts that have been recently reported as a dissection guide to reduce margin positivity during RP.56

Biochemical RecuRRence

The American Urological Association defines BCR as an initial serum PSA value equal to or higher than 0.2 ng/mL followed by a subsequent confirmatory level of PSA

table i.—�Comparative positive surgical margins, continence rates and potency rates reported in various studies following RALP.

AuthorTo

tal ca

ses

PSM

FU Patie

nts

eva

luat

ed

Follo

w u

p m

ethod

Defi

nat

ion o

f co

nti-

nen

ce

Contin

ence

rat

e, %

Defi

nat

ion o

f pote

ncy

Pote

ncy

rat

e

Menon (US),2007 68 2652 - 36 months 1142 Self administered, validated

No pad or 1 pad/day

95.20% ESI 93%

Krambeck (US), 2009 69 294 15.60% 16 months 294 Self administered, validated

No pad or security pad

91.9% ESI 70%

Murphy (US), 2009 70 400 19.20% 22 months 395 Self administered, validated


91.4% SHIM≥21 62%

Shikanov (US), 2009 71 1362 19.50% 24 months 380 Self administered, validated

No pad 80% ESI 69%

Carlucci (US), 2009 72 700 11.90% 12 months 309 Self administered, validated


94% ESI 83%

Patel (US), 2010 73 1100 10.64% 18 months 404 Self administered, validated

No pad 97.90% ESI 96.60%

Sharma (UK), 2011 74 500 24% 12 months 500 Self administered, validated


91% IIEF-6≥16 75%

Xylinas (F), 2011 75 540 30% 24 months 500 Self administered, validated

No leak no pad 88% ESI 63%

Kim (SK), 2011 76 528 27.10% 12 months 495 Physicians interview

No pad 95% ESI 84%

Tewari (US), 2013 77 2536 8.50% >12 months 1335 Self administered, validated

No pad 98% ESI 92.40%

Samadi (US), 2013 78 1436 18% 12 months 1105 Self administered, validated


93% SHIM≥16 84%

PSM: positive surgical margin; FU: follow-up period



$4437 [IQR: $3,989–$5,141]; P<0.001).65 The main differences were in surgical supply cost (RALP, $2015; ORP, $185) and oper-ating room (OR) cost (RALP, $2798; ORP, $1611; P<0.001). Lotan et al. found that RRP was the most cost-effective approach with a cost advantage of $487 and $1726 over LP and RALP, respectively.66 This large dif-ference in RRP and RAP costs was due to a cost of $857 per case for robot purchase and maintenance, and the high cost of $1705 for equipment per case.

Moreover, introduction of robotics has re-sulted in 35.3% of the hospitals that owned a robot performing 85% of all RPs, with 9% of very high volume hospitals perform-ing 57% of all RPs.67 Cost benefits which are gained as a result of shorter OR times, less blood loss and need for transfusions, shorter hospital stays, less use of pain med-ication, and earlier return to work after a shorter convalescence following RALP need to be factored in future studies.

Conclusions

More than a decade after its introduc-tion RALP has been shown to be a viable option for patients with clinically localized PC. The current literature shows that RALP has overtaken open RP as the primary sur-gical approach in PC management. Future studies with longer patients’ follow-up will address oncological outcomes such as disease-specific and overall mortality after RALP. Furthermore, open questions regard-ing the economics of RALP remain. More importantly, the patient’s perspective has to be kept in mind, avoiding hype, portraying realistic outcomes data so as to avoid post procedure dissatisfaction and regret.

Riassunto

Prostatectomia laparoscopica robotica nel 2013

La prostatectomia laparoscopica robotica ha su-perato la prostatectomia radicale a cielo aperto qua-le approccio chirurgico più diffuso per la prostatec-tomia radicale negli Stati Uniti. Nel presente articolo

Functional outcomes

urinary continence

Urinary incontinence after radical pros-tatectomy is caused due to damage to the urinary sphincter and alterations in the pel-vic floor musculature. Less often, unstable detrusor muscle can induce urgency incon-tinence; while post-operative anastomotic stricture and/or low- compliance bladder can induce overflow incontinence. Various surgical techniques such as 1) optimizing preservation of urethral rhabdosphincter length, without affecting the positive sur-gical margin rate;42 2) total reconstruction of the vesico-urethral junction;45 3) pres-ervation of puboprostatic ligaments and arcus tendineus. Incising the puboprostat-ic ligaments just proximal to the prostate apex, and careful dissection in that plane is used so as to avoid detaching the ure-thral rhabdosphincter from its anterolateral ligamentous attachments;61 4) periurethral retropubic suspension stitch;62 and 5) nerve sparing 63 are known to improve urinary continence outcomes.

erectile Dysfunction

Postoperative potency rates ranging from 3.4% to 96.6% have been reported. These rates are largely dependent on the type of nerve sparing done and the surgical tech-nique.64 For patients with postoperative erectile dysfunction, the choices of treat-ment include phosphodiestrase type 5 in-hibitors, intraurethral or intracavernosal vasodilators vacuum erection devices, and penile prosthesis.

Economics

The increased costs associated with RALP remain a matter of debate. Bolenz et al. reported in an analysis of 262 RALP, 220 laparoscopic RP and 161 open RP that the median direct cost was higher for RALP than for open RP (RALP: $6,52 [interquar-tile range (IQR): $6,283-$7,369]; open RP:



16. Guillonneau B, Vallancien G. Laparoscopic radi-cal prostatectomy: the Montsouris technique. J Urol 2000;163:1643-9.

17. Binder J, Department of Urology and Paediatric Urol-ogy UH, Johann‐Wolfgang‐Goethe University, Frank-furt am Main, Germany, Kramer W, Department of Urology and Paediatric Urology UH, Johann‐Wolf-gang‐Goethe University, Frankfurt am Main, Germa-ny. Robotically‐assisted laparoscopic radical prostate-ctomy. BJU Int 2001;87:408-10.

18. Menon M, Shrivastava A, Tewari A, Sarle R, Hemal A, Peabody JO et al. Laparoscopic and robot assisted radical prostatectomy: establishment of a structured program and preliminary analysis of outcomes. J Urol 2002;168:945-9.

19. Tewari A, Peabody J, Sarle R, Balakrishnan G, Hemal A, Shrivastava A et al. Technique of da vinci robot-as-sisted anatomic radical prostatectomy. Urology 2002: 60:569-72

20. Trinh QD, Sammon J, Sun M, Ravi P, Ghani KR, Bianchi M et al. Perioperative outcomes of robot-assisted radical prostatectomy compared with open radical prostatectomy: results from the nationwide inpatient sample. Eur Urol 2012;61:679-85.

21. Sonn GA, Natarajan S, Margolis DJA, MacAiran M, Lieu P, Huang J et al. Targeted biopsy in the detec-tion of prostate cancer using an office based mag-netic resonance ultrasound fusion device. The J Urol 2013;189:86-91.

22. Hricak H, White S, Vigneron D, Kurhanewicz J, Kosco A, Levin D et al. Carcinoma of the prostate gland: MR imaging with pelvic phased-array coils versus inte-grated endorectal--pelvic phased-array coils. Radiol-ogy 1994;193:703-9.

23. Schnall MD, Pollack HM. Magnetic resonance imag-ing of the prostate gland. Urol Radiol 1990: 12:109-14.

24. Kirkham APS, Emberton M, Allen C. How good is MRI at detecting and characterising cancer within the prostate? Eur Urol 2006;50:1163-75.

25. Heijmink SW, Ftterer JJ, Hambrock T, Takahashi S, Scheenen TW, Huisman HJ et al. Prostate Cancer: Body-Array versus Endorectal Coil MR Imaging at 3 T—Comparison of Image Quality, Localization, and Staging Performance1. Radiology 2007;244:184-95.

26. Morgan VA, Riches SF, Thomas K, Vanas N, Parker C, Giles S et al. Diffusion-weighted magnetic resonance imaging for monitoring prostate cancer progression in patients managed by active surveillance. Br J Ra-diol 2011;84:31-7.

27. Giannarini G, Petralia G, Thoeny HC. Potential and limitations of diffusion-weighted magnetic resonance imaging in kidney, prostate, and bladder cancer in-cluding pelvic lymph node staging: a critical analysis of the literature. Eur Urol 2012;61:326-40.

28. Turkbey B, Pinto PA, Mani H, Bernardo M, Pang Y, McKinney Y et al. Prostate Cancer: Value of Multi-Prostate Cancer: Value of Multi-parametric MR Imaging at 3 T for Detection—His-topathologifc Correlation 1. Radiology 2010;255:89-99.

29. Turkbey B, Mani H, Shah V, Rastinehad AR, Bernardo M, Pohida T et al. Multiparametric 3T prostate mag-netic resonance imaging to detect cancer: histopatho-logical correlation using prostatectomy specimens processed in customized magnetic resonance imag-ing based molds. J Urol 2011;186:1818-24.

30. Barentsz JO, Richenberg J, Clements R, Choyke P, Verma S, Villeirs G et al. ESUR prostate MR guidelines 2012. Eur Radiol 2012;22:746-57.

31. Tewari AK, Srivastava A, Huang MW, Robinson BD, Shevchuk MM, Durand M et al. Anatomical grades of nerve sparing: a risk stratified approach to neural

descriviamo brevemente l’evoluzione di questa tec-nica mininvasiva. Vengono discussi gli attuali ap-procci diagnostici di imaging a risonanza magnetica multiparametrico e biopsia con fusione utilizzati nell’iter diagnostico preoperatorio del paziente, seguiti da una descrizione dell’approccio atermico di preservazione del nervo con stratificazione del rischio e ricostruzione anatomica totale. Infine, pre-sentiamo una valutazione critica degli esiti pubbli-cati relativi a oncologia, continenza e potenza.

parole chiaVe: Prostatectomia - Robotica - Tumori prostatici.

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Conflicts of interest.—Dr. Ashutosh Tewari discloses that he is the principal investigator on research grants from In-tuitive Surgical, Inc. (Sunnyvale, California, USA) and Bos-ton Scientific Corporation; he is a non-compensated direc-tor of Prostate Cancer Institute (Pune, India) and Global Prostate Cancer Research Foundation; he has received re-search funding from, The LeFrak Family Foundation, Mr. and Mrs. Paul Kanavos, Craig Effron & Company, Charles Evans Foundation and Christian and Heidi Lange Family Foundation.

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Documents

Technique of Robotic Prostatectomy and outcomes