Introduction and objectivesSurgeons should aim for continuous quality improvement. The aim of this study was to evaluate the impact of incremental changes to Robot Assisted Radical Prostatectomy (RARP) technique on intra-operative and early post-operative outcomes. Patients and methods All cases of RARP performed by a single surgeon in a tertiary institution over a 2-year period were included in this evaluation. Routine clinical data were collected. Cases were retrospectively allocated to four groups depending on key technical steps (1 = standard anterior approach; 2 = anterior approach with preservation of endopelvic fascia, puboprostatic fascia and urachus; 3 = posterior approach for nerve spare, with preservation of endopelvic fascia, puboprostatic fascia and urachus; 4 = Retzius-sparing posterior approach). Results 187 patients were allocated to groups: 1 = 22, 2 = 53, 3 = 90, 4 = 22. There were no significant differences in preoperative characteristics, except age: 1 = 62.5, 2 = 62, 3 = 62.5, 4 = 58.5 (p = 0.02). Intra-operative differences were found in console time: 1 = 195, 2 = 167, 3 = 195 4 = 136.5 min (p < 0.001); and proportion of non-nerve sparing cases: 1 = 36%, 2 = 17%, 3 = 13%, 4 = 0% (p = 0.044). No significant differences were found in lymph node dissections, blood loss or complications. Post-operatively, no differences were found in length of stay, pathological characteristics, margin status, lymph node yield, complications or PSA levels. Significant differences were seen in pad-free continence at 6 weeks: 1 = 23%, 2 = 23%, 3 = 34%, 4 = 73% (p < 0.01); and social continence (using 1 pad) at 6-weeks: 1 = 59%, 2 = 87%, 3 = 81%, 4 = 95% (p = 0.01). Significant differences in pad-free continence persisted at 12 months: 1 = 63%, 2 = 81%, 3 = 78%, 4 = 100% (p = 0.019). Conclusion Our results suggest that aggregated marginal gains from incremental modification of RARP leads to significantly improved continence outcomes without compromising patient safety or oncological control.

To assess whether the timing of post-operative Phosphodiesterase Inhibitor (PDE5i) therapy after Robot-Assisted Radical Prostatectomy (RARP) is associated with a change in early erectile function (EF) outcomes, continence or safety outcomes. Data were prospectively collected from a single surgeon in one tertiary centre. 158 patients were treated with PDE5i therapy post RARP over a 2-year period. PDE5i therapy was started: immediately (day 1–2) post-op in 29%, early (day 3–14) post-op in 37% and late (after day 14) post-op in 34%. EPIC-26 EF scores were collected pre-op and post-op. There were no significant differences in pre-operative characteristics between the therapy groups. Drop in EF scores and percentage return to baseline for unilateral nerve sparing was, respectively, 9 and 11.1% of immediate therapy, 7 and 14.8% of early therapy and 9.7 and 9.5% of late therapy (p = 0.9 and p = 0.6). For bilateral nerve sparing, this was, respectively, 3.5 and 42.9% immediate therapy, 5.5 and 35.5% early therapy and 7.3 and 25% late therapy (p = 0.017 and p = 0.045). Pad free and social continence were achieved in 54% and 37% of those receiving immediate therapy, 60% and 33% for early therapy and 26% and 54% for late therapy. There were no differences in compliance, complication or readmission outcomes. In patients with bilateral nerve sparing RARP, immediate post-operative PDE5i therapy can protect EF and improve early continence outcomes. Therefore, immediate PDE5i therapy should be considered in patients following nerve sparing RARP to maximise functional outcomes.

Objectives To assess whether the timing of post-operative Phosphodiesterase Inhibitor (PDE5i) therapy after Robot Assisted Radical Prostatectomy (RARP) is associated with a change in early erectile function outcomes. Additionally, to determine whether there are differences in continence or safety outcomes. Subjects/patients and methods Data was prospectively collected from a single surgeon in one tertiary centre and retrospectively evaluated. 158 patients were treated with PDE5i therapy post RARP over a two-year period. PDE5i therapy was started: immediately (day 1-2) post-op in 29%, early (day 3-14) post-op in 37% and late (after day 14) post-op in 34%. EPIC-26 Erectile Function (EF) scores were collected pre-op and post-op with a median follow-up time of 43 days. Results The median age was 64 and the median BMI was 27. 9% of the series had Charlson Co-Morbidities. There were no significant differences in pre-operative characteristics between the therapy groups. Patients that had bilateral nerve sparing had a mean drop in Erectile Function (EF) score by 5.4 compared to 8.8 in the unilateral group. Additionally, 34.9% of bilateral nerve sparing patients returned to baseline compared to 12.1% of unilateral. Drop in EF scores and percentage return to baseline for unilateral nerve sparing was respectively 9 and 11.1% of immediate therapy, 7 and 14.8% of early therapy and 9.7 and 9.5% of late therapy (p=0.9 and p=0.6). For bilateral nerve sparing this was respectively 3.5 and 42.9% immediate therapy, 5.5 and 35.5% early therapy and 7.3 and 25% late therapy (p=0.017 and p=0.045). Pad free and social continence was achieved in 54% and 37% of those receiving immediate therapy, 60% and 33% for early therapy and 26% and 54% for late therapy. There were no differences in compliance, complication or readmission outcomes. Conclusion In patients with bilateral nerve sparing RARP, immediate post-operative PDE5i therapy may protect EF. Early onset (3-14 days) may also provide a benefit compared to initiating PDE5i therapy later (after 14 days). Expediting therapy for patients undergoing unilateral nerve sparing may also provide a benefit; however, the differences are less pronounced. Immediate or early PDE5i therapy also improved early continence outcomes for patients with bilateral nerve sparing, compared to late therapy. There were no differences in compliance, complication or readmission rates between the groups. Therefore, immediate PDE5i therapy should be considered in patients following nerve sparing RARP in order to maximise functional outcomes, especially in those undergoing bilateral nerve spare.

Background The learning curve for retzius sparing robotic radical prostatectomy is not fully understood. Objective This study attempts to identify the learning-curve across the first 130 cases of a single surgeon. Design, Setting, and Participants: All retzius sparing robotic radical prostatectomy cases performed by a single surgeon at a high-volume tertiary hospital between April 2019 and July 2022 were included. Outcome Measurements and Statistical Analysis: Outcome measures included positive surgical margin rate, complication rates and unplanned readmission to hospital, postoperative urinary continence, erectile function, and PSA measurement. Cases were divided chronologically into 3 groups and differences between groups assessed. Results and Limitation: 130 RS-RARP cases were identified. Differences were found between groups in several areas. Positive surgical margin rate fell between Group 1 (30.2%) and Group 3 (9.1%). Safety, post-operative continence, erectile function and PSA remained stable. Median patient age increased between group 1 (59yrs) and Group 3 (66.5yrs) (P = 0.04). Proportion of patients with stage > T2 increased between Group 1 (27.9%) and Group 2 (41.9%) (P = 0.036). Median console time increased between Group 1 (120 mins) and Group 2 (150 mins,) (P = 0.01). Median gland weight increased between Group 1 (28g) and Group 3 (35.5g) (P < 0.001). Conclusions The positive surgical margin rate improved over the learning curve, despite the complexity of cases increasing, reflected in older patients, larger prostates and higher stage disease. Safety and functional outcomes are excellent throughout. The learning curve might be facilitated by careful case selection favouring smaller prostates with less advanced disease. Patient Summary: We analysed the learning-curve for Retzius-sparing robotic radical prostatectomy. Across the first 130 cases positive surgical margin rate fell; safety and continence remained excellent. Selection of smaller and less advanced cases may facilitate learning.